After a Broken Bone, the Risk of a Second Fracture

In other countries, and within some medical networks in the United States, including the Kaiser Permanente system in California, there are coordinated services to assure appropriate post-fracture follow-up. In 2013, the International Osteoporosis Foundation introduced a campaign called Capture the Fracture to assure that “fragility fracture sufferers receive appropriate assessment and intervention to reduce future fracture risk,” but such organized preventive measures have remained rare in the United States.

Establishing fracture liaison services, as they are called, faces a major stumbling block in this country. There’s no mechanism to pay the person who coordinates care between the orthopedic surgeon and the practicing physician. Medicare doesn’t cover the cost of a coordinator, Dr. Siris said, “so there’s no incentive to get a post-fracture patient into medical hands. Many primary care doctors don’t even know that their patients broke a hip.”

Given the astronomical costs to Medicare of hip fractures, Dr. Khosla called the failure to cover the cost of coordinating services to prevent a second fracture “penny-wise and pound-foolish.” (Of course, this is but one of many economically questionable limitations of Medicare. Consider, for example, its failure to cover hearing aids, the lack of which increases the risk of dementia, falls and a host of other expensive medical problems that Medicare does pay for.)

The consensus group’s 13 recommendations for preventing fractures include advice to not smoke or use tobacco, to limit alcohol consumption to two drinks a day for men and one for women, and to exercise regularly, at least three times a week, including weight-bearing, muscle-strengthening and balance and postural exercises. Doctors are urged to discuss both the benefits and possible risks of medications that can help prevent fractures.

Many patients have been unduly frightened, Dr. Khosla said, by the amount of attention given to the rare risks of an atypical femur fracture or jaw decay when taking bisphosphonates like Fosamax that can help maintain bone strength.

“When the drugs are used correctly for three to five years, followed by a drug holiday, and attention is paid to warning symptoms like leg or dental pain, the benefits of treatment way outweigh the risks,” he said.

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