Reducing Missed Opportunities: A QIP on Secondary Fracture Prevention Following Vertebral Fragility Fractures

Introduction: Vertebral fragility fractures are a key indicator of underlying osteoporosis and strongly predict future fractures. However, they are frequently overlooked, particularly when asymptomatic or identified incidentally on imaging, resulting in missed opportunities for secondary fracture prevention. 

Methods: A quality improvement project was implemented across four frailty wards. Interventions included an educational poster on vertebral fracture management distributed electronically and displayed on wards, alongside clinical note stickers prompting osteoporosis assessment following identification of vertebral compression fractures. In-patients with acute or chronic vertebral compression fractures identified on current imaging were evaluated after implementation of these interventions.

Results: Thirty-five patients were identified (mean age 86 years; mean length of stay 20 days), including 14 with acute and 21 with chronic vertebral compression fractures.

Among patients with acute fractures, 6 had known osteoporosis. Ten commenced new treatment (9 zoledronic acid, 1 oral bisphosphonate), including 2 escalated from oral to intravenous therapy. Four received no treatment because of low creatinine clearance with moderate frailty or end-of-life care.

Among patients with chronic fractures, 12 had known osteoporosis. Six commenced new treatment (4 Zoledronic acid, and 2 oral bisphosphonates), and 1 was planned for zoledronic acid pending dental work. Five were already receiving bone protection therapy. One was referred for DEXA scan. Treatment was not appropriate in 8 patients due to low creatinine clearance with moderate to severe frailty, end-of-life care and patient preference.

Conclusions: Educational materials and clinical prompt interventions improved recognition and management of vertebral fragility fractures, facilitating timely initiation of bone-protective therapy in patients aged 75 years and older, without unnecessary delays for DEXA scanning. Wider implementation of clinician awareness, standardised radiology reporting and strengthened Fracture Liaison Services may further reduce missed opportunities for secondary fracture prevention.