Osteoporosis management and fracture prevention

OSTEOPOROSIS is a chronic disease associated with ageing and is increasing in Australia and the Asia Pacific. The Asia Pacific, home to more than half of the world’s population, is ageing rapidly. The age structure of this population is set to undergo an unprecedented demographic shift in the coming decades, resulting in the proportion of individuals who will be aged 65 years and over increasing several-fold, as compared with younger working-age individuals. Maintaining the mobility of these older individuals and, therefore, their independence, will allow nations and their policymakers to adjust to the realities of this new demographic era by reducing hospitalisations.

Prevention of osteoporosis and falls – and subsequent fragility fractures – must be recognised as a health care priority throughout the Asia Pacific. More than 1.2 million Australians have osteoporosis, with about 24 000 hip fractures occurring each year (here and here), which is projected to cost $1.13 billion per annum by 2022 (here and here). By contrast, projections for hip fractures in the Asia Pacific dwarf this number. In 2018, more than 1.1 million hip fractures were anticipated to occur in nine countries or regions in the Asia Pacific, incurring an estimated direct cost of US$7.4 billion.

However, by 2050, the number of hip fractures will more than double to more than 2.5 million cases annually, resulting in projected costs of almost US$15 billion by 2050 and comprising over 50% of the world’s hip fractures. Notably, China sustained 43.1% of the region’s hip fractures in 2018, but incurred just 22.7% of the costs, while Japan sustained 15.9% of the hip fractures, but incurred 66.4% of the costs. However, a recent update revealed the Chinese costs were conservative, and are likely to be more than double based on more recent estimates. This demographic change is the reason international organisations, such as the International Osteoporosis Foundation (IOF), are focusing on this region for preventive strategies, for which some Australian initiatives could provide a good model.

The first and, arguably, most obvious step on this journey for better bone health for the Asia Pacific must be to focus on secondary fracture prevention, to ensure the first fragility fracture is the last. Strategies to achieve this are first, the development and implementation of evidence-based osteoporosis management guidelines and, second, through the funding and implementation of fracture liaison services (FLS), whereby patients presenting to a health care service with a new fragility fracture are investigated for osteoporosis, and treatment is initiated.

In Australia, GPs are the health care professionals who most commonly treat osteoporosis, and therefore play a key role in fracture prevention strategies. In particular, two key fracture prevention initiatives involve GPs:

Osteoporosis guidelines

GPs were members of the writing group for the 2017 Royal Australian College of General Practitioners (RACGP) and Osteoporosis Australia (OA) osteoporosis management guidelines for postmenopausal women and men aged over 50 years, and subsequent position statements reflecting updated guidance.

Fracture liaison services

FLS are coordinated, multidisciplinary programs designed to reliably deliver secondary fracture prevention through the identification, investigation and initiation of anti-osteoporosis treatment in patients with fragility fractures, ensuring the best transition of patient care from hospital to community. For patients with hip fractures, this is embedded in the Australian Commission on Safety and Quality in Health Care 2016 Hip Fracture Care Clinical Care Standard.

Quality Statement number 6 specifically deals with the issue of secondary fracture prevention:

“Before a patient with a hip fracture leaves hospital, they are offered a falls and bone health assessment, and a management plan based on this assessment, to reduce the risk of another fracture.”

However, in 2017 the Australian and New Zealand Hip Fracture Registry reported only 31% and 16% of patients in New Zealand and Australia, respectively, were receiving treatment for osteoporosis at discharge from the acute hospital setting. This reflects a system failure of Australian hospitals in osteoporosis management that could be rectified by stronger GP engagement in identifying patients with fragility fractures.

In late 2019, OA and the Australian Government officially launched the 2019 National Strategic Action Plan for Osteoporosis with the federal Minister for Health, the Honourable Greg Hunt MP. This evidence-based Action Plan provides a roadmap to improve the prevention, diagnosis and management of osteoporosis nationally. The government has since provided $4 million to support implementation of this national action plan, which focuses on three key priorities:

• increasing osteoporosis awareness and education with a focus on prevention;
• improving osteoporosis diagnosis, management and care; and
• data collection, monitoring and strategic research.

A critical and major part of the program is in piloting the development, implementation and evaluation of an FLS function in GP practices across Australia, a completely novel approach compared with the current, unsuccessful approach of targeting patients with fragility fractures during an acute hospital admission.

However, in other Asia Pacific countries, the health care providers primarily responsible for osteoporosis management may differ and include orthopaedic surgeons, endocrinologists, rheumatologists and gynaecologists. Therefore, approaches need to be country-specific, but would benefit from the harmonisation of the tools to be used (osteoporosis management guidelines and FLS) across the region. This requirement recently led to the birth of the Asia Pacific Consortium on Osteoporosis (APCO) comprising osteoporosis experts from several countries in the Asia Pacific, charged with developing tangible solutions to the substantive challenges involving osteoporosis management and fracture prevention in this most populated and fastest growing region of the world.

The Asia Pacific region has within it tremendously diverse socio-economic and health care systems. APCO aspires to be a catalyst for ideas and an enabler for individuals in the health care arena who are committed to osteoporosis care, to bring about change in the Asia Pacific region, with regard to osteoporosis care and management. APCO is a non-partisan and apolitical organisation. Its individual members currently number 39, and represent 19 countries and regions, including Australia and New Zealand. They serve as a tangible and powerful link between GPs, specialists, learned societies, thought leaders and policymakers in their respective countries and APCO.

APCO’s mission is to engage with relevant stakeholders, including health care providers, policymakers and the public, to help develop and implement country and region-specific programs for the prevention and treatment of osteoporosis and its complication of fragility fractures in the Asia Pacific. It has a plan and a position to achieve this mission.

APCO’s plan is to harmonise the guidelines for the management of osteoporosis across the Asia Pacific, by developing a proposed pan-Asia Pacific framework.

APCO’s position is the APCO Framework, designed for the introduction and implementation of minimum clinical standards for the screening, diagnosis and management of osteoporosis targeting a broad range of high risk groups across the Asia Pacific. These include:

• people with a history of fragility fractures;
• people with pre-existing medical conditions that heighten their risk of bone loss and fragility fractures;
• those taking medications associated with bone loss and fragility fractures;
• those with risk factors for osteoporosis and fragility fractures (based on country-specific fracture intervention thresholds for absolute fracture risk); and
• the elderly (aged ≥ 70 years).

The Framework will serve as a platform upon which new national guidelines can be developed or existing ones be revised. It will also facilitate benchmarking of the provision of care both at an individual health care facility, as well as at a national level. For each country or region, an assessment of the differences between the core recommendations of current clinical guidelines and the standards advocated in the Framework will inform the improvements that need to be made at the national and regional level.

The primary purpose of APCO is to support health care professionals to deliver best practice for people who are living with osteoporosis. The diversity of the APCO membership is a great strength, as it creates a forum for the exchange of ideas between experts working in widely varying health care systems and clinical settings. The principles underlying the formation and functioning of APCO could potentially be adopted by any region in the world.

Australia is taking a leading role in APCO by hosting the organisation’s administration within Osteoporosis Australia and by utilising the recent 2017 RACGP/OA guidelines for osteoporosis management as a contribution to the development of the APCO Framework. Learnings from the Framework development will feed back into refreshed Australian osteoporosis management guidelines and the introduction of minimal clinical standards for osteoporosis care in Australia.

Professor Peter Ebeling, AO is an endocrinologist and Head of the Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences at Monash University, Melbourne. Prof Ebeling is also Medical Director of Osteoporosis Australia; Board Member of the International Osteoporosis Foundation; Past President of the Endocrine Society of Australia; and Past President of the Australian and New Zealand Bone and Mineral Society (ANZBMS). He served as inaugural Director of the Australian Institute of Musculoskeletal Science (AIMSS).

Dr Manju Chandran, Chairperson of the Asia Pacific Consortium on Osteoporosis (APCO), is a Senior Consultant Endocrinologist and Director of the Osteoporosis and Bone Metabolism Unit that she founded in 2007 at Singapore General Hospital. She is Chairperson of the Singapore Ministry of Health’s Agency for Care Effectiveness Appropriate Care Guide for Osteoporosis Management in Primary Care, Immediate Past Chairperson of the Chapter of Endocrinologists, College of Physicians Singapore, Past President of the Endocrine and Metabolic Society of Singapore, Member of the Board and of the Council of Scientific Advisors of the International Osteoporosis Foundation (IOF) and Vice Chair of the Asia Pacific Panel of the International Society of Clinical Densitometry (ISCD).

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.