Skip to main content

Advertisement

SpringerLink
Log in

Quality Improvement Initiatives in Fragility Fracture Care and Prevention

  • Quality of Care in Osteoporosis (S Silverman and J Curtis, Section Editors)
  • Published:
Current Osteoporosis Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review sought to describe quality improvement initiatives in fragility fracture care and prevention.

Recent Findings

A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance.

Summary

Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. United Nations Department of Economic and Social Affairs Population Division. World Population Prospects: The 2017 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP.248. New York; 2017.

  2. United Nations Department of Economic and Social Affairs Population Division. World Population Prospects: Volume II: Demographic Profiles 2017 Revision (ST/ESA/SER.A/400). New York; 2017.

  3. France24. In historic first, G20 weighs ageing as global risk. 2019. https://www.france24.com/en/20190609-historic-first-g20-weighs-ageing-global-risk Accessed 29 Sept 2019.

  4. Cooper C, Ferrari S. IOF Compendium of Osteoporosis. In Harvey N, Dennison E, editors. 1st ed. Nyons: International Osteoporosis Foundation; 2019.

  5. United Nations Economic and Social Commission for Asia and the Pacific. 2016 ESCAP population data sheet. Bangkok: Social Development Division, Economic and Social Commission for Asia and the Pacific (ESCAP); 2016.

    Google Scholar 

  6. Si L, Winzenberg TM, Jiang Q, Chen M, Palmer AJ. Projection of osteoporosis-related fractures and costs in China: 2010-2050. Osteoporos Int. 2015;26:1929–37.

    Article  CAS  Google Scholar 

  7. Hernlund E, Svedbom A, Ivergard M, et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8:136.

    Article  CAS  Google Scholar 

  8. United Nations Department of Economic and Social Affairs Population Division. World Population Ageing. New York: United Nations; 2015.

    Google Scholar 

  9. Zerbini CA, Szejnfeld VL, Abergaria BH, et al. Incidence of hip fracture in Brazil and the development of a FRAX model. Arch Osteoporos. 2015;10:224.

    Article  CAS  Google Scholar 

  10. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22:465–75.

    Article  Google Scholar 

  11. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004;35:375–82.

    Article  CAS  Google Scholar 

  12. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000;15:721–39.

    Article  CAS  Google Scholar 

  13. Gallagher JC, Melton LJ, Riggs BL, Bergstrath E. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop Relat Res. 1980:163–71.

  14. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eisman J. Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int. 2003;14:780–4.

    Article  Google Scholar 

  15. McLellan A, Reid D, Forbes K et al. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland; 2004.

  16. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res. 2007;461:226–30.

    PubMed  Google Scholar 

  17. • Harvey NC, McCloskey EV, Mitchell PJ, et al. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int. 2017;28:1507–29. This paper provides a comprehensive summary of the therapeutic evidence base specifically in the context of secondary fracture prevention.

    Article  CAS  Google Scholar 

  18. Harvey NC, McCloskey EV. Gaps and solutions in bone health: a global framework for improvement. In: Misteli L, Laverty C, Stenmark J, editors. World Osteoporosis Day Thematic Report. Nyon: International Osteoporosis Foundation; 2016.

    Google Scholar 

  19. Lih A, Nandapalan H, Kim M, Yap C, Lee P, Ganda K, et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int. 2011;22:849–58.

    Article  CAS  Google Scholar 

  20. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006;88:25–34.

    PubMed  Google Scholar 

  21. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int. 2003;14:1028–34.

    Article  Google Scholar 

  22. Dell R, Greene D, Schelkun SR, Williams K. Osteoporosis disease management: the role of the orthopaedic surgeon. J Bone Joint Surg Am. 2008;90(Suppl 4):188–94.

    Article  Google Scholar 

  23. Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2013;24:393–406.

    Article  CAS  Google Scholar 

  24. • Ganda K, Mitchell PJ, Seibel MJ. Models of secondary fracture prevention: systematic review and meta-analysis of outcomes. In: Seibel MJ, Mitchell PJ, editors. Secondary Fracture Prevention: An International Perspective. San Diego: Elsevier; 2019. p. 33–62. This recent meta-analysis provides an update on the impact of Fracture Liaison Services as a function of the intensity of the service model.

    Chapter  Google Scholar 

  25. Seibel MJ, Mitchell PJ, editors. Secondary fracture prevention: an international perspective. San Diego: Elsevier; 2019.

    Google Scholar 

  26. Wu CH, Tu ST, Chang YF, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone. 2018;111:92–100.

    Article  Google Scholar 

  27. •• Javaid MK, Kyer C, Mitchell PJ, et al. Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture® Best Practice Framework tool. Osteoporos Int. 2015;26:2573–8. This paper illustrates the effectiveness of the IOF Capture the Fracture®Programe Best Practice Framework as a tool to benchmark performance of FLS globally.

    Article  CAS  Google Scholar 

  28. •• Javaid MK, Vasilakis N, Dickinson R, et al. Fracture Liaison Service Database Annual report December 2018: Achieving effective service delivery by Fracture Liaison Services. London: Royal College of Physicians; 2018. The UK national FLS Database is the first such database in the world. This report could provide colleagues in other countries with insights on how to establish a national FLS Database in their own countries.

    Google Scholar 

  29. Majumdar SR, McAlister FA, Johnson JA, Rowe BH, Bellerose D, Hassan I, et al. Comparing strategies targeting osteoporosis to prevent fractures after an upper extremity fracture (C-STOP Trial): a randomized controlled trial. J Bone Miner Res. 2018;33:2114–21.

    Article  Google Scholar 

  30. McAlister FA, Ye C, Beaupre LA. Adherence to osteoporosis therapy after an upper extremity fracture: a pre-specified substudy of the C-STOP randomized controlled trial. Osteoporos Int. 2019;30:127–34.

    Article  CAS  Google Scholar 

  31. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet. 1996;348:1535–41.

    Article  CAS  Google Scholar 

  32. van den Berg P, van Haard PMM, Geusens PP, van den Bergh J, Schweitzer DH. Challenges and opportunities to improve fracture liaison service attendance: fracture registration and patient characteristics and motivations. Osteoporos Int. 2019;30:1597–606.

    Article  Google Scholar 

  33. Osteoporosis New Zealand. Bone Care 2020: A systematic approach to hip fracture care and prevention for New Zealand. Wellington; 2012.

  34. Accident Compensation Corporation. Ministry of Health, Health Quality & Safety Commission New Zealand, New Zealand Government. Live Stronger for Longer: Prevent falls and fractures. 2019. http://livestronger.org.nz/. Accessed 29 Sept 2019.

  35. Accident Compensation Corporation. Ministry of Health, Health Quality & Safety Commission New Zealand. Falls & fractures outcomes framework: Supporting quality improvement across the health system to reduce harm from falls. 2019. https://public.tableau.com/profile/hqi2803#!/vizhome/FallsFracturesOutcomesFramework/Landing. Accessed 29 Sept 2019.

  36. • Chang L-Y, Tsai K-S, Peng J-K, et al. The development of Taiwan Fracture Liaison Service network. Osteoporos Sarcopenia. 2018;4:47–52. The approach to drive widespread implementation of the FLS model throughout Taiwan is an example of best practice which could be replicated elsewhere.

    Article  Google Scholar 

  37. International Osteoporosis Foundation. IOF Capture the Fracture®: Map of Best Practice. 2019. https://capturethefracture.org/map-of-best-practice. Accessed 29 Sept 2019.

  38. International Osteoporosis Foundation. Capture the Fracture®: Taiwanese society reports successes in secondary fracture prevention. 2017. https://www.capturethefracture.org/taiwanese-society-reports-successes-secondary-fracture-prevention. Accessed 29 Sept 2019.

  39. Mitchell PJ. Best practices in secondary fracture prevention: fracture liaison services. Curr Osteoporos Rep. 2013;11:52–60.

    Article  Google Scholar 

  40. Gittoes N, McLellan AR, Cooper A, et al. Effective secondary prevention of fragility fractures: clinical standards for fracture liaison services. Camerton: National Osteoporosis Society; 2015.

    Google Scholar 

  41. Royal Osteoporosis Society. FLS Implementation Toolkit. 2019. https://theros.org.uk/healthcare-professionals/fracture-liaison-services/implementation-toolkit/. Accessed 29 Sept 2019.

  42. Royal College of Physicians. Fracture Liaison Service Database (FLS-DB). 2019. https://www.rcplondon.ac.uk/projects/fracture-liaison-service-database-fls-db. Accessed 29 Sept 2019

  43. Royal College of Physicians. Fracture Liaison Service Database (FLS-DB) facilities audit - FLS breakpoint: opportunities for improving patient care following a fragility fracture. London: Royal College of Physicians; 2016.

    Google Scholar 

  44. Royal College of Physicians. FLS-DB clinical audit: identifying high-quality care in the NHS for secondary fracture prevention. London: Royal College of Physicians; 2017.

    Google Scholar 

  45. Axelsson KF, Jacobsson R, Lund D, Lorentzon M. Effectiveness of a minimal resource fracture liaison service. Osteoporos Int. 2016;27:3165–75.

    Article  CAS  Google Scholar 

  46. Andreasen C, Solberg LB, Basso T, et al. Effect of a fracture liaison service on the rate of subsequent fracture among patients with a fragility fracture in the Norwegian Capture the Fracture Initiative (NoFRACT): a trial protocol. JAMA Netw Open. 2018;1:e185701.

    Article  Google Scholar 

  47. Borgen TT, Bjornerem A, Solberg LB, et al. High prevalence of vertebral fractures and low trabecular bone score in patients with fragility fractures: a cross-sectional sub-study of NoFRACT. Bone. 2019;122:14–21.

    Article  Google Scholar 

  48. Tei RMH, Ramlau-Hansen CH, Plana-Ripoll O, et al. OFELIA: prevalence of osteoporosis in fragility fracture patients. Calcif Tissue Int. 2019;104:102–14.

    Article  CAS  Google Scholar 

  49. Tei RMH, Plana-Ripoll O, Brink O, Langdahl BL. An optimised fracture liaison service model: maintained diagnostic sensitivity despite reduced number of diagnostic tests performed. Calcif Tissue Int. 2019;104:641–9.

    Article  CAS  Google Scholar 

  50. Akesson K, Marsh D, Mitchell PJ, McLellan A, Stenmark J, Pierroz DD, et al. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013;24:2135–52.

    Article  CAS  Google Scholar 

  51. International Osteoporosis Foundation. Capture the Fracture® Programme website. 2019. https://www.capturethefracture.org/. Accessed 29 Sept 2019.

  52. International Osteoporosis Foundation. Capture the Fracture® Website - Mentorship page. 2019. https://capturethefracture.org/mentorship-programme. Accessed 29 Sept 2019.

  53. International Osteoporosis Foundation. IOF Global Patient Charter. 2017. https://www.iofbonehealth.org/iof-global-patient-charter. Accessed 29 Sept 2019.

  54. Center for Medical Technology Policy. Strategic Roadmap to Prevent Secondary Fractures. Baltimore; 2017.

  55. American Society for Bone and Mineral Research. Patients 65 Years of Age or Older Who Experience a Hip or Spine Fracture Should be Treated for Osteoporosis, Says Global Coalition of Bone Health Experts and Patient Advocacy Organizations. 2018. http://www.asbmr.org/about/pressreleases/detail.aspx?cid=8281a027-f61f-446f-ba1f-77b4a2222d8e. Accessed 29 Sept 2019.

  56. •• Dreinhofer KE, Mitchell PJ, Begue T, et al. A global call to action to improve the care of people with fragility fractures. Injury. 2018;49:1393–7. This Global Call to Action received an unprecedented level of endorsement from healthcare professional organisations throughout the world, and may serve as a catalyst to stimulate formtion of national multi-sector, multidisciplinary alliances to expedite national policy change.

    Article  CAS  Google Scholar 

  57. International Osteoporosis Foundation. Launch of multidisciplinary alliance aiming to curb Asia Pacific’s fragility fractures. 2018. https://www.iofbonehealth.org/news/launch-multidisciplinary-alliance-aiming-curb-asia-pacific%E2%80%99s-fragility-fractures. Accessed 19 Sept 2019.

Download references

Funding

Amgen Asia provided financial support to fund a secretariat function, event management and communication activities leading up to the formation of the Asia Pacific Fragility Fracture Alliance (APFFA), noting Amgen Asia had no role in the development of this publication.

Author information

Authors and Affiliations

  1. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK

    Paul J. Mitchell

  2. School of Medicine, Sydney Campus, The University of Notre Dame Australia, 140 Broadway, Sydney, NSW, 2007, Australia

    Paul J. Mitchell

  3. Fragility Fracture Network, c/o MCI Schweiz AG, Schaffhauserstrasse 550, 8052, Zürich, Switzerland

    Paul J. Mitchell, Matthew Costa, Karsten E. Dreinhöfer & David R. Marsh

  4. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

    Cyrus Cooper

  5. NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK

    Cyrus Cooper

  6. NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK

    Cyrus Cooper & M. Kassim Javaid

  7. International Osteoporosis Foundation, 9 rue Juste-Olivier, CH-1260, Nyon, Switzerland

    Cyrus Cooper, Masaki Fujita, Philippe Halbout, Kristina Åkesson & M. Kassim Javaid

  8. Department of Orthopaedics, Skane University Hospital, Malmö, Sweden

    Kristina Åkesson

  9. Department of Clinical Sciences, Lund University, Malmö, Sweden

    Kristina Åkesson

  10. Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK

    Matthew Costa

  11. Department of Musculoskeletal Rehabilitation, Prevention and Health Service Research, Center for Sport Science and Sport Medicine (CSSB), Center for Musculoskeletal Surgery (CMSC), Charité Universitätsmedizin, Berlin, Germany

    Karsten E. Dreinhöfer

  12. Department of Orthopedics and Traumatology, Medical Park Berlin Humboldtmühle, Berlin, Germany

    Karsten E. Dreinhöfer

  13. University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK

    David R. Marsh

  14. Department of Orthopedic Surgery, Beacon International Specialist Centre, Petaling Jaya, Selangor, Malaysia

    Joon-Kiong Lee

  15. Advanced Neuroscience and Orthopedic Centre (ANOC), Kuala Lumpur, Malaysia

    Joon-Kiong Lee

  16. Department of Geriatrics and Gerontology and Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan

    Ding-Cheng (Derrick) Chan

  17. Superintendent Office, Chutung Branch, National Taiwan University Hospital, Hsinchu County, Taiwan

    Ding-Cheng (Derrick) Chan

Authors
  1. Paul J. Mitchell
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Cyrus Cooper
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Masaki Fujita
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Philippe Halbout
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kristina Åkesson
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Matthew Costa
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Karsten E. Dreinhöfer
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. David R. Marsh
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Joon-Kiong Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ding-Cheng (Derrick) Chan
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. M. Kassim Javaid
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Conflict of Interest

Paul Mitchell (PM): PM has undertaken consultancy for governments, national and international osteoporosis societies, healthcare professional organisations and private sector companies relating to systematic approaches to fragility fracture care and prevention since 2005.

Cyrus Cooper (CC): CC has received consulting fees and honoraria from Amgen, Danone, Eli Lilly, GSK, Medtronic, Merck, Nestle, Novartis, Pfizer, Roche, Servier, Shire, Takeda and UCB.

Masaki Fujita (MF): MF has no disclosures relating to this work. MF is the Project Leader of the Capture the Fracture® Programme of the International Osteoporosis Foundation.

Philippe Halbout (PH): PH has no disclosures relating to this work. PH is the Chief Executive Officer of the International Osteoporosis Foundation.

Kristina Åkesson (KA): KA has no disclosures relating to this work. KA has received consultancy fees from Amgen, Eli Lilly, Renapharma and UCB.

Matthew Costa (MC): MC has no disclosures relating to this work.

Karsten Dreinhöfer (KD): KD has undertaken consultancy for governments, national osteoporosis societies, healthcare professional organisations and private sector companies relating to systematic approaches to fragility fracture care and prevention since 2004.

David Marsh (DM): DM has no disclosures relating to this work.

Joon-Kiong Lee (JKL): JKL has no disclosures relating to this work.

Ding-Cheng (Derrick) Chan (DCC): DCC has no disclosures relating to this work. DCC is a consultant for Amgen.

M. Kassim Javaid (MKJ): In the last 5 years, MKJ received honoraria, unrestricted research grants, travel and/or subsistence expenses from Amgen, Lilly UK, Internis, Consilient Health, Zebra Medical Vision, Kyowa Kirin Hakin and UCB.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Quality of Care in Osteoporosis

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mitchell, P.J., Cooper, C., Fujita, M. et al. Quality Improvement Initiatives in Fragility Fracture Care and Prevention. Curr Osteoporos Rep 17, 510–520 (2019). https://doi.org/10.1007/s11914-019-00544-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11914-019-00544-8

Keywords

Search

Navigation