|
Manitoba

Manitoba Health, Seniors and Active Living

Set text to smallest size Set text to normal size Set text to larger size Set text to largest size
Manitoba Bone Density Program

Optimizing Post-Fracture Management


What is a Fragility Fracture?

A fracture occurring spontaneously or following minor injury such as a fall from standing height or less (also referred to ask low-trauma or low-energy fractures).  Commonly involved sites are the proximal femur (“hip”), vertebral bodies (“spine”), distal forearm (“wrist”) or proximal humerus (“shoulder”) which are collectively referred to as Major Osteoporotic Fractures.  Other sites (e.g., pelvis, ribs) are still important.  Fractures affecting the head, neck, ankle, carpal bones, hands and feet are excluded.

Fracture Statistics

  • Over 80% of fractures in those over age 50 are due to a low-trauma (fragility) mechanism.  Each year there are approximately 1000 hip fractures in Manitoba in persons age 60 and over.  Even a larger number of people experience fractures of the spine, wrist, shoulder, pelvis.
  • Fragility fractures are important markers of increased risk for further fractures.
  • In Manitoba the annual direct costs are well in excess of $10 million for hip fractures during the first year alone and over $30 million if other osteoporotic fractures are considered.
  • A hip fracture patient who returns home after hospitalization costs the health care system in excess of $21,385 in direct costs, while a patient who must be institutionalized costs over twice as much at $44,156.
  • The human cost of osteoporotic fractures is significant.  About 20% of women and 30% of men who suffer a hip fracture die within 12 months, often from related complications.  Long term pain and disability, fear of falling, lifestyle changes, isolation and increased burden on caregivers can result.
  • After a vertebral or hip fracture younger people often incur high indirect costs such as sick leave, loss of job days, unemployment payments, and loss of productivity.
  • Of 18 different health conditions, hip and vertebral fractures were among the top three conditions with extended hospital stays and substantial health care costs.
  • Fractures due to osteoporosis have been associated with an increased length of hospital stay and with increased rates of institutionalization. The impact on the health care system and the cost to society is substantial.
  • Only 44% of people hospitalized with a hip fracture are discharged to their home while 10% go to another hospital, 27% go to rehabilitation care and 17% go to long-term care facilities.  In Manitoba 24% of women and men age 75 years and older previously living in the community are transferred to long-term care in the 12 months following an incident hip fracture.

The Post Fracture Care Gap

Despite the human and economic costs, fewer than 20% of patients with fragility fractures receive appropriate testing and/or anti-osteoporosis treatment post fracture.

Deciding on Pharmacological Treatment Post Fracture

Deciding on Pharmacological Treatment Post Fracture

Modified from www.osteoporosis.ca.

Post Fracture Notification Program in Manitoba: Development Phase

In 2008-2011 a pilot project tested a simple post-fracture notification initiative to improve post fracture care.  (Funded by The Manitoba Patient Access Network, whose mandate is to identify, advocate, support and guide health system change and process improvement initiatives. The network is financially supported by the Wait Times Reduction Fund and receives secretariat services from Manitoba Health, Healthy Living and Senior’s Wait Times Task Force.)

Results were published in CMAJ (Leslie WD, LaBine L, Klassen P, Dreilich D, Caetano PA. Randomized controlled trial for closing the post-fracture care gap at the population level. Canadian Medical Association Journal 184(3):290-6, 2012).  Relying upon physician billings to identify fracture events reported to Manitoba Health, women and men age 50 and older with major osteoporotic fractures (hip, spine, humerus or Colles’ fracture) were randomized (1:1:1) to one of the following three groups:

  • usual care (no contact),
  • physician-only notification (MD only) or
  • physician/patient notification (MD & Patient).

Information letters under Manitoba Health letterhead were sent out to the primary care physician and/or patient.  The language in these letters was specific to these 2 groups.  To address concerns over discontinuous care of patient seen at the time of fracture and for subsequent follow-up, the physician notification specifically targeted the individual involved in the initial report to Manitoba Health as well as the primary care physician. 

Between June 2008 and May 2010 (Phase I study period) 4,264 fracture patients meeting the inclusion/exclusion criteria were studied.  The initiative successfully increased testing and treatment rates post fracture 12 months post fracture:

Post fracture care in women
Post fracture care in men

Post fracture care in men
Post fracture care in women

Post Fracture Notification Program in Manitoba: Implementation Phase

Since June 2010 this initiative has become a funded program at Manitoba Health as an ongoing patient care initiative.  Manitoba Health, Seniors and Active Living' notifies primary care physicians when one of their patients is identified as having a possible fracture (hip, forearm, vertebral or humerus), unless:

  • Patient age is less than 50.
  • There has been a recent post fracture notification for the same patient.
  • The patient is currently on treatment with an osteoporosis medication.
  • The patient has had BMD testing within the preceding 3 years.

The letter notification includes a BMD requisition, the flowchart shown above, and advises that: “Non-traumatic (fragility) fractures can indicate underlying osteoporosis and increased risk for recurrent fractures.  Depending on the clinical circumstances, further assessment for osteoporosis may be warranted.  This could include an assessment of other risk factors for osteoporosis and fracture including bone mineral density (BMD) testing, and therefore a copy of the Manitoba BMD test requisition and post-fracture treatment flowchart is included for your consideration.  Patients with fragility fractures affecting the hip or spine, and patients with multiple fragility fracture episodes, are considered high risk and should be considered for pharmacologic treatment according to the 2010 clinical practice guidelines for osteoporosis published in CMAJ.  BMD testing in this setting is recommended but is not essential for treatment initiation. This letter is part of a patient care strategy intended to improve patient health and address potential care gaps in osteoporosis prevention and treatment through notification of fracture events.”

Relevant Canadian and Manitoba Publications

  1. Public Health Agency of Canada, Impact of Osteoporosis in Canada and what are Canadians doing to maintain healthy bones
  2. Hodsman AB, Leslie WD, Tsang JF, Gamble G.  10-year probability of recurrent fractures following wrist and other osteoporotic fractures in a large clinical cohort: An analysis from the Manitoba Bone Density Program.  Archives of Internal Medicine 168(20): 2261-7, 2008
  3. Bessette L, Ste-Marie LG, Jean S et al. (2008) The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporos.Int.19:79-86
  4. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown J, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD, for the Scientific Advisory Council of Osteoporosis Canada. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada. Canadian Medical Association Journal 182(17):1864-1873, 2010.
  5. Leslie WD, Metge CJ, Azimaee M, Lix LM, Finlayson GS, Morin SN, Caetano P. Direct costs of fractures in Canada and trends 1996-2006: A population-based analysis. The Journal of Bone and Mineral Research 26(10):2419-2429, 2011.
  6. Hopkins R, Tarride J-E, Leslie WD, Metge C, Lix L, Morin S, Finlayson G, Azimaee M, Pullenayegum E, Goeree R, Adachi JD, Papaioannou A, Thabane, L. Estimating the excess costs for patients with incident fractures, prevalent fractures, and non-fracture osteoporosis. Osteoporosis International [Epub ahead of print)
  7. Morin S, Lix LM, Azimaee M, Metge C, Caetano P, Leslie WD. Mortality rates after incident non-traumatic fractures in older men and women. Osteoporosis International 22:2439–2448, 2011.
  8. Papaioannou AB, Adachi JD, Parkinson W, Stephenson G, Bedard M. Lengthy hospitalization associated with vertebral fractures despite control for co morbid conditions. Osteoporosis Int 2001:12(10):870-874
  9. Morin S, Lix LM, Azimaee M, Metge C, Majumdar S, Leslie WD. Institutionalization following incident non-traumatic fractures in community dwelling men and women.  Osteoporosis International Osteoporosis International 23:2381–2386, 2012
  10. Leslie WD, Giangregorio LM, Yogendran M, Azimaee M, Morin SN, Metge CJ, Caetano P, Lix LM. A population-based analysis of the post-fracture care gap 1996-2008: The situation is not improving.  Osteoporosis International 23:1623-1629, 2012
  11. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group World Health Organ Tech Rep Ser 1994: 843:1-129
  12. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown J, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD, for the Scientific Advisory Council of Osteoporosis Canada. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada. Canadian Medical Association Journal 182(17):1864-1873, 2010.
  13. Caetano PA, LaBine L, Klassen P, Dreilich D, Leslie WD. Closing the post-fracture care gap using administrative health databases: Design and implementation of a randomized controlled trial. The Journal of Clinical Densitometry 14(4):422-7, 2011.
  14. CMAJ (Leslie WD, LaBine L, Klassen P, Dreilich D, Caetano PA. Randomized controlled trial for closing the post-fracture care gap at the population level. Canadian Medical Association Journal 184(3):290-6, 2012