Making the First Fracture the Last Fracture: ASBMR Task Force Report on Secondary Fracture Prevention for the ASBMR Task Force on Secondary Fracture Prevention

Abstract

Fragility fractures are common, affecting almost one in two older women and one in three older men. Every fragility fracture signals increased risk of future fractures as well as risk of premature mortality. Despite the major health care impact worldwide, currently there are few systems in place to identify and ''capture'' individuals after a fragility fracture to ensure appropriate assessment and treatment (according to national guidelines) to reduce future fracture risk and adverse health outcomes. The Task Force reviewed the current evidence about different systematic interventional approaches, their logical background, as well as the medical and ethical rationale. This included reviewing the evidence supporting cost-effective interventions and developing a toolkit for reducing secondary fracture incidence. This report presents this evidence for cost-effective interventions versus the human and health care costs associated with the failure to address further fractures. In particular, it summarizes the evidence for various forms of Fracture Liaison Service as the most effective intervention for secondary fracture prevention. It also summarizes the evidence that certain interventions, particularly those based on patient and/or community-focused educational approaches, are consistently, if unexpectedly, ineffective. As an international group, representing 36 countries throughout Asia-Pacific, South America, Europe, and North America, the Task Force reviewed and summarized the international data on barriers encountered in implementing risk-reduction strategies. It presents the ethical imperatives for providing quality of care in osteoporosis management. As part of an implementation strategy, it describes both the quality improvement methods best suited to transforming care and the research questions that remain outstanding. The overarching outcome of the Task Force's work has been the provision of a rational background and the scientific evidence underpinning secondary fracture prevention and stresses the utility of one form or another of a Fracture Liaison Service in achieving those quality outcomes worldwide. ß 2012 American Society for Bone and Mineral Research.

Full text

Page 1

Making the First Fracture the Last Fracture:
ASBMR Task Force Report on Secondary
Fracture Prevention
John A Eisman,1Earl R Bogoch,2Rick Dell,3J Timothy Harrington,4Ross E McKinney Jr.,5
Alastair McLellan,6Paul J Mitchell,7Stuart Silverman,8Rick Singleton,9and
Ethel Siris10for the ASBMR Task Force on Secondary Fracture Prevention
1Clinical Translation and Advanced Education, Garvan Institute of Medical Research; University of New South Wales; St Vincent’s
Hospital; and School of Medicine Sydney, University of Notre Dame, Sydney, NSW, Australia
2Mobility Program Clinical Research Unit, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital; and Division
of Orthopaedics, Department of Surgery, University of Toronto, Toronto, Canada
3Orthopedics, Kaiser Permanente Southern California, Downey, CA, USA
4Professor of Medicine (retired), University of Wisconsin School of Medicine and Public Health; Joiner Associates LLC, Madison, WI, USA
5Duke University School of Medicine, Durham, NC, USA
6Endocrinology, Western Infirmary, Glasgow, Scotland
7University of Derby, Derby, United Kingdom
8Rheumatology, Cedars-Sinai Medical Center, UCLA, Los Angeles, CA, USA
9Pastoral Care and Ethics, Health Sciences Centre, St. John’s, NL, Canada
10Columbia University Medical Center, New York, NY, USA
ABSTRACT
Fragility fractures are common, affecting almost one in two older women and one in three older men. Every fragility fracture signals
increased risk of future fractures as well as risk of premature mortality. Despite the major health care impact worldwide, currently there
are few systems in place to identify and ‘‘capture’’ individuals after a fragility fracture to ensure appropriate assessment and treatment
(according to national guidelines) to reduce future fracture risk and adverse health outcomes. The Task Force reviewed the current
evidenceaboutdifferentsystematicinterventionalapproaches,theirlogicalbackground,aswellasthemedicalandethicalrationale.This
included reviewing the evidence supporting cost-effective interventions and developing a toolkit for reducing secondary fracture
incidence. This report presents this evidence for cost-effective interventions versus the human and health care costs associated with the
failure to address further fractures. In particular, it summarizes the evidence for various forms of Fracture Liaison Service as the most
effective intervention for secondary fracture prevention. It also summarizes the evidence that certain interventions, particularly those
based on patient and/or community-focused educational approaches, are consistently, if unexpectedly, ineffective. As an international
group, representing 36 countries throughout Asia-Pacific, South America, Europe, and North America, the Task Force reviewed and
summarized the international data on barriers encountered in implementing risk-reduction strategies. It presents the ethical imperatives
for providing quality of care in osteoporosis management. As part of an implementation strategy, it describes both the quality
improvement methods best suited to transforming care and the research questions that remain outstanding. The overarching outcome
of the Task Force’s work has been the provision of a rational background and the scientific evidence underpinning secondary fracture
prevention and stresses the utility of one form or another of a Fracture Liaison Service in achieving those quality outcomes worldwide.
? 2012 American Society for Bone and Mineral Research.
KEY WORDS: FRACTURE PREVENTION; FRACTURE LIAISON SERVICES; MODELS OF CARE; BARRIERS TO CARE; IMPLEMENTATION RESEARCH
Introduction
T
he purpose of this report is to provide a logical background,
medical and ethical rationale, and toolkit for reducing
secondary fracture incidence, particularly hip fractures, and
health care costs. It presents the evidence for cost-effective
interventions to prevent further fractures in those who suffer
fragility fractures. In particular, it summarizes the evidence for
PERSPECTIVE
J JBMR BMR
Received in original form April 3, 2012; revised form June 11, 2012; accepted June 22, 2012. Published online July, 2012.
Address correspondence to: John A Eisman, MBBS, PhD, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, NSW 2010 Australia.
E-mail: j.eisman@garvan.org.au
Additional Supporting Information may be found in the online version of this article.
Journal of Bone and Mineral Research, Vol. 27, No. 9, September 2012, pp 1–8
DOI: 10.1002/jbmr.1698
? 2012 American Society for Bone and Mineral Research
1

Page 2

effective interventions for secondary fracture prevention, and
against those that have been shown to be (unexpectedly)
ineffective. It also reviews the international data on barriers that
have been encountered in implementing these strategies. It
discusses the ethical imperatives for providing osteoporosis
management, and describes both the quality improvement
methods best suited to transforming care and the research
questions that remain outstanding.
The First Target Is to Reduce Hip Fracture
Incidence by 20% by 2020
Hip fractures have the greatest impact, carry the greatest
morbidity and mortality, and are the most costly.(1)Patients who
have sustained a hip fracture are the group at highest risk for
further fracture and should be prioritized for assessment for
initiation of treatment to prevent secondary fractures.(2–4)
Contrary to common assumptions, hip fracture patients can
benefit greatly from treatment.(5,6)
secondary fractures should be offered to all men and women
over age 50 years with any fragility fractures, because all fragility
fractures such as wrist fractures are often ‘‘sentinel’’ fractures(7–10)
that may precede a hip fracture in the cycle in which fracture
leads to fracture.(11–14)Non-hip fractures account for about 80%
of the clinical fracture burden presenting to any hospital,
anywhere in the world(15–17)—a burden affecting younger
patients that is also typically neglected as an opportunity for
assessment and treatment focused on prevention of secondary
fractures.(18,19)In addition, the total morbidity burden of non-hip
fractures is actually greater, because such fractures are relatively
common and occur in a larger, younger population, and thus
represent a greater burden of potential life-years lost.(20,21)Any
andallfragilityfracturesshouldbeinvestigatedaslowtrauma;ie,
if the fracture would not have been expected if the same event
had happened in a healthy young person.
The daunting burden of fragility fractures expressed in excess
morbidity, mortality, and costs is not inevitable. The challenge
is to identify the individuals at high risk and apply the
demonstrated effective interventions for the purpose of
reducing their risk of future fractures, especially hip fractures.
We describe the positive impacts of Fracture Liaison Services
(FLS)(15,22–26)inlocaland regionalhealth systems and discourage
reliance on other approaches, notably educational strategies,
that have been reproducibly ineffective. In particular, high-
functioning FLS that aggressively identify and manage patients
after a fracture have been successful in raising the unacceptably
low current postfracture assessment/treatment rate of 20%(9,18)
into the acceptable 80% to 90% range. These have been
evaluatedandshown tobe effectiveinvariousjurisdictions.(15,22–29)
This report adds to the growing international calls for
improvements in care using coordinator-based systems(24)but
adds the international dimension, in addition to European and
North American perspectives. This has been achieved through
65 key opinion leaders from 36 countries, in almost all major
international jurisdictions, providing their wide range of views
and experience on the barriers to implementation. This is
particularly important, given that the majority of the global
Initiatives to prevent
burden of disease during the next four decades is projected to
arise in Asia and South America. The contributions of Task Force
members from Asia and Latin America support the generaliz-
ability and adaptability of the system-based approach on a truly
global scale. This new and extensive set of information has not
been documented before and, distinct from the International
Osteoporosis Foundation’s advocacy,(24)provides the ‘‘toolkit’’
resource to support implementation of change. A serious barrier
to establishment of an effective FLS is not knowing how to make
a business case to secure its funding. The full document
(including Supporting Appendix A) provides support to clinical
champions throughout the world to make this case successfully.
The full-length toolkit provides much detail needed to draft
successful business plans at the same time as providing the
background information that underpins recognizing and
categorizing the specific challenges in individual jurisdictions.
This is truly a tool for clinical translation and improved health
care implementation.
Ethical Dimensions of Secondary Fracture
Prevention
Patients deserve optimal management of their health care, but
the fragmentation of many health care services inevitably
impedes the ideal. In the case of secondary fracture prevention,
the older patient typically presents with the first fracture to an
emergency department or an orthopedic surgeon. Those care
providers have the skill set to provide acute medical manage-
ment and repair broken bones. However, there is an additional
dimension: the knowledge that a fracture has occurred in
someone at risk for low bone mass identifies this person to be
at increased risk for future fracture. There is the highest level
of evidence that osteoporosis can be medically managed to
decrease the probability of future fractures.(30)The data clearly
demonstrate that:
?
ahighproportionofsecondaryfracturescanbepreventedby
appropriate management(5,31–37);
an initial fracture in an at-risk person is sufficient grounds to
require a full evaluation, including bone mineral density
(BMD) measurement and fracture risk assessment, and,
unless contraindicated, initiation of treatment for any
underlying bone fragility.(7–14)
?
Long-term management of this chronic illness is ill-suited to
the immediate care skill sets of most emergency physicians and
orthopedists. The underlying bone fragility and multifactorial
increased fracture risk may be managed subsequently by
endocrinologists, rheumatologists, geriatricians, internists and
other primary care practitioners, physiatrists (rehabilitation
physicians), and physical and occupational therapists, usually
in collaboration. These providers have the training and together
have the opportunity and the patient contact necessary to
provide chronic care for a problem that is inadequately
addressed by any acute care provider in isolation. The
systems-level problem is that too often the acute care providers
have neither formal linkages nor established referral patterns to
2
EISMAN ET AL.
Journal of Bone and Mineral Research

Page 3

the
providers.(38)
The data are sufficiently compelling to characterize an
appropriate referral as an obligation to do the right thing,
providing a pathway to the best outcome. This referral must
encompass a full evaluation and formal decision for appropriate
therapy unless the clinical situation requires otherwise. To do
any less certainly falls short of acceptable clinical and ethical
standards. The argument of ‘‘first do no harm’’ has been misused
in this context to justify allowing this known risk to go without
intervention, assessment, or adequate follow-up to reduce the
likelihood of further complications or adverse outcomes. It might
be argued that, in many cases, neither the orthopedist nor
the emergency physician is the ideal person to initiate such
investigation and treatment, but that does not absolve them
of the responsibility to ensure that the patient or family are
fully aware of the risk and to effectively arrange appropriate
evaluation and follow-up. Given the two sets of data above,
all three categories of care providers—the acute care clinicians
managing the index fracture, the care providers evaluating and
managing osteoporosis, and the health care system that ought
to assure excellence in patient record management and systems
of referral—should accept their medical and ethical obligations
in this important and treatable condition. We have the evidence,
the professionals have the knowledge, but neither the individual
clinicians nor the systems are doing enough of what needs to be
done to protect at-risk people from further risk. Although
responsibilityforthisharmbyomissionisvague,itisnonetheless
real.Consideringtheimpactofsecondaryfracturesonthequality
oflifefortheolderwomanormancompelsustoponderthedual
obligations to do the right things and to do things right.
At a systems level, when a patient presents with a fracture
to the emergency room or to an orthopedist, there should be
a care pathway in place to ensure that clinicians evaluate for
osteoporosis, future fracture risk, and for the need for treatment
for prevention of secondary fractures. In different settings this
pathwaymaybeaffectedbyprimaryorsecondarycareclinicians.
It is distinct from the management of cognitive, affective, and
physical functional deficits to optimize recovery. Similarly, if and
whenever the patient presents to a primary care physician with
a history of fracture, the same appropriate evaluation should
automatically be triggered.
patients’osteoporosisandchronic,long-termcare
Major Barriers to Optimal Fracture
Prevention in Fracture Patients
Secondary fracture prevention management is assigned a low
priority by primary care physicians, specialists, health adminis-
trators, policy makers, and the general public as a result of a lack
of awareness of the gravity of this condition and thus a lack of
interest. Osteoporosis is still dismissed as a problem linked to
aging, rather than an opportunity for treatment to diminish
the incidence of future fractures. This translates currently
to inadequate commitment to and financing of necessary
investigations and treatments. Despite comparable heath
impacts to osteoporosis, other noncommunicable diseases,
suchasdiabetesandcardiovasculardisease,enjoyhigherpriority
in governmental programs. Prevention campaigns at the
national level and effective treatment for all people with a high
risk of fractures have lagged behind other conditions.
Better management is severely limited by lack of funding for
dedicated FLS personnel to identify patients and follow-up on
treatment. In our commonly fragmented systems there is no
salary support for such initiatives, causing patients to be
discharged without follow-up. In many jurisdictions internation-
ally, there is also limited funding for risk assessment and, more
importantly, for long-term pharmaceutical management. Doc-
tors are occupied with, and preoccupied by, primary fracture
treatment, and do not dependably make these arrangements.
Supporting Appendix B summarizes the barriers identified in a
poll of the international members of the Task Force.
Reducing Duplication of Improvement
Efforts
There are several initiatives sponsored by the U.S. National
Osteoporosis Foundation,(39)the International Osteoporosis
Foundation,(40)and national osteoporosis patient societies,(41–44)
including the ‘‘Capture the Fracture’’ campaign, the U.S. National
Bone Health Alliance,(39)American Society for Bone and Mineral
Research,(45)Arbeitsgemeinschaft fu ¨r Osteosynthesefragen (AO)
Foundation,(46)International Society for Fracture Repair,(47)
World Health Organization,(48)American Academy of Orthopedic
Surgeons,(49)American Orthopedic Association,(50)European
Federation of National Associations of Orthopaedics and
Traumatology (EFORT), the Bone and Joint Decade,(51)Fragility
Fracture Network,(52)and other groups related to osteoporosis
prevention, treatment of fragility fractures, secondary preven-
tion, and relevant research and education. Our Task Force
suggests that a cooperative approach, and even national central
clearinghouses for secondary fracture prevention initiatives,
could align and streamline these efforts to prevent waste and
duplication, enhance progress, and create solutions.
Key Elements for Success/Initiatives
That Work
A number of key elements shared by the growing number of
successful and sustained initiatives, that have been published,
are:
?
Integrated systems with cost-saving incentives to pursue
secondary prevention of fragility fractures.
Reimbursementfor‘‘doingtherightthing’’topreventsecond
fractures, along with penalties for not doing so.
Increased awareness of professionals and patients, particu-
larly through respected patient organizations that are
independent of industry and can address some of the issues
of primary prevention.
Commitment of the orthopedic community to improved
medical care for fragility fracture patients through a
multidisciplinary advisory board and educational materials.
Implementation of an FLS for the medical management of
low-trauma fractures carried out by a nurse coordinator or
other dedicated personnel working in fracture clinics and on
?
?
?
?
Journal of Bone and Mineral Research
MAKING THE FIRST FRACTURE THE LAST FRACTURE
3

Page 4

orthopedic/trauma wards. Their task is to take responsibility
for identifying fragility fracture patients, educate them,
perform risk assessments, determine indications for treat-
ment according to national guidelines, communicate with
the treating physicians to ensure appropriate therapy,
facilitate communication between the specialists and the
primary care physician, follow up with patients to ensure
persistence on care, and gather data to follow the success of
the program.
Recognition of the consequences of hip fracture; ie, medical
complications, loss of capacity in activities of daily living, and
osteoporosis treatment, by small groups in private hospitals
or clinics, sometimes geriatrics clinics, with some participa-
tion from orthopedists who are beginning to refer hip
fracture patients to geriatricians.
Improved government awareness and influence, including
the lobbying of decision makers by local champions. More
active involvement in this lobbying activity by national
osteoporosis societies is important and effective. Lobbying
by the International Osteoporosis Foundation is also helpful.
Initiatives on a state/national/political level connect to
administrative and political key stakeholders.
Formulating nationwide guidelines endorsed by key medical
specialties and patient organizations.
Country-specific comprehensive program guides (‘‘Blue
Books’’) on fragility fractures as an awareness tool for health
authorities and health professionals.
Implementation registry; eg, national hip fracture registries.
Wide availability of management algorithms, nurse co-
ordination of care, and task management disease registry
software.
?
?
?
?
?
?
?
It is important to consider what has been shown to work
reliably inanumberofenvironments.Theconsistently successful
approach is an FLS. These have reduced subsequent fractures in
several countries by integrating fracture care with secondary
fracture prevention through management of low bone mass and
fracture risk. This approach has been adopted recently as
national policy in the UK National Health Service.(53)It has been
adopted in some integrated Health Maintenance Organizations
in the United States,(54,55)in a government-funded province-
wide project in Ontario, Canada,(56)and in some centers in
Australia(27)with similar reach and effectiveness. The successful
FLS programs described in this document and in peer-reviewed
publications by those who championed them have shown that
reducing fracture events is achievable, and that it depends
primarily on redesigning delivery of care to coordinate
management across the inpatient-outpatient interface and
across provider specialties and over time.
The FLS requires the participation and cooperation of both
the orthopedic service that treats the fracture and the clinical
services (eg, primary care, gerontology, endocrinology or
rheumatology, physiotherapy, rehabilitation) that then actively
manage the postfracture patient to reduce the risk of a next
fracture. The FLS coordinator is often but not necessarily a nurse
who engages with the patient shortly after the fracture occurs
andensuresthatsecondarycausesforfractureareassessed,BMD
testing is performed as appropriate, and fracture risk assessment
performed utilizing a validated tool. Critically, the FLS coordina-
tor ensures that antifracture medication is prescribed (where
indicated), together with calcium and vitamin D supplementa-
tion (as needed), and provides follow-up to maximize treatment
adherence. This individual may provide some or all of this
medical care, or may primarily be the connection to the medical
practitioner noted above who reviews the laboratory and BMD
testing results and prescribes pharmacologic therapy. A major
barrier to creation of an effective FLS in most environments is
obtaining long-term and stable funding for the services of the
FLS coordinator.
The deployment of FLS programs has a dual benefit. They
reduce the numbers of subsequent fractures, including the more
expensive hip fractures, and reduce health care costs.(23,27,28)
There is growing evidence that effective therapy also translates
to reductions in premature mortality.(6,57)There is sufficient
evidence that broad deployment of FLS strategies would reduce
the incidence of hip fractures by 20% or more over several years.
Reaching Consensus to Create an FLS
As noted above, too often health care providers and system
administrators operate within local health systems that are
failing to provide the necessary care for prevention of secondary
fractures in fracture patients. Fragmented, highly variable care,
and missed preventive opportunities are the rule. Health
financing systems and government health policies commonly
also fail to support the development of FLS programs. In
particular,amajorbarriertocreationofaneffectiveFLSinseveral
environments is the will to ‘‘find’’ and allocate funding for the
services of the FLS coordinator. As a result, the numbers and
costs of avoidable fractures escalate, as the aging population
grows larger.
Providers and administrators within local health systems need
to address five fundamental questions to forge the consensus
required to create an FLS:
1. What do we need to do? Providethe care that is published in
allclinical practiceguidelines forallfragilityfracture patients.
How should we do it? Build an FLS program using the
approaches described by the champions as described in this
document and in their original publications.
Who should do what? Bring all the local stakeholders
together—at least orthopedic surgeons, primary physicians,
and osteoporosis consultants—within an integrated system
of care and reach agreement on what roles each will fulfill to
improvecareasateamandnotindividually.Theanswerswill
vary based on provider resources, patterns of care, and the
financial environment. Those dedicated to improvement
must persist and prevail when predictable objections arise.
How should we measure performance and recognize
success? A fracture population must be defined, registered,
and tracked to provide, document, and continuously
improve care. The incidence of new fractures must be
monitored in both this registered population and for all
new fragility fractures at the system level. A retrospective
assessment of secondary fracture prevention care provided
to the prior year’s fracture population would serve as a
2.
3.
4.
4
EISMAN ET AL.
Journal of Bone and Mineral Research

Page 5

baseline and as a motivating comparator, a ‘‘wake-up call’’
for change.
What are the costs of care, how should they be paid, and by
whom?These answers willvaryfrom onelocalsystemandits
financial arrangements to the next, but a key starting point is
to ask and answer: ‘‘Who will pay for the care coordinators
that are essential for educating patients and integrating care
across the system?’’
5.
Framework and Toolkit
Changing health systems to provide more effective care for
secondary fracture prevention in fracture patients is neither easy
nor straightforward, but improvement is possible, and the need
iscompelling. Each FLS has had champions who actively monitor
the program’s performance and actively determine what is
working and what is not working to achieve their process and
outcome goals. The goal ofthis Task Force is toactively assist FLS
programs already implemented or about to be implemented to
achieve their process and outcomes measures. This can be
facilitated by an international network of FLS care managers and
champions who will freely share best practices, FLS toolkits,
and their experience in problem solving issues that inevitably
arise with any FLS during either the implementation or the
optimization phases. The Kaiser Healthy Bones Team has already
greatly benefited from the free sharing of ideas and toolkits from
other FLS care managers and champions. We need to expand on
this FLS Network so we all benefit from each other’s expertise.
The goal of this Task Force report is to provide a logical
framework, rationale, and tool kit to reduce fracture incidence
and health care costs, with the first target to reduce hip fracture
incidence by 20% by 2020. These items are presented in
the online part of this document, which contains sections on
the following:
I. Current evidence on the health, social and financial impact of
osteoporotic fractures and the failure to capture individuals
postfracture for evaluation for intervention:
?
?
?
is a costly missed opportunity for patients, payers and
politicians.
The fragility fracture cycle;
Fracture epidemiology and health care costs;
Failure to reliably deliver secondary fracture prevention
II. The international osteoporosis community’s experience of
systems approaches in different health care delivery systems
and identification of the common denominators and barriers
for successful programs are reviewed:
?
reporting.
?
?
focusing pharmacological interventions on those at
high risk.
?
?
one develop systems in countries lacking primary care
infrastructure?
Outcome assessment and the need for standards of
Risk assessment tools.
Targets for pharmacological treatment thresholds and
International variation in pathways of care.
Barriers to secondary fracture prevention—how does
?
Reviews of the literature on secondary fracture preven-
tion interventions—descriptive categories of interven-
tions, and characteristics of effective programs that take
an ‘‘active’’ and systematic approach to assessment and
initiation of treatment as required.
The role of education—these ‘‘passive’’ approaches have
perhaps surprisingly but consistently not translated to
improvements in care worldwide.
?
III.A successful systems-based approach to secondary fracture
prevention:
?
and intervention.
?
?
?
with dual-energy X-ray absorptiometry (DXA), vertebral
fracture risk assessment, and investigations for second-
ary causes of low bone mass.
?
vitamin D supplementation, education, falls prevention.
?
postfracture secondary prevention: Glasgow Fracture
Liaison Service; Toronto St. Michael’s Hospital Osteopo-
rosis Exemplary Care Program; Ontario Osteoporosis
Strategy Fracture Clinic Screening Program; and Kaiser
Permanente Healthy Bones Project.
?
and cost savings, and quality of care.
?
stakeholders, the principles of a SIMPLE (Simple in
design; Inexpensive to start; Measurable outcomes; Pays
for itself; Lasts over time; Evolves with time) delivery
system methodology, and active use of the Plan-Do-
Study-Act (PDSA) model to aggressively improve their
process goals.
?
the FLS.
Key steps in the pathway—identification, investigation,
Determining the scope of service provision.
Identification of patients with fractures.
Postfracture investigation, including risk assessment
Interventions—pharmaceutical treatment, calcium and
Successful models of systems-based approaches to
The FLS—what it can achieve, proven cost-effectiveness
FLS design and implementation—identification of
Factors that contribute to successful outcomes from
IV. Development of a unified approach to osteoporosis health
care delivery that will have positive impact on secondary
fracture preventive care for fragility fracture patients. This
approach considers all perspectives, including the ‘‘5 Ps’’:
Patients, Physicians, Politicians, Pharmaceutical companies,
and third-party Payers. To achieve general buy-in and
support of local champions, the following are considered:
?
?
?
Canada, United States, and Australia;
?
of a national consensus on systematic approaches to
secondary fracture prevention.
Prioritization of activity;
Development of national consensus;
Examples of unified approaches in the United Kingdom,
Key steps in the development and implementation
Conclusion
Fragility fractures, including hip fractures, are a major health care
problem worldwide. They affect men as well as women. Their
Journal of Bone and Mineral Research
MAKING THE FIRST FRACTURE THE LAST FRACTURE
5

Page 6

clinical impact is predominantly in those over the age of 50 years
and is not confined to the geriatric population in their 80s
and beyond. In the current clinical environment of care for the
fracture events, providers often neglect the patient’s risk for
future fractures, and they need to address this risk. Amelioration
of this situation will require a concerted worldwide effort, locally,
nationally and internationally.
Recommendation for osteoporosis evaluation provided by an
orthopedic surgeon after their management of a fracture, and
the patient’s awareness that fractures lead to further fractures
and that treatments are available that can prevent this from
happening,wouldhelpbutarenotsufficient.Theoccurrenceofa
fragility fracture needs to be linked automatically with provision
of postfracture assessment for osteoporosis, future fracture risk,
andneedfortreatmenttopreventsecondaryfractures.However,
successful secondary prevention measures depend not only on
investigation and initiation of treatment, but on maintenance of
treatment—adherence and compliance, which pose additional
challenges.
In every environment reported, an FLS is the most effective,
perhaps the only effective, tool for such change. This approach
creates a continuum of care that overcomes the gaps in
postfracture investigation and intervention and the unnecessar-
ily high incidence of subsequent fractures. Implementing such
services is required at the site of fracture treatment to link
the incident fracture with management of secondary fracture
prevention, and to enhance patients’ adherence to treatment
over time. An international survey has found similar barriers
around the world (Supporting Appendix B), and that FLS
strategies are effective wherever they have been tried.
A variety of implementation challenges and research issues
lie ahead. These begin with health systems adopting continuous
improvement methods, eg, PDSA, to monitor and transform
delivery in different environments, and sharing their experi-
ences. Longer-term cost-effectiveness studies are also needed to
quantify the ‘‘real world’’ cost savings achievable through more
efficient preventive strategies in those populations demonstrat-
ed to be at highest risk.
The continuing thrust of this Task Force is to provide the
rational background information and science as well as the tools
that will facilitate implementation of effective FLSs worldwide.
Disclosures
See Supporting Appendix C.
The American Society for Bone and Mineral Research (ASBMR)
is well served by the fact that many of those responsible for
policy development and implementation have diverse interests
and are involved in a variety of activities outside the society. The
ASBMR protects itself and its reputation by ensuring impartial
decision making. Accordingly, the ASBMR requires that all
ASBMR officers, councilors, committee chairs, editors-in-chief,
associate editors, and certain other appointed representatives
disclose any real or apparent conflicts of interest (including
investments or positions in companies involved in the bone and
mineral metabolism field), as well as any duality of interests
(including affiliations, organizational interests, and/or positions
held in entities relevant to the bone and mineral metabolism
field and/or the American Society for Bone and Mineral
Research).
Acknowledgments
As co-chairs of the Task Force, John Eisman and Ethel Siris
particularly acknowledge Earl Bogoch, Paul Mitchell, Rick Dell,
Alastair McLellan, Tim Harrington, and Stuart Silverman, as well
as Ross McKinney and Rick Singleton, for their major and many
contributions to this Report. We thank the international mem-
bers of the Task Force for their major insights into and contribu-
tions about local jurisdictional issues. We all thank the ASBMR
management team, particularly Douglas Fesler and Earline Mar-
shall, for their untiring efforts in effectively and efficiently sup-
porting the work of the Task Force. The Task Force also thanks
Dagmar Gross of MedSci Communications & Consulting Co. for
assistance with the preparation of this manuscript.
ASBMR Task Force on Osteoporotic Fracture Secondary Pre-
vention: John A.Eisman (Co-Chair), Ethel S Siris (Co-Chair), Robert
Adler (Virginia, USA), Kristina Akesson (Malmo, Sweden), Michael
Amling (Hamburg, Germany), Sanford Baim (Colorado, USA),
Suthorn Bavonratanavech (Bangkok, Thailand), Maria Luisa
Bianchi (Milan, Italy), John Bilezikian (New York, USA), Nicolaas
CBudhiparama(Jakarta, Indonesia),JacquelineRCenter(Sydney,
Australia), Thierry Chevalley (Geneva, Switzerland), Patricia Clark
(Mexico City, Mexico), Cyrus Cooper (Southampton, United King-
dom), Adolfo Diez-Perez (Barcelona, Spain), Beatrice J Edwards
(Illinois, USA), A Joseph Foldes (Jerusalem, Israel), Ghada El-Hajj
Fuleihan (Beirut, Lebanon), Piet Geusens (Diepenbeek, Belgium),
Yong-Chan Ha, Seoul (South Korea), Hiroshi Hagino (Yonago,
Japan), Phuoc Hung Do (Ho Chi Minh City, Vietnam), Mark L
Johnson (Missouri, USA), Annie WC Kung (Hong Kong, China),
Bente L Langdahl (Aarhus, Denmark), Edith Lau (Hong Kong,
China), Anh Thu Le (Ho Chi Minh City, Vietnam), Meryl S LeBoff
(Massachusetts, USA), Joon Kiong Lee (Selangor, Malaysia),
Willem F Lems (Amsterdam, The Netherlands), Xu Ling (Beijing,
China), Adriana Braga de Castro Machado (Sao Paulo, Brazil), Jay
Magaziner (Maryland, USA), Rajesh Malhotra (New Delhi, India),
David Marsh (Stanmore, United Kingdom), Basel Masri (Amman,
Jordan), Mario Rui G Mascarenhas (Lisboa, Portugal), Haakon E
Meyer (Oslo, Norway), Ambrish Mittal (New Delhi, India), Kyoung
Ho Moon (Incheon, South Korea), Seong-Hwan Moon (Seoul,
South Korea), Eric D Newman (Pennsylvania, USA), Peijian Tong
(Hangzhou, China), Robert R Recker (Nebraska, USA), Jose ´ Adolfo
Rodrı ´guez Portales (Santiago, Chile), Kenneth G Saag (Alabama,
USA), Markus J Seibel (Sydney, Australia), Steven R Schelkun
(California, USA), Daniel H Solomon (Massachusetts, USA), Jan
J Stepan (Prague, Czech Republic), Bernardo Stolnicki (Rio de
Janeiro, Brazil), BB Wang (Liaoning Province, China), Ye-Yeon
Won (Suwon, South Korea), Marie-Christine De Vernejoul
(Paris, France), Kyu Hyun Yang (Seoul, South Korea), Ding Yue
(Guangzhou, China), Hyun-Koo Yoon (Seoul, South Korea).
References
1. British Orthopaedic Association, British Geriatrics Society. The care of
patients with fragility fracture 2nd ed. [Internet].: London: British
6
EISMAN ET AL.
Journal of Bone and Mineral Research

Page 7

Orthopaedic Association; Sep [cited 2012 Jul 9]. Available from:
http://www.fractures.com/pdf/BOA-BGS-Blue-Book.pdf. 2007.
2. Lonnroos E, Kautiainen H, Karppi P, Hartikainen S, Kiviranta I, Sulkava
R. Incidence of second hip fractures. A population-based study.
Osteoporos Int. 2007;18(9):1279–85.
3. Nymark T, Lauritsen JM, Ovesen O, Rock ND, Jeune B. Short time-
frame from first to second hip fracture in the Funen County Hip
Fracture Study. Osteoporos Int. 2006;17(9):1353–7.
4. Lawrence TM, Wenn R, Boulton CT, Moran CG. Age-specific incidence
of first and second fractures of the hip. J Bone Joint Surg Br.
2010;92(2):258–61.
5. Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman
F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H,
Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D,
Eriksen EF. Cummings SR; HORIZON Pivotal Fracture Trial. Once-
yearly zoledronic acid for treatment of postmenopausal osteoporo-
sis. N Engl J Med. 2007;356(18):1809–22.
6. Lyles KW, Colon-Emeric CS, Magaziner JS, Adachi JD, Pieper CF,
Mautalen C, Hyldstrup L, Recknor C, Nordsletten L, Moore KA,
Lavecchia C, Zhang J, Mesenbrink P, Hodgson PK, Abrams K, Orloff
JJ, Horowitz Z, Eriksen EF, Boonen S. HORIZON Pivotal Fracture Trial.
Zoledronic acid and clinical fracture and mortality after hip fracture.
N Engl J Med. 2007;357(18):1799–809.
7. Gallagher JC, Melton LJ, Riggs BL, Bergstrath E. Epidemiology of
fractures of the proximal femur in Rochester, Minnesota. Clin Orthop
Relat Res. 1980 Jul-Aug; (150): 163–71.
8. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eisman J. Osteo-
porotic fracture: missed opportunity for intervention. Osteoporos Int.
2003;14(9):780–4.
9. McLellan A, Reid D, Forbes K, Reid R, Campbell C, Gregori A, Raby N,
Simpson A. Effectiveness of strategies for the secondary prevention
of osteoporotic fractures in Scotland (CEPS 99/03) [Internet]. Glas-
gow,Scotland:NHSQualityImprovementScotland;[cited2012Jul9].
Available from: http://www.healthcareimprovementscotland.org/
previous_resources/audit_report/osteoporotic_fractures_audit.aspx.
2004.
10. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior
fractures are common in patients with subsequent hip fractures. Clin
Orthop Relat Res. 2007;461:226–30.
11. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M.
Patientswithpriorfractureshaveanincreasedrisk offuturefractures:
asummaryoftheliteratureandstatisticalsynthesis.JBoneMinerRes.
2000;15(4):721–39.
12. Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P,
EismanJ, FujiwaraS, GarneroP, KrogerH,McCloskeyEV,MellstromD,
Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A. A meta-analysis
of previous fracture and subsequent fracture risk. Bone. 2004;
35(2):375–82.
13. Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C,
De Laet C, Jonsson B. Fracture risk following an osteoporotic fracture.
Osteoporos Int. 2004;15(3):175–9.
14. Center JR, Bliuc D, Nguyen TV, Eisman JA. Risk of subsequent fracture
after low-trauma fracture in men and women. JAMA. 2007;297(4):
387–94.
15. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison
service: success of a program for the evaluation and management
of patients with osteoporotic fracture. Osteoporos Int. 2003;14(12):
1028–34.
16. Johnell O, Kanis JA. An estimate of the worldwide prevalence
and disability associated with osteoporotic fractures. Osteoporos
Int. 2006;17(12):1726–33.
17. OfficeoftheSurgeonGeneral.Bonehealthandosteoporosis:areport
of the Surgeon General [Internet]. Washington, DC: U.S. Department
of Health and Human Services; [cited 2012 Jul 9]. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK45513/.
18. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in
the diagnosis and treatment of osteoporosis after a fragility fracture:
a systematic review. Osteoporos Int. 2004;15(10):767–8.
19. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD.
Fragility fractures and the osteoporosis care gap: an international
phenomenon. Semin Arthritis Rheum. 2006;35(5):293–305.
20. Shi N, Foley K, Lenhart G, Badamgarav E. Direct healthcare costs of
hip, vertebral, and non-hip, non-vertebral fractures. Bone. 2009;
45(6):1084–90.
21. Song X, Shi N, Badamgarav E, Kallich J, Varker H, Lenhart G, Curtis JR.
Cost burden of second fracture in the US Health System. Bone.
2011;48(4):828–36.
22. Dell R, Greene D, Schelkun SR, Williams K. Osteoporosis disease
management: the role of the orthopaedic surgeon. J Bone Joint
Surg Am. 2008; 90 (Suppl 4):188–94.
23. Sander B, Elliot-Gibson V, Beaton DE, Bogoch ER, Maetzel A.
A coordinator program in post-fracture osteoporosis management
improves outcomes and saves costs. J Bone Joint Surg Am. 2008;
90(6):1197–205.
24. Marsh D, Akesson K, Beaton DE, Bogoch ER, Boonen S, Brandi ML,
McLellan AR, Mitchell PJ, Sale JE, Wahl DA. IOF CSA Fracture Working
Group. Coordinator-based systems for secondary prevention in
fragility fracture patients. Osteoporos Int. 2011;22(7):2051–65.
25. Harrington JT, Barash HL, Day S, Lease J. Redesigning the care of
fragility fracture patients to improve osteoporosis management:
a health care improvement project. Arthritis Rheum. 2005;53(2):
198–204.
26. Sale JE, Beaton D, Posen J, Elliot-Gibson V, Bogoch E. Systematic
review on interventions to improve osteoporosis investigation and
treatment in fragility fracture patients. Osteoporos Int. 2011;22(7):
2067–82.
27. Cooper MS, Palmer AJ, Seibel MJ. Cost-effectiveness of the Concord
Minimal Trauma Fracture Liaison service, a prospective, controlled
fracture prevention study. Osteoporos Int. 2012;23(1):97–107.
28. McLellanAR,WolowaczSE,ZimovetzEA,BeardSM,LockS,McCrinkL,
AdekunleF,RobertsD.Fractureliaisonservicesfortheevaluationand
management of patients with osteoporotic fracture: a cost-effective-
ness evaluation based on data collected over 8 years of service
provision. Osteoporos Int. 2011;22(7):2083–98.
29. SlaterM,SujicR, SaleJE,BogochE, BeatonD.Gettingmenoncare:no
evidence of gender inequity in osteoporosis testing and treatment
initiation in a coordinator-based fragility fracture screening program.
Canadian OrthopaedicAssociation
Supplement 2011; 1: 116-7 [Internet]. Westmount, Quebec, Canada:
Canadian Orthopaedic Association; 2011 [cited 2012 Jul 9]. Available
from: http://www.coa-aco.org/images/stories/meetings/stjohns_
2011/abstract_supplement_2011_v2.pdf.
AnnualMeetingAbstract
30. Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C.
Osteoporosis Methodology Group and The Osteoporosis Research
Advisory Group. Meta-analyses of therapies for postmenopausal
osteoporosis. IX: Summary of meta-analyses of therapies for post-
menopausal osteoporosis. Endocr Rev. 2002;23(4):570–8.
31. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt
MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC,
Quandt SA, Reiss TF, Ensrud KE. Randomised trial of effect of
alendronate on risk of fracture in women with existing vertebral
fractures. Fracture Intervention Trial Research Group. Lancet. 1996;
348(9041):1535–41.
32. Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY,
Hodsman AB, Eriksen EF, Ish-Shalom S, Genant HK, Wang O, Mitlak
BH. Effect of parathyroid hormone (1–34) on fractures and bone
mineraldensityinpostmenopausalwomenwithosteoporosis.NEngl
J Med. 2001;344(19):1434–41.
33. Reginster J, Minne HW, Sorensen OH, Hooper M, Roux C, Brandi ML,
Lund B, Ethgen D, Pack S, Roumagnac I, Eastell R. Randomized trial of
Journal of Bone and Mineral Research
MAKING THE FIRST FRACTURE THE LAST FRACTURE
7

Page 8

the effects of risedronate on vertebral fractures in women with
established postmenopausal osteoporosis. Vertebral Efficacy with
Risedronate Therapy (VERT) Study Group. Osteoporos Int. 2000;
11(1):83–91.
34. Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR,
DelmasP,ZoogHB,AustinM,WangA,KutilekS,AdamiS,ZanchettaJ,
Libanati C, Siddhanti S, Christiansen C. FREEDOM Trial. Denosumab
for prevention of fractures in postmenopausal women with osteo-
porosis. N Engl J Med. 2009;361(8):756–65.
35. Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M,
Chesnut CH 3rd, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller
PD. Effects of risedronate treatment on vertebral and nonvertebral
fractures in women with postmenopausal osteoporosis: a random-
ized controlled trial. Vertebral Efficacy With Risedronate Therapy
(VERT) Study Group. JAMA. 1999;282(14):1344–52.
36. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C,
Adami S, Fogelman I, Diamond T, Eastell R, Meunier PJ, Reginster JY.
Hip Intervention Program Study Group. Effect of risedronate on the
risk of hip fracture in elderly women.Hip InterventionProgramStudy
Group. N Engl J Med. 2001;344(5):333–40.
37. Reginster JY, Seeman E, De Vernejoul MC, Adami S, Compston J,
Phenekos C, Devogelaer JP, Curiel MD, Sawicki A, Goemaere S,
Sorensen OH, Felsenberg D, Meunier PJ. Strontium ranelate reduces
the risk of nonvertebral fractures in postmenopausal women with
osteoporosis: Treatment of Peripheral Osteoporosis (TROPOS) study.
J Clin Endocrinol Metab. 2005;90(5):2816–22.
38. Chami G, Jeys L, Freudmann M, Connor L, Siddiqi M. Are osteoporotic
fractures being adequately investigated? A questionnaire of GP &
orthopaedic surgeons. BMC Fam Pract. 2006;7:7.
39. National Bone Health Alliance. Eye on bone health: secondary
fracture prevention initiative Vol. 1 Washington DC: National Bone
Health Alliance; p. 1. 2011.
40. International Osteoporosis Foundation. Capture the fracture. Nyon,
Switzerland:InternationalOsteoporosisFoundation;2012[cited2012
Jul 9]. Available from: http://www.iofbonehealth.org/sites/default/
files/PDFs/2012-brochure-capture_the_fracture-A5.pdf.
41. Osteoporosis Canada. Osteoporosis: towards a fracture free future
[Internet].Toronto, Ontario,Canada:OsteoporosisCanada; Mar[cited
2012 Jul 9]. Available from: http://www.osteoporosis.ca/multimedia/
pdf/White_Paper_March_2011.pdf. 2011.
42. Osteoporosis Canada. Osteoporosis patient bill of rights. Toronto,
Ontario, Canada: Osteoporosis Canada; 2011.
43. National Osteoporosis Society. Our manifestos. Protecting fragile
bones: a strategy to reduce the impact of osteoporosis and fragility
fractures in England/Scotland/Wales/Northern Ireland [Internet].
Bath, UK: National Osteoporosis Society; [cited 2012 Jul 9]. Available
from: http://www.nos.org.uk/page.aspx?pid¼818. 2009.
44. National Osteoporosis Society. Care services minister attends vital
falls and fractures summit. Bath, UK: National Osteoporosis Society.
45. American Society of Bone and Mineral Research Task Force
on Systems-Based Approaches to Secondary Fracture prevention.
Systems-based approaches to secondary fracture prevention:
doing something that actually works. ASBMR 2011. 2011 Annual
Meeting, San Diego Convention Center, San Diego, CA, USA.
Washington, DC: American Society of Bone and Mineral Research;
2011.
46. Foundation AO. Fragility fractures and orthogeriatric comanagement
course in Davos. Davos, Switzerland: AO Foundation; 2011.
47. International Society for Fracture Repair. Osteoporotic fracture
campaign. London: International Society for Fracture Repair;
2011.
48. International Osteoporosis Foundation. Enormous growth in use of
WHO Fracture Risk Assessment Tool (FRAX1). Nyon, Switzerland:
International Osteoporosis Foundation; 2012.
49. American Academy of Orthopaedic Surgeons. Position statement:
recommendations for enhancing the care of patients with fragility
fractures. Rosemont, IL, USA: American Academy of Orthopaedic
Surgeons; 2009.
50. Bunta AD. It is time for everyone to own the bone. Osteoporos Int.
2011; 22 (Suppl 3):477–82.
51. US Bone and Joint Decade. Osteoporosis education kit to prevent
future fractures [Internet]. USBJD Newsletter. 2007 May/June;9(1).
[cited 2012 Jul 9]. Available from; http://www.usbjd.org/news/pdf/
USBJD_NL_May_Jun07Web.pdf.
52. Fragility Fracture Network. FFN: a global network to improve fragility
fracturemanagement and prevention
Switzerland: Fragility Fracture Network (FFN); 2011; [cited 2012
Jul 9]. Available from: http://www.ff-network.org/.
[Internet].Glattbrugg,
53. Department of Health. Falls and fractures: effective interventions in
health and social care. London: Department of Health, NHS; [cited
2012 Jul 9]. Availablefrom: http://www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/@dh/@en/@pg/documents/digitalasset/dh_
103151.pdf. 2009.
54. DellR,GreeneD.Isosteoporosisdiseasemanagementcosteffective?.
Curr Osteoporos Rep. 2010;8(1):49–55.
55. Newman ED, Ayoub WT, Starkey RH, Diehl JM, Wood GC. Osteopo-
rosis disease management in a rural health care population: hip
fracture reduction and reduced costs in postmenopausal women
after 5 years. Osteoporos Int. 2003;14(2):146–51.
56. Ministry of Health and Long-term Care, Ontario Women’s Health
Council, Osteoporosis Canada. Ontario Osteoporosis Strategy [Inter-
net]. Toronto, Ontario, Canada: Osteoporosis Canada; [cited 2012 Jul
9]. Available from: http://www.osteostrategy.on.ca/index.php/ci_id/
1238/la_id/1.htm. 2010.
57. Center JR, Bliuc D, Nguyen ND, Nguyen TV, Eisman JA. Osteoporosis
medication and reduced mortality risk in elderly women and men.
J Clin Endocrinol Metab. 2011;96(4):1006–4.
8
EISMAN ET AL.
Journal of Bone and Mineral Research