Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle.

UNLABELLED: The International Osteoporosis Foundation (IOF) Capture the Fracture Campaign aims to support implementation of Fracture Liaison Services (FLS) throughout the world.
INTRODUCTION: FLS have been shown to close the ubiquitous secondary fracture prevention care gap, ensuring that fragility fracture sufferers receive appropriate assessment and intervention to reduce future fracture risk.
METHODS: Capture the Fracture has developed internationally endorsed standards for best practice, will facilitate change at the national level to drive adoption of FLS and increase awareness of the challenges and opportunities presented by secondary fracture prevention to key stakeholders. The Best Practice Framework (BPF) sets an international benchmark for FLS, which defines essential and aspirational elements of service delivery.
RESULTS: The BPF has been reviewed by leading experts from many countries and subject to beta-testing to ensure that it is internationally relevant and fit-for-purpose. The BPF will also serve as a measurement tool for IOF to award 'Capture the Fracture Best Practice Recognition' to celebrate successful FLS worldwide and drive service development in areas of unmet need. The Capture the Fracture website will provide a suite of resources related to FLS and secondary fracture prevention, which will be updated as new materials become available. A mentoring programme will enable those in the early stages of development of FLS to learn from colleagues elsewhere that have achieved Best Practice Recognition. A grant programme is in development to aid clinical systems which require financial assistance to establish FLS in their localities.
CONCLUSION: Nearly half a billion people will reach retirement age during the next 20 years. IOF has developed Capture the Fracture because this is the single most important thing that can be done to directly improve patient care, of both women and men, and reduce the spiralling fracture-related care costs worldwide.

The International Osteoporosis Foundation Capture the Fracture Campaign

In 2012, the International Osteoporosis Foundation (IOF) launched the Capture the Fracture Campaign [1, 2]. Capture the Fracture is intended to substantially reduce the incidence of secondary fractures throughout the world. This will be delivered by establishment of a new standard of care for fragility fracture sufferers, whereby health care providers always respond to the first fracture to prevent the second and subsequent fractures. The most effective way to achieve this goal is through implementation of coordinator-based, post-fracture models of care. Exemplar models have been referred to as ‘Fracture Liaison Services’ (United Kingdom [3-7], Europe [8, 9] and Australia [10-12]), ‘Osteoporosis Coordinator Programs’ (Canada [13, 14]) or ‘Care Manager Programs’ (USA [15, 16]). For the purposes of this position paper, they will be referred to as Fracture Liaison Services (FLS).

During the first 10 years of the twenty-first century—the first Bone and Joint Decade [17]—considerable progress was made in terms of establishment of exemplar FLS in many countries [1] and the beginning of inclusion of secondary fracture prevention into national health policies [18-26]. However, FLS are currently established in a very small proportion of facilities that receive fracture patients worldwide, and many governments are yet to create the political framework to support funding of new services. The goal of Capture the Fracture is to facilitate adoption of FLS globally. This will be achieved by recognising and sharing best practice with health care professionals and their organisations, national osteoporosis societies and the patients they represent, and policymakers and their governments. This position paper describes why Capture the Fracture is needed and precisely how the campaign will operate over the coming years. IOF believes this is the single most important thing that can be done to directly improve patient care, for women and men, and reduce spiralling fracture-related health care costs worldwide.

The need for a global campaign

Half of women and a fifth of men will suffer a fragility fracture in their lifetime [23, 27–29]. In year 2000, there were an estimated 9 million new fragility fractures including 1.6 million at the hip, 1.7 million at the wrist, 0.7 million at the humerus and 1.4 million symptomatic vertebral fractures [30]. More recent studies suggest that 5.2 million fragility fractures occurred during 2010 in 12 industrialised countries in North America, Europe and the Pacific region [31] alone, and an additional 590,000 major osteoporotic fractures occurred in the Russian Federation [32]. Hip fracture rates are increasing rapidly in Beijing in China; between 2002 and 2006 rates in women rose by 58 % and by 49 % in men [33]. The costs associated with fragility fractures are currently enormous for Western populations and expected to dramatically increase in Asia, Latin America and the Middle East as these populations age:

In 2005, the total direct cost of osteoporotic fractures in Europe was 32 billion EUR per year [34], which is projected to rise to 37 billion EUR by 2025 [35]

In 2002, the combined cost of all osteoporotic fractures in the USA was 20 billion USD [36]

In 2006, China spent 1.6 billion USD on hip fracture care, which is projected to rise to 12.5 billion USD by 2020 and 265 billion USD by 2050 [37]

A challenge on this scale can be both daunting and bewildering for those charged with developing a response, whether at the level of an individual institution or a national health care system. Fortuitously, nature has provided us with an opportunity to systematically identify almost half of individuals who will break their hip in the future. Patients presenting with a fragility fracture today are twice as likely to suffer future fractures compared to peers that haven’t suffered a fracture [38, 39]. Crucially, from the obverse view, amongst individuals presenting with a hip fracture, almost half have previously broken another bone [40-43]. A broad spectrum of effective agents are available to prevent future fractures amongst those presenting with new fractures, and can be administered as daily [44-46], weekly [47, 48] or monthly tablets [49, 50], or as daily [51, 52], quarterly [53], six-monthly [54] or annual injections [55]. Thus, a clear opportunity presents to disrupt the fragility fracture cycle illustrated in Fig. 1, by consistently targeting fracture risk assessment, and treatment where appropriate, to fragility fracture sufferers [56].

Fig. 1

The fragility fracture cycle (reproduced with permission of the Department of Health in England [56])

Regrettably, the majority of health care systems around the world are currently failing to respond to the first fracture to prevent the second. The ubiquitous nature of the secondary fracture prevention care gap is evident from the national audits summarised in Table 1, for both women and men [57-66]. Additionally, a substantial number of regional and local audits have been summarised in the 2012 IOF World Osteoporosis Day Report, which mirror the findings of the national audits [1]. The secondary fracture prevention care gap is persistent. A recent prospective observational study of >60,000 women aged ≥55 years, recruited from 723 primary physician practices in 10 countries, reported that less than 20 % of women with new fractures received osteoporosis treatment [67]. A province-wide study in Manitoba, Canada has revealed that post-fracture diagnosis and treatment rates have not substantially changed between 1996/1997 and 2007/2008, despite increased awareness of osteoporosis care gaps during the intervening decade [68].

Table 1

National audits of secondary fracture prevention

Country	No. of fracture patients	Study population	Fracture risk assessment done or risk factors identified (%)	Treated for osteoporosis (%)	Reference
Australia	1,829	Minimal-trauma fracture presentations to Emergency Departments	– < 13 % had risk factors identified	–12 % received calcium	Teede et al. [57]
			–10 % ‘appropriately investigated’	–12 % received vitamin D
				–8 % received a bisphosphonate
Canada	441	Men participating in the Canadian Multicentre Osteoporosis Study (CaMos) with a prevalent clinical fracture at baseline	–At baseline, 2.3 % reported a diagnosis of osteoporosis	–At baseline, <1 % were taking a bisphosphonate	Papaioannou et al. [58]
			–At year 5, 10.3 % (39/379) with a clinical fragility fracture (incident or prevalent) reported a diagnosis of osteoporosis	–At year 5, the treatment rate for any fragility fracture was 10 % (36/379)
Germany	1,201	Patients admitted to hospital with an isolated distal radius fracture	62 % of women and 50 % of men had evidence of osteoporosis	7 % were prescribed osteoporosis-specific medication	Smektala et al. [59]
Italy	2,191	Ambulatory patients with a previous osteoporotic hip fracture attending orthopaedic clinics	No data	–< 20 % of patients had taken an antiresorptive drug before their hip fracture	Carnevale et al. [60]
				–< 50 % took any kind of treatment for osteoporosis 1.4 years after initial interview
Japan	2,328	Females suffering their first hip fracture	BMD was measured before or during hospitalisation for 16 % of patients	–19 % of patients received osteoporosis treatment in the year following fracture	Hagino et al. [61]
				–36 % of patients receiving osteoporosis treatment during hospitalisation continued at 1 year
Korea	151,065	Nationwide cohort of females with hip, spine and wrist fractures	BMD was measured for 23 % with hip fracture, 29 % with spine fracture and 9 % with wrist fracture	≥1 approved osteoporosis treatment was received by 22 % with hip fracture, 30 % with spine fracture and 8 % with wrist fracture	Gong et al. [62]
Netherlands	1,654	Patients hospitalised for a fracture of the hip, spine, wrist or other fractures	For a sample of 208 out of 1,654 cases, GP case records were available. Of these patients, 5 % had a diagnosis of osteoporosis in the GP records	15 % of patients received osteoporosis treatment within 1 year after discharge from hospital	Panneman et al. [63]
Switzerland	3,667	Patients presenting with a fragility fracture to hospital emergency wards	BMD was measured for 31 % of patients	24 % of women and 14 % of men were treated with a bone active drug, generally a bisphosphonate with or without calcium and/or vitamin D	Suhm et al. [64]
UK	9,567	Patients who presented with a hip or non-hip fragility fracture	32 % of non-hip fracture and 67 % of hip fracture patients had a clinical assessment for osteoporosis and/or fracture risk	33 % of non-hip fracture and 60 % of hip fracture patients received appropriate management for bone health	Royal College of Physicians [65]
USA	51,346	Patients hospitalised for osteoporotic hip fracture	No data	7 % received an anti-resorptive or bone-forming medication	Jennings et al. [66]

The reason that the care gap exists, and persists, is multi-factorial in nature. A systematic review from Elliot-Gibson and colleagues in 2004 identified the following issues [69]:

Cost concerns relating to diagnosis and treatment

Time required for diagnosis and case finding

Concerns relating to polypharmacy

Lack of clarity regarding where clinical responsibility resides

The issue regarding where clinical responsibility resides resonates with health care professionals throughout the world. Harrington’s metaphorical depiction captures the essence of the problem [70]:

‘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 patient disappears’

Surveys have shown that in the absence of a robust care pathway for fragility fracture patients, a ‘Catch-22’ scenario prevails [71]. 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 proven solution to close the secondary fracture prevention care gap is to eliminate this confusion by establishing a Fracture Liaison Service (FLS).

Systematic literature review of programs designed to deliver secondary preventive care reported that two thirds of services employ a dedicated coordinator to act as the link between the patient, the orthopaedic team, the osteoporosis and falls prevention services, and the primary care physician [72]. Successful and sustainable FLS report that clearly defining the scope of the service from the outset is essential. Some FLS began by focusing initially on hip fracture patients, and subsequently expanded the scope of the service until all fracture patients presenting to their institution were assessed as illustrated in Fig. 2.

Fig. 2

Defining the scope of an FLS and expansion of fracture population assessed [1] n.b. The ultimate goal of an FLS is to capture 100 % of fragility fracture sufferers. This figure recognises that development of FLS may be incremental

The core objectives of an FLS are:

Inclusive case finding

Evidence-based assessment—stratify risk, identify secondary causes of osteoporosis, tailor therapy

Initiate treatment in accordance with relevant guidelines

Improve long-term adherence with therapy

The operational characteristics of a comprehensive FLS have been described as follows [1]. The FLS will ensure fracture risk assessment, and treatment where appropriate, is delivered to all patients presenting with fragility fractures in the particular locality or institution. The service will be comprised of a dedicated case worker, often a clinical nurse specialist, who works to preagreed protocols to case-find and assess fracture patients. The FLS can be based in secondary or primary care and requires support from a medically qualified practitioner, be they a hospital doctor with expertise in fragility fracture prevention or a primary care physician with a specialist interest. The structure of a hospital-based FLS in the UK was presented in a national consensus guideline on fragility fracture care as shown in Fig. 3 [73].

Fig. 3

The operational structure of a hospital-based Fracture Liaison Service [73] Asterisk (*) older patients, where appropriate, are identified and referred for falls assessment

FLS have been established in a growing number of countries including Australia [11, 12, 74–76], Canada [13, 77–79], Ireland [80], the Netherlands [81-84], Singapore [26], Spain [85], Sweden [86, 87], Switzerland [88], the United Kingdom [3-7] and the USA [89-92]. FLS have been reported to be cost-effective by investigators in Australia [10], Canada [14, 93], the United Kingdom [94] and the USA [15], and by the Department of Health in England [95]. In 2011, the IOF published a position paper on coordinator-based systems for secondary fracture prevention [96] which was followed in 2012 by the American Society for Bone and Mineral Research Secondary Prevention Task Force Report [97]. These major international initiatives underscore the degree of consensus shared by professionals throughout the world on the need for FLS to be adopted and adapted for implementation in all countries. FLS serves as an exemplar in relation to the Health Care Quality Initiative of the Institute of Medicine (IOM) [98]. The IOM defines quality as:

‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’

We know that secondary fracture prevention is clinically and cost-effective, but does not routinely happen. FLS closes the disparity between current knowledge and current practice.

An important component of the Capture the Fracture Campaign will be to establish global reference standards for FLS. Several systematic reviews have highlighted that a range of service models have been designed to close the secondary fracture prevention care gap, with varying degrees of success [72, 99, 100]. Having clarity on precisely what constitutes best practice will provide a mechanism for FLS in different localities and countries to learn from one another. The Capture the Fracture ‘Best Practice Framework’ described later in this position paper aims to provide a mechanism to facilitate this goal.

How Capture the Fracture works

Background

The Capture the Fracture Campaign was launched at the IOF European Congress on Osteoporosis and Osteoarthritis in Bordeaux, France in March 2012. Healthcare professionals that have played a leading role in establishing FLS and representatives from national patient societies shared their efforts to embed FLS in national policy in their countries. In October 2012, the IOF World Osteoporosis Day report was devoted to Capture the Fracture [1] and disseminated at events organised by national societies throughout the world [101]. This position paper presents the aims and structure of the Capture the Fracture Campaign. A Steering Committee comprised of the authorship group of this position paper has led development of the campaign and will provide ongoing support to the implementation of the next steps.

Aims

The aims of Capture the Fracture are:

Standards: To provide internationally endorsed standards for best practice in secondary fracture prevention. Specific components are:

Best Practice Framework

Best Practice Recognition

Showcase of best practices

Change: Facilitation of change at the local and national level will be achieved by:

Mentoring programmes

Implementation guides and toolkits

Grant programme for developing systems

Awareness: Knowledge of the challenges and opportunities presented by secondary fracture prevention will be raised globally by:

An ongoing communications plan

Anthology of literature, worldwide surveys and audits

International coalition of partners and endorsers

Internationally endorsed standards

The centrepiece of the Capture the Fracture Campaign is the Best Practice Framework (BPF), provided as Appendix. The BPF is comprised of 13 standards which set an international benchmark for Fracture Liaison Services. Each standard has three levels of achievement: Level 1, Level 2 or Level 3. The BPF:

Defines the essential and aspirational building blocks that are necessary to implement a successful FLS, and

Serves as the measurement tool for IOF to award ‘Capture the Fracture Best Practice Recognition’ in celebration of successful FLS worldwide

Establishing standards for health care delivery systems that have global relevance is very difficult. However, the ‘parallel evolution’ of FLS with broadly similar structure and function in many countries of the world, as described previously, suggested that a meaningful platform for benchmarking could be created. The structure of healthcare systems varies considerably throughout the world, so the context within which FLS have, and will be established in different countries may be markedly different. Accordingly, the BPF has been developed with cognisance that the scope of an FLS—and the limits of its function and effectiveness—may be constrained by the nature of health care infrastructure in the country of origin. To this end, clinical innovators who choose to submit their FLS for benchmarking by the BPF are encouraged to:

Use existing procedures as they correspond to their health care system: Existing, individual systems and procedures that are currently in place can be used to measure performance against the standards.

Meaning of the term ‘institution’: Throughout the BPF, the word ‘institution’ is used which is intended to be a generic term for: the inpatient and/or outpatient facilities, and/or health care systems for which the FLS was established to serve.

Limit applications to ‘systems’ of care: The BPF is intended for larger ‘systems’ of care, within the larger health care setting, which consist of multidisciplinary providers and deal with a significant volume of fracture patients.

Recognise that the BPF is both achievable and ambitious: Some of the BPF standards address essential aspects of an FLS, while others are aspirational. A weight has been assigned to each standard based on how important the standard is in relation to an FLS delivering best practice care. This:

Enables recognition of systems who have achieved the most essential elements, while leaving room for improvement towards implementing the aspirational elements

Allows systems to achieve a standard of care, Silver for example, with a range of levels of achievement across the 13 standards

Applications will be received through a web-based questionnaire, at www.capturethefracture.org, which gathers information about the FLS and its achievements as they correspond to the Best Practice Framework. IOF staff will process submissions which will be reviewed and validated by members of the Steering Committee to generate a summary profile. This will determine the level of recognition to be assigned to the FLS as Unclassified, Bronze, Silver or Gold across four key fragility fracture patient groups—hip fracture, other inpatient fractures, outpatient fracture, vertebral fracture—and organizational characteristics. Applicants achieving Capture the Fracture Recognition will be recognised by IOF in the following ways:

Placement of the applicant’s FLS on the Capture the Fracture website’s interactive map, including the system name, location, link and programme showcase

Awarded use of the IOF-approved, Capture the Fracture Best Practice Recognition logo for use on the applicant’s websites and materials

Facilitating change at the local and national level

The Capture the Fracture website—www.capturethefracture.org—provides links to resources related to FLS and secondary fracture prevention. These include FLS implementation guides and national toolkits which have been developed for some countries. As new resources become available, the website will serve as a portal for sharing of materials to support healthcare professionals and national patient societies to establish FLS in their institutions and countries.

Further supporting the establishment of FLS, Capture the Fracture will organise a locality specific mentoring programme between sites that have achieved Best Practice Recognition and those systems that are in early stage development. An opportunity exists to create a global network to support sharing of the successes and challenges that will be faced in the process of implementing best practice. This network has the potential to contribute significantly to adoption of FLS throughout the world. During 2013, IOF intends to develop a grant programme to aid clinical systems around the world which require financial assistance to establish FLS.

Raising awareness

A substantial body of literature on secondary fracture prevention and FLS has developed over the last decade. A feature of the Capture the Fracture website is a Research Library which organises the world’s literature into an accessible format. This includes sections on care gaps and case finding; assessment, treatment and adherence; and health economic analysis.

IOF has undertaken to establish an international coalition of partners and endorsers to progress implementation of FLS. At the national level, establishment of multi-sector coalitions has played an important role in achieving prioritisation of secondary fracture prevention and FLS in national policy and reimbursement systems [1]. The Capture the Fracture website provides a mechanism to share such experience between organisations and national societies in different countries. Increasing awareness that the secondary fracture prevention care gap has been closed by implementation of FLS, and that policy and reimbursement systems have been created to support establishment of new FLS, will catalyse broader adoption of the model.

A global call to action

During the next 20 years, 450 million people worldwide will celebrate their 65th birthday [102]. As a result, in the absence of systematic preventive intervention, the human and financial costs of fragility fractures will rise dramatically. Policymakers, professional organisations, patient societies, payers and the private sector must work together to ensure that every fracture that could be prevented is prevented. Almost half of hip fracture patients suffer a previous fragility fracture before breaking their hip, creating an obvious opportunity for intervention. However, currently, a secondary fracture prevention care gap exists throughout the world. This care gap can and must be eliminated by implementation of Fracture Liaison Services. The Capture the Fracture Campaign provides all necessary evidence, international standards of care, practical resources and a network of innovators to support colleagues globally to close the secondary prevention care gap. We call upon those responsible for fracture patient care throughout the world to implement Fracture Liaison Services as a matter of urgency.

The standards are weighted:	The scores within each standard are:
Essential = weight of 1	Level 1 = 1
Medium = weight of 2	Level 2 = 2
Aspirational = weight of 3	Level 3 = 3

Standard		Weight		Level 1	Level 2	Level 3	Achievement Level ENTER Level1/Level2/Level3 SCORE HERE	Standard Total (weight × level)
1	Patient Identification	1	x	1	2	3		0
2	Patient Evaluation	1	x	1	2	3		0
3	Post-fracture Assessment Timing	2	x	1	2	3		0
4	Vertebral Fracture	3	x	1	2	3		0
5	Assessment Guidelines	3	x	1	2	3		0
6	Secondary Causes of Osteoporosis	3	x	1	2	3		0
7	Falls Prevention Services	1	x	1	2	3		0
8	Multifaceted health and lifestyle risk-factor Assessment	3	x	1	2	3		0
9	Medication Initiation	1	x	1	2	3		0
10	Medication Review	2	x	1	2	3		0
11	Communication Strategy	2	x	1	2	3		0
12	Long-term Management	2	x	1	2	3		0
13	Database	1	x	1	2	3		0
							TOTAL Achievement Level	0