Article Archive
January/February 2015

Fracture Follow-Up
Ethel S. Siris, MD, and David Lee, MPA
Today's Geriatric Medicine
Vol. 8 No. 1 P. 34

Osteoporosis, a disease caused by a reduction in bone strength that elevates the risk of low-trauma fractures, is common, with one in two women and one in nearly five men over the age of 50 sustaining an osteoporosis-associated fracture in their remaining lifetime.1 More than 2 million such fractures occur annually in the United States, costing nearly $20 billion each year2 and creating havoc and suffering in the lives of many who sustain fractures of the hip, vertebrae, proximal humerus, pelvis, and other major bones.

About 10 million people aged 50 and older have osteoporosis and another 43 million have low bone mass,3 numbers that will increase as our population ages. Those at highest risk of fracture are the elderly, who have experienced many years of bone loss leading to reduced bone mass and to architecturally damaged bone, and who are susceptible to falling. This combination accounts for the terrible outcome of a fall on a weakened bone that causes a break. After the fracture there is pain, disability, a deleterious alteration in the activities of daily life, and a very high risk of future fractures. Today a variety of pharmacological agents, many now generic, exist, and together with adequate calcium and vitamin D along with fall risk reduction efforts, they can reduce the risk of fracture by 30% to 70%.4

Sadly, osteoporosis remains underdiagnosed and undertreated, despite the fact that it can be easily ascertained and relatively well managed. Bone density testing, a noninvasive painless 15-minute procedure, is recommended for all women aged 65 or older and all men aged 70 and older (and anyone over the age of 50 with clinical risk factors). It estimates bone mass, reported as a T-score. The T-score represents the number of standard deviations below the mean bone density value in young normal individuals at their peak bone mass. In a person older than 50, a T-score at the spine or hip of -2.5 or lower is diagnostic for osteoporosis, and a value of -1 to -2.49 defines osteopenia or low bone mass.

Those with osteoporosis need treatment. Applying the FRAX algorithm, a free online risk assessment tool, can further refine fracture risk in patients with osteopenia. FRAX combines the low bone mineral density T-score at the femur neck with a series of well-validated clinical fracture risk factors, including age and prior fracture history, providing a 10-year absolute risk estimate for the individual. If the risk meets or exceeds certain cut points (3% 10-year risk for hip fracture or 20% 10-year risk for major osteoporotic fracture—a combination of spine, hip, proximal humerus, and distal radius fractures), treatment to lower risk is indicated.

A recent evidence-based position paper from the National Bone Health Alliance (NBHA), endorsed by the Alliance for Aging Research as well as many other medical professional societies, has recommended that a clinical diagnosis of osteoporosis be made in a postmenopausal woman or a man over the age of 50 with any one of the following characteristics: a bone density T-score of -2.5 or below, the current bone density basis for diagnosis; a hip fracture with or without a bone mineral density test; a low-trauma (eg, a fall from standing height) vertebral, proximal humerus, pelvis, and in some cases, distal radius fracture in a person with low bone mass; or a FRAX score in a person with low bone mass meeting or exceeding the treatment cut points noted earlier. Each of these situations represents reduced bone strength and an elevated risk for future fracture—the definition of osteoporosis.

A recent major public health effort has been launched to increase awareness about the elevated risk of fracture in people who have previously had a fracture and to ensure they are treated to prevent a future fracture. Indeed, one-half of patients with hip fractures have a history of a prior osteoporosis-associated fracture.5 It has been shown that the most effective way to ensure treatment in an older patient who fractures is through a fracture liaison service (FLS), a coordination of care program that links orthopedic surgeons who fix the fracture and the medical practitioner (a primary care clinician or endocrinologist, rheumatologist, or geriatrician) who needs to initiate medical therapy for secondary fracture prevention.

The key to an FLS is a coordinator, whether a nurse, nurse practitioner, physician assistant, or a well-trained nonclinician, who visits older inpatients (and, ideally outpatients) with acute fractures, educates them about osteoporosis, and arranges postfracture follow-up with the appropriate clinician to ensure medical treatment is provided. The FLS coordinator also remains in touch with the patient after treatment is started to encourage compliance and record outcomes. The main barrier to this program is the lack of a CPT code for the reimbursement of the FLS coordinator's work, but many hospitals now recognize the economic and social value of preventing further fractures and are showing some willingness to cover this expense. FLS has worked well in closed systems such as Kaiser Permanente and Geisinger, saving costs to the system and sparing patients future suffering. To support sites interested in starting an FLS program, NBHA launched its resource center on FLS programs, Fracture Prevention CENTRAL, in 2013.

Additionally, NBHA is part of a national pilot seeking to demonstrate the effectiveness of a combination of the proven FLS model of care with a cloud-based FLS solution that provides a means for participating sites to automate, benchmark, and improve their performance around selected osteoporosis and postfracture quality measures and patient care and outcomes.

In conclusion, fracture risk assessment in older adults is a critical step for both primary and secondary fracture prevention. Osteoporosis can be readily diagnosed, and appropriate treatment prevents many future fractures. FLS programs clearly work and need to be established wherever older patients receive their fracture care.

— Ethel S. Siris, MD, is the Madeline C. Stabile Professor of Medicine and director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center in New York.

— David Lee, MPA, is the executive director of the National Bone Health Alliance in Washington, D.C.

1. Office of the Surgeon General. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: Office of the Surgeon General; 2004.

2. 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(3):465-475.

3. Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014;29(11):2520-2526.

4. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's guide to prevention and treatment of osteoporosis. Osteoporosis Int. 2014; 25(10):2359-2381.

5. 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;461:226-230.