Care pathways for vertebral compression fractures

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Agnes Hill
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$Care pathways for vertebral compression fractures SYDNEY MEDICAL$ Medical Foundation Fellow Institute of Bone and Joint Research

1 Care pathways for vertebral compression fractures SYDNEY MEDICAL SCHOOL Associate Professor Manuela L Ferreira, PhD Sydney Medical Foundation Fellow Institute of Bone and Joint Research and The George Institute Sydney Medical School/The University of Sydney

2 2

3 Gap 1 No consensus on clinical pathway for management of vertebral compression fracture 3

$Gap 2: Variation in recommendations Guideline First-line care Conservative care Surgical care Osteoporosis Pharmacological Other treatment/prevention of future fractures Calcitonin for 4 Kyphoplasty$

4 Gap 2: Variation in recommendations Guideline First-line care Conservative care Surgical care Osteoporosis Pharmacological Other treatment/prevention of future fractures Calcitonin for 4 Kyphoplasty is an option (limited) weeks (moderate) Against vertebroplasty (strong) American Academy of Orthopedic Surgeons (2010) American Association of Neurological Surgeons British Society of Interventional Radiology (2005) National Institute for Health and Care Excellence Guidelines (UK) (2013) Canadian clinical practice guidelines for the diagnosis and management of osteoporosis (2002) Bed rest for a short period of time Paracetamol and NSAIDs Paracetamol, NSAIDs, or opioids L3 or L4 fracture and acute pain with L2 nerve root block (limited) Inconclusive about opioids Opioids and muscle relaxants for short periods of time Inconclusive about brace, bed rest, exercise or electrical stimulation Bisphosphonates (ibandronate) to prevent future fractures (limited) Brace to limit motion Vertebroplasty or kyphoplasty Bisphosphonates to restore bone loss Not included Not included Vertebroplasty (pain persists for 3 weeks) Conservative care Pain medication Bed rest, back braces Vertebroplasty and kyphoplasty for patients with severe ongoing pain (6 weeks after dx) Nasal or parenteral calcitonin as firstline therapy Bisphosphonates (alendronate) to prevent future fractures Presence of vertebral fracture + low BMD bisphosphonates (first-line therapy for osteoporosis)

5 Gap 3: Disconnect between evidence and recommendation Guideline First-line care Conservative care Surgical care Osteoporosis Phamarcological Other treatment/prevention of future fractures Calcitonin for 4 Kyphoplasty is an option (limited) weeks (moderate) Against vertebroplasty (strong) American Academy of Orthopedic Surgeons (2010) American Association of Neurological Surgeons British Society of Interventional Radiology (2005) National Institute for Health and Care Excellence Guidelines (UK) (2013) Canadian clinical practice guidelines for the diagnosis and management of osteoporosis (2002) Bed rest for a short period of time Paracetamol and NSAIDs Paracetamol, NSAIDs, or opioids L3 or L4 fracture and acute pain with L2 nerve root block (limited) Inconclusive about opioids Opioids and muscle relaxants for short periods of time Inconclusive about brace, bed rest, exercise or electrical stimulation Biphosphonates (ibandronate) to prevent future fractures (limited) Brace to limit motion Vertebroplasty or kyphoplasty Biphosphonates to restore bone loss Not included Not included Vertebroplasty (pain persists for 3 weeks) Conservative care Pain medication Bed rest, back braces Vertebroplasty and kyphoplasty for patients with severe ongoing pain (6 weeks after dx) Nasal or parenteral calcitonin as firstline therapy Biphosphonates (alendronate) to prevent future fractures Presence of vertebral fracture + low BMD bisphosphonates (first-line therapy for osteoporosis)

6 Hospital care variation LOS = mean 6 days for spontaneous vertebral fractures in US African-americans usually stay 3 extra days in hospitals and pay 2x more Those who pay for their own hospital costs stay 2 and ½ times longer Caucasians more likely to be discharged to long term facilities Burge et al. Value in Health,2002 6

7 Gap 5: disconnect between recommendation and care adults experiencing fragility fracture are not receiving OP management less than 2/3 of patients with fragility fracture have falls risk assessment older patients are more likely to have a diagnosis younger patients are more likely to receive treatment individuals in residential care less likely to have a BMD test or receive OP treatment than those in living at home Giangregorio et al. Arthritis and Rheumatism,

8 Fracture prevention in the primary care Royal College of General Practitioners Recommendations 1.Calcium and vitamin D supplementation (limited evidence) 2.Regular, high intensity weight bearing exercise 3.Bisphosphonates (strong evidence) 4.Regular monitoring and follow up of all patients with OP (3 6 months after initiating an intervention and annually thereafter).

9 Gap 5: disconnect between recommendation and care Cohort Characteristics Main reason for seeking care General practitioner 2,300/year back pain Age 43% 75+ years Gender 62% female Prescriptions 50% opioids Allied Health 2% Physical activity Referrals 10% advice on exercise or nutrition and weight 6% to rehabilitation, 2% to specialist Source of referral - OP management 7% New fractures 40%

10 Lack of evidence Wide variations in management Under- or over-treatment 10

11 What s next? Pain management Physical activity reduction of future fractures Physical interventions for symptomatic fractures Effectiveness of kyphoplasty, exercise, braces Clinical pathways: when do patients present to care, when and how to intervene? 11

12 GAPS Gap 1: lack of consensus on clinical pathway for management of vertebral compression fracture Gap 2: variation in recommendations Gap 3: disconnect between evidence and recommendation Gap 4: variation across different levels of care Gap 5: disconnect between recommendation and care Gap 2: Variation in recommendations 12

13 acknowledgements Arthritis Australia Institute of Bone and Joint Research/The Kolling Institute Sydney Medical Foundation, The University of Sydney The George Institute for Global Health 13

Vertebral Fragility Fracture

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