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

Introduction

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

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

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

Methods

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

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

Results

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

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)

Discussion

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 et.al meta-analysis for similar FLS models

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 % (14) Higher than expected baseline management rates compared to similar matched studies. Importance of using a control group when evaluating service interventions

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

Conclusion

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

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

Questions

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