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The risk of osteoporotic fractures in adults over the age of 50 remains significantly high. For women, 50 percent will sustain an osteoporotic fracture sometime during their life. Twenty-five percent of men will experience a fracture. These individuals also are at significant risk (more than two-fold) for a second fracture and concomitant morbidity and mortality.
“Generally speaking, we’re grossly undertreating individuals hospitalized with osteoporotic fractures. Only about 20 percent of people are treated, and that is simply far too few. The reasons are many, but probably the largest problem we are facing is a breakdown in communication between providers coupled with the fact that the majority of these individuals have other serious health conditions that may take priority in their primary care,” says Susan L. Greenspan, MD.
Dr. Greenspan is dually trained in geriatrics and endocrinology, and currently serves as director of the UPMC Osteoporosis Prevention and Treatment Center, director of the Bone Health Program at UPMC Magee-Womens Hospital, and as principal investigator of both the Pittsburgh Claude D. Pepper Older Americans Independence Center and the Division’s NIH-funded T32 Program in Research Training in geriatrics. Dr. Greenspan’s research focus encompasses the pathophysiology, evaluation, and treatment of osteoporosis.
In 2014, Dr. Greenspan and the Division of Geriatric Medicine piloted a Fracture Liaison Service (FLS) as part of a combined quality improvement (QI) study with two other open health care systems to evaluate its efficacy in preventing secondary osteoporotic fractures by identifying patients early in the process of recovery from a fracture and intervening accordingly to better manage their underlying osteoporosis. Based upon the success of that initial QI study, the present day FLS was started in 2015 and has been delivering quality post-fracture care to patients in UPMC Presbyterian hospital since that time. The interventions provided for patients enrolled in the QI study, as well as the current patients in the FLS includes a number of components. Most patients receive a DXA scan and appropriate lab testing.
The results of these tests and their implications are carefully reviewed with the patients to ensure they adequately comprehend the information. Treatment options are recommended and discussed, medications prescribed if necessary, and direct follow-ups with patients occur several months after the initial visit. “We discuss fall prevention and strategies at home to decrease that risk. If they smoke, we talk about its impact on bone density and the various cessation programs available. I explain the vital importance of calcium and vitamin D. Patients have my contact information, along with an education packet so they can call me directly with any questions or concerns once they leave,” says Karen Vujevich, MSN, CRNP, who is the fracture liaison coordinator at UPMC working alongside Dr. Greenspan. Importantly, all of this is communicated to the patient’s primary care provider for continuity of care and follow-up.
“Generally speaking, we’re grossly undertreating individuals with osteoporotic fractures. Only about 20 percent of people are treated, and that is simply far too few. ”
Susan L. Greenspan, MD
In February 2018, Dr. Greenspan and her study colleagues at the other two participating FLS pilot sites published their initial findings in the journal Osteoporosis International. The paper, titled Implementing a Fracture Liaison Service Open Model of Care Utilizing a Cloud-Based Tool provides a full accounting of the study methods and findings for the initial cohort of patients (93 meeting all eligibility requirements) enrolled into the program between April and December 2014. Data on these patients was gathered through June 2015 in order to provide measurements for six months post-enrollment.
Results of the pilot intervention showed considerable improvements across all of the primary outcomes, which were percentages of individuals receiving bone mineral density tests (DXA), vitamin levels, calcium and vitamin D supplementation, and prescription of medication therapy for osteoporosis if warranted by standard guidelines.
In aggregate across the three pilot study sites, the percentages of individuals getting BMD testing increased from 21.2 percent to 92.9 percent. Serum vitamin D measurements went from 25.2 percent to 84 percent.
The percentage of patients recommended supplements for calcium and/or vitamin D increased to 92.6 percent from the baseline of 35.8 percent. Finally, medications prescribed for osteoporosis treatment jumped from 19.5 percent pre-FLS intervention to 54.1 percent after the FLS intervention.
“When you look at the pilot study as a whole, I think we can confidently say that this type of intervention can work in an open system, and we can use it to intervene positively with these at-risk patients. The intensive approach and intervention of the fracture liaison shows significant promise.”
“We don’t yet know if this kind of intervention will stave off subsequent fractures in this population, nor do we know yet if we can scale these systems up to the size needed for a large, open health care system, but our future studies will be examining these important aspects,” says Dr. Greenspan.
Greenspan SL, Singer A, Vujevich K, Marchand B, Thompson DA, Hsu Y-J, Vaidya D, Stern LS, Zeldow D, Lee DB, Karp S, Recker R. Implementing a Fracture Liaison Service Open Model of Care Utilizing a Cloud-Based Tool. Osteoporos Int. 2018; 29: 953-960.