The purpose of this article was to highlight some of the new educational and clinical tools that have been developed in an effort to better inform both physicians and the public about bone quality and fracture risk. Specifically, we explored (1) new tools (ie, fracture-risk calculators) that can identify individuals at high risk for fracture; (2) clinical performance measures being used to move the fracture-prevention agenda forward; (3) strategies that are being used to ensure that patients at high risk for fractures are identified; and (4) authoritative, easy-to-access Web sites for learning about bone quality. Tremendous strides have been made, yet each effort has its unique limitations.
The authors acknowledge limitations to this review. First, the paper focuses on only two tools, FRAX® and FRC, as measures for identifying fracture risk. Although each of these tools offers an extraordinary step forward in making it possible to estimate individual fracture risk, they do have shortcomings. Most important, neither tool includes input for the tendency to fall (although this limitation is partially compensated for by adjusting fracture risk for age). Additionally, FRAX®/FRC do not allow for inclusion of spinal BMD. Third, they do not include all known fracture risk factors because many of these factors were not included in the databases on which the tools are based. FRAX®/FRC can only be used in untreated patients. FRAX®/FRC can be used only by physicians who have access to the Internet. Finally, fracture risk varies significantly by country, and only a limited number of country models are available.
A second overall limitation of the present study is that it is restricted to quality measures developed in the United States and focuses on a quality improvement effort developed by a single orthopaedic organization. Fractures are a worldwide concern, and a more exhaustive review would include quality initiatives from across the globe. Third, our review of efforts to identify individuals at risk for fracture was limited because almost all published studies focus on women; little data are available on identifying men at risk. There are likewise little data available on fracture risk in African Americans, Hispanics, and American Indians. Finally, our list of educational websites is far from comprehensive. Faced with an abundance of sites and limited space, we purposefully limited our list to sites in the English language and those maintained by nonprofit sources.
Cost-effectiveness analyses and treatment guidelines based on US fracture rates and costs have recently been published [13
]. These analyses suggest pharmacotherapy should be initiated when the 10-year risk of hip fracture is 3% or more or the 10-year risk for any of four fractures (hip, wrist, humerus, and lyspine) is greater than 20%. However, although FRAX®/FRC identify patients at high risk for fracture, they do not predict whether treatment will safely reduce the fracture rate. Reducing fracture rates depends on other factors such as underlying disease states, allergies, and drug-drug interactions. Moreover, FRAX® is based on fracture rates in untreated individuals and does not account for the effects of osteoporosis treatment. For this reason, it cannot be used in patients who have already received osteoporosis therapy.
Perhaps the greatest challenge will be to get healthcare professionals to incorporate FRAX® and/or FRC into their practices. Cranney et al. have demonstrated physicians currently rely heavily on bone density reports to guide therapeutic decision-making and do not factor in other risk elements [11
A growing body of evidence suggests performance measures can help educate physicians and motivate them to follow guidelines. Perhaps the most famous program is Get With the Guidelines [36
], an effort initiated by the American Heart Association to increase the use of beta blockers after a heart attack. This program has been so successful that, as described by Lee in “Eulogy for a Quality Measure,” “prescription of a beta-blocker following myocardial infarction” has been retired. Compliance is so high that the measure can no longer be used to distinguish programs [38
]. The challenge for proponents of bone quality performance improvement efforts such as Own the Bone is to match this extraordinary success story.
Although there is still ample room for improvement, rates of screening for low bone quality are rising slowly [9
]. There is, moreover, indirect evidence that screening and treatment efforts are making a difference. In the United States [6
] and Canada [39
], hip fracture rates and subsequent mortality among persons 65 years and older are declining, especially among women older than 85 years, despite the fact that comorbidities among patients with fractures have increased. Although the decrease in incidence corresponds temporally with the market release of several bisphosphonates, this pharmacotherapy alone does not fully explain the decline in the fracture rate. Brauer et al. [6
] suggest the decline in fracture rate may also be attributable to a greater focus on healthy lifestyles.
Although recent research has reflected a new willingness on the part of the orthopaedic community to assume the challenge of improving efforts to prevent subsequent fractures [49
], the data suggest this is not really the case. Haaland et al. have noted that in patients with hip fractures, the greatest predictor of diagnosis and treatment for osteoporosis in a previously undiagnosed individual was transfer to a rehabilitation or geriatrics unit [28
]. As noted earlier, data from NCQA continue to document low levels of compliance with their quality measures in managed care environments. Patients at risk for subsequent fractures are the population OTB hopes most to impact.
A frequent explanation for low rates of screening in the general population, particularly by primary care physicians, is that there are so many other life-threatening problems needing attention (eg, hypertension, diabetes) that osteoporosis screening is a low priority [5
]. Unfortunately, a recent article by Nayak et al. demonstrated those patients with the most risk factors for fracture are also the most likely not to receive diagnostic tests and treatment. In addition, men with osteoporosis appear to be identified and treated even less often than women [44
As clearly demonstrated by the Web sites delineated in the Results section and tables, numerous foundations, organizations, and advocacy groups have launched major efforts to enhance the knowledge of physicians and the public about bone quality via Web sites. Unfortunately, research data clearly show that adherence to osteoporosis therapy, once the decision to treat is made, is very poor. Explanations for this behavior are wide-ranging. The decision to start an osteoporosis treatment in the first place appears to be correlated with the patient’s confidence in the effectiveness of the osteoporosis therapies and their general mistrust of medications altogether [59
]. The decision whether to continue taking an osteoporosis medication includes fear of possible side effects and dosing requirements [56
]. Unfortunately, there are no proven strategies for improving adherence. However, there is a growing consensus that simply referring patients to Web sites or downloading relevant handouts will not do the job. As noted earlier in the discussion of work by Gardner et al., nurse-patient (and physician-patient) interaction and discussion are a critical component of the education effort [24
These are exciting times in medicine. Personalized medicine and point-of-care technologies hold hope that each individual’s evaluation and treatment will be evidence-based and specific to his or her needs. In the field of bone health, with the advent of tools such as FRAX® and FRC, we now have effective tools with which to gauge an individual’s risk of fracture. Equally promising, we now have extensive Web-based tools for educating both patients and clinicians. Realizing the full benefits of these advances, however, will not be easy. It will require surmounting extraordinary hurdles that go far beyond the scope of this article. For example, will insurers support osteoporosis screening, care coordination, and therapy? How can we overcome the considerable level of denial among the baby boomers, now rapidly becoming our senior population, who do not want to admit that they might be susceptible to a “little old lady disease”? How, too, do we increase their sense of personal responsibility to maximize and maintain their bone health with simple strategies such as exercise as well as adequate calcium and vitamin D? How do we ensure that those patients who do fracture, and thus demonstrate that they at substantial risk for future fracture, receive optimum evaluation and care? Will Own the Bone or other performance-improvement efforts succeed in achieving the bone quality and reduction in fracture rates patients deserve? The Web sites and strategies discussed in this article are an important first step, but much work remains to be done.