Evaluation of the Osteoporosis Secondary Fracture Prevention Program at Queen Mary Hospital: successful recruitment is associated with lower re-fracture and mortality rates at one and five years

Abstract

Introduction: Osteoporosis is a silent metabolic bone disease and it only manifests itself with the complication of fracture. Antiosteoporosis medications reduce fractures with prolonged treatment. With rapid aging of the population, the number of fractures and its cost of treatment will be expected to increase exponentially. A structured triage protocol is necessary to identify patients who will benefit most from osteoporosis drug treatment. Objectives: To develop a triage protocol for an osteoporosis secondary fracture prevention program. Methodology: Patients admitted to Queen Mary Hospital with fractures underwent a multidisciplinary, structured triage protocol to identify patients for evaluation and treatment. The triage was done by a registered nurse in-charged of the program. Recruited subjects underwent investigation were offered education and medical consultation, lifestyle modification and drug treatment for osteoporosis. The outcome of the program was assessed at one year by the following criteria: (1) recruitment rate; (2) drug treatment rate; (3) re-fracture rate, and (4) mortality rate. Results: 2,169 fracture patients admitted to Queen Mary Hospital between 1999 and 2009 were assessed. 1,844 (85.0%) patients were recruited and 325 (15.0%) patients were excluded from the program. Among those recruited into the program, 1355 (73.5%) patients underwent investigations: 169 (12.5%) patients were diagnosed with secondary osteoporosis; 967 (71.4%) patients were diagnosed primary osteoporosis initiated anti-osteoporosis medications. 489 (26.5%) patients recruited into the program but refused further investigations and medications. 246 (11.3%) patients were excluded from the program due to poor quality of life (bed/chair-bound, inability to swallow), and 79 (3.7%) were excluded due to unstable medical conditions within 3 months post-fracture. Patient recruited into the program and put on anti-osteoporosis medication had lower mortality rate and re-fracture rates at one and five years (mortality rates: 2.7% at 1-year and 8.5% at 5-years; and re-fracture rates: 2.1% at 1-year and 9.1% at 5-years) compared with patient recruited into the program but refused further investigation and/ or medication (mortality rates: 6.6% at 1-year and 22.3% at 5-years, and re-fracture rate: 2.3% at 1-year and 12.9% at 5-years). Patients being excluded from the program due to (1) poor quality of life had 3.8% mortality rate at 1-year and 41.7% at 5-years, and 2.6% re-fracture rate at 1-year and 24.4% at 5-years; (2) unstable medical condition within three months post-fracture had a 2.6% mortality rate at 1-year and 42.6% at 5-years, and 2.5% re-fracture rate at 1-year, and 18.9% at 5-years. Conclusion: The triage protocol for secondary fracture prevention was successful in identifying subjects with good quality of life and more likely to benefit from treatment. The program was associated with a reduction in re-fracture rate and mortality rate at 1- and 5-years. There was a higher incident of mortality and re-fracture rates for patients excluded from the program. Further investigations are necessary to explore the relationship. Unfortunately, despite active recruitment, elderly patients with osteoporotic fractures had low acceptance of this program. Education and promotion of the secondary fracture prevention program is urgently needed.