A Call to Action
preventing secondary fragility fractures

Dennis Jeanes
Special to the Canadian Orthopaedic Association

Amid the symposia, CME sessions and socializing at the COA’s recent Annual Meeting in Toronto, a small group of care-givers and advocates met to discuss forming a national alliance that would then campaign for an integrated strategy to prevent secondary fragility fractures.

Dr. Earl Bogoch, who convened the meeting, noted that patients who present in orthopaedic clinics for the first time with fragility fractures are often not identified after initial treatment for follow-up osteoporosis care: “These are lost opportunities to possibly prevent a more serious secondary fracture. By focusing on this discrete population, we know we are concentrating our resources on the highest priority patients. What is needed is an integrated approach in each province to identify first-time fragility-fracture patients and direct them to an appropriate care path.”

Literature review has shown that the most successful interventions involve case management and follow-up by a fracture coordinator who identifies patients, educates them and then guides them to appropriate multidisciplinary care. The cost savings of this approach more than offset the costs of a coordinator.

These findings resonate with the 2003 Ontario Osteoporosis Strategy, a forward-looking document that has identified gaps in delivering osteoporosis care, including a lack of information and low public awareness of the risks of fragility fractures, inappropriate bone mineral density testing, as well as an absence of case management and integrated fracture-care programmes.

In response, the Ontario Osteoporosis Strategy is taking a multi-faceted approach by:

• developing educational programmes for seniors and children;

• updating guidelines and instituting quality-assurance protocols for BMD testing;

• integrating post-fracture care in emergency departments and primary-care clinics with fracture coordinators and area managers as part of the LIHN (local integrated health network) initiative;

• introducing patient self-management and falls-prevention programmes; and

• creating CME programmes for primary-care physicians and allied health professionals, as well as introducing fragility fracture management into the graduate and undergraduate curriculum.

As a result, “Ontario is the first jurisdiction to have an integrated fragility-fracture prevention programme,” says Dr. Famida Jiwa, coordinator of the Ontario Osteoporosis Strategy for the Ontario Ministry of Health and Long-Term Care. “Programme costs are around 1% of provincial treatment costs for osteoporosis. About 530,000 Ontarians have osteoporosis, and some 57,000 fragility fractures are treated in Ontario annually.”

After less than a year, much of the necessary infrastructure is in place and the programme has achieved some momentum. Six LIHN Area Managers are in place to provide liaison with primary-care health professionals, and stakeholders have reached consensus on the skill set required to function as a fracture-clinic coordinator. By year’s end, at least five coordinators are expected to be in place, with more to come. Osteoporosis Canada’s Ontario division is an active partner with the Ministry (responsible for developing BMD protocols and adult education).

In a subsequent roundtable discussion, regional disparities in fragility-fracture care quickly became apparent. Only Quebec and BC have formal programmes besides Ontario. Dr. Ken Hughes described the Risk Watch programme in the greater Vancouver area, which identifies primary fragility fractures and osteoporosis in presenting patients: “Chronic disease management for such conditions as asthma, osteoarthritis and osteoporosis is a high priority for the provincial ministry. Distribution of primary-care guidelines for identifying fragility fractures and for using system resources to intervene have decreased risk of fractures by 10%. But the programme needs a full-time coordinator.”

Rheumatologist Dr. Jacques Brown recalled that, six years ago, research about primary fragility fractures determined that BMD testing wasn’t sensitive enough. Further research was undertaken to improve osteoporosis diagnosis and care in the jurisdictions of three regional health authorities (Quebec City, Trois Rivières and Montreal), which managed to recruit about 15% of fragility-fracture patients. Regional public-health authorities supported the research by contacting post-menopausal women with fragility fractures: “However, many people were missed because diagnostic and referral guidelines weren’t effective. Government is not responding to requests for assistance apparently because it mistakenly believes the research would raise treatment costs as a result of improved diagnostics.”

Although there was only a fledgling fracture referral programme in Calgary and nothing at all in Edmonton, Karen Ormerod, CEO and president of Osteoporosis Canada, suggested that the Alberta Bone and Joint Institute was a unique provincial asset that should be encouraged to join an eventual alliance. She further noted that in certain areas of Canada, different local chapters of Osteoporosis Canada were evolving into regional divisions, which foreseeably could provide a fragility-fracture alliance with more robust assistance: “Increased patient demand for treatment means that advocacy is a priority for Osteoporosis Canada, and as a result our director of government relations is actively recruiting and empowering patients. Any effective advocacy programme must combine professional authority with a patient’s moral authority.”

Participants in the meeting agreed that strategies should be developed on a provincial basis, because each government has its own regional agenda and responds more positively if programme proposals mesh with its established priorities, such as managing chronic-disease or reducing wait times. “The Ontario fragility-fracture programme received its funding because in the long-run it saves the government money,” Dr. Bogoch observed. “More data are needed on health areas where government has already invested, also links between demographics, co-morbidities and osteoporosis need to be further explored for possible footholds into existing policies and programmes.”

Doug Thomson agreed to post a proposal to the COA’s Board of Directors about a nation-wide fragility-fracture prevention programme on provincial association web pages. The COA, he said, would likely play a central role in distributing information and an eventual toolkit about fragility fractures to its membership and participating stakeholders. A number of government-relations approaches (cold calls, advocacy days, MPP breakfasts) were discussed. The important thing, said Ms. Ormerod, was to choose a model, develop a strategy and maintain a united voice. Osteoporosis Canada has developed an advocacy manual and electronic copies are available. Dr. Jiwa offered to act as an informal resource and contact person about the Ontario programme. And everyone agreed that the top priority was to create a steering committee to move the project forward.