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The Future of Fracture Risk Assessment in the Management of Osteoporosis
ARTICLE IN PRESS Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health, vol. ■, no. ■, 1–7, 2017 © 2017 The International Society for Clinical Densitometry. 1094-6950/■:1–7/$36.00 http://dx.doi.org/10.1016/j.jocd.2017.06.015
Original Article
The Future of Fracture Risk Assessment in the Management of Osteoporosis Sanford Baim* Department of Medicine, Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL, USA
Abstract There have been many advances in the field of osteoporosis that add to a greater understanding of skeletal integrity and the adverse effects menopause and aging have on bone. The World Health Organization, the International Osteoporosis Foundation, and numerous additional governmental and privately sponsored organizations, societies, and their respective task forces have provided guidance for the use of appropriate fracture assessment methodologies and fracture risk assessment tools, and for the prevention and management of osteoporosis. Despite these worldwide efforts, a majority of patients at high risk of fracture have not had bone density testing and are not diagnosed or offered osteoporosis treatment before or even after sustaining a fragility fracture. The future of fracture risk assessment and, in general, osteoporosis management requires health-care systems to develop customizable electronic medical record (EMR) systems that incorporate the tools necessary to identify patients at high fracture risk. As provided in the example of an advanced health-care osteoporosis model, an EMR can be fully customizable to identify fractures and patients at high risk of fracture, to assist clinicians in selecting the most efficacious osteoporosis treatments, and to provide long-term follow-up with or without serial bone density testing. Future fracture risk assessment models will likely be further refined by incorporating advanced fracture predictive technologies for integration into algorithms that have improved discrimination, calibration, risk reclassification capabilities, and clinical utility. These models will include accurate and reproducible bone biomarkers and genomic testing that will be automatically integrated into worldwide EMR systems for screening large numbers of at-risk populations and younger patients for future prediction and prevention of disease. The integration of this type of a fracture prediction model into future electronic medical record systems will result in the prevention of osteoporosis fractures. Key Words: Fracture liaison service; fracture risk; primary fracture prevention; risk assessment tool; secondary fracture prevention.
Introduction
(1–3). There are 200 million women who have osteoporosis worldwide, with 1.6 million women sustaining an osteoporotic hip fracture annually. As the world population ages, it is estimated that by 2050, the annual number of hip fractures will increase to between 4.5 and 6.3 million (1–3). The importance of fracture risk assessment has been discussed at length by all the contributing coauthors to this volume (4). The assessment of fracture risk is the keystone to the prevention and management of osteoporosis. There are 2 different but interdependent discussion points that should be considered when taking into account an effective model for the identification and treatment of
It is estimated that 1 in 2–3 women and 1 in 4–5 men in developed countries are expected to sustain an osteoporosis fracture that is associated with significant morbidity, mortality, and adverse psychological, social, and financial consequences for the affected individual family and society *Address correspondence to: Sanford Baim, MD, FACR, CCD, Department of Medicine, Section of Endocrinology, Rush University Medical Center 1725 W. Harrison Street Suite 250, Chicago, IL 60612, USA. E-mail: [email protected]
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ARTICLE IN PRESS 2 patients at risk for osteoporosis fractures. The first is concerned with the technologies available for the measurement of bone mass and skeletal integrity and the algorithms that integrate clinical risk factors (CRFs) for fracture with these measurements into a highly predictable fracture tool. An in-depth review of the present and future evolution of the technologies available for the measurement of bone mass and skeletal integrity and available fracture risk algorithms, including their respective and comparative performance measures (discrimination, calibration, reclassification, and clinical utility), have been discussed at length elsewhere in this volume of the Journal of Clinical Densitometry (4). The second discussion point is concerned with the importance of integrating the results of skeletal measurement technologies and osteoporosis algorithms into worldwide health-care systems that will not burden the clinician but rather assist in identifying patients at high fracture risk for consideration of medical intervention. The following discussion will further address the integration of both concepts into an effective model for the evaluation and treatment of osteoporosis. The discussion of the future of osteoporosis fracture risk assessment begins with the characterization of osteoporosis. Osteoporosis is characterized by reduced bone mass, disrupted bone architecture, and increased risk of fragility fractures (5). The diagnosis of osteoporosis can be made clinically after an individual sustains a fragility fracture or is defined by the World Health Organization (WHO) diagnostic criteria as a bone mineral density (BMD) T-score of less than or equal to −2.5 standard deviations below a young Caucasian reference population performed by dualenergy X-ray absorptiometry (DXA) at the spine, the hip, or the forearm (6,7). The choice of the T-2.5 threshold for the DXA BMD diagnosis of osteoporosis was based on the prevalence of BMD at or below this threshold in postmenopausal women measured at the spine, the hip, and the forearm that correlated with the lifetime risk of fractures at the 3 anatomical sites (6,7). There are significant limitations to the use of the T-score for the diagnosis of osteoporosis and as a treatment threshold inclusive of the fact that the majority of osteoporosis fractures occur in patients who do not have osteoporosis but rather osteopenia or normal BMD. The definition has been more recently updated by the WHO to include the femoral neck region (DXA) (8) that is presently being used with fracture algorithms (tools) to improve fracture prediction (9–12). National guidelines that use DXA BMD T-score thresholds alone for the diagnosis and pharmacological treatment of osteoporosis imply that osteoporosis is a monofactorial disorder with the T-2.5 threshold being found to have low sensitivity and low positive predictive value for osteoporotic fractures (13–17). There are additional reasons that a T-2.5 cannot be considered as a worldwide diagnostic and therapeutic intervention threshold. Two important reasons are the 10-fold difference in fracture rates worldwide and numerous CRFs that are known to influence fracture risk independent of BMD (18,19).
Baim
Alternatives to DXA T-Scores for the Assessment of Fracture Risk There have been many advances in the technologies that measure and explain skeletal integrity and the adverse effects menopause and aging have on bone as discussed in this volume of the Journal of Clinical Densitometry (4). I would refer the reader to these excellent reviews and the potential use of each technology for fracture risk assessment. Although there will be significant advances in the technologies that measure skeletal integrity and predict future fractures, there will always be the fact that osteoporotic fractures are multifactorial in origin and are associated with many CRFs that may or may not directly impact the quantitative measurement of BMD or other measurement parameters. An important example of a nonBMD-dependent CRF that is associated with increased osteoporotic fractures is high falls risk associated with severe arthritis of the weight-bearing joints, metabolic and neurological diseases that affect position sense and neuromuscular functioning, uncorrectable visual loss, and many others that have been comprehensively reviewed by one of the coauthors in this volume (4). Because of the limitations of bone mass and skeletal integrity measurements alone to precisely predict an individual’s fracture risk, algorithms have been designed to incorporate CRF for fractures with or without BMD resulting in improved hip, spine, forearm, humerus, and any future fracture prediction (9–12). Fracture risk algorithms using absolute rather than relative risk estimates are being used worldwide in national guidelines to determine which patients are at the highest fracture risk and should be considered for treatment as has been comprehensively reviewed in this special edition (4,20–24).
Worldwide Prevention Efforts Using Fracture Risk Stratification and the Fracture Liaison Service (FLS) Model The WHO, the International Osteoporosis Foundation, and numerous governmental and privately sponsored national organizations have not only provided osteoporosis educational resources for the public, medical profession, and government but have also provided guidance for the use of appropriate fracture assessment methodologies, fracture risk assessment tools, and guidelines for the prevention and management of osteoporosis (24). Despite these worldwide efforts, a majority of patients at high risk of fracture have not had bone density measurement by any available technology and are not diagnosed or offered osteoporosis treatment before or even after sustaining a fragility fracture (20–25). There are many challenges inherent in the universal implementation of a risk stratification-treatment model to appreciably reduce the risk of an initial osteoporosis fracture (primary fracture prevention) or an identificationtreatment model for patients who have previously sustained an osteoporotic fracture (secondary fracture prevention).
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ARTICLE IN PRESS Fracture Risk Assessment in the Management of Osteoporosis Challenges to the implementation of either model include the continued inadequate osteoporosis education at all levels, the absence of a grass roots public outcry for change, the fragmentation of health-care delivery systems resulting in poor communication between physicians, insufficient time provided in the clinical setting for clinicians to contemplate patient care issues, subspecialization of health care resulting in a singular focused intent, paper charting, excessive requirements for documentation and reimbursement with paper or electronic medical records, and insufficient financial and technical resources. The failure of postosteoporosis fracture care has resulted in a number of innovative medical centers in the early to mid-2000s to begin piloting a new concept of taking direct responsibility at the time of admission, also known as ownership, of an osteoporotic hip fracture. This has taken the form of an inpatient fracture liaison consulting service on the orthopedic unit. Commonly, a nurse or a nurse practitioner rather than a physician assesses fracture patients, confirms an osteoporotic fracture, communicates the risk of future fracture, educates the hip fracture patient and their family about osteoporosis, and schedules appropriate follow-up in an osteoporosis outpatient clinic for their medical management (26–34). The concept of the FLS has evolved because of its significant positive impact on reducing future fractures and cost-effectiveness (26–34). The FLS model has been championed by the International Osteoporosis Foundation, the National Osteoporosis Foundation, the Bone Health Alliance, the National Osteoporosis Society, and other national organizations to “capture the fracture” at the time of admission to the emergency department (ED) and inpatient services (35). A comprehensive overview, format for developing a FLS, and cost effectiveness of FLS worldwide can be found on numerous websites (36–39). Rough estimates suggest there are at least 200 FLSs in various stages of development in North America.
Challenges to Fracture Reduction Within Health-Care Systems Despite the combined efforts of numerous organizations and societies that focus on osteoporosis, academic and privately funded medical centers that engage in advanced osteoporosis research, and the pharmaceutical industry that has discovered and brought to market efficacious osteoporosis medical therapies, there is universal concern that significant progress in the diagnosis and treatment of osteoporosis across the spectrum of health-care delivery systems has not occurred. In fact, treatment rates after a patient sustains an osteoporosis hip fracture have actually worsened since early in this century (40–42). A paramount problem in standardizing osteoporosis care is the difficulty integrating fracture risk assessment methodologies, tools, and proven fracture-reducing strategies within health-care delivery systems and at the same time how they can be easily used by clinicians, can be adaptable to the advancements in the field, and can accommodate local or
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regional requirements, and the cultural, financial, or other prerequisites of the communities served. To develop primary and secondary osteoporosis fracture prevention programs using a proven fracture prediction and therapeutic intervention model, one must overcome the fragmentation and incongruence of health-care delivery. Fragmentation may be present in government-sponsored as well as private health-care delivery systems whether the latter is a nonprofit or for-profit organization.The most fragmented systems occur in the setting of nonuniversal healthcare coverage with a multitude of health-care delivery systems that have none or minimal cross-talk linking of health-care records. Fragmented health-care systems do not easily provide clinicians with system-wide access to osteoporosis fracture risk and osteoporosis management tools based on the latest country-specific and international guidelines (43).
An Advanced Model for the Prevention of Osteoporosis Fractures Rush University Medical Center (Rush; Chicago, IL, USA) is an academic tertiary care referral center where the author has had the privilege of practicing medicine and is in the process of developing an “osteoporosis center of excellence” for the primary and secondary prevention of fractures that is inclusive of osteoporosis clinical research. Before developing the Rush FLS, a retrospective analysis of fracture admissions to Rush over the previous 12 mo was conducted and presented to the university administration and departments of medicine, orthopedic surgery, and neurosurgery. The results of the analysis were consistent with published data disclosing the underdiagnosis and the undertreatment of patients admitted to hospitals with acute fragility fractures (40–42). The development of the Rush electronic medical record (EMR) fracture alert and the FLS required the support of the RUSH administration, including the dean of the medical school, vice deans of clinical operations and research, the chief medical officer, chairs of the departments of medicine, orthopedic surgery and neurosurgery, section chiefs of endocrinology and hospital medicine, the president of the physician medical group, and the Rush Medical Staff Quality Committee as a quality improvement initiative. A successful FLS requires vesting by all members of the aforementioned team inclusive of the hospital administration, support staff, and physicians involved with its day-to-day functioning, especially the central role played by the departments of orthopedic surgery and neurosurgery. A close collaboration with surgical colleagues is fundamental to a successful FLS. This was accomplished by (1) developing specific osteoporosis educational programs for the surgical attending staff, fellows, residents, and nurses; (2) screening orthopedic surgery and neurosurgery patients before surgery for osteoporosis and other secondary etiologies often responsible for poor skeletal healing; (3) collaborating in the treatment of postsurgical patients with delayed skeletal healing and nonunion;
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ARTICLE IN PRESS 4 (4) developing surgical outcomes clinical research; and (5) incorporating a surgical perspective in the overall Rush bone educational curriculum. An efficient and effective inpatient FLS required the development of an automated fracture alert system within the institution’s EMR by members of the informational technology center working with the author. The Rush osteoporosis fracture alert system is triggered automatically by sophisticated algorithms that identify the tens of thousands of ICD-10 fracture terminology (The 10th Revision of the International Statistical Classification of Diseases and Related Health Problems) (44) within numerous subsections of a patient’s EMR. Excluding nonosteoporotic anatomical fracture sites, the alert is triggered in patients with an acute fracture or history of a previous fracture in patients 50 and older admitted to all inpatient services and the ED. Inpatient services include all medical, surgical, rehabilitation, and psychiatric inpatient units. All fracture alerts accepted by the inpatient or ED attending physician requires the clinician to click on the “FLS consult button” that results in an instantaneous official FLS consultation request to be sent to the endocrinology clinic, an automated hardcopy printout generated, and notification of the FLS endocrinology fellow and attending physician. The ED fracture alert requires special identification and filtering of fracture patients who are not hospitalized but rather referred to an outpatient orthopedic or neurosurgical clinic. The ED fracture alert is triggered in the EMR of the patient using the same criteria as the Rush inpatient triggers. After the ED attending physician accepts the fracture alert and places the FLS consult by clicking on the “FLS Consult button,” an automated FLS consult is generated at the time of discharge from the ED and transmitted electronically to the endocrinology clinic for patient callback and scheduling. At the time of discharge, the ED patient is also provided with a hardcopy explanation for referral to the endocrinology FLS clinic and the appropriate contact information for scheduling the appointment. The Rush fracture alert screens over 155,000 patient admissions to all inpatient units and the ED in every 12 mo of operation. All FLS consults via the fracture alert are voluntary and have been explained to all Rush physicians by educational seminars before the institution and the activation in the Rush EMR. There is an embedded online link within the fracture alert to published hospital guidelines for inpatient fracture identification and treatment (45). Cancellation of the fracture alert by the patient’s attending physician requires an explanation to be written into a response section by the physician that is routinely reviewed by the FLS staff for compliance with the guidelines set by the Medical Staff Quality Committee. Canceled alerts without an explanation require a chart review and analysis as part of the same Medical Staff Quality Committee compliance program outlined previously. If an explanation for cancellation is not evident after the chart review, physicians are cordially contacted and provided additional information regarding the adverse outcomes of osteoporosis fractures and the clinical utility of the
Baim FLS in assisting with the diagnosis and treatment of their patients (46). Before being seen by the FLS, high trauma fractures without obvious underlying osteoporosis and pathological fractures caused by malignancy or infection are also filtered by the FLS endocrinology fellow and attending physician on the FLS consult service. Any questions about the appropriateness of the FLS consult characteristically results in a direct physician-to-physician discussion. The Rush FLS is a physician organized and managed permanent consultative service at Rush. It is a subservice of the endocrinology bone inpatient consultative service. The inpatient endocrinology bone service is consulted for metabolic bone diseases and mineral disorders as well as osteoporosis with or without fractures. One of the primary purposes of the Rush FLS that distinguishes itself from other FLS is the emphasis on the osteoporosis education of all members of the patient’s health-care team and those rotating through the endocrinology section. The endocrinology bone service is composed of the FLS attending physician, an endocrinology fellow, and rotating residents from medicine and other clinical services, students, and observers from other universities and medical centers. The overriding goal of this educational emphasis is to provide future clinicians the tools that are required to identify osteoporosis and fractures, CRFs for fracture inclusive of falls, and when and what type of medical therapies are available for the appropriate management of osteoporosis. Osteoporosis patients that are consulted by the FLS are evaluated for secondary etiologies for fracture and are provided alternative medical treatments for nonsurgical fractures that are inclusive of a comprehensive falls prevention rehabilitative program. Verbal and visual education and written materials concerning osteoporosis, fractures, and available medical therapies are provided to the patient, their families, and medical and nursing staff. Whenever possible, the patient is scheduled for an outpatient DXA, if required, on the same day as their clinic visits to endocrinology-bone, orthopedic surgery, neurosurgery, and rehabilitation (rehabilitative medicine, physical and occupational therapy). Other than the initial informational technology costs for developing the alert and the time required for assistance in analyzing ongoing data, there has been no additional cost to Rush beyond the salary of the endocrinology FLS attending staff during consult rounds. These costs are offset by the consultative services provided. The future of secondary fracture prevention at Rush is also being addressed with plans under way to expand the automated fracture alerts to the entire outpatient clinic population. When successfully completed, approximately 700,000 patient visits per year will be automatically screened for patients 50 yr or older with either an acute fracture or a history of a fracture. As in the case of inpatient and ED fracture alerts, there will be an EMR touch-button link to additional osteoporosis educational materials and accepted guidelines that can be updated when advances in the field are available for inclusion.
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ARTICLE IN PRESS Fracture Risk Assessment in the Management of Osteoporosis Although establishing an FLS is an important first step in secondary fracture prevention, it does not guarantee a significant reduction in future fractures in individual patients as has been observed by the author and other FLS (47). Despite significant inpatient efforts to educate the fracture patients and their family to the future physical, psychological, and financial burdens of osteoporosis fractures, there remain many impediments to outpatient follow-up and compliance to medical therapy. This is most evident in our patients with physical and psychological disabilities and in those who lack adequate family support. Additionally, difficulties in transportation to the outpatient clinic, long distances to travel, and fragmentation in the health-care delivery system are often encountered. Therefore, with adequate comprehensive home health care and clinician follow-up, there is a greater likelihood that efficacious osteoporosis treatments will result in improved worldwide fracture reduction.
The Future of Fracture Assessment and Osteoporosis Management Future health-care delivery EMR systems will have customizable features for the inclusion of future bone mass and skeletal integrity measurement technologies and fracture risk assessment tools, the latter requiring adaption to the variability of worldwide fracture rates and changing life expectancy. The EMR will be able to identify patients with a history of fractures and high fracture risk. It will assist clinicians in applying the local, national, regional, or international guidelines currently in use for the initiation of treatment for postmenopausal and age-related osteoporosis, secondary osteoporosis, and osteoporosis in childhood and adolescence. This will require an innovative health-care environment where limited resources can be effectively routed to areas of significant health-care need such as osteoporosis. The coordination of a highly effective FLS and comprehensive medical follow-up in an outpatient osteoporosis clinic or in conjunction with home health care is essential for a successful secondary fracture prevention program. However, a fundamental problem that has not been resolved in the overall management of osteoporosis is the implementation of primary fracture prevention throughout health-care systems. An advanced system-wide EMR can assist in this endeavor and is presently being developed. Rush University Medical Center is in the process of developing automated triggers for primary fracture prevention in patients with select CRFs that are associated with secondary osteoporosis and increased fracture risk. The initial prevention model automated alerts will include breast cancer patients on unopposed aromatase inhibitor therapy, prostate cancer patients on unopposed androgen deprivation therapy, and unopposed glucocorticoid therapy for disease management other than for adrenal insufficiency. Rush has also begun working on the integration of a fracture risk algorithm into the EMR for automated clinician notification of high risk patients before a fracture event.
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In conclusion, the future of osteoporosis management will consist of the further refinement of advanced fracture predictive technologies and methodologies that are inclusive of but not limited to highly accurate and reproducible bone biomarkers and bone genomic testing. These technological advances will be integrated into fracture algorithms that have excellent performance characteristics; discrimination, calibration, reclassification, and independent validation. Further integration of these advanced algorithms into adaptable EMR systems worldwide will provide the necessary tools for the identification of patients at high future fracture risk. In the future, fracture risk algorithms will be functioning behind the scenes and updated whenever a patient’s chart is opened and new data are entered into the EMR. This will provide the patient and their clinician with an immediate and ongoing risk assessment that will be dependent on previously established and newly emergent osteoporosis CRFs, the latter being actively modified in the EMR by the patient or any member of their medical team. High fracture risk alerts will automatically notify the patient and their clinician of the osteoporosis risks and provide immediate options for their attenuation. Effective osteoporosis care will also require therapeutic options that decrease fracture risk with known benefits to risk information that will be immediately available in the EMR and included for patient-clinician discussion at the point of service and for future reference. It is essential not only for our international and national osteoporosis societies but also for all of us in the field to promote osteoporosis education and its potential adverse consequences. A universal effort is required to ensure the commitment of the medical, governmental, and political establishments as well as the lay public to obtain the necessary financial and technical resources to effectively execute a successful osteoporosis public health program worldwide.
Acknowledgments The author would like to acknowledge the assistance of the following individuals at Rush University Medical Center for their indispensable support in the development of the Rush Fracture Liaison Service: Drs. Antonio C. Bianco, Omar B. Leteef, Jochem Reiser, Amir K. Jaffer, Joshua J. Jacobs, Richard W. Byrne, Brian W. Kim, and Edward J. Ward, and the present and previous Deans of Rush Medical College, Dr. K. Ranga Rama Krishnan and Thomas Deutsch. I would also like to thank the Rush clinical informatics team and the informational technology group, especially Dr. Bala Hota and Ruth Kniuksta, for working with me to develop the Rush fracture alerts and to analyze the FLS data.
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Baim 21. National Osteoporosis Guidelines Group, Guidelines for the diagnosis and Management of Osteoporosis in the UK. 2014. Available at: http://www.shef.ac.uk/NOGG/NOGG_Pocket _Guide_for_Healthcare_Professionals.pdf. Accessed: February 18, 2017. 22. Osteoporosis Canada, 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. 2010. Available at: http://www.cmaj.ca/content/ early/2010/10/12/cmaj.100771.full.pdf+html?ijkey =edc6c6048e7d4acdc41368fe3f1e622bf5a2deac&keytype2=tf _ipsecsha. Accessed: February 18, 2017. 23. Lebanese National Task Force for Osteoporosis and Metabolic Disorders, Executive Summary- Lebanese FRAXBased Osteoporosis Guidelines 2013. 2013. Available at: http:// www.osteos.org.lb/admin/uploads/Frax%20Leb%20OP %20Guidelines%202013%20-exec%20summ.pdf. Accessed: February 18, 2017. 24. International Osteoporosis Foundation list of National Guidelines. 2017. Available at: https://www.iofbonehealth.org/ guideline-references. Accessed: February 18, 2017. 25. WHO, Who Scientific Group On The Assessment Of Osteoporosis At Primary Health Care Level, 2003. Available at: http://www.who.int/chp/topics/Osteoporosis.pdf. Accessed: February 18, 2017. 26. Dell R. 2011 Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int 22(3):S457–S460. 27. McLellan AR, Gallacher SJ, Fraser M, McQuillian C. 2003 The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 14:1028–1034. 28. Chevalley T, Hoffmeyer P, Bonjour J-P, Rizzoli R. 2002 An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int 13:450– 455. 29. Carpintero P, Gil-Garay E, Hernandez-Vaquero D, et al. 2009 Interventions to improve inpatient osteoporosis management following first osteoporotic fracture: the PREVENT project. Osteoporos Int 129:245–250. 30. Wallace IR, Callachand F, Elliott J, Gardiner PV. 2011 An evaluation of an enhanced fracture liaison service as the optimal model for secondary prevention of osteoporosis. JRSM Short Rep 2:8. 31. Boudou L, Gerbay B, Chopin F, Ollagnier E. 2011 Management of osteoporosis in fracture liaison service associated with long-term adherence to treatment. Osteoporos Int 22:2099– 2106. 32. Bogoch ER, Elliot-Gibson VE, Beaton DE, et al. 2006 Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopedic environment. J Bone Joint Surg Am 88-A(1):25– 34. 33. Cooper MS, Palmer AJ, Seibel MJ. 2012 Cost-effectiveness of the concord minimal trauma fracture liaison service, a prospective, controlled fracture prevention study. Osteoporos Int 23:97–107. 34. Ahmed M, Durcan L, O’Beirne J, et al. 2012 Fracture liaison service in a non-regional orthopedic clinic-a cost effective service. Ir Med J 105(1):24, 26-7. 35. International Osteoporosis Foundation, Capture the Fracture. 2011. Available at: https://www.iofbonehealth.org/capture -fracture. Accessed: February 18, 2017. 36. International Osteoporosis Foundation. International Osteoporosis Foundation Report 2012. Available at: http://share .iofbonehealth.org/WOD/2012/report/WOD12-Report.pdf. Accessed: February 18, 2017.
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ARTICLE IN PRESS Fracture Risk Assessment in the Management of Osteoporosis 37. National Bone Health Alliance; Fracture Liaison Service, 2017. Available at: http://www.nbha.org/. Accessed: February 18, 2017. 38. National Osteoporosis Foundation, Fracture Liaison Service. 2014. Available at: https://my.nof.org/bone-source/education/ fls-training. Accessed: February 18, 2017. 39. American Orthopedic Association, Own The Bone. Available at: http://www.ownthebone.org/. Accessed: February 18, 2017. 40. Khosla S, Cauley JA, Compston J, et al. 2017 Addressing the crisis in the treatment of osteoporosis: a path forward. J Bone Miner Res 32:1–7. 41. Kanis JA, Svedbom A, Harvey N, McCloskey EU. 2014 The osteoporosis treatment gap. J Bone Miner Res 29:1926– 1928. 42. Solomon DH, Johnstone SS, Boytson NN, et al. 2014 Osteoporosis medication use in U.S. patients between 2002–2011. J Bone Miner Res 29:1929–1937.
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43. Halvorson GC. 2009 Health care will not reform itself. CRC Press, 79–94. 44. World Health Organization, International Statistical Classification of Diseases and Related Health Problems, ICD-10. 1990. Available at: http://www.who.int/classifications/icd/en/. Accessed: February 18, 2017. 45. The Joint Commission, Improving and Measuring Osteoporosis Management. 2008. Available at: https://www.jointcommission .org/improving_and_measuring_osteoporosis _management/. Accessed February 18, 2017. 46. Milli J, Shah S, Baim S. Rush Fracture Liaison Service for Capturing “missed opportunities” to treat osteoporosis, oral presentation and abstract, ASBMR Annual Scientific Meeting, September 17, 2016, JBMR, 2016 Epub. 47. Chandran M, Cheen M, Ying H, et al. 2016 Dropping the ball and falling off the care wagon. Facotors correlating with nonadherence to secondary fracture prevention programs. J Clin Densitom 19(1):117–124.
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Original Article
The Future of Fracture Risk Assessment in the Management of Osteoporosis Sanford Baim* Department of Medicine, Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL, USA
Abstract There have been many advances in the field of osteoporosis that add to a greater understanding of skeletal integrity and the adverse effects menopause and aging have on bone. The World Health Organization, the International Osteoporosis Foundation, and numerous additional governmental and privately sponsored organizations, societies, and their respective task forces have provided guidance for the use of appropriate fracture assessment methodologies and fracture risk assessment tools, and for the prevention and management of osteoporosis. Despite these worldwide efforts, a majority of patients at high risk of fracture have not had bone density testing and are not diagnosed or offered osteoporosis treatment before or even after sustaining a fragility fracture. The future of fracture risk assessment and, in general, osteoporosis management requires health-care systems to develop customizable electronic medical record (EMR) systems that incorporate the tools necessary to identify patients at high fracture risk. As provided in the example of an advanced health-care osteoporosis model, an EMR can be fully customizable to identify fractures and patients at high risk of fracture, to assist clinicians in selecting the most efficacious osteoporosis treatments, and to provide long-term follow-up with or without serial bone density testing. Future fracture risk assessment models will likely be further refined by incorporating advanced fracture predictive technologies for integration into algorithms that have improved discrimination, calibration, risk reclassification capabilities, and clinical utility. These models will include accurate and reproducible bone biomarkers and genomic testing that will be automatically integrated into worldwide EMR systems for screening large numbers of at-risk populations and younger patients for future prediction and prevention of disease. The integration of this type of a fracture prediction model into future electronic medical record systems will result in the prevention of osteoporosis fractures. Key Words: Fracture liaison service; fracture risk; primary fracture prevention; risk assessment tool; secondary fracture prevention.
Introduction
(1–3). There are 200 million women who have osteoporosis worldwide, with 1.6 million women sustaining an osteoporotic hip fracture annually. As the world population ages, it is estimated that by 2050, the annual number of hip fractures will increase to between 4.5 and 6.3 million (1–3). The importance of fracture risk assessment has been discussed at length by all the contributing coauthors to this volume (4). The assessment of fracture risk is the keystone to the prevention and management of osteoporosis. There are 2 different but interdependent discussion points that should be considered when taking into account an effective model for the identification and treatment of
It is estimated that 1 in 2–3 women and 1 in 4–5 men in developed countries are expected to sustain an osteoporosis fracture that is associated with significant morbidity, mortality, and adverse psychological, social, and financial consequences for the affected individual family and society *Address correspondence to: Sanford Baim, MD, FACR, CCD, Department of Medicine, Section of Endocrinology, Rush University Medical Center 1725 W. Harrison Street Suite 250, Chicago, IL 60612, USA. E-mail: [email protected]
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ARTICLE IN PRESS 2 patients at risk for osteoporosis fractures. The first is concerned with the technologies available for the measurement of bone mass and skeletal integrity and the algorithms that integrate clinical risk factors (CRFs) for fracture with these measurements into a highly predictable fracture tool. An in-depth review of the present and future evolution of the technologies available for the measurement of bone mass and skeletal integrity and available fracture risk algorithms, including their respective and comparative performance measures (discrimination, calibration, reclassification, and clinical utility), have been discussed at length elsewhere in this volume of the Journal of Clinical Densitometry (4). The second discussion point is concerned with the importance of integrating the results of skeletal measurement technologies and osteoporosis algorithms into worldwide health-care systems that will not burden the clinician but rather assist in identifying patients at high fracture risk for consideration of medical intervention. The following discussion will further address the integration of both concepts into an effective model for the evaluation and treatment of osteoporosis. The discussion of the future of osteoporosis fracture risk assessment begins with the characterization of osteoporosis. Osteoporosis is characterized by reduced bone mass, disrupted bone architecture, and increased risk of fragility fractures (5). The diagnosis of osteoporosis can be made clinically after an individual sustains a fragility fracture or is defined by the World Health Organization (WHO) diagnostic criteria as a bone mineral density (BMD) T-score of less than or equal to −2.5 standard deviations below a young Caucasian reference population performed by dualenergy X-ray absorptiometry (DXA) at the spine, the hip, or the forearm (6,7). The choice of the T-2.5 threshold for the DXA BMD diagnosis of osteoporosis was based on the prevalence of BMD at or below this threshold in postmenopausal women measured at the spine, the hip, and the forearm that correlated with the lifetime risk of fractures at the 3 anatomical sites (6,7). There are significant limitations to the use of the T-score for the diagnosis of osteoporosis and as a treatment threshold inclusive of the fact that the majority of osteoporosis fractures occur in patients who do not have osteoporosis but rather osteopenia or normal BMD. The definition has been more recently updated by the WHO to include the femoral neck region (DXA) (8) that is presently being used with fracture algorithms (tools) to improve fracture prediction (9–12). National guidelines that use DXA BMD T-score thresholds alone for the diagnosis and pharmacological treatment of osteoporosis imply that osteoporosis is a monofactorial disorder with the T-2.5 threshold being found to have low sensitivity and low positive predictive value for osteoporotic fractures (13–17). There are additional reasons that a T-2.5 cannot be considered as a worldwide diagnostic and therapeutic intervention threshold. Two important reasons are the 10-fold difference in fracture rates worldwide and numerous CRFs that are known to influence fracture risk independent of BMD (18,19).
Baim
Alternatives to DXA T-Scores for the Assessment of Fracture Risk There have been many advances in the technologies that measure and explain skeletal integrity and the adverse effects menopause and aging have on bone as discussed in this volume of the Journal of Clinical Densitometry (4). I would refer the reader to these excellent reviews and the potential use of each technology for fracture risk assessment. Although there will be significant advances in the technologies that measure skeletal integrity and predict future fractures, there will always be the fact that osteoporotic fractures are multifactorial in origin and are associated with many CRFs that may or may not directly impact the quantitative measurement of BMD or other measurement parameters. An important example of a nonBMD-dependent CRF that is associated with increased osteoporotic fractures is high falls risk associated with severe arthritis of the weight-bearing joints, metabolic and neurological diseases that affect position sense and neuromuscular functioning, uncorrectable visual loss, and many others that have been comprehensively reviewed by one of the coauthors in this volume (4). Because of the limitations of bone mass and skeletal integrity measurements alone to precisely predict an individual’s fracture risk, algorithms have been designed to incorporate CRF for fractures with or without BMD resulting in improved hip, spine, forearm, humerus, and any future fracture prediction (9–12). Fracture risk algorithms using absolute rather than relative risk estimates are being used worldwide in national guidelines to determine which patients are at the highest fracture risk and should be considered for treatment as has been comprehensively reviewed in this special edition (4,20–24).
Worldwide Prevention Efforts Using Fracture Risk Stratification and the Fracture Liaison Service (FLS) Model The WHO, the International Osteoporosis Foundation, and numerous governmental and privately sponsored national organizations have not only provided osteoporosis educational resources for the public, medical profession, and government but have also provided guidance for the use of appropriate fracture assessment methodologies, fracture risk assessment tools, and guidelines for the prevention and management of osteoporosis (24). Despite these worldwide efforts, a majority of patients at high risk of fracture have not had bone density measurement by any available technology and are not diagnosed or offered osteoporosis treatment before or even after sustaining a fragility fracture (20–25). There are many challenges inherent in the universal implementation of a risk stratification-treatment model to appreciably reduce the risk of an initial osteoporosis fracture (primary fracture prevention) or an identificationtreatment model for patients who have previously sustained an osteoporotic fracture (secondary fracture prevention).
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ARTICLE IN PRESS Fracture Risk Assessment in the Management of Osteoporosis Challenges to the implementation of either model include the continued inadequate osteoporosis education at all levels, the absence of a grass roots public outcry for change, the fragmentation of health-care delivery systems resulting in poor communication between physicians, insufficient time provided in the clinical setting for clinicians to contemplate patient care issues, subspecialization of health care resulting in a singular focused intent, paper charting, excessive requirements for documentation and reimbursement with paper or electronic medical records, and insufficient financial and technical resources. The failure of postosteoporosis fracture care has resulted in a number of innovative medical centers in the early to mid-2000s to begin piloting a new concept of taking direct responsibility at the time of admission, also known as ownership, of an osteoporotic hip fracture. This has taken the form of an inpatient fracture liaison consulting service on the orthopedic unit. Commonly, a nurse or a nurse practitioner rather than a physician assesses fracture patients, confirms an osteoporotic fracture, communicates the risk of future fracture, educates the hip fracture patient and their family about osteoporosis, and schedules appropriate follow-up in an osteoporosis outpatient clinic for their medical management (26–34). The concept of the FLS has evolved because of its significant positive impact on reducing future fractures and cost-effectiveness (26–34). The FLS model has been championed by the International Osteoporosis Foundation, the National Osteoporosis Foundation, the Bone Health Alliance, the National Osteoporosis Society, and other national organizations to “capture the fracture” at the time of admission to the emergency department (ED) and inpatient services (35). A comprehensive overview, format for developing a FLS, and cost effectiveness of FLS worldwide can be found on numerous websites (36–39). Rough estimates suggest there are at least 200 FLSs in various stages of development in North America.
Challenges to Fracture Reduction Within Health-Care Systems Despite the combined efforts of numerous organizations and societies that focus on osteoporosis, academic and privately funded medical centers that engage in advanced osteoporosis research, and the pharmaceutical industry that has discovered and brought to market efficacious osteoporosis medical therapies, there is universal concern that significant progress in the diagnosis and treatment of osteoporosis across the spectrum of health-care delivery systems has not occurred. In fact, treatment rates after a patient sustains an osteoporosis hip fracture have actually worsened since early in this century (40–42). A paramount problem in standardizing osteoporosis care is the difficulty integrating fracture risk assessment methodologies, tools, and proven fracture-reducing strategies within health-care delivery systems and at the same time how they can be easily used by clinicians, can be adaptable to the advancements in the field, and can accommodate local or
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regional requirements, and the cultural, financial, or other prerequisites of the communities served. To develop primary and secondary osteoporosis fracture prevention programs using a proven fracture prediction and therapeutic intervention model, one must overcome the fragmentation and incongruence of health-care delivery. Fragmentation may be present in government-sponsored as well as private health-care delivery systems whether the latter is a nonprofit or for-profit organization.The most fragmented systems occur in the setting of nonuniversal healthcare coverage with a multitude of health-care delivery systems that have none or minimal cross-talk linking of health-care records. Fragmented health-care systems do not easily provide clinicians with system-wide access to osteoporosis fracture risk and osteoporosis management tools based on the latest country-specific and international guidelines (43).
An Advanced Model for the Prevention of Osteoporosis Fractures Rush University Medical Center (Rush; Chicago, IL, USA) is an academic tertiary care referral center where the author has had the privilege of practicing medicine and is in the process of developing an “osteoporosis center of excellence” for the primary and secondary prevention of fractures that is inclusive of osteoporosis clinical research. Before developing the Rush FLS, a retrospective analysis of fracture admissions to Rush over the previous 12 mo was conducted and presented to the university administration and departments of medicine, orthopedic surgery, and neurosurgery. The results of the analysis were consistent with published data disclosing the underdiagnosis and the undertreatment of patients admitted to hospitals with acute fragility fractures (40–42). The development of the Rush electronic medical record (EMR) fracture alert and the FLS required the support of the RUSH administration, including the dean of the medical school, vice deans of clinical operations and research, the chief medical officer, chairs of the departments of medicine, orthopedic surgery and neurosurgery, section chiefs of endocrinology and hospital medicine, the president of the physician medical group, and the Rush Medical Staff Quality Committee as a quality improvement initiative. A successful FLS requires vesting by all members of the aforementioned team inclusive of the hospital administration, support staff, and physicians involved with its day-to-day functioning, especially the central role played by the departments of orthopedic surgery and neurosurgery. A close collaboration with surgical colleagues is fundamental to a successful FLS. This was accomplished by (1) developing specific osteoporosis educational programs for the surgical attending staff, fellows, residents, and nurses; (2) screening orthopedic surgery and neurosurgery patients before surgery for osteoporosis and other secondary etiologies often responsible for poor skeletal healing; (3) collaborating in the treatment of postsurgical patients with delayed skeletal healing and nonunion;
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ARTICLE IN PRESS 4 (4) developing surgical outcomes clinical research; and (5) incorporating a surgical perspective in the overall Rush bone educational curriculum. An efficient and effective inpatient FLS required the development of an automated fracture alert system within the institution’s EMR by members of the informational technology center working with the author. The Rush osteoporosis fracture alert system is triggered automatically by sophisticated algorithms that identify the tens of thousands of ICD-10 fracture terminology (The 10th Revision of the International Statistical Classification of Diseases and Related Health Problems) (44) within numerous subsections of a patient’s EMR. Excluding nonosteoporotic anatomical fracture sites, the alert is triggered in patients with an acute fracture or history of a previous fracture in patients 50 and older admitted to all inpatient services and the ED. Inpatient services include all medical, surgical, rehabilitation, and psychiatric inpatient units. All fracture alerts accepted by the inpatient or ED attending physician requires the clinician to click on the “FLS consult button” that results in an instantaneous official FLS consultation request to be sent to the endocrinology clinic, an automated hardcopy printout generated, and notification of the FLS endocrinology fellow and attending physician. The ED fracture alert requires special identification and filtering of fracture patients who are not hospitalized but rather referred to an outpatient orthopedic or neurosurgical clinic. The ED fracture alert is triggered in the EMR of the patient using the same criteria as the Rush inpatient triggers. After the ED attending physician accepts the fracture alert and places the FLS consult by clicking on the “FLS Consult button,” an automated FLS consult is generated at the time of discharge from the ED and transmitted electronically to the endocrinology clinic for patient callback and scheduling. At the time of discharge, the ED patient is also provided with a hardcopy explanation for referral to the endocrinology FLS clinic and the appropriate contact information for scheduling the appointment. The Rush fracture alert screens over 155,000 patient admissions to all inpatient units and the ED in every 12 mo of operation. All FLS consults via the fracture alert are voluntary and have been explained to all Rush physicians by educational seminars before the institution and the activation in the Rush EMR. There is an embedded online link within the fracture alert to published hospital guidelines for inpatient fracture identification and treatment (45). Cancellation of the fracture alert by the patient’s attending physician requires an explanation to be written into a response section by the physician that is routinely reviewed by the FLS staff for compliance with the guidelines set by the Medical Staff Quality Committee. Canceled alerts without an explanation require a chart review and analysis as part of the same Medical Staff Quality Committee compliance program outlined previously. If an explanation for cancellation is not evident after the chart review, physicians are cordially contacted and provided additional information regarding the adverse outcomes of osteoporosis fractures and the clinical utility of the
Baim FLS in assisting with the diagnosis and treatment of their patients (46). Before being seen by the FLS, high trauma fractures without obvious underlying osteoporosis and pathological fractures caused by malignancy or infection are also filtered by the FLS endocrinology fellow and attending physician on the FLS consult service. Any questions about the appropriateness of the FLS consult characteristically results in a direct physician-to-physician discussion. The Rush FLS is a physician organized and managed permanent consultative service at Rush. It is a subservice of the endocrinology bone inpatient consultative service. The inpatient endocrinology bone service is consulted for metabolic bone diseases and mineral disorders as well as osteoporosis with or without fractures. One of the primary purposes of the Rush FLS that distinguishes itself from other FLS is the emphasis on the osteoporosis education of all members of the patient’s health-care team and those rotating through the endocrinology section. The endocrinology bone service is composed of the FLS attending physician, an endocrinology fellow, and rotating residents from medicine and other clinical services, students, and observers from other universities and medical centers. The overriding goal of this educational emphasis is to provide future clinicians the tools that are required to identify osteoporosis and fractures, CRFs for fracture inclusive of falls, and when and what type of medical therapies are available for the appropriate management of osteoporosis. Osteoporosis patients that are consulted by the FLS are evaluated for secondary etiologies for fracture and are provided alternative medical treatments for nonsurgical fractures that are inclusive of a comprehensive falls prevention rehabilitative program. Verbal and visual education and written materials concerning osteoporosis, fractures, and available medical therapies are provided to the patient, their families, and medical and nursing staff. Whenever possible, the patient is scheduled for an outpatient DXA, if required, on the same day as their clinic visits to endocrinology-bone, orthopedic surgery, neurosurgery, and rehabilitation (rehabilitative medicine, physical and occupational therapy). Other than the initial informational technology costs for developing the alert and the time required for assistance in analyzing ongoing data, there has been no additional cost to Rush beyond the salary of the endocrinology FLS attending staff during consult rounds. These costs are offset by the consultative services provided. The future of secondary fracture prevention at Rush is also being addressed with plans under way to expand the automated fracture alerts to the entire outpatient clinic population. When successfully completed, approximately 700,000 patient visits per year will be automatically screened for patients 50 yr or older with either an acute fracture or a history of a fracture. As in the case of inpatient and ED fracture alerts, there will be an EMR touch-button link to additional osteoporosis educational materials and accepted guidelines that can be updated when advances in the field are available for inclusion.
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ARTICLE IN PRESS Fracture Risk Assessment in the Management of Osteoporosis Although establishing an FLS is an important first step in secondary fracture prevention, it does not guarantee a significant reduction in future fractures in individual patients as has been observed by the author and other FLS (47). Despite significant inpatient efforts to educate the fracture patients and their family to the future physical, psychological, and financial burdens of osteoporosis fractures, there remain many impediments to outpatient follow-up and compliance to medical therapy. This is most evident in our patients with physical and psychological disabilities and in those who lack adequate family support. Additionally, difficulties in transportation to the outpatient clinic, long distances to travel, and fragmentation in the health-care delivery system are often encountered. Therefore, with adequate comprehensive home health care and clinician follow-up, there is a greater likelihood that efficacious osteoporosis treatments will result in improved worldwide fracture reduction.
The Future of Fracture Assessment and Osteoporosis Management Future health-care delivery EMR systems will have customizable features for the inclusion of future bone mass and skeletal integrity measurement technologies and fracture risk assessment tools, the latter requiring adaption to the variability of worldwide fracture rates and changing life expectancy. The EMR will be able to identify patients with a history of fractures and high fracture risk. It will assist clinicians in applying the local, national, regional, or international guidelines currently in use for the initiation of treatment for postmenopausal and age-related osteoporosis, secondary osteoporosis, and osteoporosis in childhood and adolescence. This will require an innovative health-care environment where limited resources can be effectively routed to areas of significant health-care need such as osteoporosis. The coordination of a highly effective FLS and comprehensive medical follow-up in an outpatient osteoporosis clinic or in conjunction with home health care is essential for a successful secondary fracture prevention program. However, a fundamental problem that has not been resolved in the overall management of osteoporosis is the implementation of primary fracture prevention throughout health-care systems. An advanced system-wide EMR can assist in this endeavor and is presently being developed. Rush University Medical Center is in the process of developing automated triggers for primary fracture prevention in patients with select CRFs that are associated with secondary osteoporosis and increased fracture risk. The initial prevention model automated alerts will include breast cancer patients on unopposed aromatase inhibitor therapy, prostate cancer patients on unopposed androgen deprivation therapy, and unopposed glucocorticoid therapy for disease management other than for adrenal insufficiency. Rush has also begun working on the integration of a fracture risk algorithm into the EMR for automated clinician notification of high risk patients before a fracture event.
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In conclusion, the future of osteoporosis management will consist of the further refinement of advanced fracture predictive technologies and methodologies that are inclusive of but not limited to highly accurate and reproducible bone biomarkers and bone genomic testing. These technological advances will be integrated into fracture algorithms that have excellent performance characteristics; discrimination, calibration, reclassification, and independent validation. Further integration of these advanced algorithms into adaptable EMR systems worldwide will provide the necessary tools for the identification of patients at high future fracture risk. In the future, fracture risk algorithms will be functioning behind the scenes and updated whenever a patient’s chart is opened and new data are entered into the EMR. This will provide the patient and their clinician with an immediate and ongoing risk assessment that will be dependent on previously established and newly emergent osteoporosis CRFs, the latter being actively modified in the EMR by the patient or any member of their medical team. High fracture risk alerts will automatically notify the patient and their clinician of the osteoporosis risks and provide immediate options for their attenuation. Effective osteoporosis care will also require therapeutic options that decrease fracture risk with known benefits to risk information that will be immediately available in the EMR and included for patient-clinician discussion at the point of service and for future reference. It is essential not only for our international and national osteoporosis societies but also for all of us in the field to promote osteoporosis education and its potential adverse consequences. A universal effort is required to ensure the commitment of the medical, governmental, and political establishments as well as the lay public to obtain the necessary financial and technical resources to effectively execute a successful osteoporosis public health program worldwide.
Acknowledgments The author would like to acknowledge the assistance of the following individuals at Rush University Medical Center for their indispensable support in the development of the Rush Fracture Liaison Service: Drs. Antonio C. Bianco, Omar B. Leteef, Jochem Reiser, Amir K. Jaffer, Joshua J. Jacobs, Richard W. Byrne, Brian W. Kim, and Edward J. Ward, and the present and previous Deans of Rush Medical College, Dr. K. Ranga Rama Krishnan and Thomas Deutsch. I would also like to thank the Rush clinical informatics team and the informational technology group, especially Dr. Bala Hota and Ruth Kniuksta, for working with me to develop the Rush fracture alerts and to analyze the FLS data.
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ARTICLE IN PRESS Fracture Risk Assessment in the Management of Osteoporosis 37. National Bone Health Alliance; Fracture Liaison Service, 2017. Available at: http://www.nbha.org/. Accessed: February 18, 2017. 38. National Osteoporosis Foundation, Fracture Liaison Service. 2014. Available at: https://my.nof.org/bone-source/education/ fls-training. Accessed: February 18, 2017. 39. American Orthopedic Association, Own The Bone. Available at: http://www.ownthebone.org/. Accessed: February 18, 2017. 40. Khosla S, Cauley JA, Compston J, et al. 2017 Addressing the crisis in the treatment of osteoporosis: a path forward. J Bone Miner Res 32:1–7. 41. Kanis JA, Svedbom A, Harvey N, McCloskey EU. 2014 The osteoporosis treatment gap. J Bone Miner Res 29:1926– 1928. 42. Solomon DH, Johnstone SS, Boytson NN, et al. 2014 Osteoporosis medication use in U.S. patients between 2002–2011. J Bone Miner Res 29:1929–1937.
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43. Halvorson GC. 2009 Health care will not reform itself. CRC Press, 79–94. 44. World Health Organization, International Statistical Classification of Diseases and Related Health Problems, ICD-10. 1990. Available at: http://www.who.int/classifications/icd/en/. Accessed: February 18, 2017. 45. The Joint Commission, Improving and Measuring Osteoporosis Management. 2008. Available at: https://www.jointcommission .org/improving_and_measuring_osteoporosis _management/. Accessed February 18, 2017. 46. Milli J, Shah S, Baim S. Rush Fracture Liaison Service for Capturing “missed opportunities” to treat osteoporosis, oral presentation and abstract, ASBMR Annual Scientific Meeting, September 17, 2016, JBMR, 2016 Epub. 47. Chandran M, Cheen M, Ying H, et al. 2016 Dropping the ball and falling off the care wagon. Facotors correlating with nonadherence to secondary fracture prevention programs. J Clin Densitom 19(1):117–124.
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