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CE ARTICLE

Multidisciplinary osteoporosis management of post low-energy trauma hip-fracture patients Nicole Skorupski, MSN, NP-C (Nurse Practitioner) & Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN (Professor, Director of Adult-Gerontological, Family, and Women’s Health Nurse Practitioner Primary Care Specialty) Yale University School of Nursing, New Haven, Connecticut

Keywords Osteoporosis; fracture risk; collaboration; nurse practitioners. Correspondence Ivy M. Alexander, PhD, APRN, ANP-BC, FAAN, PO Box 9740, 100 Church Street South, Suite #200, New Haven, Connecticut 06536-0740. Tel: 203-737-2359; Fax: 203-785-6455; E-mail: [email protected] Received: April 2012; accepted: October 2012 doi :10.1111/1745-7599.12002 To obtain CE credit for this activity, go to www.aanp.org and click on the CE Center. Locate the listing for this article and complete the post-test. Follow the instructions to print your CE certificate. Disclosures One of the authors (I.A.) has served as a consultant and speaker for Amgen, manufacturer of denosumab. No other relationship exists between any of the authors and any commercial entity of product mentioned in this article that might represent a conflict of interest. There was no solicitation of the authors by any commercial entity to submit the manuscript for publication.

Abstract Purpose: The purpose of this article is to increase awareness of osteoporosis incidence in patients with hip fracture among providers and allied health professionals, to increase osteoporosis recognition and treatment in post hip-fracture patients, and to provide guidance on how to improve continuity of care and collaboration between members of the multidisciplinary healthcare team. Data sources: Recent evidence from the literature is reviewed to identify effective management strategies for post low-energy trauma hip-fracture patients and prevention of future osteoporotic fracture, regardless of osteoporosis diagnosis prior to the initial fracture. Conclusions: Despite the availability of accurate screening technologies and highly efficacious antiosteoporosis medications, implementation of these measures for low-energy trauma hip-fracture patients remains critically low. This is because of a number of factors including hesitancy to integrate care across specialty lines, lack of reliable referral systems, and resistance to change. There is also a lack of recognition of the connection between low-energy trauma hip fracture and osteoporosis by many healthcare professionals. Implications for practice: All members of the multidisciplinary care team are called to action to adopt osteoporosis evaluation and treatment strategies that research has shown to be effective on a larger scale in the post hip-fracture setting.

Introduction There are a significant number of hip fractures each year, many attributable to osteoporosis. The National Hospital Discharge Survey conducted by the U.S. Department of Health & Human Services (DHHS) estimates that 264,000 Americans aged 65 and older were admitted for hip fracture in 2007 alone (DHHS, 2010). However, few patients who experience hip fracture are recognized as having osteoporosis and their osteoporosis goes untreated. In those patients in whom osteoporosis is recognized and treated, follow-up and adherence to treatment is often poor. The purpose of this article is to increase awareness of os-

teoporosis incidence in patients with hip fracture among providers and allied health professionals, to increase osteoporosis recognition and treatment in post hip-fracture patients, and to provide guidance on how to improve continuity of care and collaboration between members of the multidisciplinary healthcare team. Osteoporosis (porous bone) is marked by decreased density of the bone infrastructure, leading to a decrease in overall bone strength (National Osteoporosis Foundation [NOF], 2008). Bone naturally decreases in density with the aging process; however, some individuals are at risk for greater bone loss (Bartel & Frisch, 2009).

C 2012 The Author(s) Journal of the American Association of Nurse Practitioners 25 (2013) 3–10 C 2012 American Association of Nurse Practitioners Journal compilation

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Multidisciplinary osteoporosis management

Dual-energy x-ray absorptiometry (DXA) measured at the femoral neck (at minimum) is considered the gold standard for assessing bone mineral density (BMD). It involves directing two different energy x-ray beams at the bones, and estimating their density based on x-ray absorption levels (United States Preventative Services Task Force [USPSTF], 2010). The World Health Organization (WHO) defines osteoporosis as a BMD of more than or equal to 2.5 standard deviations below the average for a healthy adult aged 20–29, of the same sex as the client undergoing scanning (WHO, 2007). A complete clinical evaluation and R physical exam also informs the diagnosis. The FRAX algorithm developed by the WHO combines data from the DXA measurement with patient specific risk factors (low body weight, small frame, prolonged glucocorticoid use, smoking, family history, sedentary lifestyle, alcohol or caffeine use, etc.) to estimate an individual’s 10-year fracture risk. Data support use of this algorithm in men aged 40 and older and postmenopausal women who have not been started on pharmacotherapy for osteoporosis (WHO, 2007).

Hip fracture and osteoporosis An estimated 44 million Americans are at an increased risk of fracture related to osteoporosis, according to the NOF (2011). Osteoporosis is responsible for more than 2 million fractures and $19 billion in medical costs each year in the United States alone (NOF, 2011). The most recent Summary Meeting Report from the WHO Scientific Group on Assessment of Osteoporosis at the Primary Health Care Level reports hip as a major site of fracture, accounting for 311,000 of osteoporosis-related fractures in the Americas in 2000 (WHO, 2007). Approximately 297,000 of which occurred in the United States (NOF, 2011). Osteoporosis-related fractures, particularly of the hip, are marked by high rates of morbidity and mortality within the following year (Bartl & Frisch, 2009). It is estimated that 24% of patients with hip fracture over the age of 50 die within the first postfracture year. Furthermore, only 15% regain the ability to walk unaided within the first 6 months, and 1 in 5 require long-term care post fracture (NOF, 2011). Interventions that promote rapid healing and return to independent functioning are vital, as are those that prevent future fractures. Women who experience a low-energy trauma hip fracture are at a fourfold increased risk of a second hip fracture (NOF, 2011). The risk of repeat fracture is greatest in the first 6 months (Bartl & Frisch, 2009). Low-energy trauma hip fracture is a hip fracture that occurs under instances of blunt force that would not be expected to cause fracture in healthy, 4

N. Skorupski & I. M. Alexander

dense bone, for example, landing on one’s hip following a fall when walking (NOF, 2011).

Recognizing the link between low-energy trauma hip fracture and osteoporosis Little is known about the best protocol for evaluation and management of risk associated with osteoporosis and/or refracture in patients who have experienced a hip fracture (Collinge, LeBus, Gardner, & Gehrig, 2008). This article provides evidence-based recommendations for osteoporosis management to reduce the incidence of fracture and promote optimum bone health that can be adopted by primary care providers (PCPs); specialists such as rheumatologists, endocrinologists, and geriatricians; and orthopedic surgeons to improve evaluation and treatment of osteoporosis in patients who have sustained a hip fracture (Collinge et al., 2008).

Need for multidisciplinary osteoporosis management Evidence suggests that multidisciplinary osteoporosis care management is associated with earlier initiation of treatment and appreciably lower rates of repeat fracture and mortality (Ip, Leung, & Kung, 2010). The following allied health professionals have an important role to play in the management of patients following lowenergy trauma hip fracture: PCPs, osteoporosis specialists, nutritionists, physical and occupational therapists, home healthcare team members, pharmacists, and smoking cessation counselors. Specialists commonly include rheumatologists, endocrinologists, and increasingly, geriatricians. Unfortunately, few of these providers are available who have the expertise and commitment needed to provide expert osteoporosis care (Harrington & Deal, 2006). This critical shortage of stakeholders to provide oversight contributes to poor case management and represents an obstacle to continuity of care that may result in refracture (Greene & Dell, 2010). There are also often a number of care transitions that occur post hip fracture, each of which represents an opportunity for a breakdown in the continuity of care, including hospital to rehabilitation, rehabilitation to long-term care, and long-term care to community. Recent literature confirms that a shortage of multidisciplinary healthcare team members with the expertise and investment needed to provide proper osteoporosis management greatly influences the phenomenon of osteoporosis in the context of low-energy trauma hip fracture, along with decreased BMD and the presence of osteoporosis risk factors (Bogoch et al., 2006; Collinge et al., 2008; Harrington & Deal, 2006; Ip et al., 2010;


Pope, 2009). Barriers also exist with respect to screening and evaluation, pharmacotherapy, and resistance to lifestyle modifications; however, each member of the multidisciplinary team has an important role to play in overcoming these challenges. Immediately post hip fracture, focus in the orthopedic treatment setting is on basic post fracture care, pain management, and promotion of mobility whenever safe and possible. It is also critical to success that the osteoporosis evaluation and referral processes begin alongside initial hip-fracture treatment in the orthopedic setting. However, one study compared rates of initiation of osteoporosis treatment following hip fracture amongst various hospital services including orthopedic surgery, medicine, and rehabilitation, and discovered that orthopedic surgery had the lowest rate of initiation at only 12%, compared with 58% for medicine, and 44% for rehabilitation (Gregory, Lam, & Howell, 2010). It should be the minimum responsibility of the orthopedic and medical teams to ensure that the patient is properly evaluated for BMD via DXA scanning and laboratory testing prior to discharge. Bogoch et al. (2006) also examined osteoporosis care in the orthopedic setting through development of an Osteoporosis Exemplary Care Program to identify and treat high-risk patients with osteoporosis following fragility fracture. The program succeeded in diagnosing and providing osteoporosis treatment or referral for greater than 96% of patients enrolled in the study. They concluded that orthopedic surgeons have an important role to play, either through referral or early treatment, in order to avoid losing patients to follow-up after hospital discharge. This course of action is particularly vital with patients who had sustained a hip fracture, as many of them were found by the study to have additional risks for osteoporosis that required further attention, including family history (22%) and history of smoking (56%).

Screening and evaluation of osteoporosis post hip fracture DXA scanning is required to aid in the diagnosis of osteoporosis in patients who have sustained a hip fracture. Some patients, however, are unable or unwilling to be seen for follow-up scanning because of mobility restrictions (Collinge et al., 2008). Interval scanning every 2–3 years is recommended to monitor response to therapy, and this presents yet another challenge for patients and providers to ensure that long-term care continues (USPSTF, 2010). Teng, Curtis, and Saag (2009) found that post fracture, fewer than 15% of patients received a DXA scan. In particular, non-Caucasian and male populations are notoriously underscreened and underdiagnosed. At min-


imum, comprehensive medical, osteoporotic, endocrine, nutritional, family, and current injury histories should be taken for all patients following a low-energy trauma hip fracture. Endocrine history should include onset of menarche and menopause for women, and history of low testosterone for men (Collinge et al., 2008). This information is to be supplemented by laboratory testing including blood and urine calcium levels, thyroid and parathyroid hormone levels, 25-hydroxy (25-OH) vitamin D, and testosterone levels in men (NOF, 2011). Ip et al. (2010) also point out that osteoporosis treatment decisions in the post hip-fracture setting should not be delayed by lack of DXA equipment or data. The opportunity to treat patients who have experienced low-energy trauma hip fracture, which is easy to diagnose in the absence of DXA measurements, should not be missed. Collinge et al. (2008) examined the use of an alternative technology to measure BMD, quantitative ultrasound (QUS). QUS is measured at the heel, and is ideal for the orthopedic treatment setting because it can be taken at the bedside. This intervention, paired with patient education and a 1-year follow-up via telephone, resulted in identification of 30% of the sample population as being at high risk for osteoporosis and related complications. Treatment was successfully initiated in 96% of this high-risk population. At the 1-year follow-up, 57% had seen their PCP after discharge from the hospital, 47% had continued medical treatment, and no additional fractures were sustained. This protocol demonstrated that significant success in osteoporosis management can be achieved when screening begins in the hospital or orthopedic setting. It also further emphasized the need for primary care follow-up and treatment continuation, as a striking 82% of patients who saw their PCP within 1 year continued drug therapy. Additional data regarding the accuracy of QUS is needed before it can be routinely recommended as comparable to DXA scanning in the detection of osteoporosis. One meta-analysis of 1908 relevant articles calculated a sensitivity of 79% and specificity of 58% for QUS as compared to DXA (Nayak et al., 2006 ). Hospitalization for hip fracture represents a unique opportunity to identify individuals at high-risk for osteoporosis, and intervene as necessary. Many patients do not associate their hip fracture with a diagnosis of osteoporosis, and therefore do not see the benefit of engaging in an antiosteoporosis treatment plan that may or may not include pharmacotherapy to prevent future fracture (Jennings et al., 2010). An accurate diagnosis of osteoporosis made during hospitalization for hip fracture increases the patient’s chances of receiving appropriate outpatient osteoporosis treatment (Rabenda et al., 2008). For optimum continuation of osteoporosis management after the patient is discharged from the orthopedic 5


setting, care coordination and reliable referral systems must be established. Imaging results and any diagnosis of osteoporosis must be communicated to the patient’s PCP, along with records from hospital admission. Smooth transition of the multidisciplinary team approach into the primary care setting is essential for successful osteoporosis management. Several studies have shown that hospital-based consultation and case management services are effective in promoting increased initiation rates for osteoporosis treatment by PCPs, following hospitalization for fracture (Bogoch et al., 2006; Collinge et al., 2008; Gregory et al., 2010; Jennings et al., 2010; Rabenda et al., 2008). However, few of these programs have been adopted, and therefore treatment initiation rates remain low (Jennings et al., 2010).

Promoting lifestyle modifications post hip fracture Instituting and maintaining lifestyle modifications including calcium and vitamin D supplementation, smoking cessation, exercise, weight management, and fall prevention measures, are central components of optimal osteoporosis care. Ideally, these preventative strategies should begin in adolescence for early instillation of good health habits and maximal effect on peak bone mass (Rawlins, 2009). Sufficient counseling and education provided by the patient’s PCP is essential to overcoming reluctance to adopt lifestyle modifications at this stage. PCPs may need to refer out or consult with specialists including nutritionists, smoking cessation counselors, and home health aides. Good nutrition is required for optimum bone health and fall prevention. Sufficient protein, calcium, and vitamin D intake have been associated with increased hip BMD and decreased falls (Ip et al., 2010). Calcium and vitamin D supplementation have been shown to have higher patient adherence and continuation rates over antiosteoporosis medications, and represents a relatively simple, evidence-based intervention that is acceptable to most patients (Collinge et al., 2008). Current Recommended Dietary Allowances in accordance with the 2011 Institute of Medicine (IOM) report are 1000 mg of calcium for males aged 51–70, and 1200 mg for females aged 51 and older and males 71 years of age and older (IOM, 2011). Calcium carbonate and calcium citrate are the most commonly available forms available for calcium supplementation. Calcium carbonate is less costly; however, it requires stomach acid for absorption and therefore must be taken with food. Calcium citrate may be taken with or without food (Office of Dietary Supplements/National Institutes of Health, 2011a). 6


The IOM recommends 600 IU of vitamin D daily for males and females aged 51–70, and 800 IU for those 71 and older (IOM, 2011). Vitamin D is available in two forms for supplementation: D2 and D3 . Both are nearly identical in terms of their metabolism and action in the body, however vitamin D3 appears to be more potent compared to D2 when each is administered in high doses. However, at the nutritional doses outlined above as recommended by IOM, both forms are equally effective at increasing serum 25-OH vitamin D levels (Office of Dietary Supplements/National Institutes of Health, 2011a). Nutritionists are key stakeholders in providing education and promoting adequate dietary and supplemental intake of calcium and vitamin D. Hospital pharmacy services also have an important role to play in assuring that all hip-fracture patients are initiated on (or continue receiving) calcium and vitamin D supplementation during their stay, regardless of antiosteoporosis medication status (Jennings et al., 2010). Post fracture exercise, balance training, and a comprehensive rehabilitation program that includes both weight bearing and resistive activity promotes increased functionality and decreased mortality as well as reduces fall risk (Ip et al., 2010). Daily weight bearing exercise is recommended, although it may take several months of rehabilitation post hip fracture before this is possible (Rawlins, 2009). Mobility restrictions inherent to hip fracture often render some aspects of rehabilitation and treatment difficult (Collinge et al., 2008). Coordination with occupational and physical therapy is particularly valuable in these situations to promote return to independent functioning and reduce frailty while preventing falls. Pain management is an important aspect of care and will increase the patient’s participation in exercise and rehabilitation following a hip fracture. Massage therapy should be considered as an alternative or adjunct to pharmacotherapy. It can be beneficial for soothing muscles, reducing pain, increasing flexibility, and improving healing because of increased blood flow. The overlying theme for all of the above-mentioned lifestyle modifications is that without proper patient education and the patient’s investment in and desire for treatment, interventions will most likely be unsuccessful. Depression is relatively common in the post hip-fracture setting, and can negatively affect treatment outcomes. Providers must recognize and properly screen patients for depression and substance use or abuse. Avoidance of alcohol and tobacco should be recommended, as should use of assistive devices, removal of loose floor rugs, and correction of vision as needed. PCPs should also conduct a comprehensive medication review for each of their patients and be alert for side effects of sedation or orthostatic hypotension (Rawlins, 2009). Consultation with clinical



Table 1 U.S. FDA approved pharmacotherapies for osteoporosis treatment in the United States Drug Risedronate (Actonel) Alendronate (Fosamax) Ibandronate (Boniva) Zolendronic acid (Reclast) Estrogen (Premarin, Menostar) Denosumab (Prolia) Calcitonin (Miacalcin, Fortical) Teriparatide (Forteo) RAloxifene (Evista)

Class

Formulation, dosing

Indication

Bisphosphonate Bisphosphonate Bisphosphonate Bisphosphonate Estrogen Monoclonal antibody RANKL inhibitor PTH antagonist PTH antagonist Selective estrogen receptor modulator (SERM)

PO, daily, weekly, or monthly PO, daily or weekly PO or IV, daily or monthly IV, annually PO or transdermal, daily or weekly SC, biannually Intranasal, daily SC, daily PO, daily

PMO, GIO, male OP PMO, GIO, male OP PMO PMO PMO PMO PMO PMO, male OP PMO

Note: PMO, postmenopausal osteoporosis; GIO, glucocorticoid induced osteoporosis; PTH, parathyroid hormone. C 2010. Source: National Osteoporosis Foundation (NOF)

pharmacists regarding medication selection can be very useful, especially for patients with polypharmacy.

Pharmacotherapy post hip fracture There are a number of Food and Drug Administration approved pharmacotherapies available for the treatment of osteoporosis (see Table 1). Oral bisphosphonates may be difficult for some patients to take, as they must remain sitting or standing for at least 30 min after administration, with nothing to eat or drink. This is a major contributor to decreased medication adherence (Mitchner & Harris, 2009). Other factors that decrease adherence are the lack of understanding among patients regarding the asymptomatic nature of the disease (Rabenda et al., 2008) and the severe morbidities associated with untreated osteoporosis (Teng et al., 2009). Available safety and clinical data are limited for some of the newer antiosteoporosis medications, which poses a challenge for providers who attempt to prescribe them (Mitchner & Harris, 2009). Teng et al. (2009) found that post fracture, fewer than 15% of patients were initiated on antiosteoporosis medications. Another study found that only 24% of women over 60 who sustained a fracture, a particularly high risk group for osteoporosis and refracture, began drug therapy within 1 year (Pope, 2009). One factor in this may be that some providers hold the false belief that little can be done for the elderly who sustain a fracture, so they do not initiate a full evaluation or consider pharmacotherapy (Teng et al., 2009). There may also be confusion amongst providers regarding who is responsible for initiation of therapy (Rabenda et al., 2008). One bisphosphonate does appear to emerge as the treatment of choice to prevent repeat hip fracture, zoledronic acid. Significant clinical data reveals a 35% reduction in all types of clinical fracture with this drug, and a 28% reduction in all causes of mortality post hip fracture. The bisphosphonates alendronate and risedronate

were shown to decrease vertebral fracture risk by 38% and 44%, respectively; however, data for reduction in nonvertebral fracture risk were insignificant or unavailable (Ip et al., 2010). Teriparatide, a form of human parathyroid hormone, is the only therapy approved for osteoporosis that has bone-forming capability. It has been shown to reduce rates of all fracture types; however, nonvertebral fracture risk reduction data were insignificant when compared to placebo (Ip et al., 2010; Mitchner & Harris, 2009). Yearly zoledronic acid was the only therapy shown to reduce vertebral and nonvertebral fracture risk, and have the added benefit of increased survival in post hip-fracture clients (Ip et al., 2010). Intravenous formulations including zoledronic acid and ibandronate do not require that patients remain sitting or standing for 30 min after administration, and therefore are ideal for administration in the postoperative, hospital setting (Jennings et al., 2010). The same is true for denosumab, the RANK ligand inhibitor of osteoclast activity, which is administered twice annually through subcutaneous injection by a healthcare professional (Lewiecki, 2010). Bisphosphonate therapy is not without side effects and is not appropriate for all patients. Common side effects of oral formulations include nausea, heartburn, irritation of the esophagus or stomach, and in some cases, difficulty swallowing. Bone, joint, or muscle pain may also develop with bisphosphonate therapy. Patients should be counseled to report any new onset hip or thigh bone pain, as this may be a sign of atypical fracture of the femur, a rare but serious side effect of bisphosphonates. Other rare yet serious side effects that have been reported include uveitis and osteonecrosis of the jaw. Providers should use caution or avoid bisphosphonates in individuals with renal disease, low serum calcium or vitamin D levels, certain problems of the esophagus, and anyone who is unable to remain sitting or standing for at least 30 min after administration. Although knowledge of the side effects of long-term bisphosphonate therapy is limited, current research suggests that providers should consider a drug 7


holiday after 5–7 years of continuous use, depending on fracture history and T-score (NOF, 2008).

Discussion There is a great need to increase the awareness of osteoporosis risk factors among all members of the healthcare team, especially in the post hip-fracture treatment setting (Pope, 2009). Providers and specialists should be able to easily recognize these risks, counsel patients on how to reduce them, and become more vigilant in screening for osteoporosis post fracture. Providers must also address the need for careful oversight of osteoporosis management by assuming the roles of coordinator and champion with a stake in providing the highest quality, evidencebased care. These are perhaps the first crucial steps toward bridging osteoporosis healthcare gaps and tackling disparities from the ground up (Teng et al., 2009). All of the above research underscores the need for more individualized, multifaceted approaches to managing osteoporosis in patients who have sustained a low-energy trauma hip fracture (Teng et al., 2009). Healthcare providers must employ evidence-based diagnostics, lifestyle modifications and pharmacotherapies, under dedicated coordination and oversight, by a nurse practitioner (NP), for example. Please see Table 2 for a summary of the recommendations made here for multidisciplinary management of osteoporosis. All aspects of therapy should be continually reevaluated across the patient’s life span for effectiveness and appropriateness (Mitchner & Harris, 2009). Research studies have shown that provision of osteoporosis therapy under nurse coordination and a specified management plan results in more effective care. Creation and upkeep of a patient registry is also beneficial to facilitate care and manage tasks (Harrington & Deal, 2006). Under an osteoporosis disease management program directed by NPs, Greene and Dell (2010) observed a 263% increase in the number of DXA scans done each year. They also reported a 153% increase in the number of patients taking antiosteoporosis medications each year, and a 38.1% decrease in the hip-fracture reoccurrence rate. Development of a reliable referral system for DXA scanning post fracture, one that spans across specialties to include all members of the multidisciplinary care team, is also key to success in improving care (Harrington & Deal, 2006). Reluctance by health professionals to integrate care across specialty lines and the lack of a reliable referral system reduce the number of patients who are effectively evaluated and treated for osteoporosis post fracture (Harrington & Deal, 2006). Hospital physicians and surgeons may be hesitant to screen for osteoporosis, which 8


Table 2 Summary of recommendations for management of osteoporosis of post low-energy trauma hip-fracture patients Initial evaluation and work up Obtain comprehensive history—medical, osteoporotic/fracture, endocrine, nutritional, substance abuse, family; DXA scan; Laboratory testing—serum and urine calcium, 25(OH)D, thyroid and parathyroid hormone levels, testosterone (men). Initiate lifestyle modifications Calcium carbonate or citrate supplementation 1000 mg daily for males 51–70 1200 mg daily for females 51+, males 71+; Vitamin D2 or D3 supplementation 600 IU daily for males and females 51–70 800 IU daily for males and females 71+; Smoking and alcohol cessation; Daily weight bearing exercise, resistive activity, balance training, rehabilitation; Fall prevention, use of assistive devices, removal of loose floor rugs, correction of vision. Consideration of pharmacotherapy NOF (2010) recommends pharmacologic therapy for postmenopausal women and men 50+ who meet the following criteria Hip or vertebral fracture Other prior fracture or low bone mass as indicated by T-score between -1.0 and -2.5, measured at femoral neck, total hip, or spine T-score ≤ -2.5 at the femoral neck, total hip, or spine (secondary causes excluded) T-score between -1.0 and -2.5, and presence of secondary causes associated with high risk of fracture (glucocorticoid use, total immobilization) 10-year probably of hip fracture ≥ 3% or 10-year probably of any major osteopororsis-related fracture ≥ 20% based on WHO FRAX Follow-up Reevaluate appropriateness and effectiveness of treatment plan annually; Repeat DXA scan every 2–3 years, as appropriate based on clinical judgment; If long-term bisphosphonate therapy (5–7 years), consider drug holiday of 6–12 months.

has long been considered an outpatient responsibility (Jennings et al., 2010). Failure to notify the patient’s PCP of the incidence of fracture and/or DXA results also delays treatment (Pope, 2009). Orthopedists, PCPs, nutritionists, physical and occupational therapists, home healthcare team members, etc., are all valuable stakeholders in the successful management of osteoporosis and prevention of repeat fracture in patients who have sustained a low-energy trauma hip fracture. Accord and collaboration amongst these team members should be centered around common goals, as a multidisciplinary approach has been shown to be most effective (Ip et al., 2010). Furthermore, it is the responsibility of all providers to be



familiar with current guidelines for practice, and to incorporate other advanced-practice professionals, namely NPs, physician assistants, and specialists with expertise in osteoporosis management, into the healthcare team. This creates an ideal environment for the ongoing assessment of osteoporosis risk and treatment (Pope, 2009). Resistance to change is yet another large hurdle to overcome; however, system and process level changes have been demonstrated to be more effective and long lasting than interventions aimed at healthcare providers alone, or those that strictly provide financial incentives. It is not sufficient to acknowledge what changes must be made to improve osteoporosis care, rather, knowledge of how to effectively bring about such change is essential. This is not instinctive, and methods of redesigning care at the system level must be taught and continually reinforced (Teng et al., 2009). As highlighted by Harrington and Deal (2006), the existence of one or more case managers or coordinators, supported by other staff, is required to monitor and champion change in the healthcare setting. Lastly, it is important that realistic and manageable goals are set for change, and that the process is viewed as cyclical rather than linear (Teng et al., 2009). Improvements to multidisciplinary management of osteoporosis in patients following low-energy trauma hip fracture cannot be expected to happen overnight.

Considerations for the future Unfortunately, there is a paucity of research comparing efficacy of osteoporosis pharmacotherapies head-tohead (Mitchner & Harris, 2009), especially in patients who have sustained hip fracture. There is only one clinical drug trial that has been conducted in patients with recent hip fracture (Ip et al., 2010). These represent critical areas where future research is needed. We also need to better support patients through education and motivation with respect to lifestyle modifications. Rawlins (2009) suggests motivational interviewing as one potentially effective strategy; however, further investigation is warranted to identify additional methodologies that are cost and time effective. Studies have shown that efforts to promote outpatient PCP follow-up resulted in increased rates of osteoporosis recognition and treatment. However, the greatest success in improving management of osteoporosis begins with in-hospital initiation by the multidisciplinary care team. In fact, in-hospital initiation of calcium and vitamin D therapy in post hip-fracture patients was found by one study to be the only factor associated with a significantly elevated rate of antiosteoporosis medication therapy (Jennings et al., 2010). Including multidisciplinary osteoporosis management post hip fracture as a hospital

quality indicator may also help to elicit more widespread implementation of interventions known to be effective, yet underutilized (Cadarette et al., 2008). Yet another challenge is posed by Medicare, which may neglect to reimburse hospitals for DXA scanning or bisphosphonate administration during a hip-fracture hospitalization (Jennings et al., 2010). Financial incentives for hospitals would also help to facilitate improved osteoporosis management. This is in the best interest of Medicare and other insurance providers given the high medical costs attributed to hip fracture annually. Despite the availability of accurate screening technologies and highly efficacious antiosteoporosis medications, implementation of these measures for low-energy trauma hip-fracture patients remains critically low. All members of the multidisciplinary care team are called to action to adopt the osteoporosis evaluation and treatment strategies that research has shown to be effective, on a larger scale in the post hip-fracture setting.

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