Background
The risk of breaking a bone quadruples after the age of 50 years and increases exponentially with age.1 2 Osteoporosis is one of the most common diagnoses among people over the age of 50 years in Norway, which has one of the highest incidences and prevalences of hip fractures.3–5 Without secondary fracture prevention, the later outcome may be more serious fractures, such as vertebral fractures or hip fractures (femoral neck fractures).6 7 The consequences of serious fractures in old age are serious: one in four elderly individuals who suffer a hip fracture dies within a year, and one in four ends up permanently living in a nursing home, while the rest rarely return to the same functional level they had before the fracture.8 It is a substantial cost, for both the individual and society.
Before the Capture The Fracture Initiative from the International Osteoporosis Foundation (IOF) and the Fragility Fracture Network was developed, the responsibility and initiative to diagnose and provide secondary prevention to reduce the risk of a severe subsequent fracture were arbitrary, and the treatment gap was up to 85%–90%.4 In 2015, the Norwegian Orthopaedic Society created nationwide fracture liaison service (FLS) guidelines for orthopaedic departments, inspired by similar routines, that is, those developed in Great Britain and by the IOF.6 9 10 The guidelines were developed to begin providing treatment for patients with a fragility fracture and T score of −1.5 SD or lower. The Best Practice Framework (BPF) recommends capturing and detecting osteoporosis in the population aged ≥50 years with a fracture (index fracture), for example, in the wrist, and to begin secondary fracture prevention with antiosteoporosis drugs.9 The BPF recommends keeping a quality registry to ensure best practice. For nearly two decades at Stavanger University Hospital (SUH), we have kept a local quality registry for all fracture treatments (the SUH Fracture Registry, further referred to as the ‘fracture registry’) to enable the exportation of a complete list of patients entitled to an FLS appointment. Recently, quality registries and patient-level key performance indicators have been tested and recommended.11 Hospitals are now increasingly ensuring that every individual over 50 years of age with a fracture undergoes an assessment in which the risk of further fracture is assessed.12 13 The process to determine whether the criteria in the BPF are fulfilled for an FLS quality registry is often time-consuming and requires additional human resources.
We are aware that the number of patients with low-energy fractures is high and likely to increase as this population increases throughout this decade.14 Good, effective secondary prevention measures have been available for long time, but the healthcare system has lacked the routines to identify patients at risk.15 This applies within both primary and specialist healthcare facilities.
Since 2016, the orthopaedic department at SUH has steadily implemented a procedure to detect and diagnose patients with bone fractures due to osteoporosis. In August 2020, we started the Orthopaedic Osteoporosis Outpatient Clinic for patients aged ≥50 years with fracture. This enabled us to capture all potential FLS patients and provide them with best-practice treatment at SUH. FLS nurses perform dual-energy X-ray absorptiometry (DXA) measurements in the FLS clinic, screen for other risk factors and start osteoporosis treatment, if necessary, in consultation with a medical doctor.
Implementing new workflows, new guidelines or both requires time and effort. Implementation requires thorough preparation and planning for all of the steps in the implementation process. The step-by-step model was developed by Capture the Fracture, a Worldwide Initiative to Prevent Second Fracture.9 Several hospitals, including SUH, have introduced these quality indicator (QI) steps. One step requires a quality registry to maintain continuous quality control. Structured health records (SHRs) are needed to achieve a quality registry for a hectic outpatient FLS setting.
Today, most quality registries, including the FLS registry at SUH, require entering data twice: in both another programme and the unstructured health record (ie, an Excel sheet, Access database, RedCap).This is time-consuming and resource-consuming. The Norwegian Directorate of e-health recommends an SHR in their report ‘design of a health technology scheme’.16 17 The e-health strategy set by The Norwegian Directorate of e-health on behalf of the Ministry of Health and Care Services is to establish national standards, alleviate healthcare provider workflows in the electronic records and export data to medical quality registries, avoiding entering data two or three times.16 The opportunities have been available since electronic health records (EHRs) were introduced in the 1990s. However, in today’s EHRs, there are still problems regarding the importation and exportation of data to other medical systems, unstructured information (text/prose), and the exportation of data to quality controls or registries, and entering data twice is time-consuming.18 ,19 Increasing advantages are seen from the use of structured patient medical information in EHRs regarding efficient medical resource and time use,that is, importing relevant data from the last health record or exporting data to patient safety projects or quality registries.20–22Thus, the ‘3-in-1 effect’ should be within reach.