From the Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Abstract

• Objective: To review and summarize the literature regarding current approaches to secondary prevention of low-trauma osteoporotic fractures.
• Methods: PubMed search and summary of existing literature related to complications and secondary prevention of osteoporotic fractures was performed.
• Results: Fragility fractures are associated with high rates of short and long term morbidities and carry a high risk of mortality and fracture recurrence. Several of the currently available anti-osteoporosis medications have been shown to decrease the risk of fracture recurrence in patients with prevalent osteoporotic fractures and some may even decrease mortality. However, only a minority of patients with fragility fractures are adequately evaluated and treated for osteoporosis. Fracture liaison services that ensure identification and risk stratification of patients with fragility fractures and proper evaluation and treatment of osteoporosis have proven effective at enhancing osteoporosis care in these patients, decreasing fracture recurrence and possibly even decreasing long-term mortality, while providing long-term cost savings. Unfortunately, however, this model of care has not been widely adopted and implemented.
• Conclusion: Fragility fractures represent a major health care problem for aging populations. Unfortunately, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Key words: osteoporosis; fracture; fragility; low-trauma; bone density.

Low-trauma fractures are fractures that occur from a trauma equivalent to a fall from standing height or less [1,2]. They can involve any skeletal site, but the most significant are vertebral, pelvic, wrist and hip fractures, which together represent close to 90% of all low-trauma fractures [3,4]. The overall burden of low-trauma fractures is quite high worldwide and is projected to increase over time [3–6]. In 2010, 3.5 million new low-trauma fractures were reported in the European Union [3]. In the United States, there were more than 2 million fractures in 2005, and it is estimated that more than 3 million fractures will occur in year 2025 [4].

Low-trauma fractures are generally indicative of compromised bone strength—especially when they involve the hip—and are thus often referred to as fragility fractures. While the traditional definition of osteoporosis is a bone mineral density (BMD) T-score of -2.5 or lower, low-trauma fractures of the hip are also diagnostic of osteoporosis, regardless of bone mineral density [2,7–9]. In addition, low-trauma fractures of the vertebrae, the proximal humerus, and the pelvis are considered diagnostic of osteoporosis when combined with T-scores between -1 and -2.5 [2,7]. Bone biopsies and high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with low-trauma fractures and normal BMD suggest microarchitectural alterations and abnormalities of collagen orientation and crosslinking within the bone matrix [10-12], leading to decreased bone strength.

This review will address the individual and societal costs of low-trauma fractures and issues related to secondary prevention of fractures, with specific emphasis on pharmacotherapy and fracture liaison services.

Impact of Low-Trauma Fractures

Acute and Long-Term Complications

Of all fragility fractures, hip fractures are the ones most likely to result in serious acute complications. The most common acute complications are delirium in up to 50% of patients and malnutrition in up to 60%, both of which predict slower and less complete recovery [13–16]. Other complications include urinary tract infections in up to 60% of patients in certain reports [17], thromboembolic disease with deep venous thrombosis in around 27% of patients and pulmonary embolism in up to 7% [16], and acute kidney injury in about 15% [18].

In addition, it is not uncommon for patients to suffer from significant long-term functional limitations following fragility fractures. While vertebral fractures do not frequently lead to hospitalization or institutionalization, they often lead to significant physical limitations and chronic pain [19,20] and to negative effects on self-esteem, mood, and body image [21,22]. However, the most remarkable functional decline and limitations are seen after hip fractures [23–25]. In a study of 2800 women and men with hip fracture, Beringer et al found that more than 30% were still institutionalized, and only 40% were able to walk outdoors independently 1 year later. Predictors of poor outcome included male sex, advanced age, cognitive impairment, and presence of comorbidities [23].

It is not surprising then that a fracture is often associated with an overall decline in the individual’s quality of life and this has been demonstrated in several studies [26–28]. In the largest study of this type, Tarride et al examined over 23,000 patients with fragility fractures and found a sharp decline in health-related quality of life (HRQOL) immediately after the fracture, which remained below baseline for up to 3 years [26]. The decline was worse in patients with hip and spine fractures compared to other fractures [27].

Mortality Following Fragility Fractures

Perhaps the most concerning complication, however, is the excess mortality seen after fractures. Several studies have demonstrated excess mortality after vertebral fractures, especially in the year following the fracture [29–33], but the highest increase in mortality was observed following hip fractures. In fact, the 30-day mortality after a hip fracture approximates 7% [23] and the excess 1-year mortality is estimated at 8% to 36% [34,35]. While the highest risk of mortality is seen in the first year following the fracture, the increased risk persists for at least 5 to 6 years [36]. Malnutrition, decreased mobility, male sex, and the number of coexisting medical comorbidities further increase the risk of mortality [29,32,34,36,37].

Risk of Fracture Recurrence

In both men and women, a fragility fracture at any site increases the risk of subsequent fractures [38–41], and the risk increases with the number of prevalent fractures [42]. Gehlbach et al estimated an 80% increase in the risk of fracture recurrence after 1 fracture, a threefold increase after 2 fractures, and an almost fivefold increase after 3 fractures [42]. The increase in risk is even more pronounced following vertebral fractures specifically, doubling after the first fracture an increasing by up to ninefold after 3 fractures [42, 43]. This increase in risk is highest in the first year following the fracture but may persist for up to 10 years [39,43].

Fracture Impact on Society

Fractures are associated with a high financial burden to society, in terms of direct acute care costs and long-term rehabilitation [3,4,44–48]. In 2010, the direct cost from fractures in the EU was estimated at €24.6 billion [3]. In the US, this cost was around $14.0 billion in 2002 and $16.9 billion in 2005 [4,48], and in Canada it was $1.5 billion in 2011 [47]. These numbers increase substantially when costs associated with long-term post-fracture rehabilitation are included, with an additional estimated yearly cost of €10.7 billion in the EU and $1.03 billion in Canada [3,47].

While hip fractures account for only about 18% of all low-trauma fractures, they are associated with the highest cost burden, accounting for about 50% to 70% of the total fracture-associated expenditures [3,4,44]. This is likely due to the fact almost all hip fractures require hospitalization, most require surgical repair and rehabilitation, and because they lead to the highest rates of morbidity and mortality.

Can Fracture Recurrence After a Low-Trauma Fracture Be Prevented?

Many approaches to secondary fracture prevention have been proposed, including but not limited to fall prevention, exercise therapy, nutrition therapy, prevention and treatment of sarcopenia, vitamin D and calcium supplementation, and osteoporosis pharmacotherapy [49–53]. Of those, osteoporosis pharmacotherapy has the strongest and most compelling efficacy data and will be reviewed in the following sections.

Effect of Antiresorptive Therapy After a Fracture

In the Fracture Intervention Trial (FIT), alendronate decreased the risk of new vertebral fractures by about 47% and of hip fractures by about 50% in women with preexisting vertebral fractures [54,55]. Similar fracture protection benefits were demonstrated in the Hip Intervention Program (HIP), where risedronate decreased the risk of hip fractures by 60% in women with prior history of vertebral fractures [56].

The best data regarding secondary prevention of hip fractures however comes from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial, where patients were randomized to zoledronic acid or placebo within 90 days of a hip fracture. Over a median duration of therapy of about 2 years, zoledronic acid decreased the risk of any new clinical fracture by 35%, of new vertebral fractures by 46%, and of recurrent hip fractures by 30% [57].

Effect of Anabolic Therapy After a Fracture

The Fracture Prevention Trial (FPT) compared the effect of teriparatide to placebo in women with at least 1 moderate or 2 mild atraumatic vertebral fractures and showed a 65% reduction in the risk of new vertebral fractures and a 53% reduction in the risk of new non-vertebral fractures [58]. Likewise, the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) enrolled women with at least 2 mild vertebral fractures, 1 moderate vertebral fracture or history of a low trauma fracture of the forearm, humerus, sacrum, pelvis, hip, femur, or tibia. In this trial, abaloparatide decreased the risk of new vertebral fractures by 85% and of new non-vertebral fractures by 43% compared to placebo [59].

Will Anti-Osteoporosis Therapy After a Low-Trauma Fracture Impact Fracture Healing?

One major question regarding the use of anti-osteoporosis drugs in patients with a recent fracture is the effect that treatment might have on bone healing after fracture or fracture-repair surgery. With antiresorptive agents in particular, the main concern is whether suppression of bone turnover may lead to delayed bone healing, since healing requires callus remodeling. A small prospective study evaluated fracture healing in 196 patients treated for a distal radius fracture, 153 of whom were on a bisphosphonate at the time of the fracture. While bisphosphonate use was associated with a longer time to radiographic union, the time to union was only 6 days longer in the bisphosphonate group (55 days versus 49 days to union in the bisphosphonate and control groups, respectively), and has generally not been felt to be clinically significant [60]. The most reassuring data regarding this question however, comes from the HORIZON trial where 2127 men and women were randomized to zoledronic acid or placebo within 90 days of a hip fracture. No difference in healing between the 2 groups was seen, regardless of the time of initiation of zoledronic acid (within 2 weeks of fracture, between 2 and 4 weeks, between 4 and 6 weeks or after 6 weeks) [61].

The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].

In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.

The Gap Between Science and Practice

Practice Guidelines Versus Actual Practice

Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].

However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].

Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].

Barriers to Care: Where Are We Failing?

The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.

However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].

Fracture Liaison Services—A Potential Solution to Enhance Secondary Fracture Prevention

What is a Fracture Liaison Service?

Several solutions have been proposed to remedy the main barriers that interfere with proper secondary treatment of osteoporosis, namely patient education, provider education, and the initiation of programs to enhance coordination and continuity of care between treating teams. Taken together, these interventions have been modestly effective at increasing the odds of BMD measurement and initiation of osteoporosis therapy [98, 99]. Interventions that focused mainly on provider and/or patient education were the least effective, especially when they did not rely on direct in-person interactions, and programs intended to enhance transitions of care were more effective [96,99,100].

These programs are commonly referred to as fracture liaison services (FLS). They aim to identify patients with low-trauma fractures, provide risk assessment and education to the patient, and in some cases provide the patient with post-fracture osteoporosis care. These services typically require a dedicated case manager, who is often a clinical nurse specialist, ideally supported by a medical practitioner with expertise in the treatment of osteoporosis. The FLS case manager uses predetermined protocols that facilitate patient identification, risk assessment and management [101]. Some programs are hospital-based, identifying and evaluating patients while still hospitalized for their hip fracture, and others are based in clinics, aiming to provide services after discharge from the initial acute hospitalization [96,99–101].

How Effective Are Fracture Liaison Services?

Several FLS models have been proposed and tested, with some limited to patient identification and risk stratification, and others more intensive, involving initiation of BMD testing or BMD testing and osteoporosis treatment. In a meta-analysis of FLS programs, Ganda et al grouped programs into 3 categories: Type A programs involved patient identification, assessment and treatment, type B programs involved patient identification and assessment only without treatment, and type C programs involved patient identification combined with alerting of the patients and providers to the need to assess and treat. The effectiveness of the programs in terms of BMD testing and initiation of therapy increased with intensity. Type A programs were the most effective with BMD testing and treatment initiation rates of 79.4% and 46.4% respectively, followed by type B programs which had BMD testing and treatment initiation rates of 59.5% and 40.6% respectively, then type C programs which had BMD testing and treatment initiation rates of 43.4% and 23.4% respectively [100].

The most intensive programs have also been shown to significantly decrease the risk of fracture recurrence, with a reduction in the rate of re-fracture from 19.7% to 4.1% within 4 weeks [102], and a 37.2 % reduction within 3 years [103,104]. Additionally, intensive FLS programs involving pharmacotherapy with a bisphosphonate may be associated with a reduction in mortality after a hip fracture. Beaupre et al evaluated the mortality benefit associated with oral bisphosphonate therapy in the setting of a FLS and demonstrated an 8% decline in mortality per month of oral bisphosphonate use, and an approximate 60% reduction per year of use in comparison to patients who did not receive treatment [105]. This finding was consistent with the reduction in mortality seen with zoledronic acid in the HORIZON trial, which was in part attributable to decreased re-fracture rates, but primarily due to reduction in the occurrence of pneumonia and arrhythmias in patients receiving the drug [57,106].

While fracture liaison services may be associated with increased immediate costs—such as the costs of hiring a case manager, BMD testing and pharmacotherapy, and in some cases a data management system—several cost-effectiveness analyses have shown associated long-term cost savings [107–109]. This is not surprising given that they decrease re-fracture rates, leading to a decline in the very costly immediate and long-term fracture care costs.

Summary

In summary, fragility fractures present a major health care problem for aging populations, leading to significant costs and high morbidity and mortality. Assessment and treatment of osteoporosis following a fragility fracture can decrease the risk of fracture recurrence, long-term costs, morbidities, and possibly mortality. In the last decade, several national and international initiatives have been created to promote and encourage secondary prevention of fragility fractures [110–113]. However, these programs have all been voluntary and there are currently no reliable mechanisms to ensure broad implementation of secondary fracture prevention interventions. As a result, and while several isolated secondary prevention programs have shown great success, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Corresponding author: Amal Shibli-Rahhal, MD, MS, Dept. of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

Financial disclosures:

From the Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Abstract

• Objective: To review and summarize the literature regarding current approaches to secondary prevention of low-trauma osteoporotic fractures.
• Methods: PubMed search and summary of existing literature related to complications and secondary prevention of osteoporotic fractures was performed.
• Results: Fragility fractures are associated with high rates of short and long term morbidities and carry a high risk of mortality and fracture recurrence. Several of the currently available anti-osteoporosis medications have been shown to decrease the risk of fracture recurrence in patients with prevalent osteoporotic fractures and some may even decrease mortality. However, only a minority of patients with fragility fractures are adequately evaluated and treated for osteoporosis. Fracture liaison services that ensure identification and risk stratification of patients with fragility fractures and proper evaluation and treatment of osteoporosis have proven effective at enhancing osteoporosis care in these patients, decreasing fracture recurrence and possibly even decreasing long-term mortality, while providing long-term cost savings. Unfortunately, however, this model of care has not been widely adopted and implemented.
• Conclusion: Fragility fractures represent a major health care problem for aging populations. Unfortunately, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Key words: osteoporosis; fracture; fragility; low-trauma; bone density.

Low-trauma fractures are fractures that occur from a trauma equivalent to a fall from standing height or less [1,2]. They can involve any skeletal site, but the most significant are vertebral, pelvic, wrist and hip fractures, which together represent close to 90% of all low-trauma fractures [3,4]. The overall burden of low-trauma fractures is quite high worldwide and is projected to increase over time [3–6]. In 2010, 3.5 million new low-trauma fractures were reported in the European Union [3]. In the United States, there were more than 2 million fractures in 2005, and it is estimated that more than 3 million fractures will occur in year 2025 [4].

Low-trauma fractures are generally indicative of compromised bone strength—especially when they involve the hip—and are thus often referred to as fragility fractures. While the traditional definition of osteoporosis is a bone mineral density (BMD) T-score of -2.5 or lower, low-trauma fractures of the hip are also diagnostic of osteoporosis, regardless of bone mineral density [2,7–9]. In addition, low-trauma fractures of the vertebrae, the proximal humerus, and the pelvis are considered diagnostic of osteoporosis when combined with T-scores between -1 and -2.5 [2,7]. Bone biopsies and high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with low-trauma fractures and normal BMD suggest microarchitectural alterations and abnormalities of collagen orientation and crosslinking within the bone matrix [10-12], leading to decreased bone strength.

This review will address the individual and societal costs of low-trauma fractures and issues related to secondary prevention of fractures, with specific emphasis on pharmacotherapy and fracture liaison services.

Impact of Low-Trauma Fractures

Acute and Long-Term Complications

Of all fragility fractures, hip fractures are the ones most likely to result in serious acute complications. The most common acute complications are delirium in up to 50% of patients and malnutrition in up to 60%, both of which predict slower and less complete recovery [13–16]. Other complications include urinary tract infections in up to 60% of patients in certain reports [17], thromboembolic disease with deep venous thrombosis in around 27% of patients and pulmonary embolism in up to 7% [16], and acute kidney injury in about 15% [18].

In addition, it is not uncommon for patients to suffer from significant long-term functional limitations following fragility fractures. While vertebral fractures do not frequently lead to hospitalization or institutionalization, they often lead to significant physical limitations and chronic pain [19,20] and to negative effects on self-esteem, mood, and body image [21,22]. However, the most remarkable functional decline and limitations are seen after hip fractures [23–25]. In a study of 2800 women and men with hip fracture, Beringer et al found that more than 30% were still institutionalized, and only 40% were able to walk outdoors independently 1 year later. Predictors of poor outcome included male sex, advanced age, cognitive impairment, and presence of comorbidities [23].

It is not surprising then that a fracture is often associated with an overall decline in the individual’s quality of life and this has been demonstrated in several studies [26–28]. In the largest study of this type, Tarride et al examined over 23,000 patients with fragility fractures and found a sharp decline in health-related quality of life (HRQOL) immediately after the fracture, which remained below baseline for up to 3 years [26]. The decline was worse in patients with hip and spine fractures compared to other fractures [27].

Mortality Following Fragility Fractures

Perhaps the most concerning complication, however, is the excess mortality seen after fractures. Several studies have demonstrated excess mortality after vertebral fractures, especially in the year following the fracture [29–33], but the highest increase in mortality was observed following hip fractures. In fact, the 30-day mortality after a hip fracture approximates 7% [23] and the excess 1-year mortality is estimated at 8% to 36% [34,35]. While the highest risk of mortality is seen in the first year following the fracture, the increased risk persists for at least 5 to 6 years [36]. Malnutrition, decreased mobility, male sex, and the number of coexisting medical comorbidities further increase the risk of mortality [29,32,34,36,37].

Risk of Fracture Recurrence

In both men and women, a fragility fracture at any site increases the risk of subsequent fractures [38–41], and the risk increases with the number of prevalent fractures [42]. Gehlbach et al estimated an 80% increase in the risk of fracture recurrence after 1 fracture, a threefold increase after 2 fractures, and an almost fivefold increase after 3 fractures [42]. The increase in risk is even more pronounced following vertebral fractures specifically, doubling after the first fracture an increasing by up to ninefold after 3 fractures [42, 43]. This increase in risk is highest in the first year following the fracture but may persist for up to 10 years [39,43].

Fracture Impact on Society

Fractures are associated with a high financial burden to society, in terms of direct acute care costs and long-term rehabilitation [3,4,44–48]. In 2010, the direct cost from fractures in the EU was estimated at €24.6 billion [3]. In the US, this cost was around $14.0 billion in 2002 and $16.9 billion in 2005 [4,48], and in Canada it was $1.5 billion in 2011 [47]. These numbers increase substantially when costs associated with long-term post-fracture rehabilitation are included, with an additional estimated yearly cost of €10.7 billion in the EU and $1.03 billion in Canada [3,47].

While hip fractures account for only about 18% of all low-trauma fractures, they are associated with the highest cost burden, accounting for about 50% to 70% of the total fracture-associated expenditures [3,4,44]. This is likely due to the fact almost all hip fractures require hospitalization, most require surgical repair and rehabilitation, and because they lead to the highest rates of morbidity and mortality.

Can Fracture Recurrence After a Low-Trauma Fracture Be Prevented?

Many approaches to secondary fracture prevention have been proposed, including but not limited to fall prevention, exercise therapy, nutrition therapy, prevention and treatment of sarcopenia, vitamin D and calcium supplementation, and osteoporosis pharmacotherapy [49–53]. Of those, osteoporosis pharmacotherapy has the strongest and most compelling efficacy data and will be reviewed in the following sections.

Effect of Antiresorptive Therapy After a Fracture

In the Fracture Intervention Trial (FIT), alendronate decreased the risk of new vertebral fractures by about 47% and of hip fractures by about 50% in women with preexisting vertebral fractures [54,55]. Similar fracture protection benefits were demonstrated in the Hip Intervention Program (HIP), where risedronate decreased the risk of hip fractures by 60% in women with prior history of vertebral fractures [56].

The best data regarding secondary prevention of hip fractures however comes from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial, where patients were randomized to zoledronic acid or placebo within 90 days of a hip fracture. Over a median duration of therapy of about 2 years, zoledronic acid decreased the risk of any new clinical fracture by 35%, of new vertebral fractures by 46%, and of recurrent hip fractures by 30% [57].

Effect of Anabolic Therapy After a Fracture

The Fracture Prevention Trial (FPT) compared the effect of teriparatide to placebo in women with at least 1 moderate or 2 mild atraumatic vertebral fractures and showed a 65% reduction in the risk of new vertebral fractures and a 53% reduction in the risk of new non-vertebral fractures [58]. Likewise, the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) enrolled women with at least 2 mild vertebral fractures, 1 moderate vertebral fracture or history of a low trauma fracture of the forearm, humerus, sacrum, pelvis, hip, femur, or tibia. In this trial, abaloparatide decreased the risk of new vertebral fractures by 85% and of new non-vertebral fractures by 43% compared to placebo [59].

Will Anti-Osteoporosis Therapy After a Low-Trauma Fracture Impact Fracture Healing?

One major question regarding the use of anti-osteoporosis drugs in patients with a recent fracture is the effect that treatment might have on bone healing after fracture or fracture-repair surgery. With antiresorptive agents in particular, the main concern is whether suppression of bone turnover may lead to delayed bone healing, since healing requires callus remodeling. A small prospective study evaluated fracture healing in 196 patients treated for a distal radius fracture, 153 of whom were on a bisphosphonate at the time of the fracture. While bisphosphonate use was associated with a longer time to radiographic union, the time to union was only 6 days longer in the bisphosphonate group (55 days versus 49 days to union in the bisphosphonate and control groups, respectively), and has generally not been felt to be clinically significant [60]. The most reassuring data regarding this question however, comes from the HORIZON trial where 2127 men and women were randomized to zoledronic acid or placebo within 90 days of a hip fracture. No difference in healing between the 2 groups was seen, regardless of the time of initiation of zoledronic acid (within 2 weeks of fracture, between 2 and 4 weeks, between 4 and 6 weeks or after 6 weeks) [61].

The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].

In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.

The Gap Between Science and Practice

Practice Guidelines Versus Actual Practice

Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].

However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].

Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].

Barriers to Care: Where Are We Failing?

The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.

However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].

Fracture Liaison Services—A Potential Solution to Enhance Secondary Fracture Prevention

What is a Fracture Liaison Service?

Several solutions have been proposed to remedy the main barriers that interfere with proper secondary treatment of osteoporosis, namely patient education, provider education, and the initiation of programs to enhance coordination and continuity of care between treating teams. Taken together, these interventions have been modestly effective at increasing the odds of BMD measurement and initiation of osteoporosis therapy [98, 99]. Interventions that focused mainly on provider and/or patient education were the least effective, especially when they did not rely on direct in-person interactions, and programs intended to enhance transitions of care were more effective [96,99,100].

These programs are commonly referred to as fracture liaison services (FLS). They aim to identify patients with low-trauma fractures, provide risk assessment and education to the patient, and in some cases provide the patient with post-fracture osteoporosis care. These services typically require a dedicated case manager, who is often a clinical nurse specialist, ideally supported by a medical practitioner with expertise in the treatment of osteoporosis. The FLS case manager uses predetermined protocols that facilitate patient identification, risk assessment and management [101]. Some programs are hospital-based, identifying and evaluating patients while still hospitalized for their hip fracture, and others are based in clinics, aiming to provide services after discharge from the initial acute hospitalization [96,99–101].

How Effective Are Fracture Liaison Services?

Several FLS models have been proposed and tested, with some limited to patient identification and risk stratification, and others more intensive, involving initiation of BMD testing or BMD testing and osteoporosis treatment. In a meta-analysis of FLS programs, Ganda et al grouped programs into 3 categories: Type A programs involved patient identification, assessment and treatment, type B programs involved patient identification and assessment only without treatment, and type C programs involved patient identification combined with alerting of the patients and providers to the need to assess and treat. The effectiveness of the programs in terms of BMD testing and initiation of therapy increased with intensity. Type A programs were the most effective with BMD testing and treatment initiation rates of 79.4% and 46.4% respectively, followed by type B programs which had BMD testing and treatment initiation rates of 59.5% and 40.6% respectively, then type C programs which had BMD testing and treatment initiation rates of 43.4% and 23.4% respectively [100].

The most intensive programs have also been shown to significantly decrease the risk of fracture recurrence, with a reduction in the rate of re-fracture from 19.7% to 4.1% within 4 weeks [102], and a 37.2 % reduction within 3 years [103,104]. Additionally, intensive FLS programs involving pharmacotherapy with a bisphosphonate may be associated with a reduction in mortality after a hip fracture. Beaupre et al evaluated the mortality benefit associated with oral bisphosphonate therapy in the setting of a FLS and demonstrated an 8% decline in mortality per month of oral bisphosphonate use, and an approximate 60% reduction per year of use in comparison to patients who did not receive treatment [105]. This finding was consistent with the reduction in mortality seen with zoledronic acid in the HORIZON trial, which was in part attributable to decreased re-fracture rates, but primarily due to reduction in the occurrence of pneumonia and arrhythmias in patients receiving the drug [57,106].

While fracture liaison services may be associated with increased immediate costs—such as the costs of hiring a case manager, BMD testing and pharmacotherapy, and in some cases a data management system—several cost-effectiveness analyses have shown associated long-term cost savings [107–109]. This is not surprising given that they decrease re-fracture rates, leading to a decline in the very costly immediate and long-term fracture care costs.

Summary

In summary, fragility fractures present a major health care problem for aging populations, leading to significant costs and high morbidity and mortality. Assessment and treatment of osteoporosis following a fragility fracture can decrease the risk of fracture recurrence, long-term costs, morbidities, and possibly mortality. In the last decade, several national and international initiatives have been created to promote and encourage secondary prevention of fragility fractures [110–113]. However, these programs have all been voluntary and there are currently no reliable mechanisms to ensure broad implementation of secondary fracture prevention interventions. As a result, and while several isolated secondary prevention programs have shown great success, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Corresponding author: Amal Shibli-Rahhal, MD, MS, Dept. of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

Financial disclosures:

From the Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.

Abstract

• Objective: To review and summarize the literature regarding current approaches to secondary prevention of low-trauma osteoporotic fractures.
• Methods: PubMed search and summary of existing literature related to complications and secondary prevention of osteoporotic fractures was performed.
• Results: Fragility fractures are associated with high rates of short and long term morbidities and carry a high risk of mortality and fracture recurrence. Several of the currently available anti-osteoporosis medications have been shown to decrease the risk of fracture recurrence in patients with prevalent osteoporotic fractures and some may even decrease mortality. However, only a minority of patients with fragility fractures are adequately evaluated and treated for osteoporosis. Fracture liaison services that ensure identification and risk stratification of patients with fragility fractures and proper evaluation and treatment of osteoporosis have proven effective at enhancing osteoporosis care in these patients, decreasing fracture recurrence and possibly even decreasing long-term mortality, while providing long-term cost savings. Unfortunately, however, this model of care has not been widely adopted and implemented.
• Conclusion: Fragility fractures represent a major health care problem for aging populations. Unfortunately, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Key words: osteoporosis; fracture; fragility; low-trauma; bone density.

Low-trauma fractures are fractures that occur from a trauma equivalent to a fall from standing height or less [1,2]. They can involve any skeletal site, but the most significant are vertebral, pelvic, wrist and hip fractures, which together represent close to 90% of all low-trauma fractures [3,4]. The overall burden of low-trauma fractures is quite high worldwide and is projected to increase over time [3–6]. In 2010, 3.5 million new low-trauma fractures were reported in the European Union [3]. In the United States, there were more than 2 million fractures in 2005, and it is estimated that more than 3 million fractures will occur in year 2025 [4].

Low-trauma fractures are generally indicative of compromised bone strength—especially when they involve the hip—and are thus often referred to as fragility fractures. While the traditional definition of osteoporosis is a bone mineral density (BMD) T-score of -2.5 or lower, low-trauma fractures of the hip are also diagnostic of osteoporosis, regardless of bone mineral density [2,7–9]. In addition, low-trauma fractures of the vertebrae, the proximal humerus, and the pelvis are considered diagnostic of osteoporosis when combined with T-scores between -1 and -2.5 [2,7]. Bone biopsies and high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with low-trauma fractures and normal BMD suggest microarchitectural alterations and abnormalities of collagen orientation and crosslinking within the bone matrix [10-12], leading to decreased bone strength.

This review will address the individual and societal costs of low-trauma fractures and issues related to secondary prevention of fractures, with specific emphasis on pharmacotherapy and fracture liaison services.

Impact of Low-Trauma Fractures

Acute and Long-Term Complications

Of all fragility fractures, hip fractures are the ones most likely to result in serious acute complications. The most common acute complications are delirium in up to 50% of patients and malnutrition in up to 60%, both of which predict slower and less complete recovery [13–16]. Other complications include urinary tract infections in up to 60% of patients in certain reports [17], thromboembolic disease with deep venous thrombosis in around 27% of patients and pulmonary embolism in up to 7% [16], and acute kidney injury in about 15% [18].

In addition, it is not uncommon for patients to suffer from significant long-term functional limitations following fragility fractures. While vertebral fractures do not frequently lead to hospitalization or institutionalization, they often lead to significant physical limitations and chronic pain [19,20] and to negative effects on self-esteem, mood, and body image [21,22]. However, the most remarkable functional decline and limitations are seen after hip fractures [23–25]. In a study of 2800 women and men with hip fracture, Beringer et al found that more than 30% were still institutionalized, and only 40% were able to walk outdoors independently 1 year later. Predictors of poor outcome included male sex, advanced age, cognitive impairment, and presence of comorbidities [23].

It is not surprising then that a fracture is often associated with an overall decline in the individual’s quality of life and this has been demonstrated in several studies [26–28]. In the largest study of this type, Tarride et al examined over 23,000 patients with fragility fractures and found a sharp decline in health-related quality of life (HRQOL) immediately after the fracture, which remained below baseline for up to 3 years [26]. The decline was worse in patients with hip and spine fractures compared to other fractures [27].

Mortality Following Fragility Fractures

Perhaps the most concerning complication, however, is the excess mortality seen after fractures. Several studies have demonstrated excess mortality after vertebral fractures, especially in the year following the fracture [29–33], but the highest increase in mortality was observed following hip fractures. In fact, the 30-day mortality after a hip fracture approximates 7% [23] and the excess 1-year mortality is estimated at 8% to 36% [34,35]. While the highest risk of mortality is seen in the first year following the fracture, the increased risk persists for at least 5 to 6 years [36]. Malnutrition, decreased mobility, male sex, and the number of coexisting medical comorbidities further increase the risk of mortality [29,32,34,36,37].

Risk of Fracture Recurrence

In both men and women, a fragility fracture at any site increases the risk of subsequent fractures [38–41], and the risk increases with the number of prevalent fractures [42]. Gehlbach et al estimated an 80% increase in the risk of fracture recurrence after 1 fracture, a threefold increase after 2 fractures, and an almost fivefold increase after 3 fractures [42]. The increase in risk is even more pronounced following vertebral fractures specifically, doubling after the first fracture an increasing by up to ninefold after 3 fractures [42, 43]. This increase in risk is highest in the first year following the fracture but may persist for up to 10 years [39,43].

Fracture Impact on Society

Fractures are associated with a high financial burden to society, in terms of direct acute care costs and long-term rehabilitation [3,4,44–48]. In 2010, the direct cost from fractures in the EU was estimated at €24.6 billion [3]. In the US, this cost was around $14.0 billion in 2002 and $16.9 billion in 2005 [4,48], and in Canada it was $1.5 billion in 2011 [47]. These numbers increase substantially when costs associated with long-term post-fracture rehabilitation are included, with an additional estimated yearly cost of €10.7 billion in the EU and $1.03 billion in Canada [3,47].

While hip fractures account for only about 18% of all low-trauma fractures, they are associated with the highest cost burden, accounting for about 50% to 70% of the total fracture-associated expenditures [3,4,44]. This is likely due to the fact almost all hip fractures require hospitalization, most require surgical repair and rehabilitation, and because they lead to the highest rates of morbidity and mortality.

Can Fracture Recurrence After a Low-Trauma Fracture Be Prevented?

Many approaches to secondary fracture prevention have been proposed, including but not limited to fall prevention, exercise therapy, nutrition therapy, prevention and treatment of sarcopenia, vitamin D and calcium supplementation, and osteoporosis pharmacotherapy [49–53]. Of those, osteoporosis pharmacotherapy has the strongest and most compelling efficacy data and will be reviewed in the following sections.

Effect of Antiresorptive Therapy After a Fracture

In the Fracture Intervention Trial (FIT), alendronate decreased the risk of new vertebral fractures by about 47% and of hip fractures by about 50% in women with preexisting vertebral fractures [54,55]. Similar fracture protection benefits were demonstrated in the Hip Intervention Program (HIP), where risedronate decreased the risk of hip fractures by 60% in women with prior history of vertebral fractures [56].

The best data regarding secondary prevention of hip fractures however comes from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial, where patients were randomized to zoledronic acid or placebo within 90 days of a hip fracture. Over a median duration of therapy of about 2 years, zoledronic acid decreased the risk of any new clinical fracture by 35%, of new vertebral fractures by 46%, and of recurrent hip fractures by 30% [57].

Effect of Anabolic Therapy After a Fracture

The Fracture Prevention Trial (FPT) compared the effect of teriparatide to placebo in women with at least 1 moderate or 2 mild atraumatic vertebral fractures and showed a 65% reduction in the risk of new vertebral fractures and a 53% reduction in the risk of new non-vertebral fractures [58]. Likewise, the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) enrolled women with at least 2 mild vertebral fractures, 1 moderate vertebral fracture or history of a low trauma fracture of the forearm, humerus, sacrum, pelvis, hip, femur, or tibia. In this trial, abaloparatide decreased the risk of new vertebral fractures by 85% and of new non-vertebral fractures by 43% compared to placebo [59].

Will Anti-Osteoporosis Therapy After a Low-Trauma Fracture Impact Fracture Healing?

One major question regarding the use of anti-osteoporosis drugs in patients with a recent fracture is the effect that treatment might have on bone healing after fracture or fracture-repair surgery. With antiresorptive agents in particular, the main concern is whether suppression of bone turnover may lead to delayed bone healing, since healing requires callus remodeling. A small prospective study evaluated fracture healing in 196 patients treated for a distal radius fracture, 153 of whom were on a bisphosphonate at the time of the fracture. While bisphosphonate use was associated with a longer time to radiographic union, the time to union was only 6 days longer in the bisphosphonate group (55 days versus 49 days to union in the bisphosphonate and control groups, respectively), and has generally not been felt to be clinically significant [60]. The most reassuring data regarding this question however, comes from the HORIZON trial where 2127 men and women were randomized to zoledronic acid or placebo within 90 days of a hip fracture. No difference in healing between the 2 groups was seen, regardless of the time of initiation of zoledronic acid (within 2 weeks of fracture, between 2 and 4 weeks, between 4 and 6 weeks or after 6 weeks) [61].

The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].

In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.

The Gap Between Science and Practice

Practice Guidelines Versus Actual Practice

Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].

However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].

Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].

Barriers to Care: Where Are We Failing?

The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.

However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].

Fracture Liaison Services—A Potential Solution to Enhance Secondary Fracture Prevention

What is a Fracture Liaison Service?

Several solutions have been proposed to remedy the main barriers that interfere with proper secondary treatment of osteoporosis, namely patient education, provider education, and the initiation of programs to enhance coordination and continuity of care between treating teams. Taken together, these interventions have been modestly effective at increasing the odds of BMD measurement and initiation of osteoporosis therapy [98, 99]. Interventions that focused mainly on provider and/or patient education were the least effective, especially when they did not rely on direct in-person interactions, and programs intended to enhance transitions of care were more effective [96,99,100].

These programs are commonly referred to as fracture liaison services (FLS). They aim to identify patients with low-trauma fractures, provide risk assessment and education to the patient, and in some cases provide the patient with post-fracture osteoporosis care. These services typically require a dedicated case manager, who is often a clinical nurse specialist, ideally supported by a medical practitioner with expertise in the treatment of osteoporosis. The FLS case manager uses predetermined protocols that facilitate patient identification, risk assessment and management [101]. Some programs are hospital-based, identifying and evaluating patients while still hospitalized for their hip fracture, and others are based in clinics, aiming to provide services after discharge from the initial acute hospitalization [96,99–101].

How Effective Are Fracture Liaison Services?

Several FLS models have been proposed and tested, with some limited to patient identification and risk stratification, and others more intensive, involving initiation of BMD testing or BMD testing and osteoporosis treatment. In a meta-analysis of FLS programs, Ganda et al grouped programs into 3 categories: Type A programs involved patient identification, assessment and treatment, type B programs involved patient identification and assessment only without treatment, and type C programs involved patient identification combined with alerting of the patients and providers to the need to assess and treat. The effectiveness of the programs in terms of BMD testing and initiation of therapy increased with intensity. Type A programs were the most effective with BMD testing and treatment initiation rates of 79.4% and 46.4% respectively, followed by type B programs which had BMD testing and treatment initiation rates of 59.5% and 40.6% respectively, then type C programs which had BMD testing and treatment initiation rates of 43.4% and 23.4% respectively [100].

The most intensive programs have also been shown to significantly decrease the risk of fracture recurrence, with a reduction in the rate of re-fracture from 19.7% to 4.1% within 4 weeks [102], and a 37.2 % reduction within 3 years [103,104]. Additionally, intensive FLS programs involving pharmacotherapy with a bisphosphonate may be associated with a reduction in mortality after a hip fracture. Beaupre et al evaluated the mortality benefit associated with oral bisphosphonate therapy in the setting of a FLS and demonstrated an 8% decline in mortality per month of oral bisphosphonate use, and an approximate 60% reduction per year of use in comparison to patients who did not receive treatment [105]. This finding was consistent with the reduction in mortality seen with zoledronic acid in the HORIZON trial, which was in part attributable to decreased re-fracture rates, but primarily due to reduction in the occurrence of pneumonia and arrhythmias in patients receiving the drug [57,106].

While fracture liaison services may be associated with increased immediate costs—such as the costs of hiring a case manager, BMD testing and pharmacotherapy, and in some cases a data management system—several cost-effectiveness analyses have shown associated long-term cost savings [107–109]. This is not surprising given that they decrease re-fracture rates, leading to a decline in the very costly immediate and long-term fracture care costs.

Summary

In summary, fragility fractures present a major health care problem for aging populations, leading to significant costs and high morbidity and mortality. Assessment and treatment of osteoporosis following a fragility fracture can decrease the risk of fracture recurrence, long-term costs, morbidities, and possibly mortality. In the last decade, several national and international initiatives have been created to promote and encourage secondary prevention of fragility fractures [110–113]. However, these programs have all been voluntary and there are currently no reliable mechanisms to ensure broad implementation of secondary fracture prevention interventions. As a result, and while several isolated secondary prevention programs have shown great success, most patients with low-trauma fractures still receive suboptimal osteoporosis care.

Corresponding author: Amal Shibli-Rahhal, MD, MS, Dept. of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242.

Financial disclosures:

As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.

For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.

“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.

Shedding light on those opportunities is the overall objective of this session, he said.

“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”

The second objective addresses the training that is required for some of these career options.

“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.

Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.

The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.

“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”

“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.

Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B

As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.

For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.

“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.

Shedding light on those opportunities is the overall objective of this session, he said.

“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”

The second objective addresses the training that is required for some of these career options.

“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.

Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.

The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.

“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”

“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.

Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B

As quality continues to take on a more important role in the health care delivery system, new opportunities for employment are taking shape.

For the hospitalist, that can mean a number of different career paths. What those paths could look like is the subject of the session “Making a Career Out of Quality” at 11:00 a.m. Tuesday.

“Because [quality] is a growing field and because many of the roles that are being created are often new within health systems,” the options hospitalists might have – or the highest value–added roles they might create – are not obvious, said Paul W. Helgerson, MD, SFHM, of the University of Virginia, Charlottesville, a presenter at the session.

Shedding light on those opportunities is the overall objective of this session, he said.

“One objective is to display for attendees what the diversity of roles looks like in this space,” Dr. Helgerson said. “If I am interested in spending part of my time or part of my career in quality, ‘What do people do?’ The truth is there is a whole array of different things.”

The second objective addresses the training that is required for some of these career options.

“We want to be able to represent what the whole breadth of the training experience could look like, from individual mentorship at the local level to formal training for a few days or even a few months nationwide,” he said.

Finally, the session will provide some boots-on-the-ground insight from clinicians at various stages in this space. Dr. Helgerson wants to highlight effective strategies to develop one’s career efficiently and effectively, to align with institutional leadership to create high-impact projects, and to look outside institutions for mentors to help make the career path successful.

The panel features three different perspectives. Dr. Helgerson will talk about his role at the University of Virginia and the work he has done in faculty development and interdisciplinary team development. Read G. Pierce, MD, of the University of Colorado at Denver, Aurora, is heavily involved in leadership training, and Nazima Allaudeen, MD, of the VA Palo Alto (Calif.) Health Care System, will talk about quality outcomes improvement on an operational level.

“My specific section is about different training in QI and that takes a lot of different shapes,” Dr. Allaudeen said. “There is a lot out there that people may not know about, and we will help explain how to match people with the right type of training that will be of the most value.”

“A hospitalist will be able to walk out of this session with a plan,” Dr. Helgerson said.

Making a Career Out of Quality
Tuesday, 11 a.m.-Noon
Crystal Ballroom G1/A&B

“Zero harm” refers to the concept of not having any patients harmed as a result of their interactions with a health care system. For example, no laboratory results are misread or overlooked, no medication errors occur, a patient is not misdiagnosed, and a patient does not fall or get an infection.

As clinicians work to improve quality and safety for patients, some have been able to reach the ideal concept of zero harm.

“But the goal of zero harm should become everyone’s new mantra and, to get there, health care providers need to add new dimensions to their typical quality improvement and patient safety efforts,” said Karyn D. Baum, MD, MSEd, MHA, associate chief medical officer, University of Minnesota, Minneapolis, who will speak during the session “Aiming for Zero Preventable Harm.”

Dr. Baum said the interactive lecture, which she will present with MaryEllen Pfeiffer, DO, SFHM, director of patient safety, WellSpan Health, York, Pa., is designed to review the concept of zero harm. The duo will discuss what this goal entails and explain the skills and concepts that providers need to implement at their sites.

Many of these, which are needed to achieve zero harm, are similar to those already employed in quality improvement efforts, such as employing a plan-do-study-act cycle. To achieve zero harm, however, providers must relentlessly execute all of these efforts. In addition, newer concepts, such as more hospital board involvement in safety, need to be woven into previous concepts for health systems to reach this goal.

“When looking to achieve zero patient harm, look through the lens of operations and care delivery; it will become clear what changes need to be made in order to reach that goal,” Dr. Baum said.

Dr. Baum is a speaker for Boehringer Ingelheim on transitions of care and a consultant for Excelsior HealthCare Group.

Aiming for Zero Preventable Harm
Tues., 2:50-3:50 p.m.
Crystal Ballroom G1/A&B

“Zero harm” refers to the concept of not having any patients harmed as a result of their interactions with a health care system. For example, no laboratory results are misread or overlooked, no medication errors occur, a patient is not misdiagnosed, and a patient does not fall or get an infection.

As clinicians work to improve quality and safety for patients, some have been able to reach the ideal concept of zero harm.

“But the goal of zero harm should become everyone’s new mantra and, to get there, health care providers need to add new dimensions to their typical quality improvement and patient safety efforts,” said Karyn D. Baum, MD, MSEd, MHA, associate chief medical officer, University of Minnesota, Minneapolis, who will speak during the session “Aiming for Zero Preventable Harm.”

Dr. Baum said the interactive lecture, which she will present with MaryEllen Pfeiffer, DO, SFHM, director of patient safety, WellSpan Health, York, Pa., is designed to review the concept of zero harm. The duo will discuss what this goal entails and explain the skills and concepts that providers need to implement at their sites.

Many of these, which are needed to achieve zero harm, are similar to those already employed in quality improvement efforts, such as employing a plan-do-study-act cycle. To achieve zero harm, however, providers must relentlessly execute all of these efforts. In addition, newer concepts, such as more hospital board involvement in safety, need to be woven into previous concepts for health systems to reach this goal.

“When looking to achieve zero patient harm, look through the lens of operations and care delivery; it will become clear what changes need to be made in order to reach that goal,” Dr. Baum said.

Dr. Baum is a speaker for Boehringer Ingelheim on transitions of care and a consultant for Excelsior HealthCare Group.

Aiming for Zero Preventable Harm
Tues., 2:50-3:50 p.m.
Crystal Ballroom G1/A&B

“Zero harm” refers to the concept of not having any patients harmed as a result of their interactions with a health care system. For example, no laboratory results are misread or overlooked, no medication errors occur, a patient is not misdiagnosed, and a patient does not fall or get an infection.

As clinicians work to improve quality and safety for patients, some have been able to reach the ideal concept of zero harm.

“But the goal of zero harm should become everyone’s new mantra and, to get there, health care providers need to add new dimensions to their typical quality improvement and patient safety efforts,” said Karyn D. Baum, MD, MSEd, MHA, associate chief medical officer, University of Minnesota, Minneapolis, who will speak during the session “Aiming for Zero Preventable Harm.”

Dr. Baum said the interactive lecture, which she will present with MaryEllen Pfeiffer, DO, SFHM, director of patient safety, WellSpan Health, York, Pa., is designed to review the concept of zero harm. The duo will discuss what this goal entails and explain the skills and concepts that providers need to implement at their sites.

Many of these, which are needed to achieve zero harm, are similar to those already employed in quality improvement efforts, such as employing a plan-do-study-act cycle. To achieve zero harm, however, providers must relentlessly execute all of these efforts. In addition, newer concepts, such as more hospital board involvement in safety, need to be woven into previous concepts for health systems to reach this goal.

“When looking to achieve zero patient harm, look through the lens of operations and care delivery; it will become clear what changes need to be made in order to reach that goal,” Dr. Baum said.

Dr. Baum is a speaker for Boehringer Ingelheim on transitions of care and a consultant for Excelsior HealthCare Group.

Aiming for Zero Preventable Harm
Tues., 2:50-3:50 p.m.
Crystal Ballroom G1/A&B

The work of the Japanese Society of Hospital General Medicine – the foremost membership organization supporting hospitalists in Japan – will be the focus of “Hospital Medicine in Japan” on Tuesday from 12:45-1:30 p.m. in Grand Ballroom 12-14.

“Hospital Medicine is being adopted and spread around the world,” stated Larry Wellikson, MD, MHM, the CEO of SHM. “We have invited the leaders of the Japanese Society of Hospital General Medicine to come to HM18 to give our attendees the inside story on how hospital medicine is changing the management of acutely ill patients in Japan.

The Japanese society held its 15th annual conference in September 2017. SHM was represented on the faculty by outgoing Board President Ron Greeno, MD, MHM.

Hospital Medicine in Japan will be led by three prominent Japanese hospitalists: Jun Hayashi, MD, PhD, of Kyushu University Hospital in Fukuoka; Toshio Naito, MD, PhD, of Juntendo University in Tokyo; and Susumu Tazuma, MD, PhD, of Hiroshima University Hospital. Dr. Naito is also president of the Japanese Society.

“For the past several years, SHM has taken a more deliberate approach to cultivating international relationships,” said Ethan Gray, CAE, vice president of SHM membership.

“Similar to the factors that influence hospital medicine implementation in general, SHM’s role around the world will need to be nuanced,” he said. “The society is taking cues from leaders on the ground to determine how we can be supportive.”

• Canada – Founded as an SHM chapter in 2001, the Canadian Society of Hospital Medicine is the leading hospitalist membership society in Canada and hosts regular educational conferences that include SHM leaders as faculty.
• Brazil – Hospitalists began organizing in 2006, creating the foundation for the launch of an official SHM chapter in 2016. SHM provides faculty for both on-site conferences in Brazil and webinars.
• The Middle East – An official chapter was initiated in 2016 with leadership from Qatar, Saudi Arabia, and the United Arab Emirates. SHM faculty has participated in its regional educational sessions.
• The Netherlands – A government-funded pilot program has been training hospitalists in the Netherlands since 2012. Its official SHM chapter was founded in 2017. As the government reviews the training program pilot, SHM may help chapter leaders to define hospital medicine’s role in the Dutch health system.

“In addition to these official associations, SHM is cultivating relationships with other international organizations serving the hospital medicine community,” Mr. Gray stated. “This includes interactions with the Japanese Society, as well as the Society for Acute Medicine in the United Kingdom.”

Preliminary conversations have taken place with leaders in several other countries about establishing SHM chapters, he said, including Argentina, India, Panama, Portugal, Singapore, Slovakia, South Korea, and Spain. Discussions also include potential delivery of resources to providers and establishment of a venue for research sharing and networking.

As SHM expands its international activities, it is dedicating staff resources to international chapter development, including the facilitation of virtual communities on its Hospital Medical Exchange (HMX).

“Our goal,” Mr. Gray said, “is to learn from one another.”

Hospital Medicine in Japan
Tuesday, 12:45-1:30 p.m.
Grand Ballroom 12-14

The work of the Japanese Society of Hospital General Medicine – the foremost membership organization supporting hospitalists in Japan – will be the focus of “Hospital Medicine in Japan” on Tuesday from 12:45-1:30 p.m. in Grand Ballroom 12-14.

“Hospital Medicine is being adopted and spread around the world,” stated Larry Wellikson, MD, MHM, the CEO of SHM. “We have invited the leaders of the Japanese Society of Hospital General Medicine to come to HM18 to give our attendees the inside story on how hospital medicine is changing the management of acutely ill patients in Japan.

The Japanese society held its 15th annual conference in September 2017. SHM was represented on the faculty by outgoing Board President Ron Greeno, MD, MHM.

Hospital Medicine in Japan will be led by three prominent Japanese hospitalists: Jun Hayashi, MD, PhD, of Kyushu University Hospital in Fukuoka; Toshio Naito, MD, PhD, of Juntendo University in Tokyo; and Susumu Tazuma, MD, PhD, of Hiroshima University Hospital. Dr. Naito is also president of the Japanese Society.

“For the past several years, SHM has taken a more deliberate approach to cultivating international relationships,” said Ethan Gray, CAE, vice president of SHM membership.

“Similar to the factors that influence hospital medicine implementation in general, SHM’s role around the world will need to be nuanced,” he said. “The society is taking cues from leaders on the ground to determine how we can be supportive.”

• Canada – Founded as an SHM chapter in 2001, the Canadian Society of Hospital Medicine is the leading hospitalist membership society in Canada and hosts regular educational conferences that include SHM leaders as faculty.
• Brazil – Hospitalists began organizing in 2006, creating the foundation for the launch of an official SHM chapter in 2016. SHM provides faculty for both on-site conferences in Brazil and webinars.
• The Middle East – An official chapter was initiated in 2016 with leadership from Qatar, Saudi Arabia, and the United Arab Emirates. SHM faculty has participated in its regional educational sessions.
• The Netherlands – A government-funded pilot program has been training hospitalists in the Netherlands since 2012. Its official SHM chapter was founded in 2017. As the government reviews the training program pilot, SHM may help chapter leaders to define hospital medicine’s role in the Dutch health system.

“In addition to these official associations, SHM is cultivating relationships with other international organizations serving the hospital medicine community,” Mr. Gray stated. “This includes interactions with the Japanese Society, as well as the Society for Acute Medicine in the United Kingdom.”

Preliminary conversations have taken place with leaders in several other countries about establishing SHM chapters, he said, including Argentina, India, Panama, Portugal, Singapore, Slovakia, South Korea, and Spain. Discussions also include potential delivery of resources to providers and establishment of a venue for research sharing and networking.

As SHM expands its international activities, it is dedicating staff resources to international chapter development, including the facilitation of virtual communities on its Hospital Medical Exchange (HMX).

“Our goal,” Mr. Gray said, “is to learn from one another.”

Hospital Medicine in Japan
Tuesday, 12:45-1:30 p.m.
Grand Ballroom 12-14

The work of the Japanese Society of Hospital General Medicine – the foremost membership organization supporting hospitalists in Japan – will be the focus of “Hospital Medicine in Japan” on Tuesday from 12:45-1:30 p.m. in Grand Ballroom 12-14.

“Hospital Medicine is being adopted and spread around the world,” stated Larry Wellikson, MD, MHM, the CEO of SHM. “We have invited the leaders of the Japanese Society of Hospital General Medicine to come to HM18 to give our attendees the inside story on how hospital medicine is changing the management of acutely ill patients in Japan.

The Japanese society held its 15th annual conference in September 2017. SHM was represented on the faculty by outgoing Board President Ron Greeno, MD, MHM.

Hospital Medicine in Japan will be led by three prominent Japanese hospitalists: Jun Hayashi, MD, PhD, of Kyushu University Hospital in Fukuoka; Toshio Naito, MD, PhD, of Juntendo University in Tokyo; and Susumu Tazuma, MD, PhD, of Hiroshima University Hospital. Dr. Naito is also president of the Japanese Society.

“For the past several years, SHM has taken a more deliberate approach to cultivating international relationships,” said Ethan Gray, CAE, vice president of SHM membership.

“Similar to the factors that influence hospital medicine implementation in general, SHM’s role around the world will need to be nuanced,” he said. “The society is taking cues from leaders on the ground to determine how we can be supportive.”

• Canada – Founded as an SHM chapter in 2001, the Canadian Society of Hospital Medicine is the leading hospitalist membership society in Canada and hosts regular educational conferences that include SHM leaders as faculty.
• Brazil – Hospitalists began organizing in 2006, creating the foundation for the launch of an official SHM chapter in 2016. SHM provides faculty for both on-site conferences in Brazil and webinars.
• The Middle East – An official chapter was initiated in 2016 with leadership from Qatar, Saudi Arabia, and the United Arab Emirates. SHM faculty has participated in its regional educational sessions.
• The Netherlands – A government-funded pilot program has been training hospitalists in the Netherlands since 2012. Its official SHM chapter was founded in 2017. As the government reviews the training program pilot, SHM may help chapter leaders to define hospital medicine’s role in the Dutch health system.

“In addition to these official associations, SHM is cultivating relationships with other international organizations serving the hospital medicine community,” Mr. Gray stated. “This includes interactions with the Japanese Society, as well as the Society for Acute Medicine in the United Kingdom.”

Preliminary conversations have taken place with leaders in several other countries about establishing SHM chapters, he said, including Argentina, India, Panama, Portugal, Singapore, Slovakia, South Korea, and Spain. Discussions also include potential delivery of resources to providers and establishment of a venue for research sharing and networking.

As SHM expands its international activities, it is dedicating staff resources to international chapter development, including the facilitation of virtual communities on its Hospital Medical Exchange (HMX).

“Our goal,” Mr. Gray said, “is to learn from one another.”

Hospital Medicine in Japan
Tuesday, 12:45-1:30 p.m.
Grand Ballroom 12-14

Difficult patient interactions are a major contributing factor behind hospitalist burnout, but clinicians should know there are options.

Faye Reiff-Pasarew, MD, director of the humanism in medicine program at Mount Sinai Hospital in New York, and a presenter at the Tuesday education session “Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout,” says a broader perspective can help.

“We don’t spend a lot of time talking about what we can do in the moment to deal with these situations,” she said. “We need to help clinicians maintain their ability to continue to practice and provide excellent care.”

Dr. Reiff-Pasarew and her colleague Joshua Allen-Dicker, MD, MPH, FHM, of Beth Israel Deaconess Medical Center in Boston, will explain how the intersection of humanities and medicine can help make treating challenging patients more manageable.

“The practice of medicine is enriched by having a broader perspective on what can be useful and drawing on the wisdom of other disciplines,” Dr. Reiff-Pasarew explained. “The biomedical model can be very narrow and does not always take into account the larger aspects of people’s humanity.”

Session leaders say attendees will learn tactics that they will be able to take with them and immediately implement in their own practice.

“Medical humanities is an interdisciplinary approach drawing from the arts and social sciences to broaden our understanding of health and illness outside of the purely biomedical model,” Dr. Reiff-Pasarew said. “We are going to use different examples, from narrative medicine or graphic medicine, to show clinicians how to be more emotionally connected and give them tools to develop empathy for their patient’s perspective, even when it may manifest in very challenging ways.”

The session will begin by outlining the issues of burnout in medicine, followed by strategies for clinicians to better handle patients during an interaction. The instructors will also explain how hospitalists can better manage their – and their patients’ –emotions that may arise during a patient encounter. Attendees will learn how they can keep their emotions in check and not be overly reactive, said Dr. Reiff-Pasarew.

Finally, hospitalists will learn how best to deal with any frustrations following a session with a difficult patient.

“There can be a lot of residual stress as a result of these experiences, and many do not have a great outlet,” said Dr. Reiff-Pasarew. “We are going to do some group brainstorming about coping mechanisms, focusing particularly on creative expression.”

Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout
Tuesday, 11 a.m.-12:30 p.m.
Grand Ballroom 4-6

Difficult patient interactions are a major contributing factor behind hospitalist burnout, but clinicians should know there are options.

Faye Reiff-Pasarew, MD, director of the humanism in medicine program at Mount Sinai Hospital in New York, and a presenter at the Tuesday education session “Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout,” says a broader perspective can help.

“We don’t spend a lot of time talking about what we can do in the moment to deal with these situations,” she said. “We need to help clinicians maintain their ability to continue to practice and provide excellent care.”

Dr. Reiff-Pasarew and her colleague Joshua Allen-Dicker, MD, MPH, FHM, of Beth Israel Deaconess Medical Center in Boston, will explain how the intersection of humanities and medicine can help make treating challenging patients more manageable.

“The practice of medicine is enriched by having a broader perspective on what can be useful and drawing on the wisdom of other disciplines,” Dr. Reiff-Pasarew explained. “The biomedical model can be very narrow and does not always take into account the larger aspects of people’s humanity.”

Session leaders say attendees will learn tactics that they will be able to take with them and immediately implement in their own practice.

“Medical humanities is an interdisciplinary approach drawing from the arts and social sciences to broaden our understanding of health and illness outside of the purely biomedical model,” Dr. Reiff-Pasarew said. “We are going to use different examples, from narrative medicine or graphic medicine, to show clinicians how to be more emotionally connected and give them tools to develop empathy for their patient’s perspective, even when it may manifest in very challenging ways.”

The session will begin by outlining the issues of burnout in medicine, followed by strategies for clinicians to better handle patients during an interaction. The instructors will also explain how hospitalists can better manage their – and their patients’ –emotions that may arise during a patient encounter. Attendees will learn how they can keep their emotions in check and not be overly reactive, said Dr. Reiff-Pasarew.

Finally, hospitalists will learn how best to deal with any frustrations following a session with a difficult patient.

“There can be a lot of residual stress as a result of these experiences, and many do not have a great outlet,” said Dr. Reiff-Pasarew. “We are going to do some group brainstorming about coping mechanisms, focusing particularly on creative expression.”

Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout
Tuesday, 11 a.m.-12:30 p.m.
Grand Ballroom 4-6

Difficult patient interactions are a major contributing factor behind hospitalist burnout, but clinicians should know there are options.

Faye Reiff-Pasarew, MD, director of the humanism in medicine program at Mount Sinai Hospital in New York, and a presenter at the Tuesday education session “Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout,” says a broader perspective can help.

“We don’t spend a lot of time talking about what we can do in the moment to deal with these situations,” she said. “We need to help clinicians maintain their ability to continue to practice and provide excellent care.”

Dr. Reiff-Pasarew and her colleague Joshua Allen-Dicker, MD, MPH, FHM, of Beth Israel Deaconess Medical Center in Boston, will explain how the intersection of humanities and medicine can help make treating challenging patients more manageable.

“The practice of medicine is enriched by having a broader perspective on what can be useful and drawing on the wisdom of other disciplines,” Dr. Reiff-Pasarew explained. “The biomedical model can be very narrow and does not always take into account the larger aspects of people’s humanity.”

Session leaders say attendees will learn tactics that they will be able to take with them and immediately implement in their own practice.

“Medical humanities is an interdisciplinary approach drawing from the arts and social sciences to broaden our understanding of health and illness outside of the purely biomedical model,” Dr. Reiff-Pasarew said. “We are going to use different examples, from narrative medicine or graphic medicine, to show clinicians how to be more emotionally connected and give them tools to develop empathy for their patient’s perspective, even when it may manifest in very challenging ways.”

The session will begin by outlining the issues of burnout in medicine, followed by strategies for clinicians to better handle patients during an interaction. The instructors will also explain how hospitalists can better manage their – and their patients’ –emotions that may arise during a patient encounter. Attendees will learn how they can keep their emotions in check and not be overly reactive, said Dr. Reiff-Pasarew.

Finally, hospitalists will learn how best to deal with any frustrations following a session with a difficult patient.

“There can be a lot of residual stress as a result of these experiences, and many do not have a great outlet,” said Dr. Reiff-Pasarew. “We are going to do some group brainstorming about coping mechanisms, focusing particularly on creative expression.”

Challenging Patients, Challenging Stories: A Medical Humanities Approach to Provider Burnout
Tuesday, 11 a.m.-12:30 p.m.
Grand Ballroom 4-6

12:30 - 1:30 p.m., Product Theater 1
Expert Conversations in Heart Failure: Connecting the Pieces
Thomas Arne, Jr., DO
Sergey Kachur, MD​Sponsored by Novartis Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 2 Opioid-Induced Constipation
Jeff Gudin, MD
Director, Pain and Palliative Care
Englewood Hospital and Medical Center
Englewood, NJ
Sponsored by Salix Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 3
Challenges of Treating DVT and PE in the Hospital and After Discharge ​
Dr. Andrew Miller, Emergency Medicine, Lehigh Valley Hospital, Allentown, PA​
Sponsored by Pfizer

12:30 - 1:30 p.m., Product Theater 1
Expert Conversations in Heart Failure: Connecting the Pieces
Thomas Arne, Jr., DO
Sergey Kachur, MD​Sponsored by Novartis Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 2 Opioid-Induced Constipation
Jeff Gudin, MD
Director, Pain and Palliative Care
Englewood Hospital and Medical Center
Englewood, NJ
Sponsored by Salix Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 3
Challenges of Treating DVT and PE in the Hospital and After Discharge ​
Dr. Andrew Miller, Emergency Medicine, Lehigh Valley Hospital, Allentown, PA​
Sponsored by Pfizer

12:30 - 1:30 p.m., Product Theater 1
Expert Conversations in Heart Failure: Connecting the Pieces
Thomas Arne, Jr., DO
Sergey Kachur, MD​Sponsored by Novartis Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 2 Opioid-Induced Constipation
Jeff Gudin, MD
Director, Pain and Palliative Care
Englewood Hospital and Medical Center
Englewood, NJ
Sponsored by Salix Pharmaceuticals

12:30 - 1:30 p.m., Product Theater 3
Challenges of Treating DVT and PE in the Hospital and After Discharge ​
Dr. Andrew Miller, Emergency Medicine, Lehigh Valley Hospital, Allentown, PA​
Sponsored by Pfizer

Here are 4 articles in the April issue of Journal of Clinical Outcomes Management. 

1. Young Adult HIV Patients May Be At Increased Risk of Hypertension

2. Written Exposure Therapy Rivals Cognitive Processing Therapy For PTSD

3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors

4. Who Fares Best After Successful ECT?

Here are 4 articles in the April issue of Journal of Clinical Outcomes Management. 

1. Young Adult HIV Patients May Be At Increased Risk of Hypertension

2. Written Exposure Therapy Rivals Cognitive Processing Therapy For PTSD

3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors

4. Who Fares Best After Successful ECT?

Here are 4 articles in the April issue of Journal of Clinical Outcomes Management. 

1. Young Adult HIV Patients May Be At Increased Risk of Hypertension

2. Written Exposure Therapy Rivals Cognitive Processing Therapy For PTSD

3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors

4. Who Fares Best After Successful ECT?

If there’s one thing hospital medicine is not, it’s static. And that’s truer today than it’s ever been in the more than 20 years since the field came into existence: As the role of hospitalists continue to expand, it’s now in the setting of a rapidly changing health care scene.

So when Society of Hospital Medicine CEO Larry Wellikson, MD, MHM, takes the annual conference podium this morning for his talk on “Future Challenges for Hospital Medicine,” he’ll have a lot to cover.

His overall message, though, will boil down to this: Learn the skills you’ll need.

With hospitalists managing acute and palliative care and being involved in surgical comanagement, many may need additional training.

“There’s a blurring of our role as we link to the emergency department or critical care units, or even a blurring of where does inpatient care end and outpatient care begin?” he said. “Many of these roles hospitalists haven’t been completely trained for.” He’ll also remind the audience that one of SHM’s main roles is to help provide that training.

He said the urgency of learning new skills is only intensified by the health care field’s transition from volume-based payment to value-based payment and by consolidation of previously separate pieces of the landscape, such as the acquisition of Aetna by CVS, with its nearly 10,000 pharmacy locations and more than 1,000 MinuteClinics.

“The real cost for them is hospitalization,” Dr. Wellikson said. “Any money they spend on hospitalization is money they don’t have left over. That puts pressure on hospitalists.”

Future Challenges for Hospital Medicine
Tuesday, 9:35-10:00 a.m.
Palms Ballroom

If there’s one thing hospital medicine is not, it’s static. And that’s truer today than it’s ever been in the more than 20 years since the field came into existence: As the role of hospitalists continue to expand, it’s now in the setting of a rapidly changing health care scene.

So when Society of Hospital Medicine CEO Larry Wellikson, MD, MHM, takes the annual conference podium this morning for his talk on “Future Challenges for Hospital Medicine,” he’ll have a lot to cover.

His overall message, though, will boil down to this: Learn the skills you’ll need.

With hospitalists managing acute and palliative care and being involved in surgical comanagement, many may need additional training.

“There’s a blurring of our role as we link to the emergency department or critical care units, or even a blurring of where does inpatient care end and outpatient care begin?” he said. “Many of these roles hospitalists haven’t been completely trained for.” He’ll also remind the audience that one of SHM’s main roles is to help provide that training.

He said the urgency of learning new skills is only intensified by the health care field’s transition from volume-based payment to value-based payment and by consolidation of previously separate pieces of the landscape, such as the acquisition of Aetna by CVS, with its nearly 10,000 pharmacy locations and more than 1,000 MinuteClinics.

“The real cost for them is hospitalization,” Dr. Wellikson said. “Any money they spend on hospitalization is money they don’t have left over. That puts pressure on hospitalists.”

Future Challenges for Hospital Medicine
Tuesday, 9:35-10:00 a.m.
Palms Ballroom

If there’s one thing hospital medicine is not, it’s static. And that’s truer today than it’s ever been in the more than 20 years since the field came into existence: As the role of hospitalists continue to expand, it’s now in the setting of a rapidly changing health care scene.

So when Society of Hospital Medicine CEO Larry Wellikson, MD, MHM, takes the annual conference podium this morning for his talk on “Future Challenges for Hospital Medicine,” he’ll have a lot to cover.

His overall message, though, will boil down to this: Learn the skills you’ll need.

With hospitalists managing acute and palliative care and being involved in surgical comanagement, many may need additional training.

“There’s a blurring of our role as we link to the emergency department or critical care units, or even a blurring of where does inpatient care end and outpatient care begin?” he said. “Many of these roles hospitalists haven’t been completely trained for.” He’ll also remind the audience that one of SHM’s main roles is to help provide that training.

He said the urgency of learning new skills is only intensified by the health care field’s transition from volume-based payment to value-based payment and by consolidation of previously separate pieces of the landscape, such as the acquisition of Aetna by CVS, with its nearly 10,000 pharmacy locations and more than 1,000 MinuteClinics.

“The real cost for them is hospitalization,” Dr. Wellikson said. “Any money they spend on hospitalization is money they don’t have left over. That puts pressure on hospitalists.”

Future Challenges for Hospital Medicine
Tuesday, 9:35-10:00 a.m.
Palms Ballroom

Creating an atmosphere conducive to productive teamwork can help maximize nurse practitioners’ and physician assistants’ potential, say experts presenting at the Tuesday session “How Best NP/PA and MD Hospitalists Can Work Together.”

Session leaders Brian Wolfe, MD, FHM, a general internist at the University of Michigan, Ann Arbor, and Tracy Cardin, ACNP-BC,SFHM, the associate director of clinical integration at Adfinitas Health, Hanover, Md., will break down strategies to help incorporate different perspectives into your practice to improve its culture.

“I think culture beats strategy any day of the week, and the cultural threads we can draw from our different experiences are a lot more powerful, and a lot more translatable, across different institutions,” Dr. Wolfe said in an interview. “The purpose of this session is to get away from saying ‘Well, this is the way we do it,’ and instead say, ‘This is what kind of cultural vision we have for our NPs and PAs, and this is where we succeed, and these are the ways we fail.’ ”

Attendees will learn about what PAs and NPs are looking for in their work, what some providers are doing to change their hospital culture, and the business data behind those decisions.

“NPs and PAs are looking for autonomy, mastery, and purpose,” said Dr. Wolfe. “While some of that comes from where you work and how long your hours are, a lot of it has to do with how the culture treats you as a nurse practitioner or physician assistant and where your place is.”

Following Dr. Wolfe’s initial presentation, the facilitators will analyze cases with evident structural problems in order to uncover the underlying cultural issues.

By hearing about concrete, everyday examples, attendees will be able to recognize some of the problems within their own networks that they might deal with on a regular basis and come away with long-term solutions.

How Best NP/PA and MD Hospitalists Can Work Together:
Incorporating NPs/PAs into the workforce and Workplace Culture
Tuesday, 4:30-6 p.m.
Grand Ballroom 1-3

Creating an atmosphere conducive to productive teamwork can help maximize nurse practitioners’ and physician assistants’ potential, say experts presenting at the Tuesday session “How Best NP/PA and MD Hospitalists Can Work Together.”

Session leaders Brian Wolfe, MD, FHM, a general internist at the University of Michigan, Ann Arbor, and Tracy Cardin, ACNP-BC,SFHM, the associate director of clinical integration at Adfinitas Health, Hanover, Md., will break down strategies to help incorporate different perspectives into your practice to improve its culture.

“I think culture beats strategy any day of the week, and the cultural threads we can draw from our different experiences are a lot more powerful, and a lot more translatable, across different institutions,” Dr. Wolfe said in an interview. “The purpose of this session is to get away from saying ‘Well, this is the way we do it,’ and instead say, ‘This is what kind of cultural vision we have for our NPs and PAs, and this is where we succeed, and these are the ways we fail.’ ”

Attendees will learn about what PAs and NPs are looking for in their work, what some providers are doing to change their hospital culture, and the business data behind those decisions.

“NPs and PAs are looking for autonomy, mastery, and purpose,” said Dr. Wolfe. “While some of that comes from where you work and how long your hours are, a lot of it has to do with how the culture treats you as a nurse practitioner or physician assistant and where your place is.”

Following Dr. Wolfe’s initial presentation, the facilitators will analyze cases with evident structural problems in order to uncover the underlying cultural issues.

By hearing about concrete, everyday examples, attendees will be able to recognize some of the problems within their own networks that they might deal with on a regular basis and come away with long-term solutions.

How Best NP/PA and MD Hospitalists Can Work Together:
Incorporating NPs/PAs into the workforce and Workplace Culture
Tuesday, 4:30-6 p.m.
Grand Ballroom 1-3

Creating an atmosphere conducive to productive teamwork can help maximize nurse practitioners’ and physician assistants’ potential, say experts presenting at the Tuesday session “How Best NP/PA and MD Hospitalists Can Work Together.”

Session leaders Brian Wolfe, MD, FHM, a general internist at the University of Michigan, Ann Arbor, and Tracy Cardin, ACNP-BC,SFHM, the associate director of clinical integration at Adfinitas Health, Hanover, Md., will break down strategies to help incorporate different perspectives into your practice to improve its culture.

“I think culture beats strategy any day of the week, and the cultural threads we can draw from our different experiences are a lot more powerful, and a lot more translatable, across different institutions,” Dr. Wolfe said in an interview. “The purpose of this session is to get away from saying ‘Well, this is the way we do it,’ and instead say, ‘This is what kind of cultural vision we have for our NPs and PAs, and this is where we succeed, and these are the ways we fail.’ ”

Attendees will learn about what PAs and NPs are looking for in their work, what some providers are doing to change their hospital culture, and the business data behind those decisions.

“NPs and PAs are looking for autonomy, mastery, and purpose,” said Dr. Wolfe. “While some of that comes from where you work and how long your hours are, a lot of it has to do with how the culture treats you as a nurse practitioner or physician assistant and where your place is.”

Following Dr. Wolfe’s initial presentation, the facilitators will analyze cases with evident structural problems in order to uncover the underlying cultural issues.

By hearing about concrete, everyday examples, attendees will be able to recognize some of the problems within their own networks that they might deal with on a regular basis and come away with long-term solutions.

How Best NP/PA and MD Hospitalists Can Work Together:
Incorporating NPs/PAs into the workforce and Workplace Culture
Tuesday, 4:30-6 p.m.
Grand Ballroom 1-3

Barbara Slawski, MD, MS, SFHM, and Cynthia Cooper, MD, hadn’t met in person until early 2018. But that doesn’t mean they haven’t spent a lot of time together.

Once a month, the two hospitalists checked in with one another through wide-ranging phone calls. Together, they have combed the medical literature and conferred over the past year, making long lists of candidate studies for the “Top 20” journal articles of the year for practicing hospitalists.

The two physicians will comoderate Tuesday’s “Update in Hospital Medicine” session, where they will summarize research findings of these “Top 20” articles. Their hope is to present research that each attendee can bring home to improve patient outcomes on a daily basis, while making for a smoother and more efficient practice.

Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee, said the presentations will not simply summarize study results but also will help attendees focus on the key findings – the clinical pearls – that represent real opportunities to update practice.

Since hospital medicine crosses so many disciplines, each physician said, in separate interviews, that doing justice to the literature has been time consuming and intellectually challenging – but worthwhile.

Dr. Cooper, a hospitalist at Massachusetts General Hospital, Boston, said that, although she and Dr. Slawski practice in geographically diverse areas, their practice settings – academic medical centers – have many similarities. She said that, as she reviewed the medical literature over the past year, she gave considerable thought to the particular challenges and demands of hospitalists who practice in community hospitals and rural settings, where the level of support and access to subspecialty consults might be very different from the academic milieu.

“We hope that our unique approaches lend more breadth to the session,” said Dr. Slawski. “We want to make sure we have a good representation of SHM’s constituency, and that we present high-impact studies.”

To hit the mark of articles that are relevant for all, Dr. Cooper said she wants to make sure to focus on the practicalities of hospital-based practice – possible topics include prediction scores, hepatic encephalopathy, and the management of sepsis.

Neither Dr. Slawski nor Dr. Cooper reported any relevant conflicts of interest.

Update in Hospital Medicine
Tuesday, 1:40-2:40 p.m.
Palms Ballroom

Barbara Slawski, MD, MS, SFHM, and Cynthia Cooper, MD, hadn’t met in person until early 2018. But that doesn’t mean they haven’t spent a lot of time together.

Once a month, the two hospitalists checked in with one another through wide-ranging phone calls. Together, they have combed the medical literature and conferred over the past year, making long lists of candidate studies for the “Top 20” journal articles of the year for practicing hospitalists.

The two physicians will comoderate Tuesday’s “Update in Hospital Medicine” session, where they will summarize research findings of these “Top 20” articles. Their hope is to present research that each attendee can bring home to improve patient outcomes on a daily basis, while making for a smoother and more efficient practice.

Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee, said the presentations will not simply summarize study results but also will help attendees focus on the key findings – the clinical pearls – that represent real opportunities to update practice.

Since hospital medicine crosses so many disciplines, each physician said, in separate interviews, that doing justice to the literature has been time consuming and intellectually challenging – but worthwhile.

Dr. Cooper, a hospitalist at Massachusetts General Hospital, Boston, said that, although she and Dr. Slawski practice in geographically diverse areas, their practice settings – academic medical centers – have many similarities. She said that, as she reviewed the medical literature over the past year, she gave considerable thought to the particular challenges and demands of hospitalists who practice in community hospitals and rural settings, where the level of support and access to subspecialty consults might be very different from the academic milieu.

“We hope that our unique approaches lend more breadth to the session,” said Dr. Slawski. “We want to make sure we have a good representation of SHM’s constituency, and that we present high-impact studies.”

To hit the mark of articles that are relevant for all, Dr. Cooper said she wants to make sure to focus on the practicalities of hospital-based practice – possible topics include prediction scores, hepatic encephalopathy, and the management of sepsis.

Neither Dr. Slawski nor Dr. Cooper reported any relevant conflicts of interest.

Update in Hospital Medicine
Tuesday, 1:40-2:40 p.m.
Palms Ballroom

Barbara Slawski, MD, MS, SFHM, and Cynthia Cooper, MD, hadn’t met in person until early 2018. But that doesn’t mean they haven’t spent a lot of time together.

Once a month, the two hospitalists checked in with one another through wide-ranging phone calls. Together, they have combed the medical literature and conferred over the past year, making long lists of candidate studies for the “Top 20” journal articles of the year for practicing hospitalists.

The two physicians will comoderate Tuesday’s “Update in Hospital Medicine” session, where they will summarize research findings of these “Top 20” articles. Their hope is to present research that each attendee can bring home to improve patient outcomes on a daily basis, while making for a smoother and more efficient practice.

Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee, said the presentations will not simply summarize study results but also will help attendees focus on the key findings – the clinical pearls – that represent real opportunities to update practice.

Since hospital medicine crosses so many disciplines, each physician said, in separate interviews, that doing justice to the literature has been time consuming and intellectually challenging – but worthwhile.

Dr. Cooper, a hospitalist at Massachusetts General Hospital, Boston, said that, although she and Dr. Slawski practice in geographically diverse areas, their practice settings – academic medical centers – have many similarities. She said that, as she reviewed the medical literature over the past year, she gave considerable thought to the particular challenges and demands of hospitalists who practice in community hospitals and rural settings, where the level of support and access to subspecialty consults might be very different from the academic milieu.

“We hope that our unique approaches lend more breadth to the session,” said Dr. Slawski. “We want to make sure we have a good representation of SHM’s constituency, and that we present high-impact studies.”

To hit the mark of articles that are relevant for all, Dr. Cooper said she wants to make sure to focus on the practicalities of hospital-based practice – possible topics include prediction scores, hepatic encephalopathy, and the management of sepsis.

Neither Dr. Slawski nor Dr. Cooper reported any relevant conflicts of interest.

Update in Hospital Medicine
Tuesday, 1:40-2:40 p.m.
Palms Ballroom