Integrated approach to prevent refracture: the fracture unit project of the Ortomed scientific society

Hip fractures are serious events often leading to long-term functional impairment, nursing home admission, increased major morbidity and mortality and representing a heavy financial burden for healthcare systems. The risk of a re-fracture after a hip fracture is high (up to 20% within two years). An appropriate management for bone health can decrease re-fracture rate after the first major event. Accordingly, secondary prevention must be routine care for hip fracture patients. Unfortunately, secondary prevention is poorly addressed in surgery departments, where patients are discharged without osteoporosis assessment and proper therapeutic indications. In this respect, the objective of the Fracture Unit Project endorsed by the Italian Society of Orthopaedics and Medicine (OrtoMed) has been to assess the feasibility and the efficacy of a systematic model of care for elderly patients (≥65 years of age) admitted in hospital for a hip fracture. The core of each Fracture Unit is the closed collaboration between the orthopaedic surgeon and the bone specialist, who is ultimately responsible for the diagnostic workflow and the subsequent anti-fracture treatment for the patient. This program has been run in eight university hospitals distributed throughout Italy in three phases: 1) establishment and implementation of the Fracture Unit in clinical practice; 2) enrolment, follow-up of 900 patients admitted for a hip fracture within the three months after the constitution of the integrated care model; 3) retrospective study on the subjects admitted for a hip fractures in the three months preceding the setting up of the Fracture Unit (considered as the control group). A comparison of key performance indicators has been performed, in order to assess the efficacy of the implementation program versus the usual care. The analysis has shown a significant increase in the percentage of patients for which a secondary diagnostic-therapeutic prevention program within the Fracture Unit has been established. In a subgroup of subjects enrolled in the program, a significant increase in the appropriateness of prescribed treatments and an improvement in adherence up to 12 months after the hip fracture has been demonstrated, independently of confounding factors. A parallel project, named T.A.R.Ge.T. (Trattamento Appropriato delle Rifratture Geriatriche in Toscana, i.e. “Appropriate treatment of geriatric refractures in Tuscany”) has been run to get information for statistical and epidemiological analyses. For this purpose, data have been retrieved from the individual anonymous Regional Prescription Database, which has been built and administered by the Region of Tuscany to monitor and control health expenditure. In conclusion, the constitution of a multidisciplinary model of care such as the Fracture Unit has been shown to be feasible in all the participating Centres and able to ameliorate the diagnostic-therapeutic procedures in elderly subjects with a hip fracture, increasing both the appropriateness and the adherence to antiosteoporotic medication aimed to secondary fracture prevention.