Titled ‘Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region’, and just published in the journal Archives of Osteoporosis, the review summarises the recent progress that could inform the development of national roadmaps to improve the bone health of populations served in the Asia Pacific region.

During the United Nations (UN) ‘Decade of Healthy Ageing’, the review’s authors urge governments across the region to urgently respond to the epidemiological emergency posed by fragility fractures, in light of recent studies and reports that document a persistent and pervasive post-fracture care gap among those who have sustained a fragility fracture.

The authors emphasise that global initiatives developed by the Fragility Fracture Network (FFN) and International Osteoporosis Foundation (IOF) have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance (APFFA) has developed educational resources, including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society (APOFFS) – a new section of the Asia Pacific Orthopaedic Association (APOA) – is working to engage orthopaedic surgeons across the region, in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis (APCO) developed ‘The APCO Framework’ (comprising 16 minimum clinical standards that serve as a benchmark for the provision of optimal osteoporosis care in the region), to support national clinical guidelines and development groups. Substantial activity at the national level is further evident in many countries across the region.

During 2020 to 2022, to complement the established Australian and New Zealand Hip Fracture Registry,¹ a new Australian and New Zealand Fragility Fracture Registry was developed in both countries^2,3 led by the SOS Fracture Alliance in Australia,⁴ and Osteoporosis New Zealand (ONZ).⁵ In China, a webinar was delivered on recent progress in hip fracture care.⁶ A policy round table meeting was held to disseminate the findings of the studies described in the webinar to senior government officials. A national clinical management guideline for hip fractures is currently in development, and establishment of a Chinese National Hip Fracture Registry is also underway. In Hong Kong SAR, China, the Fragility Fracture Network Hong Kong SAR was also established in 2021, and a proposal for a new FLS model focused on vertebral compression fractures.⁷

In Japan, the benefits of the Toyama City Hospital’s 5-year-experience of implementing a multidisciplinary care model for hip fracture patients was described. There is the introduction of a new national reimbursement scheme for hip fracture patients that incentivises hospitals to undertake surgery within 48 hours and deliver evidence-based secondary fracture prevention.⁸ In Malaysia, the Fragility Fracture Network Malaysia (FFN M) has delivered a series of FLS workshops, webinars and training courses nationwide, both in-person, and virtual. Many orthopaedic surgeons, geriatricians, paramedics, and nurses participated in the program, which has attracted interest in learning about FLS, and initiating services in participants’ hospitals. A mentor-mentee program was also initiated following the program. The FFN M FLS Framework will be launched in the second half of 2022 to support improvement of existing FLS and initiation of new FLS across Malaysia in 2023 and beyond.

In the Philippines, the first FLS program in the country received its bronze-level recognition in the IOF Capture the Fracture program⁹ and development of a pilot national hip fracture registry is ongoing. In South Korea, a pilot program for home-based medical care was launched. A real-world, cost-effectiveness evaluation of the FLS model of care for hip fracture patients was undertaken in Chinese Taipei.¹⁰ In Thailand, FLS implementation, education, and monitoring also made significant strides.^11,12

In order to maintain momentum, the review’s authors explain there is an urgent need for governments region-wide, to embed the care and prevention of fragility fractures into national injury prevention strategies. While the COVID-pandemic disrupted the region, and the world in ways unimaginable in late 2019, since the ‘time before COVID’, numerous initiatives to improve the care received by those who sustain fragility fractures, have been established at both the global, and regional levels, and in many countries, and hospitals across the Asia Pacific. This adage that ‘Failing to plan is planning to fail’ is apt with respect to the prevention of serious and costly injuries that result from the most common bone disease in humans.

In 2018, the Global Call to Action on Fragility Fractures rallied diverse stakeholder sectors to undertake specific actions.¹³ As the ageing of Asia Pacific region’s population gains pace, the need for widespread implementation of these actions is becoming increasingly urgent. Accordingly, the review’s authors are rallying governments, healthcare professional organisations, and individual healthcare professionals in the Asia Pacific to prioritise the following actions throughout the remainder of 2022, and beyond:

• Governments to:
  • recognise, and respond to the threat posed to their societies from fragility fractures;
  • prioritise acute and long-term fragility fracture care and prevention in national health strategies; and
  • increase funding available to implement – at scale – proven models of care, including Orthogeriatric Services and Fracture Liaison Services (FLS) to improve outcomes for people with fragility fractures.

• Healthcare professional organisations to:
  • collaborate nationally and locally to form alliances to speak with a unified voice to policymakers;
  • produce consensus guidelines setting clear standards for adequate care using the best available research evidence, and propose metrics to evaluate performance; and
  • expand education and research programs that can establish best practice.

• Individual healthcare professionals to:
  • seek, create and follow evidence-based best practice;
  • form multidisciplinary teams with colleagues to identify and address the needs of people with fragility fractures; and
  • in their day-to-day clinical practice, participate in quality improvement programs to continuously improve the care provided to those with fragility fractures.

To read the full article, click here. 

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The review, titled Experience of a systematic approach to care and prevention of fragility fractures in New Zealand, just published in the journal Archives of Osteoporosis, describes the development and implementation of a systematic approach to both care and prevention for New Zealanders living with fragility fractures, and those at high risk of first fracture.

In 2012, Osteoporosis New Zealand published BoneCare 2020: A systematic approach to hip fracture care and prevention for New Zealand. At the time of publication, New Zealand lacked a coordinated, national strategy and systems to optimally manage those who sustained fragility fractures. This systematic approach to bone health in New Zealand successfully engaged a broad array of stakeholders to work towards mutually agreed goals.

An informal alliance of organisations progressed implementation of the objectives proposed in BoneCare 2020 during 2012 to 2016. However, the alliance was formalised in 2017, under the Live Stronger for Longer programme. Partners and contributors include the Accident Compensation Corporation (ACC), Ministry of Health, Health Quality and Safety Commission New Zealand, Osteoporosis New Zealand, Carers New Zealand, Age Concern, St. John Ambulance, Stroke Foundation of New Zealand, District Health Boards, Primary Health Organisations, and representatives of healthcare professional organisations.

The authors reviewed how each of the following six objectives outlined in BoneCare 2020  were implemented across New Zealand throughout 2012 to 2022:

1. Improve outcomes and quality of care after hip fractures by delivering Australian and New Zealand professional standards of care monitored by the New Zealand Hip Fracture Registry.
2. Respond to the first fracture, to prevent the second, through universal access to Fracture Liaison Services (FLS) in every District Health Board in New Zealand.
3. General practitioners (GPs) to stratify fracture risk within their practice population utilising fracture risk assessment tools supported by local access to axial bone densitometry.
4. Consistent delivery of public health messages – to adults with healthy bones aged 65 years and over – on preserving physical activity, healthy lifestyles and reducing environmental hazards.
5. Consistent delivery of public health messages – to adults with healthy bones aged 19–64 years – to exercise regularly, eat well to maintain a healthy body weight, and create healthy lifestyle habits.
6. Consistent delivery of public health messages – to children with healthy bones aged up to 18 years – on accrual of peak bone mass through a well-balanced diet and regular exercise, which promotes bone development.

The authors note the majority of the progress made in implementing the systematic approach to care and prevention of fragility fractures proposed in Osteoporosis New Zealand’s BoneCare 2020, has been facilitated by a national alliance of stakeholder organisations from different sectors. This has primarily been in relation to the care of individuals who have sustained hip, or other fragility fractures, supported by the production of clinical standards and registries to benchmark the provision of care. The creation of a consumer-facing, not-for-profit “brand” emphasising bone health, rather than osteoporosis, is showing early promise in the promotion of greater public awareness.

The authors proposed the progression of existing initiatives and the introduction of new initiatives for 2022 to 2030. According to the six objectives proposed in BoneCare 2020, achievements by 2030 should include:

Objective 1: The care of people who sustain hip fractures to be documented in the New Zealand arm of the Australian and New Zealand Hip Fracture Registry, and, from 2023 to 2030, all patients to receive best practice as described by the Australian and New Zealand Hip Fracture Care Clinical Care Standard.

Objective 2: Universal access to IOF-accredited Gold Star FLS to be available from 2025, and for the care of those who sustain fragility fractures at any relevant skeletal site, to be benchmarked against the second edition of the Clinical Standards for FLS in New Zealand, in the New Zealand arm of the Australian and New Zealand Fragility Fracture Registry.

Objective 3: A collaboration led by the Royal New Zealand College of General Practitioners, Osteoporosis New Zealand, Ministry of Health, Health NZ, Māori Health Authority, and ACC, to ensure reliable identification, investigation, and interventions for all New Zealanders who are at high risk of sustaining fragility fractures, underpinned by state-of-the-art information technology solutions and regularly updated national clinical guidance.

Objective 4: New Zealanders aged 65 years or over to complete the Know your Bones online self-assessment, and discuss their personalised report with their GP. Osteoporosis New Zealand, ACC, and the Ministry of Health to collaborate to develop awareness campaigns relating to preserving physical activity, healthy lifestyles, and reducing environmental hazards.

Objective 5: New Zealanders aged 50–64 years to complete the Know your Bones online self-assessment, and discuss their personalised report with their GP. Osteoporosis New Zealand to collaborate with all relevant stakeholder organisations to develop awareness campaigns relating to regular exercise, nutrition to maintain a healthy body weight, and creating healthy lifestyle habits.

Objective 6: Osteoporosis New Zealand to collaborate with the Ministry of Education, academic educators, and teachers, and their professional organisations, to incorporate content relating to bone health into the school curricula for science, health and physical education.

Osteoporosis New Zealand is committed to collaboratively developing BoneCare 2030 with all organisations that have contributed to date, and to expand the stakeholder group to strengthen the approach for aspects where limited progress has been made, including the consideration of equitable outcomes being actively designed for, and monitored.

To read the full article, click here. 

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Orthopaedic surgeons are pivotal to the early diagnosis and treatment of osteoporosis to prevent first fracture. Bone mineral density (BMD) measurement using DXA scan, combined with a FRAX score, should form part of their daily clinical practice in managing those at high risk of osteoporosis, explains Dato’ Dr. Joon-Kiong Lee, Asia Pacific Fragility Fracture Alliance (APFFA) Joint Steering Committee Co-Chair, and Deputy Medical Director, Beacon Hospital, Petaling Jaya, Malaysia, in his article published in the Journal of Orthopaedic Surgery, titled ‘Take action for bone health’.

“Orthopaedic surgeons should ‘take action’ in primary fracture prevention by utilising proven anti-osteoporosis treatment to reduce the risk of osteoporotic fracture, together with clinical risk factors or BMD value generated by the FRAX algorithm, to predict future fracture risk,” Dato’ Dr. Lee said.

Dato’ Dr. Lee further argues that “orthopaedic surgeons play the most pivotal role in the management of fragility fractures.”

“Patients first present to us because we manage their fractures, surgically or non-surgically, to ensure proper fracture healing and allow them to return to the best functional status possible. However, many patients presenting to us with fragility fractures do not receive appropriate assessment of their bone health and fall risk, nor appropriate anti-osteoporosis treatment, and they have never had their fall risk assessed.

“Therefore, patients present to us with recurrent fractures as they fall repeatedly; with underlying fragile bones – ‘fracture begets fracture’,” explained Dato’ Dr. Lee.

In his article, Dato’ Dr. Lee argues that “managing fragility fracture alone is far from adequate” and that orthopaedic surgeons should proactively “lead, and champion”  the following three bone health-related initiatives:

1. Introduction of a coordinated, multi-disciplinary Fracture Liaison Service (FLS) for all Asia Pacific Orthopaedic Association (APOA) members, and for FLS to become part of their standard practice in managing fragility fracture patients.
2. Inclusion of a Hip Fracture Registry (HFR) in the orthopaedic surgeon’s fragility fracture care tool chest, including use of the world-first, APFFA-developed Hip Fracture Registry Toolbox – an invaluable resource providing an overview of key lessons learned in the establishment of hip fracture registries to date, and tools to support registry development. To download the Toolbox in English, Chinese, Japanese or Korean, head to: https://apfracturealliance.org/hfr-toolbox/.
3. Harnessing APOA’s recent formation of the Asia Pacific Osteoporosis and Fragility Fracture Society (APOFFS) to raise stakeholder awareness of fragility fractures and underlying osteoporosis, and to collaborate with other regional and global organisations on osteoporosis, geriatric medicines, rehabilitation, and fragility fracture.

“Orthopaedic surgeons should be well equipped with confidence and knowledge”; be “prepared to manage the pharmacological treatment for the underlying osteoporosis; and play a more proactive role in reducing patient’s fall risk,” Dato’ Dr. Lee said.

Furthermore, orthopaedic surgeons should “be prepared to work with a multidisciplinary team comprising physicians, a rehabilitation team, dietitians, and pharmacists, in order to provide the best care possible to our patients with fragility fractures.

“We need to work closely with our general physician colleagues, and the FLS team to provide orthogeriatric care without the geriatrician. We need to change our mindset and attitude, and improve our fragility fracture practice, in order to provide our patients with the best possible care,” said Dato’ Dr. Lee.

To read the full article, click here.

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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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To help understand the burden of refracture, a study titled – An 11-year longitudinal analysis calculated the public health cost of managing refractures in people aged ≥50 years in Australia’s most populous state, and published in the Archives of Osteoporosis, has calculated current and projected refracture rates, and associated public hospital utilisation and costs in New South Wales (NSW), Australia. The study’s authors say this longitudinal analysis can provide a foundation for scaled implementation and evaluation of a novel, state-wide Osteoporotic Refracture Prevention model of care (ORP, also known as Fracture Liaison Services) to prevent refractures in those aged ≥50 years.

This analysis used linked administrative data on inpatient admissions, outpatient attendances, Emergency Department (ED) presentations, deaths, and costs prepared by the Centre for Health Record Linkage.¹⁰ Data analysis found that between 2007 and 2018, 388,743 people aged ≥50 years sustained an index fracture, while 81,601 experienced a refracture.

Refracture was more common in older people (rising from a cumulative refracture rate at 5 years of 14% in those aged 50–64 years, to 44% in those aged >90 years), women with a major index fracture (5-year cumulative refracture rate of 26% in females, compared to 19% for males), or minimal trauma index fracture, and those with an osteoporosis diagnosis (5-year cumulative refracture rate of 36% and 22%, respectively in people with, and without an osteoporosis diagnosis). Refractures increased from 8,774 in 2008, to 14,323 in 2018. The annual cost of refracture to NSW Health increased from AUD 130 million in 2009 to AUD 194 million in 2019. Projections suggest that over the next decade, if nothing changes, 292,537 refracture-related hospital admissions and ED presentations, and 570,000 outpatient attendances will occur, at an estimated total cost to NSW Health of AUD 2.4 billion.

The authors do acknowledge however, limitations of the datasets used in this study. Survivor bias’ may underestimate true refracture rates, and inter-hospital variation in quality and completeness of data coding can affect data integrity. There is an implicit understanding that this study will underestimate the prevalence of vertebral frailty fractures due to their often-asymptomatic nature. The initiation of bone protective therapy following fracture was also not assessed, given this was beyond the remit of this study. The analysis only included those treated in NSW hospitals; people who moved interstate, received treatment in other states, or were treated exclusively in primary care, were not included. Effect of fracture on quality of life, indirect costs, productivity losses, outpatient medication costs, and medication adherence, were also not studied.

Despite the above limitations however, this study provides the first comprehensive, state-wide assessment of current and predicted rate of refracture and associated service utilisation in Australia’s most populous state. Furthermore, it provides a critical foundation from which to evaluate the effectiveness of state-wide implementation of the ORP model of care — the centrepiece of the NSW Health response to this escalating public health issue. According to the study’s authors: “Implementation of the ORP model of care has the potential to decrease the rate of growth demand for acute care refracture treatment and prevent future refractures”.

Information from this longitudinal analysis will be used to shape the model of care, maintain alignment of the ORP with the principles of value-based healthcare, and evaluate the outcomes and effectiveness of the ORP in NSW, including its economic analysis, the study’s authors maintain.

“Lessons learnt from this study and from future planned work evaluating state-wide implementation of an ORP model of care will be of major relevance for other countries,” which seek to address this major public health issue, they concluded.

To read the full article, click here.

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The Asia Pacific Consortium on Osteoporosis (APCO) launched a Bone Health QI Tool Kit for healthcare professionals (HCPs) this week, to promote quality improvement (QI) of osteoporosis care.  

Designed to help stem our regional bone health crisis, the APCO Bone Health QI Tool Kit features multiple components in the screening, diagnosis, and management of osteoporosis.

“A perfect storm of a rise in osteoporosis among Asia-Pacific populations is expected to occur due to the
region’s rapidly ageing population, mounting urbanisation, and subsequent increase in sedentary lifestyles,”
said Dr Manju Chandran, APCO Chairperson, and Director of the Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Singapore.

“A recent analysis of nine Asian countries and regions reveals the number of hip fractures will more than double from 1.13 million in 2018, to 2.54 million in 2050, primarily due to changing population demographics.”

The APCO Bone Health QI Tool Kit is based on seven selected standards from The APCO Framework that apply to the clinical setting. Implementation of the QI will be through iterative Plan-Do-Study-Act (PDSA) cycles.

“Once the audits are completed, HCPs and medical centres can commence implementing changes to their clinical practice. APCO is in the process of engaging QI experts to help train APCO members to perform such projects in their individual medical centres and practices,” Dr Chandran said.

The tool kit will enable these auditing exercises to be undertaken to establish levels of adherence with those standards of care within The APCO Framework that can be implemented directly into clinical practice.

“The proportion of the Taiwanese population over 50 years of age is expected to increase from 32 per cent (7.5 million) in 2013, to 57 per cent (11.9 million) in 2050,” said Professor Derrick Chan, Co-Chair of the Asia Pacific Fragility Fracture (APFFA) Joint Steering Committee, APCO Committee member, and Director, Department of Geriatrics and Gerontology, National Taiwan University Hospital (NTUH), Chinese Taipei.

“Given the current increasing incidence of osteoporosis amongst our population, our country now has the highest prevalence of hip fracture of any country in Asia, which is also higher than the world’s average.

“The likelihood of successfully creating change to stem this bone health crisis will rest largely upon the efforts of HCPs to engage their peers to work towards shared goals. Articulating the benefits of the APCO Bone Health QI activity can help promote engagement and cooperation,” Dr Chan said.

“The critical factors to success include having a supportive organisational culture, good design and planning, and follow through on results, ensuring the data collection is meaningful and achievable.

“Data collected through the audit should be used to benchmark practice against the standards recommended by
The APCO Framework. This will show stakeholders that the audit was worth the effort, and that it contributed to tangible change,” said Dr Chan.

The APCO audit focuses on investigating the patient pathway, identifying the gaps or missed opportunities for patients at risk, and then the PDSA activity is used to improve quality of care and to formulate recommendations.

“It is hoped that lessons from implementing these clinical standards at the institutional level will be key to achieving change at the national level, through the development, or revision of national guidelines, and policy change,”
Dr Philippe Halbout, CEO, International Osteoporosis Foundation, Switzerland said.

“These coordinated systems of care aim to identify, treat and monitor patients with osteoporosis.
Timely intervention can reduce fractures by up to 50 per cent, deliver substantial financial savings, and ultimately, save lives.”

Osteoporosis is greatly under-diagnosed and under-treated in Asia, even among those at highest risk who have already fractured.

The APCO Bone Health QI Tool Kit focuses on closing this gap by:

• Understanding the baseline variables and current state of osteoporosis care in any given institution or health care practice.
• Enabling benchmarking clinical practice against The APCO Framework, evidence-based clinical practice guidelines or established protocols for the chosen standard of care.
• Using the findings to then improve the quality of care through iterative PDSA cycles.
• Using the lessons learned from implementation of the APCO Clinical Standard at an institutional level, to build momentum and work towards inclusion of the quality improvement/clinical standard in national guidelines, and lobbying for funding and policy change, as appropriate.

Practically, PDSA cycles are a quality improvement strategy that tests a change on a small scale. The PDSA builds on the learning from test cycles in a structured way before implementation on a wider scale.

The PDSA cycles are iterative. Each cycle involves the following four stages:

1. Plan – developing a plan to test the change;
2. Do – carrying out the test;
3. Study – observing and learning; and
4. Act – planning the next change cycle or full implementation.

“Assessment of adherence to pharmacological treatments that are recommended in new or revised osteoporosis clinical guidelines should be undertaken on an ongoing basis, after initiation of therapy, and appropriate corrective action can be taken if treated individuals have become non-adherent,” advised Dr Chandran.

Every patient living with osteoporosis and/or a fragility fracture passes through several points on their journey from diagnosis, through to treatment and follow-up. The interface of this pathway with other entities, for example, referrals to other care givers or departments, post- discharge follow-ups, are also important considerations in the quality of care received.

For further information about the APCO Bone Health QI Tool Kit, and to request access to the kit, head to: www.apcobonehealth.org.

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The estimated total number of new patients who presented to hospital with a hip fracture in Japan during 2012 was 175,700² – a figure projected to increase significantly, to ~320,000 by 2040.³ The difficult part of treating hip fractures in the elderly is not only the fracture itself, but various other aspects, such as perioperative care, postoperative management, rehabilitation, nursing, fall preventive measures, and osteoporosis treatment, that would serve to reduce the number of secondary fractures.

A new report published in the Archives of Orthopaedic and Trauma Surgery titled Multidisciplinary care model for geriatric patients with hip fracture describes Japan’s Toyama Municipal Hospital’s innovative concept of a multidisciplinary care model for geriatric hip fractures, and five-year outcomes, as a feasible, and effective way to provide high quality care, and generate cost savings. Given the situation, the establishment of a care model that could be introduced to Japanese hospitals, in which geriatricians are relatively scarce, was necessary. The “Toyama model” is a method of care that provides active treatment via collaboration among orthopaedic surgery, internal medicine, and all other disciplines involved in hip fracture treatment, according to the report’s authors.

The following three features formed the fundamental pillars to this multidisciplinary approach:

• To decrease time to surgery safely and smoothly

Medical examination for each patient was performed on admission in the Emergency Department by an internist. Consultation criteria for referral to specialists reduced the burden on primary care internists. An electronic united patient chart decreased the time taken for each department to receive information on the patient, and improved the efficiency of medical care. Interdisciplinary and inter-professional guidelines and a manual was developed for a full range of parameters.

• To reduce perioperative complications

There is prompt treatment of delirium in cooperation with the psychiatrist, a cooperative care algorithm for dysuria with urologists, and a perioperative co-management with geriatricians, who, while only working part-time, did so exclusively in the orthopaedic ward.

• To prevent secondary fractures

Pharmacists, dietitians, physiotherapists, and nurses started to educate both patients and family members about the prevention of secondary fracture by making use of each specialty. Since 2016, there has been a Fracture Liaison Service (FLS) on the ward, and following a patient’s discharge, to continue osteoporosis management.

On the ward, pharmacists cooperate with the physicians regarding the patient’s medication needs, and post- patient discharge. In addition, dedicated healthcare coordinators contact patients by telephone regularly after discharge, to check the continuation of anti-osteoporosis pharmacotherapy, walking ability, and re-fall event. Furthermore, they provide advice, or instruct the patient to visit the hospital, if necessary.

In this retrospective cohort study, a multidisciplinary treatment approach was applied for elderly patients who had sustained a hip fracture, since 2014. These patients (n=678, males: n=143, mean age: 84.6±7.5 years), were treated as per the multidisciplinary care model. Time to surgery, length of hospital stays, complications, osteoporosis treatment, mortality, and medical costs were evaluated.

The mean time to surgery was 1.7 days. Overall, 78.0% patients underwent surgery within 2 days. The mean duration of hospital stay was 21.0±12.4 days. The most frequent complication was deep venous thrombosis (19.0%), followed by dysuria (14.5%). Severe complications were pneumonia 3.4%, heart failure 0.8% and pulmonary embolism 0.4%. The in-hospital mortality rate was 1.2%. The 90-day, 6-month, and 1-year mortality rates were 2.5%, 6.7%, and 12.6%, respectively. The pharmacotherapy rate for osteoporosis at discharge was 90.7%, and the continuation pharmacotherapy rate was 84.7% at 1-year follow-up. The total hospitalisation medical cost per person was lower than about 400 other hospitals’ average costs per annum and totalled 14% less during the 5-year study period.

In Japan, a multidisciplinary treatment approach for geriatric fractures is rare. The study’s authors explained that “with only a few geriatricians on hand, our initial development of a closer collaboration” with internal medicine and all other departments related to hip fracture treatment “was beneficial to patients’ treatment and care”. Furthermore, with few geriatricians available to treat geriatric fractures “we were able to establish the first joint care model in Japan, … and we believe that it could be implemented in Japan as a nationwide effort” to further improve hip fracture patients’ treatment, care, and monitoring.

Report co-author, Professor Takeshi Sawaguchi, Department of Orthopaedic Surgery, Toyama Municipal Hospital, Japan, summarised his strategic approach to driving, and securing policy change, for this Japan-first, multidisciplinary care model for geriatric hip fractures.

“There is substantial evidence that the orthogeriatric co-management of geriatric hip fracture is effective. It is very helpful if the government provides reimbursement for this approach, and secondary fracture prevention. However, it is not easy to change government policy.

“To accomplish this, it is important to show evidence from your healthcare system, that this approach is beneficial for patients (involving less complications, early functional recovery and less mortality), the hospital (shorter hospital stays, increased income), and government (less healthcare cost), said Prof Sawaguchi.

“We also need to be able to demonstrate that this approach is possible to perform in average hospitals.

“This year, the Japanese government agreed with our opinion, and decided to reimburse early surgery (within 48 hours after injury), and secondary fracture prevention. We believe our trial could, therefore, prove helpful for policy change,” Prof Sawaguchi said.

To read the full article, click here.

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Post-fracture care (PFC) programs are systematic, coordinated care programs that identify, evaluate, and manage patients who have sustained a fragility fracture, with the goal of preventing further fractures. PFC programs exist in many forms, with the two main models being outpatient fracture liaison services (FLSs) and inpatient geriatric/orthogeriatric services (OGSs).³

In an Osteoporosis International review titled Post-fracture care programs for prevention of subsequent fragility fractures: a literature assessment of current trends, published March 24, 2022, the authors strive to understand trends in publications about PFC programs over the years; evaluate key characteristics of FLSs and OGSs; assess clinical effectiveness, geographic variations, and cost-effectiveness of PFC programs; and identify barriers and solutions to implementation of PFC programs.⁴

The authors explain their search for peer-reviewed articles resulted in 784 articles with relevance to PFC programs published between January 2003 and December 2020. During this period there was an increasing awareness of the importance of PFC programs in overall patient care, with the number of PFC-related publications increasing annually. Nonetheless, a publication gap remains in several countries, including those countries with a reported high incidence of fragility and/or hip fractures. This is likely impacted by geography and socioeconomic status, although further research is required to provide further information on the topic, according to the review’s authors.⁴

The benefits of FLS and OGS programs are well documented. Notably, combining FLS and OGS approaches together with the development of fragility fracture registries to provide ongoing research to advance key performance indicators (KPIs), could improve the effectiveness of PFC programs the most. Combining FLS and OGS approaches appears to result in approximately 2- to 5-times improvement in outcome measures, such as program enrolment, osteoporosis testing and diagnosis, and initiation of osteoporosis therapy.^{[5,6,7,8,9,10,11,12,13]}

It appears there is a trend toward the treatment of elderly patients, and in the diagnosis and treatment of vertebral fractures.¹⁴Articles on orthogeriatric and hip fracture care still have a stronger focus on survival and comorbidities, rather than on re-fracture rates.

As is known, patient adherence to osteoporosis medications varies, with interventions that include prescribing osteoporosis medications, often showing improved patient outcomes, but not at optimal levels. Inconsistent reporting of quality improvement measures is still a key challenge, but there is now evidence of some efforts at harmonising quality improvement measures for PFC programs,^{[15,16,17,18,19]} the review’s authors maintain.

The further success of PFC programs includes the implementation of registries, educational programs, and continuous updates of osteoporosis guidance for HCPs. The US registry AOA’s ‘Own the Bone^®’ program¹⁵ defines quality improvement measures and is credited with successfully improving the behaviours of medical professionals about osteoporosis treatment and managing patients. An independent registry²⁰ showed an increase in identification of patients with fractures who are ≥ 50 years from 0 to 74.5% as a result of registry implementation, with 33.9% of those identified patients proceeding to undergo screenings and follow-up visits. In addition, the world-first APFFA and Frailty Fracture Network, Hip Fracture Registry (HFR) Toolbox²¹ provides a distillation of information from existing national registries and practical advice on starting new registries. The Toolbox aims to advocate for, and support clinicians, hospital administrators, healthcare systems and governments with, establishing a national registry in their respective countries. For educational programs, the US-based Bone Health Extension for Community Healthcare Outcomes (TeleECHO) uses video conferencing technology, and represents a model that could be replicated to include the education of FLS coordinators and other HCPs to expand the pool of specialists who can provide bone healthcare to patients.²² Several organisations worldwide are now hosting Bone Health TeleECHO programs, including the Bone Health and Osteoporosis Foundation (BHOF) and the American Orthopaedic Association (AOA).

Lessons learned during the COVID-19 pandemic and implementing PFC delivery should include increased use of telemedicine and virtual technology, especially in rural and remote areas, according to the review’s authors.

Geographic variation-wise, PFC programs continue to expand in new and under-served regions and countries, and in countries with established PFC programs. The trend seems to be toward OGS programs. However, there is still a care gap, with issues of consideration, such as the impact of healthcare system types, and proximity to clinics or healthcare facilities, especially in countries with less developed healthcare infrastructure.

PFC programs are cost-effective,^[23,24,25] with high-intensity interventions, such as Type A FLSs, being more expensive, but generally cost-effective, or even cost-saving.^[10,26] There is evidence that reimbursement may be a bigger driver of funding decisions than quality of care.^[25,27]

The review’s authors are concerned there is still “inconsistent reporting” of economic outcomes. Not all studies report incremental cost-effectiveness ratios or quality-adjusted life-years (QALY), and “it may be more helpful to focus on cost or cost savings per patient,” they maintain. In assessing the economic cost of subsequent fragility fractures, the authors reflect that “most articles do not factor in indirect costs, such as lost productivity, even though these costs are generally considered substantial”. Lack of information is “the main barrier to prevention of subsequent fracture”, which they assert, can be addressed by educating population healthcare decision-makers, HCPs, and patients to understand the personal and societal burden of osteoporosis.

To read the full article, click here.

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In a new Therapeutic Advances in Musculoskeletal Disease review of scientific studies titled Osteoporosis in 10 years time: a glimpse into the future of osteoporosis, published on March 20, 2022, the authors focus on forecasts on the epidemiology of, and costs relating to osteoporosis in the next decade, and the future of osteoporosis diagnosis, fracture risk assessment, and treatment.¹

The Scorecard for Osteoporosis in Europe (SCOPE) is an international project providing a comprehensive picture of total direct costs relating to osteoporosis care (fragility fracture treatment and pharmacological costs). The costs equate to an astonishing €37.4 billion or USD 41.03 billion in 2010, which increased to an even greater figure in 2019 to €56.9 billion or USD 62.43 billion (+64%). This observed increase was consistent with a 50 per cent increase in costs by 2025, proposed in 2007.²

More than 4 million fractures have been reported each year in Europe over the last 5 years. These numbers are projected to increase substantially in the next decade. In fact, the SCOPE analysis has estimated that the overall number of fractures will increase by a concerning 20 per cent by 2035.¹Fortunately,effective interventions do exist, and this review outlines the following novel advances:

• Advances in imaging techniques

One of the most promising tools for estimating bone strength is the trabecular bone score (TBS). TBS can be easily implemented in most of the dual-energy X-ray absorptiometry DXA instruments.³  Hip-axis length is a way to measure the length from the great trochanter and the pelvic brim, and imaging processing software such as hip-strength analysis, and finite element analysis are other methodologies that, similarly to TBS, can be obtained from DXA analysis.

Radiofrequency echographic multi spectrometry is an innovative approach that uses ultrasound to analyse bone mineral density (BMD).^4,5

Furthermore, high-resolution peripheral quantitative computed tomography is an alternative imaging technique that can provide both quantitative and qualitative information regarding the skeleton.

• Advances in biomarkers of osteoporosis

Micro RNA (miRNA) and long-non-coding RNA (lncRNA) are novel markers and targets of great interest in the field of osteoporosis.⁶ miRNA and lncRNA can control gene expression, and are widely recognised as crucial regulators of cell development and differentiation. Consequently, targeting miRNA-103a with antagomir-103a can rescue the osteoporosis caused by immobilisation and mechanical unloading.⁷

miRNA and lncRNA are versatile markers of disease and, more interestingly, they represent a novel therapeutic target. However, targeting miRNA and lncRNA is still a futuristic prospect, nonetheless, this field has expanded considerably, and the promise of having novel agents in the next decade is now realistic, according to this review.

• Mechanical testing of bone properties in humans might represent a novel approach for osteoporosis definition.⁸ As an example, external mechanical loading has been widely used in animal studies but some applications, such as dynamic hydraulic stimulation, might be envisioned for human applications too.⁹ In addition, magnetic resonance imaging may be considered in the future as it has been shown to effectively differentiate primary mineralisation defects (e.g. osteomalacia) from structure defects (e.g. osteoporosis), possibly allowing for new, cutting-edge, virtual biopsies.¹⁰
• Novel fracture assessment tools include machine learning and deep learning approaches that are rapidly revolutionising and improving our ability to predict health outcomes.¹¹ The major advantages of the machine learning approaches over standard risk algorithms is that hundreds of clinical variables are considered, prediction of risk is automatised based on available data and, more importantly, this approach can be easily applied and automatised to hospitals that use electronic medical records, thereby reducing the burden on clinicians.
• Fracture liaison services (FLS) which involve the identification, investigation, and initiation of therapy, have been successful in reducing the incidence of new fractures.¹² In the future, FLS harmonised across hospitals could leverage automated identification of individuals who fracture, and their subsequent referral to bone specialists. This in turn, will help to define the standard of care for FLS, and both refine and improve the health system intervention. Nevertheless, worldwide, there remains a lack of awareness for osteoporosis, and FLS is not yet routine clinical practice. The review’s authors, therefore, acknowledge that there is a long way to go to harmonising FLS.
• Anabolic agents as first line treatment are associated with a significant reduction of fracture risk, but their use is restricted to 2 years, and their discontinuation is associated with a decrease in BMD levels. Therefore, prompt treatment with antiresorptive after bone anabolic agents is encouraged.

To date, there are uncertainties regarding the most appropriate exit strategy following denosumab suspension. Pre-treatment with different antiresorptive drugs might yield different results. Nevertheless, combined treatment with bone forming and antiresorptive agents seems to be the best strategy in patients at high risk of fracture, according to the review’s authors.

Sclerostin inhibitors are now available for the treatment of osteoporosis and other metabolic bone diseases. Romosozumab, a sclerostin inhibitor, represents a new therapeutic option in the armamentarium of the bone specialists. Blosozumab is among the new sclerostin inhibitor in development, for which phase III study results are expected within the next few years.¹³ DKK-1 inhibitors are in development as well.¹⁴ The potentiality of dual inhibition (DKK-1 and sclerostin) is staggering. Dual inhibition was shown to enhance cortical bridging improving fracture repair to an extent that was not considered possible before.

Yet, despite these pharmacological therapies, treatment compliance is scarce. Therefore, complementary approaches are needed. Local osteo-enhancement procedure (LOEP) is an emerging surgical procedure that has been shown to effectively reduce the risk of re-fracture.¹⁵

In summary, while osteoporosis is projected to cause millions of deaths worldwide moving forward, the review’s authors maintain: “We can face this anticipated crisis with novel diagnostic, prognostic, and therapeutic strategies. In the next decade, we will have broader access to novel and more precise methods of fracture risk prediction. Patients at high risk of fracture will be more commonly referred to the bone specialist for treatment thanks to the diffusion of FLS. Osteoporosis treatment will evolve, we will have more confidence with combined and sequential strategies, and we will have access to novel and innovative pharmacological therapies.”

To read the full article click here.

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The Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors recently published a comprehensive narrative review in ‘Osteoporosis International’ exploring the global approach to rehabilitation post- fragility fracture. The review provides evidence for a range of rehabilitation strategies instrumental in the management of fragility fractures in patients without cognitive impairment, and further provides recommendations for future research.

The continuum of care for rehabilitation post- fragility fracture is highly complex, with improvements from rehabilitation, in some cases, realised nine and 12-months following fracture.

The narrative review delved into a plethora of scientific literature and clinical studies performed between 2010 and 2020. Key findings from the review include:

Exercise

• Multi-modal exercise post- fragility fracture to the spine and hip is strongly recommended to reduce pain, and improve both physical function and quality of life.
• Progressive resistance training, weight-bearing impact training, and functional balance, agility and coordination training should all be considered in managing patients at high risk of fragility fracture.

Physiotherapy

• Outpatient physiotherapy post- hip fracture has a stronger evidence base than outpatient physiotherapy post- vertebral fracture.
• Multi-disciplinary rehabilitation programs within the context of physiotherapy, may include behavioural interventions such as counselling, workbooks, goal setting, motivational interviewing and cognitive behavioural therapy. Research suggests psychologically-informed rehabilitation programs improve patient participation.

Nutrition

• Appropriate nutritional care, through dietary changes or supplements, after a fragility fracture provides a large range of improvement in morbidity, and reduces mortality.
• Some studies have also revealed that nutritional supplements may result in less medical complications (including fewer pressure ulcers and shorter wound healing times), fewer infections, reduced length of hospital stay, lower mortality, a preservation of BMD, and better muscle function.

Patient education

• Patient education not only heightens a patient’s understanding and knowledge of osteoporosis, but may also improve other health outcomes, such as health-related quality of life, physical activity, psychosocial functioning and adherence to both pharmacological and non-pharmacological treatments.
• Education may further improve other health outcomes, such as pain, and increase a patient’s ability to self-advocate.
• Despite being a useful tool in the management of osteoporosis, patient education has been highlighted as an area of unmet need among those living with osteoporosis and fragility fractures.

According to article co-author and Rehabilitation Working Group Co-chair, Assistant Professor Daniel Pinto, United States:

“Rehabilitation interventions result in considerable improvements for patients, and the benefits can be realised up to a year after fracture. However, rehabilitation modalities are both complex and inter-reliant, involving the interaction of exercise, nutrition, physiotherapy, falls prevention programs, and patient education, among other modalities.

“In this narrative review, we looked at distinct elements of a comprehensive approach to post-fracture management, and analysed the state of the evidence for each.

“The aim was to provide a succinct resource for clinicians and for Fracture Liaison Services (FLS), which are important providers of multidisciplinary post- fracture care,” said A/Prof Pinto.

The review concludes with recommendations involving areas that require further research, including the development of individualised exercise approaches considering patient preferences and factors designed to increase adherence; clinical trials to define the exercise regimens that may lead to the greatest reduction in kyphosis and pain after a vertebral fracture; clinical trials that define exercise regimens which ensure the best recovery and shortest length of stay in rehabilitation units; gaining a better understanding of the specific educational needs of patients and their carers; and trials on the implementation of rehabilitation strategies associated with FLS for secondary fracture prevention, among others.

To read the full article, click here.

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