Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle
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The International Osteoporosis Foundation (IOF) Capture the Fracture Campaign aims to support implementation of Fracture Liaison Services (FLS) throughout the world.
FLS have been shown to close the ubiquitous secondary fracture prevention care gap, ensuring that fragility fracture sufferers receive appropriate assessment and intervention to reduce future fracture risk.
Capture the Fracture has developed internationally endorsed standards for best practice, will facilitate change at the national level to drive adoption of FLS and increase awareness of the challenges and opportunities presented by secondary fracture prevention to key stakeholders. The Best Practice Framework (BPF) sets an international benchmark for FLS, which defines essential and aspirational elements of service delivery.
The BPF has been reviewed by leading experts from many countries and subject to beta-testing to ensure that it is internationally relevant and fit-for-purpose. The BPF will also serve as a measurement tool for IOF to award ‘Capture the Fracture Best Practice Recognition’ to celebrate successful FLS worldwide and drive service development in areas of unmet need. The Capture the Fracture website will provide a suite of resources related to FLS and secondary fracture prevention, which will be updated as new materials become available. A mentoring programme will enable those in the early stages of development of FLS to learn from colleagues elsewhere that have achieved Best Practice Recognition. A grant programme is in development to aid clinical systems which require financial assistance to establish FLS in their localities.
Nearly half a billion people will reach retirement age during the next 20 years. IOF has developed Capture the Fracture because this is the single most important thing that can be done to directly improve patient care, of both women and men, and reduce the spiralling fracture-related care costs worldwide.
KeywordsCapture the Fracture Coordinator-based FLS Fracture Liaison Service Fracture prevention Fragility fracture
The International Osteoporosis Foundation Capture the Fracture Campaign
In 2012, the International Osteoporosis Foundation (IOF) launched the Capture the Fracture Campaign [1, 2]. Capture the Fracture is intended to substantially reduce the incidence of secondary fractures throughout the world. This will be delivered by establishment of a new standard of care for fragility fracture sufferers, whereby health care providers always respond to the first fracture to prevent the second and subsequent fractures. The most effective way to achieve this goal is through implementation of coordinator-based, post-fracture models of care. Exemplar models have been referred to as ‘Fracture Liaison Services’ (United Kingdom [3, 4, 5, 6, 7], Europe [8, 9] and Australia [10, 11, 12]), ‘Osteoporosis Coordinator Programs’ (Canada [13, 14]) or ‘Care Manager Programs’ (USA [15, 16]). For the purposes of this position paper, they will be referred to as Fracture Liaison Services (FLS).
During the first 10 years of the twenty-first century—the first Bone and Joint Decade —considerable progress was made in terms of establishment of exemplar FLS in many countries  and the beginning of inclusion of secondary fracture prevention into national health policies [18, 19, 20, 21, 22, 23, 24, 25, 26]. However, FLS are currently established in a very small proportion of facilities that receive fracture patients worldwide, and many governments are yet to create the political framework to support funding of new services. The goal of Capture the Fracture is to facilitate adoption of FLS globally. This will be achieved by recognising and sharing best practice with health care professionals and their organisations, national osteoporosis societies and the patients they represent, and policymakers and their governments. This position paper describes why Capture the Fracture is needed and precisely how the campaign will operate over the coming years. IOF believes this is the single most important thing that can be done to directly improve patient care, for women and men, and reduce spiralling fracture-related health care costs worldwide.
The need for a global campaign
In 2002, the combined cost of all osteoporotic fractures in the USA was 20 billion USD 
In 2006, China spent 1.6 billion USD on hip fracture care, which is projected to rise to 12.5 billion USD by 2020 and 265 billion USD by 2050 
National audits of secondary fracture prevention
No. of fracture patients
Fracture risk assessment done or risk factors identified (%)
Treated for osteoporosis (%)
Minimal-trauma fracture presentations to Emergency Departments
– < 13 % had risk factors identified
–12 % received calcium
Teede et al. 
–10 % ‘appropriately investigated’
–12 % received vitamin D
–8 % received a bisphosphonate
Men participating in the Canadian Multicentre Osteoporosis Study (CaMos) with a prevalent clinical fracture at baseline
–At baseline, 2.3 % reported a diagnosis of osteoporosis
–At baseline, <1 % were taking a bisphosphonate
Papaioannou et al. 
–At year 5, 10.3 % (39/379) with a clinical fragility fracture (incident or prevalent) reported a diagnosis of osteoporosis
–At year 5, the treatment rate for any fragility fracture was 10 % (36/379)
Patients admitted to hospital with an isolated distal radius fracture
62 % of women and 50 % of men had evidence of osteoporosis
7 % were prescribed osteoporosis-specific medication
Smektala et al. 
Ambulatory patients with a previous osteoporotic hip fracture attending orthopaedic clinics
–< 20 % of patients had taken an antiresorptive drug before their hip fracture
Carnevale et al. 
–< 50 % took any kind of treatment for osteoporosis 1.4 years after initial interview
Females suffering their first hip fracture
BMD was measured before or during hospitalisation for 16 % of patients
–19 % of patients received osteoporosis treatment in the year following fracture
Hagino et al. 
–36 % of patients receiving osteoporosis treatment during hospitalisation continued at 1 year
Nationwide cohort of females with hip, spine and wrist fractures
BMD was measured for 23 % with hip fracture, 29 % with spine fracture and 9 % with wrist fracture
≥1 approved osteoporosis treatment was received by 22 % with hip fracture, 30 % with spine fracture and 8 % with wrist fracture
Gong et al. 
Patients hospitalised for a fracture of the hip, spine, wrist or other fractures
For a sample of 208 out of 1,654 cases, GP case records were available. Of these patients, 5 % had a diagnosis of osteoporosis in the GP records
15 % of patients received osteoporosis treatment within 1 year after discharge from hospital
Panneman et al. 
Patients presenting with a fragility fracture to hospital emergency wards
BMD was measured for 31 % of patients
24 % of women and 14 % of men were treated with a bone active drug, generally a bisphosphonate with or without calcium and/or vitamin D
Suhm et al. 
Patients who presented with a hip or non-hip fragility fracture
32 % of non-hip fracture and 67 % of hip fracture patients had a clinical assessment for osteoporosis and/or fracture risk
33 % of non-hip fracture and 60 % of hip fracture patients received appropriate management for bone health
Royal College of Physicians 
Patients hospitalised for osteoporotic hip fracture
7 % received an anti-resorptive or bone-forming medication
Jennings et al. 
Cost concerns relating to diagnosis and treatment
Time required for diagnosis and case finding
Concerns relating to polypharmacy
Lack of clarity regarding where clinical responsibility resides
‘Osteoporosis care of fracture patients has been characterised as the Bermuda Triangle made up of orthopaedists, primary care physicians and osteoporosis experts into which the fracture patient disappears’
Surveys have shown that in the absence of a robust care pathway for fragility fracture patients, a ‘Catch-22’ scenario prevails . Orthopaedic surgeons rely on primary care doctors to manage osteoporosis; primary care doctors routinely only do so if so advised by the orthopaedic surgeon; and osteoporosis experts—usually endocrinologists or rheumatologists—have no cause to interact with the patient during the fracture episode. The proven solution to close the secondary fracture prevention care gap is to eliminate this confusion by establishing a Fracture Liaison Service (FLS).
Inclusive case finding
Evidence-based assessment—stratify risk, identify secondary causes of osteoporosis, tailor therapy
Initiate treatment in accordance with relevant guidelines
Improve long-term adherence with therapy
‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’
We know that secondary fracture prevention is clinically and cost-effective, but does not routinely happen. FLS closes the disparity between current knowledge and current practice.
An important component of the Capture the Fracture Campaign will be to establish global reference standards for FLS. Several systematic reviews have highlighted that a range of service models have been designed to close the secondary fracture prevention care gap, with varying degrees of success [72, 99, 100]. Having clarity on precisely what constitutes best practice will provide a mechanism for FLS in different localities and countries to learn from one another. The Capture the Fracture ‘Best Practice Framework’ described later in this position paper aims to provide a mechanism to facilitate this goal.
How Capture the Fracture works
The Capture the Fracture Campaign was launched at the IOF European Congress on Osteoporosis and Osteoarthritis in Bordeaux, France in March 2012. Healthcare professionals that have played a leading role in establishing FLS and representatives from national patient societies shared their efforts to embed FLS in national policy in their countries. In October 2012, the IOF World Osteoporosis Day report was devoted to Capture the Fracture  and disseminated at events organised by national societies throughout the world . This position paper presents the aims and structure of the Capture the Fracture Campaign. A Steering Committee comprised of the authorship group of this position paper has led development of the campaign and will provide ongoing support to the implementation of the next steps.
- Standards: To provide internationally endorsed standards for best practice in secondary fracture prevention. Specific components are:
Best Practice Framework
Best Practice Recognition
Showcase of best practices
- Change: Facilitation of change at the local and national level will be achieved by:
Implementation guides and toolkits
Grant programme for developing systems
- Awareness: Knowledge of the challenges and opportunities presented by secondary fracture prevention will be raised globally by:
An ongoing communications plan
Anthology of literature, worldwide surveys and audits
International coalition of partners and endorsers
Internationally endorsed standards
Defines the essential and aspirational building blocks that are necessary to implement a successful FLS, and
Serves as the measurement tool for IOF to award ‘Capture the Fracture Best Practice Recognition’ in celebration of successful FLS worldwide
Use existing procedures as they correspond to their health care system: Existing, individual systems and procedures that are currently in place can be used to measure performance against the standards.
Meaning of the term ‘institution’: Throughout the BPF, the word ‘institution’ is used which is intended to be a generic term for: the inpatient and/or outpatient facilities, and/or health care systems for which the FLS was established to serve.
Limit applications to ‘systems’ of care: The BPF is intended for larger ‘systems’ of care, within the larger health care setting, which consist of multidisciplinary providers and deal with a significant volume of fracture patients.
- Recognise that the BPF is both achievable and ambitious: Some of the BPF standards address essential aspects of an FLS, while others are aspirational. A weight has been assigned to each standard based on how important the standard is in relation to an FLS delivering best practice care. This:
Enables recognition of systems who have achieved the most essential elements, while leaving room for improvement towards implementing the aspirational elements
Allows systems to achieve a standard of care, Silver for example, with a range of levels of achievement across the 13 standards
Placement of the applicant’s FLS on the Capture the Fracture website’s interactive map, including the system name, location, link and programme showcase
Awarded use of the IOF-approved, Capture the Fracture Best Practice Recognition logo for use on the applicant’s websites and materials
Facilitating change at the local and national level
The Capture the Fracture website—www.capturethefracture.org—provides links to resources related to FLS and secondary fracture prevention. These include FLS implementation guides and national toolkits which have been developed for some countries. As new resources become available, the website will serve as a portal for sharing of materials to support healthcare professionals and national patient societies to establish FLS in their institutions and countries.
Further supporting the establishment of FLS, Capture the Fracture will organise a locality specific mentoring programme between sites that have achieved Best Practice Recognition and those systems that are in early stage development. An opportunity exists to create a global network to support sharing of the successes and challenges that will be faced in the process of implementing best practice. This network has the potential to contribute significantly to adoption of FLS throughout the world. During 2013, IOF intends to develop a grant programme to aid clinical systems around the world which require financial assistance to establish FLS.
A substantial body of literature on secondary fracture prevention and FLS has developed over the last decade. A feature of the Capture the Fracture website is a Research Library which organises the world’s literature into an accessible format. This includes sections on care gaps and case finding; assessment, treatment and adherence; and health economic analysis.
IOF has undertaken to establish an international coalition of partners and endorsers to progress implementation of FLS. At the national level, establishment of multi-sector coalitions has played an important role in achieving prioritisation of secondary fracture prevention and FLS in national policy and reimbursement systems . The Capture the Fracture website provides a mechanism to share such experience between organisations and national societies in different countries. Increasing awareness that the secondary fracture prevention care gap has been closed by implementation of FLS, and that policy and reimbursement systems have been created to support establishment of new FLS, will catalyse broader adoption of the model.
A global call to action
During the next 20 years, 450 million people worldwide will celebrate their 65th birthday . As a result, in the absence of systematic preventive intervention, the human and financial costs of fragility fractures will rise dramatically. Policymakers, professional organisations, patient societies, payers and the private sector must work together to ensure that every fracture that could be prevented is prevented. Almost half of hip fracture patients suffer a previous fragility fracture before breaking their hip, creating an obvious opportunity for intervention. However, currently, a secondary fracture prevention care gap exists throughout the world. This care gap can and must be eliminated by implementation of Fracture Liaison Services. The Capture the Fracture Campaign provides all necessary evidence, international standards of care, practical resources and a network of innovators to support colleagues globally to close the secondary prevention care gap. We call upon those responsible for fracture patient care throughout the world to implement Fracture Liaison Services as a matter of urgency.
The authors would like to thank Gilberto Lontro (Senior Graphic Designer, IOF), Chris Aucoin (Multimedia Intern) and Shannon MacDonald, RN (Science Coordinator, IOF) for their excellent and many contributions to development of the Capture the Fracture Campaign. We are also very grateful to the following colleagues throughout the world who have provide invaluable support in the development of the Best Practice Framework: Dr. Andrew Bunta (Own the Bone, American Orthopaedic Association, USA), Dr. Pedro Carpintero (University Hospital Reina Sofia, Cordoba, Spain), Dr. Manju Chandran (Singapore General Hospital, Singapore), Dr. Gavin Clunie (Addenbrookes Hospital, Cambridge, UK), Professor Elaine Dennison (University of Southampton, UK), Ravi Jain (Osteoporosis Canada), Professor Stephen Kates (University of Rochester Medical Center, USA), Dr. Ambrish Mithal (Medanta Medicity, Gurgaon, India), Dr. Eric Newman (Geisinger Health System, USA), Dr. Marcelo Pinheiro (Universidade Federal de São Paulo, Brazil), Professor Markus Seibel (The University of Sydney at Concord, Australia), Dr. Bernardo Stolnicki (Federal Hospital Ipanema, Brazil), Professor Thierry Thomas (Groupe de Recherche et d’Information sur L' Ostéoporose [GRIO], France), Dr. Jan Vaile (Royal Prince Alfred Hospital, Sydney, Australia), Dr. John Van Der Kallen (John Hunter Hospital, Newcastle, Australia).
Conflicts of interest
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