Models of Care for improving outcomes for people with, or even at risk of, osteoporosis include: fracture liaison, screening, education and exercise programmes.
Several Models of Care have been developed over the last two decades. Two that have become critically important are: fracture liaison services and primary care identification of fracture risk. As a result of close work between physicians/geriatricians and orthopaedic surgeons, appropriate care of hip fracture patients has considerably improved results, and the sub-speciality of ortho-geriatrics is rapidly growing worldwide.
Primary Fracture Prevention
To date, advances in fracture risk assessment can now provide clinically effective, as well as cost-effective approaches. Cost effectiveness depends on preventing the most likely and most problematic and costly fractures e.g. hip fractures
Approaches to finding individuals at high risk of suffering these fractures as their first fracture include:
- Osteoporosis induced by medicines(e.g corticosteroids): this requires consistent bone health assessment and treatment for individuals at high fracture risk in this group.
- Diseases associated with osteoporosis(e.g. malabsorption syndromes, diabetes etc): this requires routine bone health assessment and treatment for individuals living with diseases related to osteoporosis and fragility fractures.
- Absolute fracture risk calculation: this requires systematic application of tools such as FRAX to identify older persons who are at risk and currently being served by a medical practice or health system. Recently, evidence has demonstrated that actively screening older women for fracture risk using FRAX in the primary care setting leads to a reduction in the risk of hip fracture.
- Fracture risk assessment in routine practice: this requires regular fracture risk assessment by primary care providers when working with older individuals and patients at high risk of fracture.
Secondary Fracture Prevention
Models of Care have been developed to ensure fracture patients receive osteoporosis management and intervention to prevent future fractures. Two complementary Models of Care have been established in a growing number of countries:
Orthogeriatric Services (OGS)
OGS focus on delivering best practice for hip fracture patients. This includes expedited surgery, optimal management of the acute phase through adherence to clinical standards overseen by senior orthopaedic and geriatrician/internal medicine clinicians, and delivery of secondary fracture prevention which addresses both bone health and risks of falling.
Fracture Liaison Services (FLS)
A FLS is a co-ordinated Model of Care for secondary fracture prevention. A Fracture Liaison Service ensures that all patients aged 50 years or over, who require urgent care services with regard to a fragility fracture, undergo fracture risk assessment and receive treatment in accordance with prevailing clinical guidelines for osteoporosis.
The Fracture Liaison Service should also ensure that the risk of falling is addressed among older patients through referral to appropriate local services. This, together with Orthogeriatric Services, and in combination with national hip fracture registries, has been shown to improve the care of hip fracture patients.
In hospitals without an OGS, the Fracture Liaison Service provides secondary preventive care for all fragility fracture patients. Fracture Liaison Services have been shown to dramatically improve osteoporosis treatment rates for fragility fracture patients, as well as reducing secondary fracture incidence. A successful FLS is also and enormous cost-saver to both the hospitals and Funders.
Models of Care should be based around: a Primary Care strategy; a Chronic Conditions framework; Orthogeriatric Falls Prevention; an improvement framework for musculoskeletal conditions; prevention practices for minimal trauma fractures; early recognition of high fracture risk; and finally, improved utilisation and quality of treatment, along with adequately trained workforces and community-based services.
- Health professionals must consider the clinical risk factors of patients and use evidence-based guidelines for the prevention and treatment of osteoporosis in postmenopausal women and older men, in order to effectively guide the prescription of treatments.
- Patients should be educated about the efficacy of pharmacologic treatments for osteoporosis, in particular the significant benefits of treatment relative to the risks of not receiving treatment.
- There should be continual promotion of the importance of self-management in the prevention and treatment of osteoporosis and post-fracture care.
- Fracture Liaison Services must co-ordinate care between hospital and community settings.
NOFSA (National Osteoporosis Foundation South Africa)
NOFSA is the only non-profit, voluntary health organisation dedicated to promoting lifelong bone health. We focus on reducing the widespread prevalence of osteoporosis while working to find a cure for the disease, and by supporting research and developing programmes of education and advocacy.
Find out more about our work at: www.osteoporosis.org.za