Pam Harrison

September 26, 2016

ATLANTA — The dismal rate at which treatment of osteoporosis is initiated following any fragility fracture in the United States can be dramatically improved with the help of a fracture-liaison service, a demonstration project indicates.

"All three sites, including Georgetown University Hospital, where I am, and the University of Pittsburgh Medical Center and Creighton Health in Nebraska, did a baseline survey that demonstrated how terrible a job we were doing, even at sites where there were bone experts and people were very passionate about the disease," Andrea Singer, MD, Washington, DC, told a press briefing here at the American Society of Bone and Mineral Research 2016 Annual Meeting.

"So we looked at moving the bar forward in terms of identifying fracture patients and following them to see how many got a bone-density test after an acute fracture and how many were prescribed a medication," she added.

Results "were extremely significant, and on some measures went from the low teens to the high 90s, so we think this fraction-liaison-service model of care can improve outcomes and reduce medical costs for patients with osteoporosis," she noted when presenting the findings of the study.

Technology Tools Mean More Monitoring of BMD, Vitamin D Levels

Investigators from the three academic medical centers examined the effectiveness of a web-based registry application (the Fracture Liaison Service [FLS] app) designed to help deploy the FLS model of care to coordinate postfracture care for secondary fracture prevention.

This was developed by the Bone Health Collaborative, made up of the National Bone Health Alliance, the National Osteoporosis Foundation, and CECity/Premier.

The researchers performed a retrospective chart review on a total of 344 patients to collect data at each healthcare facility for a baseline assessment on the status of each facility's postfracture care.

They then compared various indices of that care 6 months after the introduction of the FLS app model of care.

Parameters assessed included how many men and women over the age of 50 received a bone-mineral density (BMD) test within 6 months of experiencing a fragility fracture.

The investigators also determined whether patients had vitamin D levels tested and whether pharmacologic therapy had been introduced within 6 months of sustaining a fracture.

A total of 148 patients were reviewed following the introduction of the FLS app model of care.

"At baseline, tests and treatment data were missing for between 20% and 30% of patients," Dr Singer reported.

"Missing data were minimized after the adoption of the FLS app," she stressed.

Indeed, the demonstration project showed that BMD tests among patients with fractures increased from 21.2% at baseline to almost 93% in the postimplementation period (P < .001).

Monitoring patients for vitamin D levels similarly improved from 22% at baseline to 84% following implementation of the FLS app (P < .001)

Prescriptions for treatment of osteoporosis also increased fairly dramatically, from 19.5% at baseline to over 54% after the FLS app had been introduced (< .001).

"Part of this is process, but it's also having technology tools that assist in that process," Dr Singer observed.

"And while that doesn't mean that everybody to whom you recommend medication takes it, it's a means by which to set a process in place where patients are identified and we can try to increase compliance."

Strong Endorsement for Fracture-Liaison Service

Commenting on the need to expand screening services and treatment to patients who've had a fragility fracture, Kenneth Saag, MD, professor of medicine and epidemiology, University of Alabama at Birmingham, pointed out that a number of osteoporosis organizations have strongly endorsed the idea of a fracture-liaison service as a good way to achieve this end.

"This is an opportunity for physicians to work with allied health professionals and to set up a structure within health systems to allow postfracture patients to get automatically referred and tied into the management of their bone health," Dr Saag observed.

A fracture-liaison service has been shown to be highly effective both in the Kaiser Permanente Health Care System in the United States and in various centers in Europe, he added.

As Dr Saag pointed out, some 2.3 million fewer DEXA tests to screen patients at risk for fracture are now being done in the United States than were done in 2009 — the direct result of a 70% reduction in reimbursement for DEXA tests compared with what physicians were previously paid.

"Peak use of osteoporosis medication was in the mid-2000s, and current data from both Medicare and private payers shows that half as many patients are taking treatment now than they were in the mid-2000s," he noted.

Indeed, the problem is particularly acute among Medicare patients, where as few as 10% are receiving treatment either 6 months before or 6 months after having sustained a hip fracture, he noted.

The decline in treatment of osteoporosis is also in part explained by patients' concerns about rare side effects from one particular class of drugs used to treat this condition, the bisphosphonates.

Survey Results Troubling: A Long Way to Go to Educate Patients

Dr Singer noted that in a recent survey carried out jointly by the National Osteoporosis Foundation and its partner INSPIRE (a large on-line patient engagement platform in the United States), over half of the patients surveyed had experienced a fracture, and the average number of broken bones per patient was three.

Approximately 60% of survey participants who had experienced a fracture had not been referred for a bone-density scan following the fracture.

Fewer than half had not received any prescription medication following the event, either.

Yet among those who had been prescribed an osteoporosis medication, almost 40% of participants never filled it, and about half of those who had started medication stopped taking it.

In general, the average length of time patients had been on medication was between zero and 2 years.

"This was a highly motivated group of people who've chosen to join an osteoporosis community because they are concerned about the disease, and yet they still don't get the connection between having had a fracture and the risk for future fracture and how important it is to treat this," Dr Singer observed.

"So these results are clearly very troubling, and we have a long way to go to better educate our patients about this disease."

Indeed, during the annual meeting, ASBMR president Douglas Kiel, MD, told the press that 34 organizations have now signed a "call to action" pledging to intensify current efforts to increase screening, diagnosis, and treatment of high-risk individuals to prevent fractures.

"We must take action to aggressively reduce the burgeoning fracture risk in our aging population caused by declining rates in testing, a decline in diagnosis, and a decline in treatment in the most high-risk patients," Dr Kiel reaffirmed.

Dr Singer receives funding from Merck. Dr Saag has served as a consultant and investigator for Amgen and Merck.

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American Society of Bone and Mineral Research 2016 Annual Meeting; September 18, 2016; Atlanta, Georgia. Abstract SU0239.

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