[62] Netherlands 1,654 Patients hospitalised for a fracture of the hip, spine, wrist or other fractures For a sample of 208 out of 1,654 cases, GP case records were available. Of these patients, 5 % had a diagnosis of osteoporosis in the GP records 15 % of patients received osteoporosis treatment within 1 year after discharge from hospital Panneman et al. [63] Switzerland 3,667 Patients presenting with a fragility fracture to hospital emergency wards BMD was measured for 31 % of patients 24 % of women and 14 % of men were treated

with a bone active selleck products drug, generally a bisphosphonate with or without calcium and/or vitamin D Suhm et al. [64] UK 9,567 Patients who presented with a hip or non-hip fragility fracture 32 % of non-hip fracture mTOR cancer and 67 % of hip fracture patients had a clinical assessment for osteoporosis and/or fracture risk 33 % of non-hip fracture and 60 % of hip fracture patients received appropriate management for bone health Royal College of Physicians [65] USA 51,346

Patients hospitalised for osteoporotic hip fracture No data 7 % received an anti-resorptive or bone-forming medication Jennings et al. [66] The reason that the care gap exists, and persists, is multi-factorial in nature. A systematic review from Elliot-Gibson and colleagues in 2004 identified the following issues [69]: Cost concerns relating to diagnosis and treatment Time required for diagnosis and case finding Concerns relating to polypharmacy Lack of clarity regarding where clinical responsibility resides The issue regarding where clinical responsibility resides resonates with health care professionals throughout the world. Harrington’s metaphorical depiction captures the essence of the problem [70]: ‘Osteoporosis care of fracture patients Exoribonuclease has been characterised as the Bermuda Triangle made up of orthopaedists, primary care physicians and osteoporosis experts into which the fracture patient disappears’ Surveys have shown that in the absence of a robust care pathway for fragility fracture

patients, a ‘Catch-22’ scenario prevails [71]. Orthopaedic surgeons rely on primary care doctors to manage osteoporosis; primary care doctors routinely only do so if so advised by the orthopaedic surgeon; and osteoporosis experts—usually endocrinologists or rheumatologists—have no cause to interact with the patient during the fracture episode. The proven solution to close the secondary fracture prevention care gap is to eliminate this confusion by establishing a Fracture Liaison Epacadostat order service (FLS). Systematic literature review of programs designed to deliver secondary preventive care reported that two thirds of services employ a dedicated coordinator to act as the link between the patient, the orthopaedic team, the osteoporosis and falls prevention services, and the primary care physician [72]. Successful and sustainable FLS report that clearly defining the scope of the service from the outset is essential.