Why the Post-Fracture Care Gap Exists

The lack of clarity regarding where clinical ownership resides in the care of Osteoporotic fragility fracture patients may be the primary problem.

 

Harrington’s metaphorical depiction captures the essence of the problem:

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 patients disappears

 

This describes a systems-based concern where 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 urgency of the problem that calls for the implementation of a systems-based solution advocated by the Capture the Fracture Campaign.

Investigators in the UK sought to understand the disconnection between orthopaedic surgeons and primary care doctors, the two clinical constituencies seemingly most well placed to deliver secondary fracture prevention. A survey published by Chami and colleagues asked orthopaedic surgeons and general practitioners (GPs) about their routine clinical practice regarding investigation of osteoporosis in three clinical scenarios:

  • A 55 year old woman with a low trauma Colles fracture
  • A 60 year old woman with a vertebral wedge fracture
  • A 70 year old woman with a low trauma neck of femur fracture

The majority of respondents recognized that fragility fracture patients should in principle be investigated for osteoporosis (81% of orthopaedic surgeons, 96% of GPs). However, in the case of the Colles fracture the majority of orthopaedic surgeons (56%) would discharge the patient without requesting investigation for osteoporosis. When faced with this scenario, the majority of GPs would take no action having assumed that the orthopaedic surgeons would have conducted investigations if appropriate (45%) or would instigate investigations only if prompted by the orthopaedic surgeon to do so (19%). Only 7% of orthopaedic surgeons and 32% of GPs would assess and/or start treatment themselves.

The hip fracture scenario generated similar responses; 66% of orthopaedic surgeons would discharge the patient without osteoporosis assessment whilst 40% of GPs would file the letter and a further 19% of GPs would initiate assessment only if recommended by the orthopaedic surgeon. Notably, in the case of vertebral wedge fracture a minority of orthopaedic surgeons (29%) would discharge the patient without any action to trigger assessment whilst the majority of GPs (58%) would routinely assess and/or start treatment themselves.

Additional reasons demonstrating why the post fracture care gap exists are identified in the systematic literature review published in 2004 by Elliot-Gibson and colleagues:

  • Cost concerns relating to diagnosis and treatment
  • Time required for diagnosis and case-finding
  • Concerns relating to poly-pharmacy
  • Lack of clarity regarding where clinical responsibility resides

A subsequent review published in 2006 by Giangregorio and colleagues evaluated studies from many countries which identified the reported issues:

  • Treatment was offered more frequently for patients with vertebral fractures in comparison to patients with non-vertebral fractures
  • Older patients were more likely to be diagnosed with osteoporosis yet younger patients were more likely to receive treatment
  • Males were less likely to be treated than women
  • Post-fracture falls assessment are not often conducted and rarely reported as an outcome of the studies

These illustrate the major opportunities afforded by secondary fracture prevention strategies to close the post-fracture care gap.