Post-fracture care programs for prevention of subsequent fragility fractures: a literature assessment of current trends.

Post-fracture care (PFC) programs evaluate and manage patients with a minimal trauma or fragility fracture to prevent subsequent fractures. We conducted a literature review to understand current trends in PFC publications, evaluate key characteristics of PFC programs, and assess their clinical effectiveness, geographic variations, and cost-effectiveness. We performed a search for peer-reviewed articles published between January 2003 and December 2020 listed in PubMed or Google Scholar. We categorized identified articles into 4 non-mutually exclusive PFC subtopics based on keywords and abstract content: PFC Types, PFC Effectiveness/Success, PFC Geography, and PFC Economics. The literature search identified 784 eligible articles. Most articles fit into multiple PFC subtopics (PFC Types, 597; PFC Effectiveness/Success, 579; PFC Geography, 255; and PFC Economics, 98). The number of publications describing how PFC programs can improve osteoporosis treatment rates has markedly increased since 2003; however, publication gaps remain, including low numbers of publications from some countries with reported high rates of osteoporosis and/or hip fractures. Fracture liaison services and geriatric/orthogeriatric services were the most common models of PFC programs, and both were shown to be cost-effective. We identified a need to expand and refine PFC programs and to standardize patient identification and reporting on quality improvement measures. Although there is an increasing awareness of the importance of PFC programs, publication gaps remain in most countries. Improvements in established PFC programs and implementation of new PFC programs are still needed to enhance equitable patient care to prevent occurrence of subsequent fractures.

Electronic search programs are effective in identifying patients with minimal trauma fractures.

We assessed two electronic search tools that screen medical records for documented fractures. Both programs reliably identified patients with any fracture but missed individuals with minimal trauma fracture to different degrees. A hybrid tool combining the methodology of both tools is likely to improve the identification of those with osteoporosis. PURPOSE: Most patients who suffer a minimal trauma fracture remain undiagnosed, placing them at high risk of refracture. Case finding can be improved by electronic search tools that screen medical records for documented fractures. Here, we assessed the efficacy of two new programs, AES and XRAIT, in identifying patients with minimal trauma fracture. METHODS: Each tool was applied to search the electronic medical record and/or radiology reports at two tertiary hospitals in Sydney, Australia, from 1 July to 31 December 2018. Samples of the extracted reports were then manually reviewed to determine the sensitivity of each program in detecting minimal trauma fractures. RESULTS: At the two centers, AES detected 872 and 1364 cases, whereas XRAIT identified 1414 and 2180 patients with fractures, respectively. The true positive rate for "any fracture" was similar for both instruments (77-88%). However, the ability to detect "minimal trauma fractures" differed between programs and centers (53-75% accuracy), with each tool identifying separate subsets of patients. Concordance between both tools was less than half of the combined total number of minimal trauma fractures (43-45%). Considering the total number of minimal trauma fractures detected by both tools combined, AES correctly identified 52-55% of cases while XRAIT identified 88-93% of cases. CONCLUSION: Both programs reliably identified patients with any fracture but missed individuals with minimal trauma fracture to different degrees. Hybrid tools combining the methodology of XRAIT and AES are likely to improve the identification of patients who require investigation and treatment for osteoporosis.

Barriers to secondary fracture prevention in primary care.

This study of current osteoporosis management patterns in general practice found that the majority of patients presenting to their local health practitioner with a recent low-trauma fracture was not managed appropriately. The analysis demonstrated that failure to investigate was highly predictive of failure to treat and that one of the major barriers to effective osteoporosis management is a lack of specific knowledge about who to investigate and treat. INTRODUCTION: Osteoporotic fractures are associated with significant morbidity and mortality. The current study aimed (i) to determine the number of patients with osteoporotic fractures who were not investigated or treated for osteoporosis by their primary care physician and (ii) to identify factors that contribute to the ongoing gap in osteoporosis care. METHODS: We conducted an observational retrospective study (2012-2014) using explicit medical record review at three major general practices in metropolitan Sydney. Patients aged 55 years or older who had a documented minimal trauma fracture (MTF) were identified. Data collected included demographics, prior fractures, testing for vitamin D/bone mineral density and initiation of osteoporosis pharmacotherapy. The main outcome measures included the number of patients who did not undergo the following: (i) a bone density scan, (ii) vitamin D measurement and/or (iii) initiation of osteoporosis pharmacotherapy. RESULTS: Of the 87 patients (69% female; mean age 71.7 years) with prevalent MTF, 55 (63%) were not referred for a bone density scan. Vitamin D levels were not measured in 36 patients (41%) and 55 patients (63%) did not receive specific osteoporosis pharmacotherapy. Failure to investigate was highly predictive of failure to treat (p < 0.001). The presence of major osteoporotic risk factors did not affect the likelihood of investigation or treatment, indicating that a major barrier to effective osteoporosis management was a lack of knowledge. CONCLUSION: Management of patients with MTF's in primary care is poor. Systems aimed at improving the identification and treatment of patients with osteoporotic fractures in this setting is required in order to close the osteoporosis care gap.

Predictors of re-fracture amongst patients managed within a secondary fracture prevention program: a 7-year prospective study.

SUMMARY: This 7-year prospective observational study determined the predictors of re-fracture amongst 234 patients managed within a Secondary Fracture Prevention programme. Poor compliance, multiple co-morbidities, corticosteroid therapy, low hip bone mineral density (BMD) or low body weight were all significantly associated with re-fracture in patients commenced on long-term anti-resorptive therapy. INTRODUCTION: Risk factors for osteoporotic fracture amongst treatment-naïve patients are well established. In contrast, predictors of re-fracture in patients optimally managed within a Secondary Fracture Prevention (SFP) programme are ill-defined. METHODS: This prospective observational study included 234 subjects with incident osteoporotic fractures managed long-term by the Concord SFP programme. Using Cox proportional hazards models, predictors of re-fracture were analysed separately for patients commenced on specific pharmacotherapy (group 1, N=171) and subjects receiving calcium and/or vitamin D supplements only (group 2, N=63). Relevant anthropometric, clinical and technical data were documented at each visit. Compliance and persistence were analysed as time-varying covariates. RESULTS: During a mean follow-up of 5.2 (range 3.5-7.3) years, 20.9% of all subjects re-fractured (26.3% in group 1, 6.3% in group 2). Multivariate predictors of re-fracture in group 1 were significant co-morbidity (HR 2.04 if >3, 95% CI 1.10-3.79, p=0.024), corticosteroid use (HR 1.75, 95% CI 1.12-2.73, p=0.013) and total hip BMD (HR 1.36 per 0.1 g/cm2 decrease, 95% CI 1.08-1.70, p=0.008). In contrast, gender, prevalent fractures and lumbar spine BMD were not associated with re-fracture. Amongst patients with complete compliance data, a medication possession ratio of ≤50% (HR 3.36, 95% CI 1.32-8.53, p=0.011) and low body weight (HR 1.04 per 1-kg decrease, 95% CI 1.003-1.08, p=0.032) were significantly associated with re-fracture. CONCLUSIONS: Amongst patients managed within a dedicated SFP programme, poor compliance, multiple co-morbidities, corticosteroid therapy, low hip BMD or low body weight are all associated with increased risk of re-fracture. This subgroup of patients therefore require intensive management including strategies to improve compliance.

Compliance and persistence to oral bisphosphonate therapy following initiation within a secondary fracture prevention program: a randomised controlled trial of specialist vs. non-specialist management.

UNLABELLED: Following initiation of oral bisphosphonate therapy through a secondary fracture prevention program, 2-year treatment compliance and persistence remained high and were similar in patients randomised to follow-up by either the program or primary care physician. Thus, community-based and specialist management are equally effective in supporting compliance and persistence with anti-osteoporotic treatments. INTRODUCTION: The purpose of this study was to determine whether management by a secondary fracture prevention (SFP) program (aka "fracture liaison service") results in better compliance and persistence to oral bisphosphonate therapy than follow-up by the primary care physician, after initiation within an SFP program. METHODS: This prospective RCT included 102 patients with incident osteoporotic fractures referred to a SFP program in Sydney, Australia. Following oral bisphosphonate therapy initiation, patients were randomised to either 6-monthly follow-up with the SFP program (group A) or referral to their primary care physician with a single SFP program visit at 24 months (group B). Compliance and persistence to treatment were measured using pharmaceutical claims data. Predictors of compliance and persistence and associations between compliance and persistence, and changes in bone mineral density (BMD) or bone resorption marker, urinary deoxypyridinoline over 24 months were analysed. RESULTS: The median medication possession ratio at 24 months was 0.78 (IQR, 0.50-0.93) in group A and 0.79 (IQR, 0.48-0.96) in group B (p = 0.68). Persistence at 24 months was also similar in both groups (64 vs. 61%, respectively; p = 0.75). After adjusting for confounders, patients in group A were not more likely to be compliant (OR, 1.06; 95% CI, 0.46-2.47) or persistent (HR, 0.83; 95% CI, 0.27-1.67) than those randomised to group B. Time-based changes in BMD or bone turnover were not associated with compliance or persistence. CONCLUSION: Compliance and persistence to oral bisphosphonate therapy remain high amongst patients initiated within an SFP program, with community-based and SFP program management being equally effective in maintaining therapeutic compliance and persistence over 2 years. These results indicate that one of the main functions of an SFP program may be the initiation of therapy rather than continuous patient monitoring.

Rapid biochemical response to denosumab in fibrous dysplasia of bone: report of two cases.

We report on the clinical and biochemical outcomes in two adult patients with active polyostotic fibrous dysplasia (FD) treated with the RANK-L inhibitor, denosumab, following unsatisfactory responses to prior long-term bisphosphonate therapy. A 44-year-old female (case 1) who had received a cumulative dose of 20 mg zoledronic acid over 2.5 years and a 48-year-old male (case 2) who had received a cumulative dose of 45 mg zoledronic acid over 8 years both experienced minimal reductions in pain scores and markers of bone turnover. Following initiation of denosumab 60 mg sc, changes in bone pain, bone turnover [assessed by serum amino-terminal propeptide of type I collagen (PINP) and urinary deoxypyridinoline] were monitored over a period of 20 and 8 months, respectively. Following administration of denosumab, both patients demonstrated a rapid and pronounced biochemical response: Within 4-7 weeks, bone turnover markers fell to levels within the respective reference range, and one patient reported a reduction in pain. Treatment with denosumab was well tolerated. However, transient asymptomatic hypocalcaemia and/or hypophosphatemia associated with a transient two to threefold increase in serum PTH levels was observed in both patients. Dosing intervals for denosumab varied significantly between the two patients, depending on disease activity at baseline. Denosumab appears to be effective in reducing bone turnover in adult patients with active FD. However, caution should be exercised, and patients should be monitored carefully as significant fluctuations in biochemical and hormonal indices can occur.

Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis.

Most people presenting with incident osteoporotic fractures are neither assessed nor treated for osteoporosis to reduce their risk of further fractures, despite the availability of effective treatments. We evaluated the effectiveness of published models of care for the secondary prevention of osteoporotic fractures. We searched eight medical literature databases to identify reports published between 1996 and 2011, describing models of care for secondary fracture prevention. Information extracted from each publication included study design, patient characteristics, identification strategies, assessment and treatment initiation strategies, as well as outcome measures (rates of bone mineral density (BMD) testing, osteoporosis treatment initiation, adherence, re-fractures and cost-effectiveness). Meta-analyses of studies with valid control groups were conducted for two outcome measures: BMD testing and osteoporosis treatment initiation. Out of 574 references, 42 articles were identified as analysable. These studies were grouped into four general models of care-type A: identification, assessment and treatment of patients as part of the service; type B: similar to A, without treatment initiation; type C: alerting patients plus primary care physicians; and type D: patient education only. Meta-regressions revealed a trend towards increased BMD testing (p = 0.06) and treatment initiation (p = 0.03) with increasing intensity of intervention. One type A service with a valid control group showed a significant decrease in re-fractures. Types A and B services were cost-effective, although definition of cost-effectiveness varied between studies. Fully coordinated, intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and/or education only.

Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study.

UNLABELLED: In the present prospective controlled observational study, we investigated the effect of a coordinated intervention program on 4-year refracture rates in patients with recent osteoporotic fractures. Compared to standard care, targeted identification, and management significantly reduced the risk of refracture by more than 80%. INTRODUCTION: The risk of refracture following an incident osteoporotic fracture is high. Despite the availability of treatments that reduce refracture and mortality rates, most patients with minimal trauma fracture (MTF) are not managed appropriately. The present prospective controlled observational study investigated the effect of a coordinated intervention program on 4-year refracture rates and time to refracture in patients with recent osteoporotic fractures. METHODS: Patients presenting with a non-vertebral MTF were actively identified and offered referral to a dedicated intervention program. Patients attending the clinic underwent a standardized set of investigations, were treated as indicated and reviewed at 12-monthly intervals ('MTF group'). Patients who elected to follow-up with their primary care physician were assigned to the concurrent control group. RESULTS: Groups were balanced for baseline anthropometric, socio-economic, and clinical risk factors. Over 4 years, 10 out of 246 patients (4.1%) in the MTF group and 31 of 157 patients (19.7%) in the control group suffered a new fracture, with a median time to refracture of 26 and 16 months, respectively (p < 0.01). Compared to the intervention group, the risk of refracture was increased by 5.3-fold in the control group (95% CI: 2.8-12.2, p < 0.01), and remained elevated (HR 5.63, 95%CI 2.73-11.6, p < 0.01) after adjustment for other significant predictors of refracture such as age and body weight. CONCLUSIONS: In patients presenting with a minimal trauma non-vertebral fracture, active identification and management significantly reduces the risk of refracture (Australian New Zealand Clinical Trials Registry ACTRN 12606000108516).

[Network for epidemiologic surveillance of animal diseases in Chad]. / Le réseau d'épidémiosurveillance des maladies animales au Tchad.

An epidemiosurveillance network for diseases of animals was introduced in Chad to ensure early reporting to animal husbandry organisations should the incidence of an existing disease increase, or should an exotic disease reappear. The network also serves for the collection of information on the principal diseases of livestock. A list of eight priority diseases was drawn up with specific surveillance objectives for each disease. Information (from surveys and sampling) from all new outbreaks of the diseases under surveillance is gathered by participants in the field (officials in public service and private veterinarians) and sent to the diagnostic laboratory, which examines the findings before disseminating them to the field. The first year of operation in the field has made it possible to evaluate the feasibility of the method and to collect fundamental epidemiological information on the diseases under surveillance. The advantage of the network is the provision of a means of communication between the field and the laboratory. The network enables collection of information in a standard form, the training of field agents and the organisation of the structure of the laboratory. Persistent problems are the motivation of some participants in the field and difficulties in communication which have to be overcome in order to obtain reliable data rapidly.

[Goat smallpox in Chad: study of the pathogeny of the virus in sheep and goats]. / Variole caprine au Tchad: étude du pouvoir pathogène du virus chez les ovins et les caprins.

A local strain of goat pox virus was tested in goats and sheep. The results showed that 65% of goats and 20% of sheep reacted positively. Only goats died few days after the inoculation (55%) and no mortality was recorded in the sheep. The strict species specificity of this strain was not observed. The difference of sensitivity between sheep and goats was statistically significant.

[Note on goat pox in Chad: study of the foci]. / Note sur la variole caprine au Tchad: étude des foyers.

Several outbreaks of goat-pox were observed from 1985 to 1989 in different villages of the N'Djamena area. The virus strain circulating in this region seemed to be host-specific for goats since sheep kept in contact with goats did not suffer from the disease. Nevertheless, it has to be studied further on whether the virus isolated from sick goats could be pathogenic for sheep.