Background/Purpose:

The “osteoporosis care gap” is noted by findings that 80% of patients do not receive treatment after an initial fracture. An initial fracture portends a 60% risk of re-fracture. A Fracture Liaison Service (FLS) is an effective means of addressing secondary fracture prevention. The type of health system model potentially impacts FLS outcomes. A closed model like Kaiser Permanente’s Healthy Bones Program, led by Orthopedic Surgery, resulted in a 40% reduction in hip fractures. Geisinger Health System’s FLS led by Rheumatology, an open-model, has noted 75% treatment rates versus 13.8% for those seen by primary care doctors alone.

Loma Linda University Medical Center (LLUMC) launched a multidisciplinary FLS in 2017. Pre-LLUMC FLS studies (2015-2016) showed that 85% of patients pre-fracture were never screened nor treated for osteoporosis; post-fracture, only 10% of patients were treated, and only 6% had dual x-ray absorptiometry (DXA). Notably, 30% had a prior fracture. LLUMC is the only tertiary medical center in the Inland Empire of Southern California. It has an open health system, historically known for specialty services. The FLS goal was to achieve a 10% improvement in therapy initiation and DXA completion. This study aims to assess the FLS’s effectiveness during the initial eight-month period.

Methods:

Data extraction from our Epic® electronic health record (EHR) through the LLUHS Patient Safety and Reliability Office was done to determine the number of inpatient FLS referrals and total eligible fractures from September 2017-April 2018. Outpatient transition to in-network osteoporosis specialist, pharmacotherapy initiation, DXA ordering and completion, vitamin D measurement, number of deaths, transition to dependent living facilities, availability of a primary care provider (PCP) in- or out-of-network were among the metrics determined.

Results:

70 patients were referred to the FLS. 81% and 14.4% had femoral and vertebral fractures, respectively. All had Vitamin D level determination. DXA was set up for 61.5% upon discharge. 13 (18.6%) transitioned to an outpatient LLUHS specialist, while 57 (81.4%) did not. Patients lost to follow-up were characterized by the following traits: lived >30 miles from LLUMC, had no regular PCP or had no in-network PCP, patient/family belief regarding lack of benefit to treatment or non-association of fractures with osteoporosis. Mortality was noted in 6 (10%) patients due to sepsis/other infection. 991 fracture encounters excluding other non-osteoporosis-related causes were admitted during the same time period.

Conclusion:

Low recruitment rates in an open-health system FLS require more outreach and coordination with both in and out-of-network primary care providers (PCP) Also increasing PCP, hospital-based provider and patient education regarding the osteoporosis care gap is essential. Since April 2018, an FLS coordinator (nurse practitioner) was hired and community-based education activities for PCPs practicing within 30-60 miles of LLUMC were done. Outcomes in 12 months are to be determined.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/fracture-liaison-service-in-an-open-health-system-outcomes-and-challenges/