AIM
Whilst Osteoporosis Refracture Prevention (ORP) services are an effective model for secondary fracture prevention (1), adherence to long-term therapies remains suboptimal (1-3). The need to improve coordination between tertiary and primary post-fracture care is increasingly recognised (4-7). This study aims to map current service processes and factors influencing integration of post-clinic care, and identify barriers and supports for seamless healthcare.
METHODS
This qualitative descriptive study used semi-structured interviews with multiple stakeholders at two metropolitan hospitals in NSW and surrounding general practices, recruiting until data saturation. Interview transcripts were analysed for emergent themes. A concept map was developed to describe thematic relationships.
RESULTS
Seven ORP clinicians, 11 GPs, and seven patients were interviewed. Six key themes were found to affect the transition of patient care from tertiary to primary care (PC): interprofessional communication issues and role ambiguity posed the greatest threat to seamless post-fracture care. Delayed, absent, inaccessible, or poor-quality communication was a frequent source of frustration for healthcare professionals. ORP clinicians lacked confidence in existing communication systems and desired bidirectional communication with PC. While GPs were confident and sought a greater role in osteoporosis management, ORP clinicians had limited confidence that patients would discuss osteoporosis with their GP and that GPs would action recommendations. For PC follow-up to occur, patients required both a strong GP-patient relationship and a perceived need to engage with PC. Patient understanding of osteoporosis (influenced by patient education, knowledge, beliefs, and behaviours) affected their PC attendance. Limited public awareness of osteoporosis and healthcare policy prioritisation were also seen to contribute to care gaps in the pre- and post-ORP clinic landscape.
CONCLUSION
This study identified key challenges facing stakeholders seeking to improving post-clinic osteoporosis care. Local policies and care pathways are suggested to address information and service delivery issues across the acute-to-primary care divide.