The New Zealand Medical Journal article, Expansion and consolidation of fracture liaison service in New Zealand public healthcare setting – Waitematā District Health Board Experience, describes the service delivery of the FLS at the Waitematā District Health Board (WDHB) for 2020, and how the service evolved in recent years. While FLS services are prevalent in almost all district health boards, the Accident and Compensation Corporation (ACC) confirmed it will provide funding support to those FLSs both willing, and able to deliver secondary fracture prevention by the International Osteoporosis Foundation’s (IOF) Capture the Fracture^® (CTF) Best Practice Framework.¹ Osteoporosis New Zealand (ONZ), in partnership with ACC, has also committed to providing practical and strategic support to those FLSs that are willing to participate in service improvement to attain CTF Best Practice recognition.

According to the article’s authors, they are now identifying a substantially larger number of fragility fracture patients by having adopted several additional methods of patient identification. In addition, they are providing more streamlined, and comprehensive management for identified patients. More recently “we started to perform follow-up to ensure treatment initiation and adherence in those needing to be treated. In late 2020, on the basis of our 2019–2020 work, we attained Gold Star recognition from the IOF CTF program,” the authors said.²

The authors reviewed and analysed the WDHB FLS database, and identified and assessed 1,225 patients. The authors either directly initiated anti-osteoporosis medication (AOM) (256); recommended starting AOM with the patient’s GP (477); or recommended continuing, or switching to a different AOM (441) in the vast majority (1174 = 95.8%). In the remaining 51 patients, AOM was either deemed unnecessary (owing to relatively young age and good DEXA indices), or the patient refused it. Three hundred and thirty dual-energy X-ray absorptiometry (DEXA) scans were arranged by FLS, and 79.5% were found to be either osteoporotic (32.9%), or osteopenic (46.6%).

The authors started conducting 4-month follow-ups in late 2019. While this has proven resource-intensive, they believe it is a key element of a mature FLS; ensuring administration of AOM where indicated is a core FLS activity. More recently, the authors also started to conduct 12-month follow-ups with the intention to ensure treatment adherence in those who are expected to be on treatment, and also to identify re-fracture. Ensuring administration of repeat IV zoledronic acid doses at appropriate time intervals remains a challenge, they explained.

Referral of high-risk cases to a falls prevention program has been another important addition to the service delivery in recent years, although there is room for improvement. The inherent challenges of Covid-19 improvisation in certain aspects of the service delivery was inevitable, though it appears not to have compromised patients’ perception of the service provided. In fact, to the contrary, with high levels of patient satisfaction recorded, according to the results of a survey. Dedicated administration staff assisted with data entry and other administrative duties with clearly defined terms entered into the database, to ensure accurate, consistent, and complete data entry, the authors said.

The core elements of a successful FLS implemented included: dedicated FLS coordinators who engaged in regular discussions with clinician(s) with expertise in osteoporosis medicine; ongoing funding; close liaison with the orthogeriatrician who cares for older, acute hip fracture patients; regular dialogue with orthopaedic, radiology and bone density provider colleagues; monthly service meetings with a supportive service manager; FLS clinical meetings to discuss challenging cases; attending professional development events for the clinical staff; and strategic support and guidance from ONZ that has given the article’s authors “a sense of direction” in driving service improvement over the years. Notably, WDHB FLS’s biggest challenge has proven insufficient, full-time equivalent staff to perform all key aspects of FLS work.

“I am delighted that our fracture liaison service continues to lead the way in pursuing excellence in secondary fracture prevention in New Zealand. I would like to take this opportunity to acknowledge all the hard work that has gone into improving our service over the years by our dedicated staff,” said Lead author and endocrinologist, Dr David Kim, Auckland.

“I also really appreciated the help and support from the hospital management and the Osteoporosis New Zealand team who made it possible for our service to continue to grow, and mature. With palpable progress being made lately in many fracture liaison services throughout New Zealand, I firmly believe that our small success story is only the beginning of bigger and better things to come for secondary fracture prevention in this country,” Dr Kim concluded.

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Representing the world’s largest global corporate-NGO partnership ever launched in the bone field, the new CTF Partnership aims to double the number of existing FLS by the end of 2022, and thereby significantly reduce secondary fractures and improve patient care, with the aspiration of reducing hip and vertebral fractures by 25% by 2025.

Even after an osteoporosis-related fracture, approximately 80% of individuals at high risk are still not identified or treated. This vast care gap is untenable and can only be tackled through the widespread implementation of post fracture care models. To achieve this goal, targeted efforts and collaboration among all stakeholders is required.

The new CTF Partnership will facilitate five targeted ‘pillars’ of action to advance both the implementation and sustainability of systematic, coordinated models of post fracture care. With an initial focus on countries in the Asia-Pacific, Europe, Latin American and Middle-East regions, we  will focus on these key areas of action: advancing policy, building coalitions, providing best practice mentorship and workshops for FLS, providing scalable resources to support FLS, and creation of a global FLS database comparative tool.

IOF also looks forward to collaborating with member organizations of APFFA as we expand Capture the Fracture’s outreach and effectiveness. We invite members to contact CTF if they identify any local existing FLS services for assessment and mapping on the CTF Map of Best Practice. IOF also welcomes APFFA’s support in policy efforts and coalition building to help further the important missions of this exciting new initiative.

Learn more about the Capture the Fracture Partnership and view the IOF press release. To contact Capture the Fracture for further information and any queries, please write to capturethefracture@iofbonehealth.org

Contributed by Prof. Cyrus Cooper, President,International Osteoporosis Foundation

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Osteoporosis is common. More than 1.1 million hip fractures were estimated to have occurred in China, Taiwan, Hong Kong SAR, India, Japan, Malaysia, Singapore, South Korea and Thailand alone, in 2018. Back, wrist, clavicle (collarbone) and pelvis are other common fracture sites.

Fractures threaten ambulation, independence and quality of life. In the case of hip fractures, only between one-third to a half of hip fracture survivors regain their ambulatory function.

Recent fracture is a powerful risk factor for subsequent fractures.  Fortunately, fracture risk can be mitigated. The risk of sustaining a further fracture can be reduced by up to 30 to 40 per cent if the underlying osteoporosis and falls risk are managed by a secondary fracture prevention program.

Despite the substantive ability to reduce future fracture risk with treatment, osteoporosis-related fractures are under-treated. This is due in part, to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. Concerningly, only around one-in-five patients who have sustained a fragility fracture, have received medical attention.

To address the under-treatment of osteoporosis-related fractures and heterogeneity in guidelines, the American Society for Bone and Mineral Research (ASBMR) assembled a multi-stakeholder coalition in 2017 to develop clinical recommendations for the optimal prevention of secondary fractures among those aged 65 years and older with a hip or vertebral fracture.

The 13 coalition-developed consensus recommendations published in the Journal of Bone and Mineral Research in 2019, address the gap that exists in the care of this patient cohort.

The recommendations are directed to all healthcare professionals involved in the care of these patients. The core fundamental recommendations emphasise the importance of:

• Communication – patients and their families must be made acutely aware that a broken bone is likely indicative of underlying osteoporosis, and places them at high risk of re-fracture, particularly in the 12-24 months following the initial fracture. It is also imperative to communicate that bone fractures often result in loss of independence and mobility, and an increased risk of morbidity. Most importantly, patients must be informed that appropriate action can be taken to reduce these risks.
• Awareness – a healthcare provider’s lack of awareness of their patient’s fracture history has been consistently identified as one of the key barriers to overcoming the provision of lifelong osteoporosis care.
• Regular falls risk assessments – the coalition’s recommendations call for a ‘history of falls’ record, evaluation of medications and comorbidities associated with increased fall risk and referral for complimentary therapies (physical, rehabilitative and psychiatric) to reduce the risk of falls. Up to one in six falls in older adults cause fractures, and around 90 per cent of hip fractures result from a simple fall from standing height or less, demonstrating falls prevention as a critical step in hip fracture prevention.
• Pharmacological intervention in a timely manner – given the risk of subsequent fracture is significantly elevated for patients at all levels of BMD, and that pharmacologic therapy for osteoporosis reduces the risk of fracture in older patients, treatment initiation should not be delayed.
• Supplementation – patients with osteoporosis are often vitamin D-deficient. Strong evidence indicates vitamin D reduces fractures when combined with calcium supplements in those at high risk of deficiency. Given calcium is critical for bone mineralisation and strength, dietary evaluation of the consumption of calcium is fundamental. Supplementation with vitamin D (800 IU per day) and calcium for those unable to achieve an intake of 1200 mg/d of calcium from food sources, is recommended.
• Routine follow up and re-evaluation – follow up and re-evaluation to reinforce patient education, monitor and evaluate the patient’s treatment plan, identify barriers to treatment adherence, and ensure regular falls risk assessments is recommended. Providing osteoporosis patients with the required educational support has proven pertinent in maintaining health-related quality of life. Conversely, failure to adequately meet a patients’ educational needs (e.g. medication, self-management, the nature of osteoporosis) has been shown to result in poor treatment adherence, and a decline in the doctor-patient relationship.

Additional recommendations include:

• considered referral to other appropriate HCPs;
• lifestyle modification (e.g. smoking cessation, less alcohol consumption, and emphasis on the importance of regular exercise); and
• discussion of the options, benefits, risks and duration of pharmacological interventions.

The recommendations emphasise that optimal management should occur within the context of a multi-disciplinary clinical system that includes case management, to ensure patients are appropriately evaluated and treated for osteoporosis and risk of further fractures.

Comprising seven global and regional member organisations from the geriatrics, orthopaedics, osteoporosis and rehabilitation sectors, APFFA embodies the coalition’s recommendations. The organisation aims to promote multidisciplinary collaboration, drive policy change and facilitate best practice in the acute care, rehabilitation and secondary prevention of fragility fractures, to ultimately deliver effective care, fewer fractures, and better outcomes for all people living in Asia Pacific.

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