Servis povezan s prijelomom Hrvatskog društva za fizikalnu i rehabilitacijsku medicinu Hrvatskoga liječničkog zbora – dokument o stajalištu

Simeon Grazio, Tatjana Nikolić, Tea Schnurrer Luke Vrbanić, Ana Poljičanin, Frane Grubišić

Osteoporotski prijelomi predstavljaju velik teret kako za bolesnika tako i za zdravstveni sustav, uključujući visoke direktne i indirektne troškove. Starenjem stanovništva njihova se pojavnost povisuje. Prepoznavanje potrebe za liječenjem osteoporoze i posljedičnih prijeloma je nedostatno, a učinkovitost slaba uslijed relativno visokog stupnja nesuradljivosti (perzistencije i adherencije) na terapiju. Prethodni prijelom jedan je od najznačajnijih čimbenika rizika za sljedeći prijelom. Stoga se pojavila potreba za sustavnim strategijama sekundarne prevencije, koje su razvijene i provode se u brojnim zemljama kroz programe naziva Servis povezan s prijelomom (engl. Fracture Liaison Service, skr. FLS). FLS uključuje zdravstvene stručnjake različitih profila, a ključnu ulogu ima koordinator. Identifikacija bolesnika s niskoenergetskim prijelomom polazišna je točka procesa FLS-a, a sam proces funkcionira na temelju utvrđenog postupnika. Tijekom hospitalizacije provodi se ciljana dijagnostička obrada, procjena rizika za sljedeće prijelome, edukacija bolesnika i njegovih bližnjih/skrbnika, a daju se preporuke za temeljnu i specifičnu farmakološku antiosteoporotsku terapiju te za druge mjere i postupke (npr. fizikalna terapija, vježbe), uključujući modifikaciju čimbenika rizika i prevenciju padova. Svi nalazi te napose preporuke moraju biti jasno navedene u otpusnom pismu i komunicirane svim članovima tima, kao i liječniku obiteljske medicine. Važno je redovito praćenje tih bolesnika, uz naglasak na suradljivosti kao preduvjetu za uspjeh liječenja i sprječavanje novih prijeloma. Na temelju programa FLS koji je ustanovljen u Kliničkom bolničkom centru Sestre milosrdnice u Zagrebu, grupa eksperata je konsenzusom predložila ključne elemente, ulogu pojedinih članova multidisciplinarnog tima i postupnik FLS-a HDFRM, s izborom prijeloma u području kuka kao indeksnog prijeloma. Prijedlog je dobio potvrdu na sastanku stručnog društva. Pritom se pridržavalo osnovnih načela FLS-a, identifikacije pacijenata s prijelomom, odgovarajuće evaluacije i individualizirane procjene rizika za sljedeći prijelom, promptnosti početka liječenja i praćenja bolesnika s osiguranjem kontinuiteta terapije. Ovaj dokument o stajalištu (engl. position paper) temeljni je dokument za FLS u hrvatskoj fizijatrijskoj zajednici te vjerujemo da će pridonijeti smanjenju morbiditeta, mortaliteta i sveukupnih zdravstvenih izdataka povezanih s osteoporotskim prijelomima.

Osteoporotic fractures represent a great burden for both the patient and the healthcare system, including high direct and indirect costs. As the population ages, their incidence increases. Recognition of the need for treatment of osteoporosis and consequent fractures is insufficient, and effectiveness is weak due to a relatively high degree of non-compliance (persistence and adherence) to therapy. A previous fracture is one of the most significant risk factors for a subsequent fracture. Therefore, there is a need for systematic secondary prevention strategies, which have been developed and implemented in numerous countries through programs called Fracture Liaison Services (FLS). FLS includes health professionals of various profiles, and the key role is played by the coordinator. The identification of a patient with a fragility fracture is the starting point of the FLS process, and the process itself functions on the basis of an established algorithm. During hospitalization, targeted diagnostic treatment, risk assessment for subsequent fractures, education of the patient and his relatives/carers are carried out, and recommendations are given for basic and specific pharmacological anti-osteoporotic therapy, as well as for other measures and procedures (e.g. physical therapy, exercises), including modification of risk factors and prevention of falls. All results, and especially recommendations, must be clearly stated in the discharge letter and
communicated to all team members, as well as to the family medicine doctor. Regular follow-up of these patients is important, with an emphasis on compliance as a prerequisite for successful treatment and prevention of new fractures. On the basis of the FLS program that was established at the University Hospital Centre Sestre milosrdnice in Zagreb, a group of experts proposed by consensus the key elements, the role of the members of the multidisciplinary team and the algorithm for the FLS of the Croatian Society for Physical and Rehabilitation Medicine of the Croatian Medical Association, with the choice of hip fracture as the index fracture. The proposal was approved at the meeting of the professional society. In doing so, the basic principles of FLS were followed, identification of patients with a fracture, appropriate evaluation and individualized assessment of the risk for the next fracture, promptness of the start of treatment and monitoring of patients with the assurance of continuity of therapy. This position paper is a fundamental document for FLS in the Croatian physiatry community, and we believe that it will contribute to the reduction of morbidity, mortality and overall health expenditures related to osteoporotic fractures.