"Our hope is that Americans can live long and live well.
Unfortunately, fractures—the most common and devastating consequence of
bone disease—frequently make it difficult...""Much of the burden of bone disease can potentially be avoided if
at-risk individuals are identified and appropriate interventions... are...
timely.... (H)ealth care providers frequently fail to identify and treat
individuals at high risk for osteoporosis or other disorders of
bone...""... a number of `red flags'... signal potential problems with an
individual's bone health at different ages. One of the most important flags is
a previous fragility-related
fracture."1
"Our hope is that Americans can live long and live well.
Unfortunately, fractures—the most common and devastating consequence of
bone disease—frequently make it difficult..."
"Much of the burden of bone disease can potentially be avoided if
at-risk individuals are identified and appropriate interventions... are...
timely.... (H)ealth care providers frequently fail to identify and treat
individuals at high risk for osteoporosis or other disorders of
bone..."
"... a number of `red flags'... signal potential problems with an
individual's bone health at different ages. One of the most important flags is
a previous fragility-related
fracture."1
In releasing the Surgeon General's report, Bone Health and
Osteoporosis, Secretary Tommy Thompson of the Department of Health and
Human Services declared: "Osteoporosis, fractures, and other chronic
diseases no longer should be thought of as an inevitable part of growing
old." Seniors should "live long and live well." To achieve
that goal, Secretary Thompson contends, we must move beyond the traditional
focus on providing health care and emphasize prevention. "By focusing on
prevention and lifestyle changes, including physical activity and nutrition,
as well as early diagnosis and appropriate treatment, Americans can avoid much
of the damaging impact of bone disease and other chronic diseases." He
argues that a good fraction of the $12 to $18 billion a year that is currently
spent on osteoporosis and fracture care can be avoided if our citizens develop
healthier lifestyles.
Secretary Thompson and Surgeon General Richard Carmona believe that we can
improve the quality of life for millions of Americans if we actively identify
fractures as a "red flag" signaling the need to begin proper
osteoporosis evaluation and treatment. The American Academy of Orthopaedic
Surgeons (AAOS) brought this matter to the attention of orthopaedists last
year, with the publication of its position statement "Recommendations
for Enhancing the Care of Patients with Fragility Fractures" (see
Appendix).
In this issue of The Journal, Gardner et
al.2 expand the
already extensive literature describing the challenges in developing effective
approaches for the care of patients who have sustained a fracture. The authors
focus on whether a perioperative intervention program that consists of patient
education and provides patients with a list of questions to ask their primary
care physician would increase the percentage of patients who received
appropriate follow-up evaluation after a fracture. The authors conclude that
such empowered patients are indeed much more likely to have appropriate
follow-up. This is a simple step that many orthopaedists can implement
easily.
However, implicit in the study are two important caveats. The first is that
the need for evaluation of secondary causes of osteoporosis must be
considered. Although Gardner et al. considered a dual-energy x-ray
absorptiometry scan alone as constituting good follow-up, a scan is only one
element of the management plan. Virtually all clinical osteoporosis
specialists believe that a fragility fracture after the age of fifty is strong
evidence of poor bone quality and a high risk of repeat fractures and that
intervention strategies including calcium and vitamin D, exercise, fall
prevention, and usually medication are required.
Second, 40% of eligible patients declined the offer to participate in the
trial conducted by Gardner et al. because they thought that their fracture was
not a result of osteoporosis. It is alarming and disappointing that, despite
what seem like endless public education campaigns relating to bone health
launched in recent years by the National Osteoporosis Foundation, the American
Academy of Orthopaedic Surgeons, and other health-conscious organizations, the
connection between fragility fractures and osteoporosis is not being made by
patients.
The valuable research and recommendations presented by Gardner et al. are
only one step in what must be a system-wide solution. As the percentage of
patients who declined to participate in their study indicates, even better
national education is essential. The public must understand that a fragility
fracture is a signal portending more fractures, and a fracture should prompt
patients to ask their physicians for an osteoporosis work-up. Similarly,
patients need to understand the critical role of physical activity, nutrition,
and lifestyle in preventing bone disease. Such education could be part of the
courses on healthy lifestyles that high schools across the country are
teaching today.
Systemic solutions are also needed to improve the education of both primary
care physicians and specialists in the proper follow-up of a patient who
presents with a fracture. Many of today's clinicians were trained at a time
when osteoporosis was considered a natural part of aging. The model presented
by Gardner et al. breaks through a professional "silo" mentality
that limits communication among specialists. Algorithm-style guidelines could
be applied to the treatment of all patients presenting with a fragility
fracture. Such guidelines could be made part of standard operating procedures
for the nation's emergency rooms as well as for discharge-planning teams. They
could also be part of continuing education programs for primary care
physicians and specialists. Physicians and other caregivers must recognize
that fracture rates can be reduced with appropriate therapy and a
comprehensive post-fracture follow-up regimen.
Traditionally, orthopaedic surgeons have claimed to "own the
bone." Our profession must view the Surgeon General's report as a
wake-up call that fracture care encompasses prevention as well as acute
management. If we are truly to "own the bone," we must lead in
developing multidisciplinary teams that design and implement algorithms to
enhance fracture care and prevention in clinics and hospitals. The AAOS
position statement and the protocol described by Gardner et al. are excellent
first steps, but there is a tremendous amount of work ahead. Let's begin!
The AAOS position statement "Recommendations for Enhancing the Care
of Patients with Fragility Fractures" is available with the electronic
versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM).