the care gap - osteoporosis australia online version.pdfthe care gap in osteoporotic fracture...

The Care Gap

MediCal issue Autumn 2016

The Care Gap in Osteoporotic Fracture Management

Research Bites: Research Review

Surgical Improvements in Osteoporosis Fracture Repair

New Sun Exposure Guidelines

Osteo-cise Pilot Shows Promise for National Roll-out

News Update

Medical iSSUe AUTUMN 20162

The Care Gap in Osteoporotic Fracture Management: A Disconnect Between Hospital and Primary Caredr Kirtan Ganda and Professor Markus seibelDept of Endocrinology, Concord Repatriation and General Hospital. the university of Sydney.

Any osteoporotic fracture predisposes to at least

a two-fold risk in further fractures,1-9 significant

morbidity and premature death.10,11 In a 2009 report

of New South Wales hospital admission data from the

Agency for Clinical Innovation (ACI),12 35% of patients

with an osteoporotic fracture were re-admitted due

to a further fracture over a 6 year period (2002-08).

The re-admissions accounted for 97,347 bed days

with an average length of stay of 22 days. However,

this figure was most likely an under-estimate as the

data only recorded re-fracture admissions to the

same hospital as the index fracture.

For over two decades, we have known that the timely

diagnosis and optimal treatment of osteoporosis

prevents further fractures by up to 70% in

these people. By now, several safe and effective

medications are available13-19 and all osteoporosis

guidelines recommend long-term treatment for

people who have sustained a minimal trauma

fracture.20-24 However, the international literature

provides ample proof that the majority (i.e. 70-85%)

of patients presenting with a minimal trauma fracture

to their GP or hospital are neither assessed for

osteoporosis, nor appropriately managed to prevent

further fractures.25-31 This is highlighted in by two

large retrospective studies of primary care practice

in Australia, which demonstrated less than one-third

of patients presenting with a minimal trauma fracture

receive specific osteoporosis pharmaco-therapy.32,33

Thus, in Australia and internationally, there is a

‘disconnect’ between the initial fracture repair

(which usually happens in hospital) and the

subsequent assessment and management of the

underlying disease (osteoporosis) in General Practice.

In response to this dire situation, a number of

systematic interventions have been developed,

ranging from education of patients and physicians to

interventions that coordinate osteoporosis education,

assessment and treatment in an all-encompassing

service, known as a Fracture Liaison Service

WelCOMe this autumn issue of Osteoblast covers a

number of important aspects of osteoporosis

care. Prof Chehade’s review on surgical

improvements in fixing osteoporosis fractures

updates you on the newest developments in

fracture repair. It is great to see how this area

has changed over the past few years, much to

the benefit of our patients. While we are really

good at fixing osteoporotic fractures, we are

much less effective in managing those patients

once they have left hospital. In fact, both in

Australia and overseas (with the exception of

a few countries such as new Zealand and the

uK), we are still looking at a wide ‘care gap’

in osteoporosis management. As reviewed by

my colleague Dr Kirtan Ganda, up to 85% of

patients with an incident osteoporotic fracture

go undiagnosed and untreated… and 50%

of these will fracture again. this untenable

situation needs to change if we ever want to

break the costly epidemic of fragility fractures

in Australia.

Prof Markus seibel


(FLS) or Secondary Fracture Prevention (SFP) program. These programs have

demonstrated that systematic, comprehensive interventions generate direct

clinical benefits34 and are highly cost-effective.35,36

There are a number of factors that contribute to the under-investigation and

under-treatment of osteoporosis. Individual barriers include a lack of awareness

and understanding amongst patients and doctors of the heightened risk of

further fractures following a first fracture. Also, the significant benefits and the

excellent safety profile of osteoporosis pharmacotherapy often go unrecognised.

Patients are often misinformed of medication side effects and benefits. There

is ample, high quality evidence from randomised placebo-controlled trials that

antiresorptive agents (e.g., risedronate, alendronate, zoledronic acid, denosumab)

and teriparatide (a bone forming drug) reduce the relative risk of fracture by

30 to 70%. Of note, data from these trials demonstrate greater risk reduction

for vertebral (50-70%) than for non-vertebral fractures (30-40%). These agents

thus have robust efficacy data, which undoubtedly outweighs the rare risk of

osteonecrosis of the jaw or atypical femoral shaft fractures, which occur at a

rate of 1 in 10,000 to 100,000 patient years.

Another common misconception is that treatment for osteoporosis after

a minimal trauma fracture is only required if the DEXA scan reveals a

bone mineral density in the osteoporotic range. However, once a person

has sustained a minimal trauma fracture, treatment should be considered

independent of bone mineral density as these patients are at high risk of

subsequent fracture. This is reflected in the PBS rules: Once a prevalent or

incident minimal trauma fracture has been identified, a BMD scan or T-score

is NOT required for a patient to qualify for subsidised treatment.

Many healthcare professionals are hesitant to initiate treatment or to change

management in response to the ‘sentinel’ event of a new osteoporotic fracture.

Also, the responsibility for post-fracture care often gets diluted between several

health care professionals, whether it is the primary care physician, orthopaedic

surgeon or specialist physician. As a result the patient more often than not gets

lost due to lack of post-fracture care coordination.

In summary, the post-fracture care gap represents a systemic failure of

‘disconnect’ between the hospital and general practice. The osteoporotic

fracture is repaired in the hospital setting, yet there is no attempt to prevent

the next fracture through osteoporosis assessment and treatment. Although

there is strong trial evidence of anti-fracture efficacy with osteoporosis

pharmacotherapy, in the majority of patients this evidence is not being

translated into current clinical practice. In order to close this care gap, it is

necessary to reconnect the acute fracture care in hospital and post-fracture

osteoporosis management in the primary care setting. Secondary Fracture

Prevention programs are ideally placed to bridge the gap but these programs

need to be established in both hospitals and primary care. Such targeted and

coordinated programs for the identification, assessment and treatment of

patients with minimal trauma fracture provide an effective vehicle to deliver

best evidence into clinical practice.

References available upon request.

“...there is a ‘disconnect’ between initial fracture repair and the subsequent assessment and management of the underlying disease (osteoporosis)...”

The Care Gap in Osteoporotic Fracture Management: A Disconnect Between Hospital and Primary Care (Cont.)


researchbitesResearch Review by Dr lisa Croucher (OA Scientific Advisor)

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An editorial published by the International Osteoporosis Foundation (IOF) argues against the growing movement towards ‘drug holidays’ for osteoporosis, instead urging doctors to make treatment decisions based on individual fracture risk.1 Concerns around links between long-term bisphosphonate use and osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) have been compounded by recent media focus on reports that imply over-use of bisphosphonates.

Clinical trial outcomes in recent years indicate the importance of basing treatment decisions on individual fracture risk. An extension of the Fracture Intervention Trial (FLEX) demonstrated a significant increase in vertebral fractures after 5 years discontinuation of alendronate, compared to women who continued therapy for 10 years,2 indicating benefit of continuing therapy in women at high risk of vertebral fractures. Similarly, the HORIZON trial showed continued reduction in vertebral fracture risk with annual zoledronic infusions over 6 years, compared to those who stopped after 3 years.3

Discussion around the need for a drug holiday has been fuelled recently by fears of rare side effects. In reality, the incidence of ONJ and AFF is extremely low at the therapeutic doses used for osteoporosis. The American Society for Bone and Mineral Research (ASBMR) estimates ONJ incidence at between 1 in 10,000 and less than 100,000 patient-treatment years. The incidence of AFF is estimated to be between 2 in 100,000 after 2 years and 78 in 100,000 after 8 years exposure. Taking into account the substantial morbidity and mortality associated with vertebral fractures, the benefits of bisphosphonate therapy clearly outweigh the risks in women at high risk of fracture. The IOF also points out that adherence to bisphosphonates is low – clinicians may be making a bad situation worse by stopping treatment in the low numbers who actually take their medication.

The IOF stops short of making clear recommendations, but states that decisions should be based on individual fracture risk. Osteoporosis Australia’s Medical and Scientific Committee is broadly in agreement with recent recommendations from a respected US-based group:4

• T-scoreworsethan-2.5atthefemoralneckafter3-5yearstreatment:continuebisphosphonatetreatment (highest risk of vertebral fracture)

• T-scoreworsethan-2.0inapatientwithapreviousvertebralorhipfracture:likelytobenefitfromcontinuedtreatment

• T-scorebetterthan-2.5atthefemoralneckinapatientwithoutpriorvertebralorhipfracture:unlikelytobenefitfromcontinuedtreatment (low risk of vertebral fracture).

There is much confusion around best practice, with little global consensus. Long-term trial data is scant and limited to post-menopausal women. More research is needed, in particular on how patients on ‘drug holidays’ should be monitored and when to re-commence treatment. In the meantime, it’s important for both clinicians and patients to remember that AFF and ONJ are extremely rare, but hip and spinal fractures are common and a major cause of disability and early death. The benefits of long-term bisphosphonate therapy for women at moderate to high risk of fracture far outweigh the risks.


New iOF report caution against automatic ‘drug holidays’ for osteoporosis


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Background The burden on our society and hospital system from osteoporosis related fractures is high. There were 60,530 reported hospitalisations in 2012-13 for a principal diagnosis of minimal trauma fracture including the hip (31.2%), forearm (15.7%), lumbar spine and pelvis (12.3%). The actual number is far greater with many either not requiring hospitalisation (eg spine) or unrecorded at discharge. Hip fractures increased 18.4% in 10 years.1 With the challenges on subacute geriatric/rehabilitation resources, this also blocks acute hospital beds.

There have been several areas in which advances have been made with the goal of improving outcomes. In addition to technical developments with surgical implants and techniques, there is a requirement for improved system approaches including improved perioperative assessement, quicker time to surgery and orthogeriatric models of care.2

The poor quality and porous nature of osteoporotic bone leads to major fixation challenges for both repair and replacement options. Importantly the poor bone is often associated with a ‘poor host’ in terms of cognitive function, medical comorbidities, frailty and sarcopenia – all of which impact not only on perioperative management but rehabilitation potential. Surgical approaches have to be aimed at restoration of function sufficient to allow immediate mobility including unrestricted weight bearing as mobility restrictions are very poorly tolerated and lead to a cascade of further problems which contribute to the high morbidity and mortality in this cohort.

Technical AdvancesThe approach in most fractures is surgical repair which relies on the interplay between fixation device, bone properties and patient’s capacity for rehabilitation. Inability to restrict load

necessitates solid initial fixation. Ongoing developments in locking plate technologies have significantly improved the surgeon’s ability to achieve solid fixation in many osteoporotic fractures, particularly around the wrist and proximal humerus where the risk of screw cut out and fixation failure are high. Essentially the head of the screw is designed to lock directly into the plate creating a fixed angle device with improved bone fixation. Traditional fixation relies on a better screw purchase to compress the plate to the bone with the screw head that is otherwise free to toggle in the plate hole (Figure 1).

Large anthropological studies have also allowed anatomical shaping of plates and associated targeting devices for less invasive surgery and to direct screws into predetermined parts of the stronger subchondral bone closer to joints.

Techniques to improve the quality of bone fixation by addressing the bone deficiencies have also improved. Bone augmentation may be achieved using autograft, allograft, synthetic bone or cementing techniques.

Hip fixation has also changed with the evolution of intramedullary nails increasingly replacing the dynamic hip screw. Inserted percutaneously, they provide more reliable fixation with less fracture collapse and more anatomical healing whilst allowing unrestricted weight bearing for the more unstable fracture patterns.3

Arthroplasty is used for fractures around joints not suitable for repair (too damaged to be fixed or require too long a delay in mobilisation). This is more commonly performed acutely for hip (hemi and total joint replacements) and shoulder fractures (hemi and ‘reverse’ total), but also knee and elbow arthroplasty. The successful implementation of the Australian Orthopaedic

Association National Joint Replacement Registry is providing high level evidence for best practice.4

New surgical approaches that limit collateral surgical damage and preserve biological healing potential such a fragment specific approaches are also contributing to improved outcomes.5

AftercareFinally, essential to long-term success is multidisciplinary integrated care and follow-up for ongoing and sustained rehabilitation, bone health and falls assessment and secondary fracture prevention.6


Surgical Improvements in Osteoporosis Fracture Repair associate Professor Mellick J Chehade Orthopaedic trauma Surgery, Research and Education, university of Adelaide

Conventional plate•Screwsintension•Plate-bonefriction

•Compressionatfracturesite•Screwinterfaceloosening

Locking plate•Screwsinshear•Plate-bonegap

•Nocompression• screw loosening

➡

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Peak national bodies, including Osteoporosis Australia, have collaborated to release

new recommendations for balancing sun exposure and vitamin D intake in an effort to

reduce the risk of skin cancer, while maintaining adequate vitamin D levels. In addition

to Osteoporosis Australia, the recommendations have been jointly published by Cancer

Council Australia, the Australasian College of Dermatologists, the Australian and New

Zealand Bone and Mineral Society and the Endocrine Society of Australia.

The Cancer Council’s latest national survey found that almost a quarter of those

surveyed had been advised by their doctor to get more vitamin D. However, the experts

agree that adequate vitamin D can be obtained without risking skin cancer due to

harmful UV exposure. The recommendations state that if the UV level is below 3, then

sun protection is not required.

During summer, when the UV index is above 3 in all of Australia, most people can obtain

sufficient vitamin D going about their daily activities and sun protection should be used

if outside for an extended period of time. During winter, vitamin D levels are traditionally

very low for most Australians. The experts have recommended that during winter, time

is spent outdoors when the UV index is below 3 without sun protection. This will ensure

that sufficient vitamin D can be maintained for bone health.

Some patients are considered at higher risk of vitamin D deficiency, including those

who are naturally very dark skinned; avoid sun exposure because of a high risk of skin

cancer; are frail and/or elderly, chronically ill or institutionalised and live largely indoors;

take particular medications; have conditions causing poor absorption of calcium and

vitamin D; or cover up for religious or cultural reasons. For these patients, if they cannot

obtain sufficient vitamin D, then a supplement may be required if appropriate. Patients

can check the UV index with the SunSmart app: cancer.org.au/sunsmartapp or visit

www.myuv.com.au

New Sun exposure GuidelinesOsteoporosis Australia’s preventative exercise program, Osteo-cise: Strong

Bones for Life, has just completed a pilot implementation in community

fitness centres. Osteo-cise is a research and evidence based multi-modal

community program designed to improve musculoskeletal health and

functional capacity in the over 50s. Crucially, the program incorporates

exercise specificity and progressive overload, targeting the muscles of the

hip, spine and wrist.

38 trainers took part in practical workshops in 3 states, and over 300 fitness

centre clients participated in the pilot. An unexpected but highly encouraging

finding was the adaptability of Osteo-cise and its capacity for integration

into established disease-specific exercise programs for the over 50s.

Recognising the potential of Osteo-cise to expand from its bone-

specific foundation to address the multiple chronic

disease priorities of the over 50s population,

Osteoporosis Australia is seeking

government support for a major

re-development and national

roll-out of Osteo-cise. The

new program will include

a web-based self-directed

program for consumers, and

the creation of GP referral

pathways will be a significant

feature. If support is granted,

the new program is expected

to launch in early 2018.

Osteo-cise Pilot Shows Promise for National Roll-out


Resources for General Practice Information and resources for general practice can be accessed online in the GP section of the Osteoporosis Australia website, located under the Healthcare Professional section. www.osteoporosis.org.au

MediCal issue Autumn 2016

Medical editor: Prof markus Seibel

editorial: melita Daru Jessica Wilkinson

advertising: melita Daru

Osteoblast is a publication of: Osteoporosis Australia ABn 45 098 570 515

PO Box 550 Broadway nSW 2007

national office 02 9518 8140 national hotline 1800 242 141

www.osteoporosis.org.au

Copyright © Osteoporosis Australia 2016. Except as provided by the Copyright Act 1968, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the publisher.

Resistance Training in the spotlight Osteoporosis Australia supported Fernwood Gyms launch of Lift

the Nation in February to highlight the importance of resistance

training for health. In terms of bone health resistance training

must be done at high intensity to have a benefit and combined

with weight bearing exercise as part of a regular exercise

program. Fernwood gyms will be open for free from June 20-26

as part of the initiative.

Osteoporosis australia biodensity equipment awardThe Osteoporosis Australia bioDensity Equipment Award was awarded to Professor Belinda Beck from Griffith University QLD. Her study will endeavour to determine how the bioDensity system can stimulate stronger bones in people who have low bone density. The results for this group will be compared to the results from a group who completed more conventional exercises.

Free and Flexible active learning Module (alM) for GP’sDo you need additional CPD Points? Our online ALM, hosted by ThinkGP is free and flexible. The ALM provides the details you need to effectively treat and manage osteoporosis and fracture risk as well as provide key bone-health information to at-risk patients. Accreditation includes 40 CPD Points with RACGP or 30 CPD Points for ACRRM. Register today at www.thinkgp.com.au/oa

astronauts and Bedridden Patients share something in Common: Progressive Bone Loss

According to NASA, astronauts who spend many

months on a space mission can lose, on average,

1 to 2 per cent of bone mass each month. They

typically experience bone loss in the lower halves of

their bodies, particularly in the vertebrae and the leg

bones. The proximal femoral bone loses 1.5 percent of

its mass per month, or roughly 10 percent over a six-

month stay in space, with the recovery after returning

to Earth taking at least three or four years. The loss of

bone mass also triggers a rise in calcium levels in the

blood, which increases the risk of kidney stones.

To help overcome the effects of bone loss while in

orbit, astronauts have to engage in physical exercise

for two and a half hours a day, six times a week during

their stay in space. Although this does not completely

eliminate the risk of bone loss, it does help to reduce

it. Other studies are underway to investigate how to

combat this issue.

Patients who remain immobile in bed over longer

periods of time also experience rapid and progressive

bone loss. Studies with ‘terranauts’ (healthy, young

Earth-bound volunteers who lie flat without exercising

for extended periods of time) have shown that

completely immobilised bones can lose up to 15%

of mineral density within three months. For ordinary

Earth-bound people the message is exercise and bone

maintenance are inextricably linked.

Source: IOF News

NeWS UPDATe

Prof Belinda Beck Griffith University QLD

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