Advances in fracture risk assessment during the last decade can now provide a platform for development of clinically effective and, crucially, cost-effective approaches. In order to ensure that a primary fracture prevention programme has the potential to be cost effective, consideration must be given to which first fragility fracture is to be prevented. 

Primary prevention of hip fracture is likely to be more cost-effective than primary prevention of wrist fracture, because hip fractures cost considerably more to manage than wrist fractures. In this regard, consideration must be given to what proportion of all hip fractures occur as an individual’s first fragility fracture at any skeletal site.

Whilst definitive data to populate such an analysis are not available, with the current evidence-base, approximately 50% of hip fracture patients have suffered clinically apparent fragility fracture(s) prior to breaking their hip, which was usually a non-vertebral fracture (hip, humerus, wrist); also dependent on age and co-morbidities [1]Port, L., et al., Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int, 2003. 14(9): p. 780-4.

[3]Bynum, J.P.W., et al., Second fractures among older adults in the year following hip, shoulder, or wrist fracture. Osteoporos Int, 2016. 27(7): p. 2207-2215.

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This analysis highlights the challenge faced by efforts to proactively case-find the relatively small proportion of individuals who are likely to suffer a hip fracture as their first fragility fracture. It should also be noted that fragility fractures at sites other than the hip impose a significant burden on older people. Vertebral fractures lead to many adverse consequences for sufferers.

Accordingly, a robust clinical case exists for primary prevention of all major osteoporosis fractures, defined as hip, clinical vertebral, wrist or proximal humerus fractures. Pragmatic approaches to case-finding individuals at high risk of suffering these fractures as their first fracture include:

• Osteoporosis induced by medicines: Consistent bone health assessment and treatment for individuals at high fracture risk in this group
• Diseases associated with osteoporosis: Incorporation of routine bone health assessment and treatment for individuals living with diseases related to osteoporosis and fragility fractures
• Absolute fracture risk calculation: Systematic application of tools such as FRAX^®  to risk stratify the older population served by a medical practice, hospital or entire health system
• Fracture risk assessment in routine practice: Systematic application of fracture risk assessment by primary care providers when interacting with older individuals and patients at high risk of fracture

Recently, evidence from the UK SCOOP trial has demonstrated that actively screening older women for fracture risk (using FRAX®) in the primary care setting leads to a reduction in the risk of incident hip fracture [4]Shepstone, L., et al., Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet, 2018. 391(10122): p. 741-747.

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Case finding individuals who have sustained fragility fractures represents the obvious first step in implementation of a systematic approach to fragility fracture prevention [5]International Osteoporosis Foundation: World Osteoporosis Day Thematic Report - Capture the Fracture: A global campaign to break the fragility fracture cycle. 2012;

See link . However, numerous audits conducted throughout the world have identified a persistent and pervasive secondary prevention care gap [6]Harvey, N.C., et al., Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int, 2017. 28(5): p. 1507-1529.

. In 2017, an ESCEO expert consensus meeting highlighted that approximately one-fifth of eligible fracture patients receive osteoporosis treatment after a fracture, and that considerable variation is evident between countries [7]Kanis, J.A., et al., Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting. Osteoporos Int, 2017. 28(7): p. 2023-2034.

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Despite effective treatments having been available since the mid-1990s and publication of many national clinical guidelines which advocate assessment and treatment of fracture patients, osteoporosis is neither assessed nor treated in the majority of cases. 

In response to this missed opportunity for intervention, models of care have been developed to ensure that fracture patients reliably receive osteoporosis management and interventions to prevent future falls. Two complementary models of care have been established in a growing number of countries [6]Harvey, N.C., et al., Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int, 2017. 28(5): p. 1507-1529.

[8]Javaid, M.K., et al., Effective secondary fracture prevention: implementation of a global benchmarking of clinical quality using the IOF Capture the Fracture(R) Best Practice Framework tool. Osteoporos Int, 2015. 26(11): p. 2573-8.

[9]Mitchell, P., et al., Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Pract Res Clin Rheumatol, 2016. 30(3): p. 536-558.

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• Orthogeriatric Services (OGS)

Also known as Orthopaedic-Geriatric Co-Care Services or Geriatric Fracture Centres, OGS focus on delivering best practice for hip fracture patients. This includes expedited surgery, optimal management of the acute phase through adherence to clinical standards overseen by senior orthopaedic and geriatrician/internal medicine clinicians, and delivery of secondary fracture prevention addressing both bone health and falls risk.

• Fracture Liaison Services (FLS)

A FLS is a coordinated model of care for secondary fracture prevention. A FLS ensures that all patients aged 50 years or over, who present to urgent care services with a fragility fracture, undergo fracture risk assessment and receive treatment in accordance with prevailing national clinical guidelines for osteoporosis. The FLS also ensures that falls risk is addressed among older patients through referral to appropriate local falls prevention [10]Marsh, D., et al., Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int, 2011. 22(7): p. 2051-65.

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Detailed analysis of the clinical effectiveness and cost-effectiveness of OGS and FLS was the subject of a recent review article [9]Mitchell, P., et al., Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Pract Res Clin Rheumatol, 2016. 30(3): p. 536-558.

. In summary, OGS in combination with national hip fracture registries have been demonstrated to transform care of hip fracture patients.  

In hospitals without an OGS, the FLS provides secondary preventive care for all fragility fracture patients. In hospitals with an OGS, the FLS provides care specifically for non-hip fragility fracture patients, which usually represents 80% of the entire fracture case load. FLS have been shown to dramatically improve osteoporosis treatment rates for fragility fracture patients and reduce secondary fracture incidence [9]Mitchell, P., et al., Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Pract Res Clin Rheumatol, 2016. 30(3): p. 536-558.

. Further, FLS may have potential beneficial effects on mortality outcomes. Patients followed up in a FLS in the Netherlands had a significant reduction in mortality of 35% over 2 years of follow-up when compared with those who underwent standard non-FLS care [11]Huntjens, K.M., et al., Fracture liaison service: impact on subsequent nonvertebral fracture incidence and mortality. J Bone Joint Surg Am, 2014. 96(4): p. e29.

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Capture the Fracture®: a global programme 
Widespread implementation of FLS is the objective of IOF’s flagship initiative with the Capture the Fracture® Programme. This programme provides resources, best practice guidance, and global recognition to help support the implementation of new FLS or improve existing FLS worldwide.

For more information visit the Capture the Fracture website