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Prevention of osteoporotic refractures Outcomes of a fracture liaison service for osteoporosis in regional Australia Dr Emily Davidson Dr Alexa Seal Dr.

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Presentation on theme: "Prevention of osteoporotic refractures Outcomes of a fracture liaison service for osteoporosis in regional Australia Dr Emily Davidson Dr Alexa Seal Dr."— Presentation transcript:

1 Prevention of osteoporotic refractures Outcomes of a fracture liaison service for osteoporosis in regional Australia Dr Emily Davidson Dr Alexa Seal Dr Zelda Doyle A/Prof Kerin Fielding A/Prof Joseph McGirr The University of Notre Dame Australia, School of Medicine Sydney, Rural Clinical School

2 Introduction

3 Impact of osteoporosis 3.3% Australian population diagnosed (1) Mortality increases after a minimal trauma fracture (2) Clinical Guidelines (4) Bone mineral density scan and Bisphosphonates or equivalent after MTF

4 Impact of osteoporosis Care Gap (5-10) Poor adherence to guidelines BMD rates suboptimal Bisphosphonates low Poor communication Fracture Liaison Services (FLS) (11,12) Coordinated approach post MTF Established services effective

5 Aim To appraise the effectiveness of a pilot fracture liaison service at improving the management of osteoporosis in minimal trauma fracture patients in a regional NSW health district

6 Methods

7 Method Prospective cohort study Eligible patients identified from hospital records MTF presentations over an eight month period Fractures: femur, tibia and fibula, ankle, pelvis, humerus, wrist, pathological Age over 45yrs Exclusion: deceased, major trauma Recruitment Mail and phone

8 Method Intervention - Pilot fracture liaison service Study groups Control - MTF in the four months before pilot Cohort - MTF in the four months after pilot Adjusted Cohort - patients followed-up by pilot FLS Clinical Outcomes assessed Proportion of patients who received a BMD after MTF Proportion newly diagnosed with osteoporosis Proportion of patients initiated or reviewed with bisphosphonates

9 Results

10 Characteristics of eligible and recruited patients 267 eligible patients and 88 participants recruited 54% from control period 46% from cohort period Females accounted for majority of cases (72%) Mean age of patients was 74 years Femur fractures were the most common, followed by wrist fractures

11 Clinical outcomes BMD after fracture 36% of control versus 63% of adjusted cohort (p = 0.049) Diagnosis of osteoporosis after fracture 18% of control versus 47% of adjusted cohort (p = 0.017) Medications initiated or reviewed after fracture Total - 20% of control and 63% of adjusted cohort (p = 0.001) Bisphosphonates - 18% of control versus 47% adjusted cohort (p = 0.017)

12 Discussion

13 Pilot Fracture Liaison Service Significantly more likely To receive a BMD scan after MTF To be newly diagnosed with osteoporosis To be initiated on bisphosphonates/equivalent, or have their medications reviewed Difference comparable to the change detected by the Ganda meta-analysis for similar FLS models

14 Control/baseline rates Study detected BMD scanning rates of 38% Northern NSW regional Base Hospital baseline rates 22% (11) Metropolitan hospital baseline rates 20% (13) Meta-analysis for FLS control rates between 9 - 24% (14) Higher than expected baseline management rates compared to similar matched studies. Importance of using a control group when evaluating service interventions

15 Limitations Historical control Unethical to deny patients service Study time frame Eight month period ? Evaluated learning curve Pilot FLS contacted less than half of the patients within the cohort group ? Learning curve of the service or model design

16 Conclusion

17 Nurse run pilot fracture liaison service can significantly improve the management of osteoporosis in patients who have sustained a minimal trauma fracture Previous or future studies of FLS may over or underestimate effectiveness if using previous documented results as control Further evaluation of the FLS is required to assess the full effect of this service in this region. A more intensive model of care may be required to increase detection rates Conclusion

18 Thank you to the staff at Wagga Wagga Base Hospital and Medicare Local for their assistance in this research study An additional thank you goes to Ms Varina Walsh, the fracture liaison coordinator for this pilot study Acknowledgements

19 Questions

20 References 1. Australian Bureau of Statistics (ABS). Australian Health Survey: First Results. Australian Bureau of Statistics. 2012. 2. Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low- trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009 Feb 4; 301(5):513-21. 3. Australin Institute of Health and Welfare. Health expenditure for arthritis and musculoskeletal conditions, 2004-05. Canberra, AIHW. 2009. 4. The Royal Australian College of General Practitioners (RACGP). Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men.The Royal Australian College of General Practitioners; 2010. 5. Teede HJ, Jayasuriya IA, Gilfillan CP. Fracture prevention strategies in patients presenting to Australian hospitals with minimal-trauma fractures: a major treatment gap. Intern Med J. 2007 Oct; 37(10):674-9 6. Barrack C.M, McGirr E.E, Fuller J.D, Foster N.M, Ewald D.P. Secondary prevention of osteoporosis post minimal trauma fracture in an Australian regional and rural population. Australian Journal of Rural Health. 2009; 17(6):6. 7. Ewald DP, Eisman JA, Ewald BD, Winzenberg TM, Seibel MJ, Ebeling PR, et al. Population rates of bone densitometry use in Australia, 2001-2005, by sex and rural versus urban location. Med J Aust. 2009 Feb 2; 190(3):126-8. 8. Kelly AM, Clooney M, Kerr D, Ebeling PR. When continuity of care breaks down: a systems failure in identification of osteoporosis risk in older patients treated for minimal trauma fractures. Med J Aust. 2008 Apr 7; 188(7):389-91.

21 References 9. Chen JS, Hogan C, Lyubomirsky G, Sambrook PN. Management of osteoporosis in primary care in Australia. Osteoporos Int. 2009 Mar; 20(3):491-6. Ebeling PR. Osteoporosis: it's time to 'mind the gap'. Intern Med J. 2007 Oct; 37(10):672-3. 10. Gallacher SJ. Setting up an osteoporosis fracture liaison service: background and potential outcomes. Best Pract Res Clin Rheumatol. 2005 Dec; 19(6):1081-94. 11. Agency for Clinical Innovation (ACI). NSW Model of Care for Osteoporosis Refracture Prevention. Agency for Clinical Innovation: Musculoskeletal Network. Sydney, ACI. 2011. 12. Vaile J, Sullivan L, Bennett C, Bleasel J. First Fracture Project: addressing the osteoporosis care gap. Intern Med J. 2007 Oct; 37(10):717-20. 13. Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2012 Jul 25; DOI 10.1007/s00198-012-2090-y 14. Eisman JA, Bogoch ER, Dell R, Harrington JT, McKinney RE, Jr., McLellan A, et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012 Oct; 27(10):2039-46.

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