For older adults, one break all too frequently leads to another.
Studies have shown that anyone age 50 or older who suffers a fragility fracture - a bone break sustained in a fall from a standing height or less - is two to five times more likely to experience a second fracture than someone who hasn't had one. The odds that a person who's suffered two such fractures will have a third are even higher.
The underlying cause for the vast majority of these non-traumatic fractures is osteoporosis, a progressive disease that decreases the weight and density of bones, making them more brittle. Osteoporosis doesn't have any obvious symptoms so in most cases it isn't noticed until a fracture occurs - and those fractures are anything but rare.
According to the National Osteoporosis Foundation (NOF), approximately half of all women and one-quarter of all men will suffer at least one fragility fracture after age 50. There are more than 2 million fragility fractures in the United States each year - more than the number of heart attack, stroke and breast cancer cases combined - with an estimated direct cost of nearly $20 billion. These breaks can significantly damage an individual's quality of life and contribute to other serious health problems, even death.
Despite all that, roughly 80 percent of all older Americans who sustain fractures are neither tested nor treated for osteoporosis. But things are changing.
"Orthopaedics has traditionally focused on fixing the fracture, but we've realized that is only part of our responsibility as physicians," said Cynthia Emory, M.D., an orthopaedic surgeon at Wake Forest Baptist Medical Center. "Identifying and treating the underlying cause is equally important so we can prevent fractures from occurring and enable our patients to continue doing the activities they enjoy."
Experts agree that fracture liaison services represent a very effective way to do both the identifying and the treating.
A fracture liaison service (FLS) is a multispecialty, preventive-care program designed to foster bone health in older adults, thereby reducing the risk of fragility fractures. Well-established and with proven records of success abroad, notably in the United Kingdom and Canada, FLS programs are catching on in the United States, thanks in part to initiatives by the NOF, National Bone Health Alliance (NBHA), American Orthopaedic Association and other organizations.
Last fall Wake Forest Baptist became one of the first academic medical centers in the country to establish a formal FLS program. That effort was led by Emory; fellow orthopaedic surgeon Anna Miller, M.D.; and certified nurse practitioner Anne Lake, who serves as the program's coordinator.
Wake Forest Baptist's FLS enrolls people 50 and over who have suffered a fracture or who have a medical condition that can adversely affect bone density. The initial visit for each patient includes a thorough review of his or her medical history and a physical examination. Depending on what those reveal, lab tests, X-rays and a bone-density scan may be administered. After all the results are collected and analyzed, the patient receives an individualized plan that may include an exercise program, dietary and lifestyle recommendations, non-prescription supplements and prescription medications, all geared toward increasing bone health and decreasing the risk of future breaks.
Patients are scheduled for follow-up visits as needed, during which their progress is evaluated and their care plan is adjusted, if necessary.
The service provides "full-perspective care coordination," said Lake, whose job as FLS coordinator includes gathering all the information about the patients, developing their therapy plans, guiding the patients through the program and keeping all of their doctors and other caregivers in the loop about their status.
"Orthopaedists and primary-care physicians obviously play major roles," said Lake, who holds a doctor of nursing practice degree. "But we'll also consult endocrinologists, rheumatologists, dietitians, physical therapists - basically anyone who can contribute to determining what's best for the individual patient."
In addition to managing Wake Forest Baptist's service, Lake is involved in efforts by the NOF and NBHA to provide hospitals and other providers with models that will help them establish FLS programs regardless of their size or scope and to develop standards for FLS programs with an eye toward their being recognized by The Joint Commission, the independent organization that accredits and certifies health care organizations and programs in the United States.
"Fracture liaison services incorporate three important aspects of health care that are being emphasized today - prevention, coordinated care and personalized medicine," Miller said. "They have been proven to be very successful in reducing the number of fragility fractures, so there's every good reason to make them available for everyone."
Wake Forest Baptist Medical Center