Why is it important for health systems to recognize fractures as a sentinel event, e.g., manage osteoporosis as a chronic condition?

From the Guidelines

Recognizing fractures as sentinel events and managing osteoporosis as a chronic condition is crucial for health systems because it enables early intervention that prevents future fractures and reduces mortality. When a patient experiences a fragility fracture, it signals underlying bone weakness that, if left untreated, leads to a cascade of additional fractures with each subsequent fracture increasing mortality risk 1. Health systems should implement fracture liaison services that identify fracture patients, assess bone health through DEXA scans and laboratory testing, and initiate appropriate treatments.

Key Considerations

• A fragility fracture in an adult is an important predictor of future fractures and requires further evaluation and treatment of the underlying osteoporosis 1.
• Most fragility fractures occur in patients with bone mineral density T scores higher than 2.5, and these fractures confirm the presence of skeletal fragility even in the presence of a well-maintained bone mineral density 1.
• First-line medications include oral bisphosphonates like alendronate (70mg weekly) or risedronate (35mg weekly), while those at higher risk may require anabolic agents such as teriparatide (20mcg daily subcutaneous injection) or romosozumab (210mg monthly subcutaneous injection for 12 months) 1.
• All patients should receive calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplementation.

Benefits of Early Intervention

• This comprehensive approach reduces subsequent fracture risk by 30-70%, decreases hospitalizations, lowers healthcare costs, and improves quality of life 1.
• Unfortunately, without systematic approaches, over 80% of fracture patients currently receive no osteoporosis evaluation or treatment, representing a significant care gap that health systems must address 1.

Implementation

• Health systems should prioritize the implementation of fracture liaison services to identify and manage patients with fragility fractures, as recommended by the international working group on DEXA best practices 1.
• Dedicated vertebral imaging and review of past imaging is useful in identifying fractures in patients at high risk for vertebral fractures 1.

From the FDA Drug Label

The fracture efficacy of risedronate sodium immediate-release 5 mg daily in the treatment of postmenopausal osteoporosis was demonstrated in 2 large, randomized, placebo-controlled, double-blind studies that enrolled a total of almost 4000 postmenopausal women under similar protocols Risedronate sodium immediate-release 5 mg daily significantly reduced the incidence of new and worsening vertebral fractures and of new vertebral fractures in both VERT NA and VERT MN at all time points Effect on Nonvertebral Fractures Treatment with Prolia resulted in a significant reduction in the incidence of nonvertebral fractures

It is important for health systems to recognize fractures as a sentinel event because they can be a sign of underlying osteoporosis, a chronic condition that requires management to prevent further fractures. The data from the studies of risedronate sodium immediate-release 5 mg daily 2 and denosumab (Prolia) 3 demonstrate that treatment can significantly reduce the incidence of vertebral and nonvertebral fractures, highlighting the importance of managing osteoporosis to prevent fractures. Key points include:

• Fracture risk reduction: Both risedronate sodium immediate-release 5 mg daily and denosumab (Prolia) have been shown to reduce the risk of fractures.
• Osteoporosis management: Managing osteoporosis as a chronic condition can help prevent further fractures and improve patient outcomes.
• Importance of recognition: Recognizing fractures as a sentinel event can help healthcare systems identify patients with osteoporosis and provide appropriate treatment to prevent further fractures.

From the Research

Importance of Recognizing Fractures as a Sentinel Event

• Fragility fractures caused by osteoporosis place a significant burden on affected individuals and impose substantial economic costs 4
• A fragility fracture implies an imminent elevated risk for subsequent fractures, particularly in the short term, highlighting the need for early intervention and management of osteoporosis as a chronic condition 4, 5
• Recognizing and reporting vertebral fractures is crucial in reducing the risk of future osteoporotic fractures, as prevalent vertebral fractures have important clinical implications in terms of future fracture risk 6

Management of Osteoporosis as a Chronic Condition

• Comprehensive post-fracture care is essential in preventing subsequent fractures, and should include early mobilization, fall risk assessment, and initiation of adequate bone-specific medication 4
• Coordinated care models, such as the fracture liaison service (FLS), have shown enhancements in the initiation of and adherence to secondary prevention of fragility fractures 4
• Bisphosphonates have been shown to prevent spine, nonspine, and hip fractures, and their use may reduce post-fracture mortality among patients with osteoporosis, particularly those with hip/vertebral fractures 7, 8

Risk of Future Fractures

• Upper extremity fragility fractures are strong predictors of subsequent fractures, and should be considered a sentinel event 5
• The 10-year probability of major osteoporotic and hip fractures is significantly higher among patients with a history of fragility fracture, highlighting the need for early intervention and management of osteoporosis 5
• The risk of future fractures can be estimated using tools such as the fracture risk assessment tool (FRAX) and prefracture fracture risk (PFFR) score, which can help identify high-risk patients and inform treatment decisions 5