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Wang M, Seibel MJ. Secondary fracture prevention in primary care: a narrative review. Osteoporos Int 2024; 35:1359-1376. [PMID: 38652313 PMCID: PMC11281980 DOI: 10.1007/s00198-024-07036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/28/2024] [Indexed: 04/25/2024]
Abstract
The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.
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Affiliation(s)
- Mawson Wang
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia.
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia.
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia
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2
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McKenna RE. Can fracture liaison services prevent second fractures in patients with osteoporosis? JAAPA 2024; 37:1-5. [PMID: 38985120 DOI: 10.1097/01.jaa.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
ABSTRACT Patients who have had fractures are at increased risk for a second or fragility fracture. A fracture liaison service (FLS), often staffed or led by physician associates/assistants or NPs, may help reduce second fractures and patient mortality. This article reviews FLSs and their effectiveness.
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Affiliation(s)
- Robert E McKenna
- Robert E. McKenna is director of accreditation and an assistant professor in the PA program at Marshall B. Ketchum University in Fullerton, Calif. The author has disclosed no potential conflicts of interest, financial or otherwise
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Mohseni V, Fahimfar N, Ansarifar A, Masoumi S, Sanjari M, Khalagi K, Bagherifard A, Larijani B, Janani L, Mansourzadeh MJ, Ostovar A, Solaymani-Dodaran M. Mortality and re-fracture rates in low trauma hip fracture. BMC Geriatr 2024; 24:381. [PMID: 38684943 PMCID: PMC11059755 DOI: 10.1186/s12877-024-04950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES This study aimed to estimate the incidence rate of re-fracture and all-cause mortality rate in patients with hip fractures caused by minor trauma in the first year following the event. MATERIALS AND METHODS This is a retrospective cohort study of patients over 50 years of age conducted in a referral hospital located in Tehran (Shafa-Yahyaian). Using the hospital information system (HIS), all patients hospitalized due to hip fractures caused by minor trauma during 2013-2019 were included in the study. We investigated the occurrence of death and re-fracture in all patients one year after the primary hip fracture. RESULTS A total of 945 patients with hip fractures during a 307,595 person-days of follow-up, were included. The mean age of the participants was 71 years (SD = 11.19), and 533 (59%) of them were women. One hundred forty-nine deaths were identified during the first year after hip fracture, resulting in a one-year mortality rate of 17.69% (95% CI: 15.06-20.77). The one-year mortality rate was 20.06% in men and 15.88% in women. Out of all the participants, 667 answered the phone call, of which 29 cases had experienced a re-fracture in the first year (incidence rate = 5.03%, 95% CI: 3.50-7.24). The incidence rates in women and men were 6.07% and 3.65%, respectively. CONCLUSION Patients with low-trauma hip fractures have shown a high rate of mortality in the first year. Considering the increase in the incidence of hip fractures with age, comprehensive strategies are needed to prevent fractures caused by minor trauma in the elderly population.
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Affiliation(s)
- Vahideh Mohseni
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Noushin Fahimfar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Ansarifar
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Safdar Masoumi
- Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Mahnaz Sanjari
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Khalagi
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolfazl Bagherifard
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Janani
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Mansourzadeh
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Afshin Ostovar
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Masoud Solaymani-Dodaran
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.
- Minimally Invasive Surgery Research Center, Hazrat-e-Rasool Hospital, Iran University of Medical Science, Tehran, Iran.
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Lu K, Wu YM, Shi Q, Gong YQ, Zhang T, Li C. A novel fracture liaison service using digital health: impact on mortality in hospitalized elderly osteoporotic fracture patients. Osteoporos Int 2024; 35:53-67. [PMID: 37698600 DOI: 10.1007/s00198-023-06905-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/30/2023] [Indexed: 09/13/2023]
Abstract
We examined the performance of an intelligent fracture liaison service (FLS) assisted by digital health (DH) to reduce all-cause mortality (ACM) risk. According to our findings, the new FLS reduced ACM by 36%. INTRODUCTION A well-designed secondary prevention program known as FLS enhances the bone densitometry-based assessment rate as well as osteoporosis (OP) medication usage following a fracture. However, there are only a few reports on FLS incorporating DH, and it remains unclear whether this integration has influenced patient ACM, which refers to the overall death rate from any cause during the study period. METHODS This retrospective observational study was conducted on data from the Fragility Fracture Registration System database linked to the Regional Health Registration Platform of Kunshan City and the Population Death Registration System of Jiangsu Province for one tertiary-level A hospital in China. Patients aged ≥ 50 years, who experienced an OP fracture between January 1, 2017, and July 27, 2022, requiring hospitalization, were selected for analysis. We compared the outcomes of patients who received routine fragility fracture management (the no-FLS group) or FLS (the FLS group). We employed multivariable Cox regression with inverse probability weighting based on the propensity score (PS). RESULTS Of 2317 patients, 756 (32.6%) received FLS and 1561 (67.4%) did not. Using PS matching, we minimized the baseline characteristic differences between the two groups in the propensity score-matched samples, relative to the unmatched samples. Based on our analysis, the new FLS reduced ACM by 36% (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.47 to 0.87; P-value = 0.004). Moreover, FLS patients experienced further reductions in fall-related mortality, refracture rate, and total refracture-related hospital costs, and had increased dual-energy X-ray absorptiometry (DXA) testing and treatment initiation rates, relative to the no-FLS patients. CONCLUSIONS A new FLS model implementation assisted by DH can effectively reduce ACM among elderly patients with OP fractures requiring surgery. In future investigations, we recommend examining the scalability of this model.
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Affiliation(s)
- Ke Lu
- Department of Orthopedics, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Ya-Ming Wu
- Department of Orthopedics, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, 215300, Jiangsu, China
| | - Qin Shi
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute of Soochow University, Suzhou, Jiangsu, China
| | - Ya-Qin Gong
- Information Department, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, Jiangsu, China
| | - Ting Zhang
- Chronic Disease Department, Kunshan Center For Disease Control and Prevention, Suzhou, Jiangsu, China
| | - Chong Li
- Department of Orthopedics, Affiliated Kunshan Hospital of Jiangsu University, No. 566 East of Qianjin Road, Suzhou, 215300, Jiangsu, China.
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Rentzeperi E, Pegiou S, Tsakiridis I, Kalogiannidis I, Kourtis A, Mamopoulos A, Athanasiadis A, Dagklis T. Diagnosis and Management of Osteoporosis: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2023; 78:657-681. [PMID: 38134337 DOI: 10.1097/ogx.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Importance Osteoporosis causes increased morbidity and mortality, and thus poses a significant economic burden to the health systems worldwide. Objective The aim of this study was to review and compare the most recently published major guidelines on diagnosis and management of this common medical entity. Evidence Acquisition A thorough comparative review of the most influential guidelines from the RACGP (Royal Australian College of General Practitioners), the ESCEO-IOF (European Society for Clinical and Economic Aspects of Osteoporosis-International Osteoporosis Foundation), the NOGG (National Osteoporosis Guideline Group), the NAMS (North American Menopause Society), the ES (Endocrine Society), and the ACOG (American College of Obstetricians and Gynecologists) was conducted. Results The reviewed guidelines generally agree on the definition, the criteria, and investigations used to diagnose osteoporosis. They also concur regarding the risk factors for osteoporosis and the suggested lifestyle modifications (calcium and vitamin D intake, normal body weight, reduction of alcohol consumption, and smoking cessation). However, there is lack of consensus on indications for fracture risk assessment in the general population and the exact indications for bone mineral density assessment. Referral to a bone specialist is reserved for complex cases of osteoporosis (NOGG, NAMS, and ACOG) or in case of inadequate access to care (RACGP). The use of hip protectors to reduce the risk of fractures is supported by RACGP, NOGG, and NAMS, solely for high-risk elderly patients in residential care settings. All guidelines reviewed recognize the efficacy of the pharmacologic agents (ie, bisphosphonates, denosumab, hormone therapy, and parathyroid hormone analogs). Nonetheless, recommendations regarding monitoring of pharmacotherapy differ, primarily in the case of bisphosphonates. The proposed intervals of repeat bone mineral density testing after initiation of drug therapy are set at 2 years (RACGP), 1-3 years (NAMS, ES, and ACOG), or 3-5 years (ESCEO-IOF and NOGG). All guidelines agree upon the restricted use of bone turnover markers only in bone specialist centers for treatment monitoring purposes. Finally, the definition of treatment failure varies among the reviewed guidelines. Conclusions Osteoporosis is a distressing condition for women, mainly those of postmenopausal age. Thus, it seems of paramount importance to develop consistent international practice protocols for more cost-effective diagnostic and management techniques, in order to improve women's quality of life.
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Affiliation(s)
| | | | | | | | | | | | | | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Galasso AC, Herzog LN, Sekar M, Hartsock LA, Reid KR. Intradepartmental orthopaedic fragility fracture liaison improves osteoporosis follow-up and treatment. Injury 2023; 54:110985. [PMID: 37599192 DOI: 10.1016/j.injury.2023.110985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/05/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVE Over 2 million people in the United States sustain fractures related to osteoporosis annually, but only 20% of these patients receive treatment for their osteoporosis. The purpose of this study was to evaluate the effects of a fragility fracture liaison within the orthopedic department on treatment and follow up for osteoporosis. DESIGN Retrospective cohort study SETTING: University Level I Trauma center PARTICIPANTS: 112 patients treated under the aegis of an interdepartmental fracture liaison and 208 patients treated following the introduction of an orthopedic fragility fracture liaison at a single institution. INTERVENTION Transition from referral to interdepartmental fracture liaison to intradepartmental orthopedic fragility fracture liaison for fragility fractures. MAIN OUTCOME MEASURES Outcomes evaluated included demographics, fracture type, DEXA scan results, follow up and treatment plan, and subsequent fracture. RESULTS The mean age at time of fracture was 75 years, and the mean BMI was 27. The most common fracture types were femoral neck fractures (29%), pertrochanteric fractures (30%) and femur fractures (8%). There was a statistically significant increase in adherence to follow up and treatment after the introduction of an orthopaedic fragility fracture liaison. CONCLUSIONS The introduction of an intradepartmental fragility fracture liaison significantly increases osteoporosis follow-up and introduces the ability to combine both osteoporosis treatment and postoperative orthopaedic care. The results of this study highlight the utility of incorporating a fragility fracture liaison within the orthopaedic department given the economic burden of fragility fractures and the morbidity associated with these fractures. LEVEL OF EVIDENCE III cohort study.
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Affiliation(s)
| | | | - Molly Sekar
- University of Arizona, College of Medicine Phoenix, United States
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7
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Moles RJ, Perry L, Naylor JM, Center J, Ebeling P, Duque G, Major G, White C, Yates C, Jennings M, Kotowicz M, Tran T, Bliuc D, Si L, Gibson K, Basger BJ, Bolton P, Barnett S, Hassett G, Kelly A, Bazarnik B, Ezz W, Luckie K, Carter SR. Safer medicines To reduce falls and refractures for OsteoPorosis (#STOP): a study protocol for a randomised controlled trial of medical specialist-initiated pharmacist-led medication management reviews in primary care. BMJ Open 2023; 13:e072050. [PMID: 37620274 PMCID: PMC10450068 DOI: 10.1136/bmjopen-2023-072050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Minimal trauma fractures (MTFs) often occur in older patients with osteoporosis and may be precipitated by falls risk-increasing drugs. One category of falls risk-increasing drugs of concern are those with sedative/anticholinergic properties. Collaborative medication management services such as Australia's Home Medicine Review (HMR) can reduce patients' intake of sedative/anticholinergics and improve continuity of care. This paper describes a protocol for an randomised controlled trial to determine the efficacy of an HMR service for patients who have sustained MTF. METHOD AND ANALYSIS Eligible participants are as follows: ≥65 years of age, using ≥5 medicines including at least one falls risk-increasing drug, who have sustained an MTF and under treatment in one of eight Osteoporosis Refracture Prevention clinics in Australia. Consenting participants will be randomised to control (standard care) or intervention groups. For the intervention group, medical specialists will refer to a pharmacist for HMR focused on reducing falls risk predominately through making recommendations to reduce falls risk medicines, and adherence to antiosteoporosis medicines. Twelve months from treatment allocation, comparisons between groups will be made. The main outcome measure is participants' cumulative exposure to sedative and anticholinergics, using the Drug Burden Index. Secondary outcomes include medication adherence, emergency department visits, hospitalisations, falls and mortality. Economic evaluation will compare the intervention strategy with standard care. ETHICS AND DISSEMINATION Approval was obtained via the New South Wales Research Ethics and Governance Information System (approval number: 2021/ETH12003) with site-specific approvals granted through Human Research Ethics Committees for each research site. Study outcomes will be published in peer-reviewed journals. It will provide robust insight into effectiveness of a pharmacist-based intervention on medicine-related falls risk for patients with osteoporosis. We anticipate that this study will take 2 years to fully accrue including follow-up. TRIAL REGISTRATION NUMBER ACTRN12622000261718.
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Affiliation(s)
- Rebekah Jane Moles
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Lin Perry
- School of Nursing and Midwifery, University of Technology Sydney Faculty of Health, Sydney, New South Wales, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Southwestern Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacqueline Center
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Peter Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Gustavo Duque
- Australian Institute for Musculoskeletal Science, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gabor Major
- Department of Rheumatology, Bone and Joint Centre, Royal Newcastle Centre, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle Faculty of Health and Medicine, Callaghan, New South Wales, Australia
| | - Christopher White
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Christopher Yates
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Matthew Jennings
- Physiotherapy, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Mark Kotowicz
- Epi-Centre for Healthy Ageing, Deakin University - Geelong Campus at Waurn Ponds, Geelong, Victoria, Australia
- Barwon Health, Geelong, Victoria, Australia
| | - Thach Tran
- Bone Biology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Dana Bliuc
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Lei Si
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Kathryn Gibson
- Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute, Liverpool, New South Wales, Australia
| | - Benjamin Joseph Basger
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Patrick Bolton
- Public Health and Community Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Stephen Barnett
- GP Academic Unit, University of Wollongong, Wollongong, New South Wales, Australia
| | - Geraldine Hassett
- Ingham Institute, Liverpool, New South Wales, Australia
- Department of Rheumatology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Ayano Kelly
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Barbara Bazarnik
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Wafaa Ezz
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kate Luckie
- Musculoskeletal Clinical Group, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Ross Carter
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Cianferotti L, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML, Corrao G, Biffi A. The integrated structure of care: evidence for the efficacy of models of clinical governance in the prevention of fragility fractures after recent sentinel fracture after the age of 50 years. Arch Osteoporos 2023; 18:109. [PMID: 37603196 PMCID: PMC10442313 DOI: 10.1007/s11657-023-01316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023]
Abstract
Randomized clinical trials and observational studies on the implementation of clinical governance models, in patients who had experienced a fragility fracture, were examined. Literature was systematically reviewed and summarized by a panel of experts who formulated recommendations for the Italian guideline. PURPOSE After experiencing a fracture, several strategies may be adopted to reduce the risk of recurrent fragility fractures and associated morbidity and mortality. Clinical governance models, such as the fracture liaison service (FLS), have been introduced for the identification, treatment, and monitoring of patients with secondary fragility fractures. A systematic review was conducted to evaluate the association between multidisciplinary care systems and several outcomes in patients with a fragility fracture in the context of the development of the Italian Guidelines. METHODS PubMed, Embase, and the Cochrane Library were investigated up to December 2020 to update the search of the Scottish Intercollegiate Guidelines Network. Randomized clinical trials (RCTs) and observational studies that analyzed clinical governance models in patients who had experienced a fragility fracture were eligible. Three authors independently extracted data and appraised the risk of bias in the included studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Effect sizes were pooled in a meta-analysis using random-effects models. Primary outcomes were bone mineral density values, antiosteoporotic therapy initiation, adherence to antiosteoporotic medications, subsequent fracture, and mortality risk, while secondary outcomes were quality of life and physical performance. RESULTS Fifteen RCTs and 62 observational studies, ranging from very low to low quality for bone mineral density values, antiosteoporotic initiation, adherence to antiosteoporotic medications, subsequent fracture, mortality, met our inclusion criteria. The implementation of clinical governance models compared to their pre-implementation or standard care/non-attenders significantly improved BMD testing rate, and increased the number of patients who initiated antiosteoporotic therapy and enhanced their adherence to the medications. Moreover, the treatment by clinical governance model respect to standard care/non-attenders significantly reduced the risk of subsequent fracture and mortality. The integrated structure of care enhanced the quality of life and physical function among patients with fragility fractures. CONCLUSIONS Based on our findings, clinicians should promote the management of patients experiencing a fragility fracture through structured and integrated models of care. The task force has formulated appropriate recommendations on the implementation of multidisciplinary care systems in patients with, or at risk of, fragility fractures.
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Affiliation(s)
- L Cianferotti
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - R Ronco
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - G Adami
- Rheumatology Unit, University of Verona, Verona, Italy
| | - R Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - R Bogini
- Local Health Unit (USL) Umbria, Perugia, Italy
| | - A P Caputi
- Department of Pharmacology, School of Medicine, University of Messina, Sicily, Italy
| | - B Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - D Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - S Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - G Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - S Leone
- AMICI Onlus, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino, Milan, Italy
| | - R Michieli
- Italian Society of General Medicine and Primary Care (SIMG), Florence, Italy
| | - S Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - T Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - M Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - E Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M Rossini
- Rheumatology Unit, University of Verona, Verona, Italy
| | - U Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M L Brandi
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Corrao
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - A Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
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9
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Park JW, Ha YC, Kim JW, Kim TY, Kim JW, Baek SH, Lee YK, Koo KH. The Korean hip fracture registry study. BMC Musculoskelet Disord 2023; 24:449. [PMID: 37268896 DOI: 10.1186/s12891-023-06546-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model. METHODS The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey. DISCUSSION KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants. TRIAL REGISTRATION Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).
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Affiliation(s)
- Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Seoul Bumin Hospital, Seoul, South Korea
| | - Jin-Woo Kim
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Seoul, South Korea
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, South Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Hoon Baek
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
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Ding BTK, Lim HF, Johari F, Kunnasegaran R. An Orthopaedic Surgeon Led Osteoporosis (OSLO) Model of Care reduces early recurrent fracture rates and improves treatment compliance in patients treated for osteoporotic fractures. Osteoporos Int 2023; 34:299-307. [PMID: 36409358 DOI: 10.1007/s00198-022-06595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/31/2022] [Indexed: 11/22/2022]
Abstract
UNLABELLED This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) in improving care of patients with primary osteoporotic fractures. The OSLO-MOC has shown to be effective in improving osteoporotic medication initiation and compliance and reducing secondary fracture rates in patients. PURPOSE This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) as compared to a Case Manager Led Osteoporosis Model of Care (CMLO-MoC) in reducing early osteoporotic re-fracture rates and treatment compliance in patients. METHODS This was a single centre, retrospective, comparative cohort study of all patients screened and treated for secondary osteoporotic fracture prevention from the 2008 to 2018 at an orthopaedic surgical unit. From the 2008 to 2013, patients were recruited under the CMLO-MoC and from 2014 to 2018, under the OSLO-MOC. Logistics regression analysis was used to identify significant predictors such as OSLO-MOC implementation, gender, ethnicity, marital status and education level for patient recruitment, treatment compliance and secondary fracture rates at 12-month follow-up. RESULTS Over a 10-year period, 7388 patients were screened of which 2855 patients were eligible for analysis. A total of 1234 patients were recruited under CMLO-MoC and 1621 patients under OSLO-MOC. Implementation of the OSLO-MOC was associated with greater patient recruitment, OR 1.26 (95%CI 1.06-1.49, P = 0.007). Of the 2855 patients recruited, OSLO-MOC implementation, OR 2.61 (95%CI 2.03-3.36, P < 0.001), and a higher level of education, OR 1.428 (95%CI 1.02-1.43, P = 0.037), were associated with improved compliance to medication at 12 months. OSLO-MOC implementation was the only factor associated with reduced risk of secondary fractures at 12 months, OR 0.14 (95%CI 0.03-0.66, P = 0.013). CONCLUSION The OSLO-MOC has shown to be effective in reducing the rate of re-fracture and osteoporotic medication initiation and compliance of patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benjamin Tze Keong Ding
- Department of Orthopaedic Surgery, Woodlands Health, 2 Yishun Central 2, Tower E, S768024, Singapore, Singapore.
| | - Hai Fon Lim
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, S768828, Singapore, Singapore
| | - Fadzleen Johari
- Nursing Specialty, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, S308433, Singapore, Singapore
| | - Remesh Kunnasegaran
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, S308433, Singapore, Singapore
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11
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Corrao G, Biffi A, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Cianferotti L, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML. Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021. Front Endocrinol (Lausanne) 2023; 14:1137671. [PMID: 37143730 PMCID: PMC10151776 DOI: 10.3389/fendo.2023.1137671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field. Purpose This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline. Methods The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations. Results Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively. Conclusions The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.
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Affiliation(s)
- Giovanni Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Raffaella Ronco
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Luisella Cianferotti
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Davide Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Salvatore Leone
- AMICI Onlus, Associazione Nazionale per le Malattie Infiammatorie Croniche dell’Intestino, Milan, Italy
| | - Raffaella Michieli
- Italian Society of General Medicine and Primary Care Società Italiana di Medicina Generale e delle cure primarie (SIMG), Florence, Italy
| | - Silvia Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - Tiziana Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | | | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | - Maria Luisa Brandi
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
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12
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Vranken L, Wyers CE, Van der Velde RY, Janzing HMJ, Kaarsemakers S, Driessen J, Eisman J, Center JR, Nguyen TV, Tran T, Bliuc D, Geusens P, van den Bergh JP. Association between incident falls and subsequent fractures in patients attending the fracture liaison service after an index fracture: a 3-year prospective observational cohort study. BMJ Open 2022; 12:e058983. [PMID: 35896286 PMCID: PMC9335024 DOI: 10.1136/bmjopen-2021-058983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 07/04/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To evaluate the risk of subsequent fractures in patients who attended the Fracture Liaison Service (FLS), with and without incident falls after the index fracture. DESIGN A 3-year prospective observational cohort study. SETTING An outpatient FLS in the Netherlands. PARTICIPANTS Patients aged 50+ years with a recent clinical fracture. OUTCOME MEASURES Incident falls and subsequent fractures. RESULTS The study included 488 patients (71.9% women, mean age: 64.6±8.6 years). During the 3-year follow-up, 959 falls had been ascertained in 296 patients (60.7%) (ie, fallers), and 60 subsequent fractures were ascertained in 53 patients (10.9%). Of the fractures, 47 (78.3%) were fall related, of which 25 (53.2%) were sustained at the first fall incident at a median of 34 weeks. An incident fall was associated with an approximately 9-fold (HR: 8.6, 95% CI 3.1 to 23.8) increase in the risk of subsequent fractures. CONCLUSION These data suggest that subsequent fractures among patients on treatment prescribed in an FLS setting are common, and that an incident fall is a strong predictor of subsequent fracture risk. Immediate attention for fall risk could be beneficial in an FLS model of care. TRIAL REGISTRATION NUMBER NL45707.072.13.
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Affiliation(s)
- Lisanne Vranken
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
- Department of Internal Medicine, Research School NUTRIM, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
- Department of Internal Medicine, Research School NUTRIM, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Robert Y Van der Velde
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
- Department of Internal Medicine, Research School NUTRIM, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Sjoerd Kaarsemakers
- Department of Orthopedic Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - Johanna Driessen
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University, Maastricht, The Netherlands
| | - John Eisman
- Department of Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Medicine, The University of Notre Dame, Sydney, New South Wales, Australia
| | - Jacqueline R Center
- Department of Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Population Health, UNSW, Sydney, New South Wales, Australia
| | - Tuan V Nguyen
- Department of Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Biomedical Engineering, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Thach Tran
- Department of Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Dana Bliuc
- Department of Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Piet Geusens
- Department of Internal Medicine, Subdivision Rheumatology, Research School CAPHRI, Maastricht Univeristy Medical Centre, Maastricht, The Netherlands
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Joop P van den Bergh
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands
- Department of Internal Medicine, Research School NUTRIM, Maastricht University Medical Centre+, Maastricht, The Netherlands
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13
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Fracture liaison: A crucial tool in the fight against fragility fracture. Maturitas 2022; 165:26-32. [PMID: 35863271 DOI: 10.1016/j.maturitas.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/27/2022] [Accepted: 07/02/2022] [Indexed: 11/24/2022]
Abstract
Over the course of the first half of the 21st century the age structure of the human population will have undergone dramatic change, leading to what has been described by the Fragility Fracture Network and the International Osteoporosis Foundation as a new demographic era. In the absence of widespread implementation of systematic approaches to chronic disease management, and prevention and treatment of osteoporosis and fragility fractures in particular, fracture rates among older people will increase significantly by mid-century. The purpose of this narrative review is to characterise the current and projected burden of fragility fractures, evaluate current gaps in delivery of best clinical practice, and summarise the literature on the Fracture Liaison Service (FLS) model of care. A definition of FLS is provided, in addition to findings of systematic reviews and associated meta-analyses conducted to assess the clinical and economic benefits of FLS. Initiatives intended to enable benchmarking of the quality of care provided by FLS are reviewed, including the flagship International Osteoporosis Foundation Capture the Fracture® Programme and examples of national clinical standards for FLS from several countries. The emergence of national clinical registries to facilitate benchmarking against clinical standards is also considered. Finally, a precis is provided of several global and regional initiatives that aim to support changes in healthcare policy to provide funding, at scale, to support widespread implementation of FLS.
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14
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Okuda R, Osaki M, Saeki Y, Okano T, Tsuda K, Nakamura T, Morio Y, Nagashima H, Hagino H. Effect of coordinator-based osteoporosis intervention on quality of life in patients with fragility fractures: a prospective randomized trial. Osteoporos Int 2022; 33:1445-1455. [PMID: 35195752 DOI: 10.1007/s00198-021-06279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Abstract
UNLABELLED We examined the effects of the coordinator-based intervention on quality of life (QOL) in the aftermath of a fragility fracture, as well as factors predictive of post-fracture QOL. The coordinator-based interventions mitigated the decrease in QOL. Secondary fracture after primary fracture, however, was a significant predictor of lower QOL. PURPOSE This study aimed to determine the effects of the coordinator-based intervention on QOL in the aftermath of a fragility fracture, as well as factors predictive of post-fracture QOL, in an Asian population. METHODS Patients with new fractures in the intervention group received the coordinator-based intervention by a designated nurse certified as a coordinator, within 3 months of injury. QOL was evaluated using the Japanese version of the EuroQol 5 Dimension 5 Level (EQ-5D-5L) scale before the fracture (through patient recollections) and at 0.5, 1, and 2 years after the primary fracture. RESULTS Data for 141 patients were analyzed: 70 in the liaison intervention (LI) group and 71 in the non-LI group. Significant intervention effects on QOL were observed at 6 months after the fracture; the QOL score was 0.079 points higher in the LI group than in the non-LI group (p=0.019). Further, the LI group reported significantly less pain/discomfort at 2 years after the fracture, compared to the non-LI group (p=0.037). In addition, secondary fractures were found to significantly prevent improvement and maintenance of QOL during the recovery period (p=0.015). CONCLUSION Short-term intervention effects were observable 6 months after the primary fracture, with the LI group mitigated the decrease in QOL. Few patients in the LI group reported pain/discomfort 2 years after the fracture, but there is uncertainty regarding its clinical significance. Secondary fracture after initial injury was a significant predictor of lower QOL after a fracture.
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Affiliation(s)
- R Okuda
- School of Health Science, Faculty of Medicine, Tottori University, 86 Nishi-Cho, Yonago, Tottori, 683-8503, Japan.
| | - M Osaki
- Rehabilitation Division, Tottori University Hospital, Yonago, Tottori, Japan
| | - Y Saeki
- Orthopedic Surgery Hospital Ward, Tottori University Hospital, Yonago, Tottori, Japan
| | - T Okano
- Department of Orthopedic Surgery, San-in Rosai Hospital, Yonago, Tottori, Japan
| | - K Tsuda
- Department of Orthopedic Surgery, Saiseikai Sakaiminato General Hospital, Sakaiminato, Tottori, Japan
| | - T Nakamura
- Department of Orthopedic Surgery, Hakuai Hospital, Yonago, Tottori, Japan
| | - Y Morio
- Department of Orthopedic Surgery, Misasa Onsen Hospital, Misasa, Tottori, Japan
| | - H Nagashima
- Department of Orthopedic Surgery, Tottori University, Yonago, Tottori, Japan
| | - H Hagino
- School of Health Science, Faculty of Medicine, Tottori University, 86 Nishi-Cho, Yonago, Tottori, 683-8503, Japan
- Rehabilitation Division, Tottori University Hospital, Yonago, Tottori, Japan
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15
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Cailleaux PE, Cohen-Solal M. Managing Musculoskeletal and Kidney Aging: A Call for Holistic Insights. Clin Interv Aging 2022; 17:717-732. [PMID: 35548383 PMCID: PMC9081621 DOI: 10.2147/cia.s357501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Martine Cohen-Solal
- Inserm UMR-S 1132 Bioscar, Université Paris Cité - Hôpital Lariboisiere, Paris, F-75010, France
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16
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García-Sempere A, Hurtado I, Peiró S, Sánchez-Sáez F, Santaana Y, Rodríguez-Bernal C, Sanfélix-Gimeno G, Sanfélix-Genovés J. Predictive Performance of the FRAX Tool Calibrated for Spain vs. an Age and Sex Model: Prospective Cohort Study with 9082 Women and Men Followed for up to 8 Years. J Clin Med 2022; 11:jcm11092409. [PMID: 35566539 PMCID: PMC9101808 DOI: 10.3390/jcm11092409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
In Spain, the Fracture Risk Assessment Tool (FRAX) was adapted using studies with a small number of patients, and there are only a few external validation studies that present limitations. In this prospective cohort study, we compared the performance of FRAX and a simple age and sex model. We used data from the ESOSVAL cohort, a cohort composed of a Mediterranean population of 11,035 women and men aged 50 years and over, followed for up to 8 years, to compare the discrimination, calibration, and reclassification of FRAX calibrated for Spain and a logistic model including only age and sex as variables. We found virtually identical AUC, 83.55% for FRAX (CI 95%: 80.46, 86.63) and 84.10% for the age and sex model (CI 95%: 80.91, 87.29), and there were similar observed-to-predicted ratios. In the reclassification analyses, patients with a hip fracture that were reclassified correctly as high risk by FRAX, compared to the age and sex model, were −2.86%, using either the 3% threshold or the observed incidence, 1.54% (95%CI: −8.44, 2.72 for the 3% threshold; 95%CI: −7.68, 1.97 for the incidence threshold). Remarkably simple and inexpensive tools that are easily transferable into electronic medical record environments may offer a comparable predictive ability to that of FRAX.
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Affiliation(s)
- Aníbal García-Sempere
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Isabel Hurtado
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Salvador Peiró
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Francisco Sánchez-Sáez
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
| | - Yared Santaana
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
| | - Clara Rodríguez-Bernal
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
- Correspondence:
| | - José Sanfélix-Genovés
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
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Blaker K, Wijewardene A, White E, Stokes G, Chong S, Ganda K, Ridley L, Brown S, White C, Clifton-Bligh R, Seibel MJ. Electronic search programs are effective in identifying patients with minimal trauma fractures. Osteoporos Int 2022; 33:435-441. [PMID: 34510231 DOI: 10.1007/s00198-021-06105-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/16/2021] [Indexed: 11/24/2022]
Abstract
UNLABELLED We assessed two electronic search tools that screen medical records for documented fractures. Both programs reliably identified patients with any fracture but missed individuals with minimal trauma fracture to different degrees. A hybrid tool combining the methodology of both tools is likely to improve the identification of those with osteoporosis. PURPOSE Most patients who suffer a minimal trauma fracture remain undiagnosed, placing them at high risk of refracture. Case finding can be improved by electronic search tools that screen medical records for documented fractures. Here, we assessed the efficacy of two new programs, AES and XRAIT, in identifying patients with minimal trauma fracture. METHODS Each tool was applied to search the electronic medical record and/or radiology reports at two tertiary hospitals in Sydney, Australia, from 1 July to 31 December 2018. Samples of the extracted reports were then manually reviewed to determine the sensitivity of each program in detecting minimal trauma fractures. RESULTS At the two centers, AES detected 872 and 1364 cases, whereas XRAIT identified 1414 and 2180 patients with fractures, respectively. The true positive rate for "any fracture" was similar for both instruments (77-88%). However, the ability to detect "minimal trauma fractures" differed between programs and centers (53-75% accuracy), with each tool identifying separate subsets of patients. Concordance between both tools was less than half of the combined total number of minimal trauma fractures (43-45%). Considering the total number of minimal trauma fractures detected by both tools combined, AES correctly identified 52-55% of cases while XRAIT identified 88-93% of cases. CONCLUSION Both programs reliably identified patients with any fracture but missed individuals with minimal trauma fracture to different degrees. Hybrid tools combining the methodology of XRAIT and AES are likely to improve the identification of patients who require investigation and treatment for osteoporosis.
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Affiliation(s)
- K Blaker
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
| | - A Wijewardene
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - E White
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - G Stokes
- Department of Endocrinology & Metabolism, Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - S Chong
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
| | - K Ganda
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, 2006, Australia
- Bone Research Program, ANZAC Research Institute, Concord, NSW, 2139, Australia
| | - L Ridley
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, 2006, Australia
- Department of Radiology, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
| | - S Brown
- Abbot Diagnostics, Macquarie Park, NSW, 2113, Australia
| | - C White
- Department of Endocrinology & Metabolism, Prince of Wales Hospital, Randwick, NSW, 2031, Australia
| | - R Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, 2006, Australia
| | - M J Seibel
- Department of Endocrinology & Metabolism, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, 2006, Australia
- Bone Research Program, ANZAC Research Institute, Concord, NSW, 2139, Australia
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Chevalley T, Brandi ML, Cavalier E, Harvey NC, Iolascon G, Cooper C, Hannouche D, Kaux JF, Kurth A, Maggi S, Maier G, Papavasiliou K, Al-Daghri N, Sosa-Henríquez M, Suhm N, Tarantino U, Reginster JY, Rizzoli R. How can the orthopedic surgeon ensure optimal vitamin D status in patients operated for an osteoporotic fracture? Osteoporos Int 2021; 32:1921-1935. [PMID: 34013461 PMCID: PMC8134831 DOI: 10.1007/s00198-021-05957-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/09/2021] [Indexed: 12/19/2022]
Abstract
In this narrative review, the role of vitamin D deficiency in the pathophysiology, healing of fragility fractures, and rehabilitation is discussed. Vitamin D status can be assessed by measuring serum 25(OH)-vitamin D level with standardized assays. There is a high prevalence of vitamin D insufficiency (25(OH)D < 50 nmol/l (i.e., 20 ng/mL)) or deficiency (25(OH)D < 25 nmol/l (i.e., 10 ng/mL)) in patients with fragility fractures and especially in those with a hip fracture. The evidence on the effects of vitamin D deficiency and/or vitamin D supplementation on fracture healing and material osseointegration is still limited. However, it appears that vitamin D have a rather positive influence on these processes. The fracture liaison service (FLS) model can help to inform orthopedic surgeons, all caregivers, and fractured patients about the importance of optimal vitamin D status in the management of patients with fragility fractures. Therefore, vitamin D status should be included in Capture the Fracture® program as an outcome of FLS in addition to dual-energy X-ray absorptiometry (DXA) and specific antiosteoporosis medication. Vitamin D plays a significant role in the pathophysiology and healing of fragility fractures and in rehabilitation after fracture. Correction of vitamin D deficiency should be one of the main outcomes in fracture liaison services.
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Affiliation(s)
- T Chevalley
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - M L Brandi
- Metabolic Bone Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - E Cavalier
- Department of Clinical Chemistry, University of Liege, CHU de Liege, Liege, Belgium
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - G Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- UKNIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - D Hannouche
- Service of Orthopaedics and Trauma Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - J-F Kaux
- Department of Physical Medicine and Rehabilitation, University and University Hospital of Liège, Liège, Belgium
| | - A Kurth
- Department of Orthopaedic and Trauma Surgery, Campus Kemperhof, Community Clinics Middle Rhine, Koblenz, Germany
| | - S Maggi
- CNR Aging Branch-IN, Padua, Italy
| | - G Maier
- Department of Orthopaedic and Rheumatological Rehabilitation, Rehazentrum am Meer, Bad Zwischenahn, Germany
| | - K Papavasiliou
- 3rd Orthopaedic Department, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, Thessaloniki, Greece
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science King Saud University, Riyadh, 11451, Saudi Arabia
| | - M Sosa-Henríquez
- University Institute of Investigation on Biomedical Sciences (IUIBMS), University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain
- Bone Metabolic Unit, Hospital University Insular, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - N Suhm
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - U Tarantino
- Department of Clinical Sciences and Translational Medicine, Faculty of Medicine and Surgery, Tor Vergata University of Rome, Via Montpellier 1, 00133, Rome, Italy
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - R Rizzoli
- Service of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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19
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Javaid MK. Efficacy and efficiency of fracture liaison services to reduce the risk of recurrent osteoporotic fractures. Aging Clin Exp Res 2021; 33:2061-2067. [PMID: 34047929 PMCID: PMC8302543 DOI: 10.1007/s40520-021-01844-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/19/2021] [Indexed: 12/15/2022]
Abstract
Background Acting to prevent the next fracture after a sentinel fracture is support by the evidence base and brings benefits for patients, clinicians and healthcare systems. However, more patients after a fragility fracture remain untreated and vulnerable to future potentially life-changing fractures. Fracture liaison services (FLS) are models of care that can close this care gap. Methods A narrative review of the key evidence for the efficacy and effectiveness of FLS was performed Results There are few randomised control trials of FLSs and none with fracture as the primary outcome. Several observational studies have also demonstrated reductions in fracture, but most were limited by potential bias. Several studies have highlighted that not every FLS is automatically effective. Conclusion Further research should focus on implementing effective FLS using published standards and only then exploring impacts on patient outcomes such as refracture rates.
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Affiliation(s)
- M K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
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20
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Jones AR, Herath M, Ebeling PR, Teede H, Vincent AJ. Models of care for osteoporosis: A systematic scoping review of efficacy and implementation characteristics. EClinicalMedicine 2021; 38:101022. [PMID: 34345811 PMCID: PMC8319463 DOI: 10.1016/j.eclinm.2021.101022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Osteoporosis affects over half of adults over 50 years worldwide. With an ageing population, osteoporosis, fractures and their associated costs are increasing. Unfortunately, despite effective therapies, many with osteoporosis remain undiagnosed and untreated. Models of care (MoC) to improve outcomes include fracture liaison services, screening, education, and exercise programs, however efficacy for these is mixed. The aim of this study is to summarise MoC in osteoporosis and describe implementation characteristics and evidence for improving outcomes. METHODS This systematic scoping review identified articles via Ovid Medline and Embase, published in English between 01/01/2009 and 15/06/2021, describing MoC for adults aged ≥18 years with, or at risk of, osteoporosis and / or health professionals caring for this group. All included at least one of clinical, consumer or clinician outcomes, with fractures and bone mineral density (BMD) change the primary clinical outcomes. Exclusion criteria were studies assessing pharmaceuticals or procedures without other interventions, or insufficient operational details. All study designs were included, with no comparator necessary. Title and abstract were reviewed by two reviewers. Full text review and data extraction was performed by these reviewers for 20% of article and, thereafter by a single author. As the review was predominantly descriptive, no comparator statistics were used. FINDINGS 314 articles were identified describing 289 MoC with fracture liaison services (n=89) and education programs (n=86) predominating. The population had prior fragility fracture in 77 studies, the median (IQR) patient number was 210 (87, 667) and the median (IQR) follow-up duration for outcome assessment was 12 (6, 12·5) months. Fracture reduction was reported by 65 studies, with 16 (37%) graded as high quality, and 19 / 47 studies with a comparator group found a reduction in fractures. BMD change was reported by 73 studies, with 41 finding improved BMD. Implementation characteristics including reach, fidelity and loss to follow-up were under-reported, and consumer and clinician perspectives rare. INTERPRETATION This comprehensive review of MoC for osteoporosis demonstrated inconsistent evidence for improving outcomes despite similar types of models. Future studies should include implementation outcomes, consumer and clinician perspectives, and fracture or BMD outcomes with sufficient duration of follow-up. Authors should consider pragmatic trial designs and co-design with clinicians and consumers.
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Affiliation(s)
- Alicia R Jones
- Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia
- Department of Endocrinology, Monash Health, Melbourne, Australia
| | - Madhuni Herath
- Department of Endocrinology, Monash Health, Melbourne, Australia
- Hudson Institute of Medical Research, Melbourne, Australia
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, Melbourne, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia
- Department of Endocrinology, Monash Health, Melbourne, Australia
| | - Amanda J Vincent
- Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia
- Department of Endocrinology, Monash Health, Melbourne, Australia
- Corresponding author at: Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia.
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21
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Which patients are at risk for not receiving anti-osteoporosis treatment following hip fracture?: An ACS NSQIP analysis. J Clin Orthop Trauma 2021; 17:169-175. [PMID: 33854944 PMCID: PMC8039719 DOI: 10.1016/j.jcot.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/15/2021] [Accepted: 03/10/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Screening and management of osteoporosis is often only considered by providers when patients present with multiple fragility fractures. The objective was to determine which patients are at risk for not receiving anti-osteoporotic medication and screening immediately following open reduction internal fixation (ORIF) for hip fracture. METHODS The 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture Database was queried to identify patients ≥ 50 years old who underwent ORIF of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures. Patients with concurrent polytrauma, malignancy, and other fragility fractures were excluded. Patients taking osteoporotic medications immediately prior to hospitalization were excluded to prevent an overlap in the screening and/or antiresorptive medication initiation rates. Multi-variate logistic regression was used to assess for factors associated with not receiving anti-osteoporotic medication immediately postoperatively. RESULTS A total of 6179 patients were identified of whom 3304 (53.5%) were treated at a facility with a documented standardized hip fracture care program. Only 28.5% (N = 1766) patients received anti-osteoporosis medication immediately following ORIF. Independent factors associated with increased odds of not initiating bone protective medication were those without a standardized hip fracture care program (odds ratio [OR] 1.80 [1.58-2.06], P < 0.001), length of stay ≤ 5 days (odds ratio [OR] 1.47 [1.28-1.69], P < 0.001), patients waiting > 1 day until operation (odds ratio [OR] 1.35 [1.13-1.60], P = 0.001), patients requiring a mobility aid preoperatively (odds ratio [OR] 1.29 [1.13-1.47], P < 0.001), and patients who could not weight bear as tolerated (WBAT) on postoperative day 1 (POD 1) (odds ratio [OR] 1.25 [1.06-1.47], P = 0.008). CONCLUSION Patients starting anti-osteoporotic medication immediately following a hip fracture in the United States remains low (28.5%). Standardized hip fracture care programs have the greatest impact with regards to initiating anti-osteoporotic medication following hip fracture.
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22
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Pasquale MK, Sheer RL, Yehoshua A, McFadden A, Chines A, Caloyeras J. Evaluation of an Osteoporosis Outreach Program for Men With a Fragility Fracture and Their Physicians. Med Care 2021; 59:148-154. [PMID: 33273290 PMCID: PMC7899217 DOI: 10.1097/mlr.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many health plans have outreach programs aimed at appropriately screening, evaluating, and treating women experiencing fragility fractures; however, few programs exist for men. OBJECTIVE The objective of this study was to develop, implement, and evaluate an osteoporosis outreach program for men with a recent fragility fracture and their physicians. RESEARCH DESIGN AND SUBJECTS A total of 10,934 male patients enrolled in a Medicare Advantage with Prescription Drug Plan with a recent fragility fracture were randomized to a program or control group. Patients and their physicians received letters followed by phone calls on osteoporosis and the importance of screening and treatment. The evaluation compared bone mineral density (BMD) test utilization and osteoporosis medication treatment (OPT) among patients who received the outreach versus no outreach at 12 months. The effect of the program was estimated through univariate and multivariable logistic regressions. RESULTS The program had a significant impact on BMD evaluation and OPT initiation. At 12 months, 10.7% of participants and 4.9% of nonparticipants received a BMD evaluation. The odds ratio (OR) (95% confidence interval) was 2.31 (1.94, 2.76), and the number needed to outreach to receive a BMD test was 18. OPT was initiated in 4.0% of participants and 2.5% of nonparticipants. The OR (95% confidence interval) of receiving OPT was 1.60 (1.24, 2.07), and the number needed to outreach was 69. Adjusted ORs were similar in magnitude and significance. CONCLUSION The program was highly effective by more than doubling the rate of BMD evaluation; however, more intensive interventions may yield an even higher screening rate.
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23
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Cattelain-Lopez E, Chu Miow Lin D, Happe A, Goupille P, Oger E, Mulleman D. Poor assessment of bone mineral density after a forearm fracture in women aged 50 years or older: Data from a French health insurance database. Joint Bone Spine 2021; 88:105121. [PMID: 33485155 DOI: 10.1016/j.jbspin.2020.105121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Elsa Cattelain-Lopez
- Université de Tours, 37000 Tours, France; Service de rhumatologie, CHRU de Tours, 37044 Tours cedex 9, France
| | - Delphine Chu Miow Lin
- Université de Tours, 37000 Tours, France; Service de rhumatologie, CHRU de Tours, 37044 Tours cedex 9, France
| | - André Happe
- UPRES-EA 7449 REPERES, CHRU de Brest, 29200 Brest, France
| | - Philippe Goupille
- Université de Tours, 37000 Tours, France; Service de rhumatologie, CHRU de Tours, 37044 Tours cedex 9, France
| | - Emmanuel Oger
- Centre régional de pharmacovigilance, pharmaco-épidémiologie et information sur le médicament, CHRU de Rennes, 35000 Rennes, France; UPRES-EA 7449 REPERES, Université de Rennes 1, 35000 Rennes, France
| | - Denis Mulleman
- Université de Tours, 37000 Tours, France; Service de rhumatologie, CHRU de Tours, 37044 Tours cedex 9, France.
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24
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Barton DW, Piple AS, Smith CT, Moskal SA, Carmouche JJ. The Clinical Impact of Fracture Liaison Services: A Systematic Review. Geriatr Orthop Surg Rehabil 2021; 12:2151459320979978. [PMID: 33489430 PMCID: PMC7809296 DOI: 10.1177/2151459320979978] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023] Open
Abstract
Introduction: A fracture liaison service (FLS) is a coordinated system of care that streamlines osteoporosis management in the orthopaedic setting and can serve as an effective form of secondary preventative care in these patients. The present work reviews the available evidence regarding the impact of fracture liaison services on clinical outcomes. Methods: The literature was reviewed for studies reporting changes in the rates of bone mineral density scanning (DXA), antiresorptive therapy, new minimum trauma fractures, and mortality between cohorts with access to an FLS or not. Studies including intention to treat level data were retained. A Medline search for “fracture liaison” OR “secondary fracture prevention” produced 146 results, 98 were excluded based on the abstract, 38 were excluded based on full-text review. Ten level III studies encompassing 48,045 patients were included, of which 5 studies encompassing 7,086 were analyzed. Odds-ratios for DXA and anti-osteoporosis pharmacotherapy rates were calculated from data. Fixed and random effects analyses were performed using the Mantel-Haenszel method. Results: Four studies reported, on average, a 6-fold improvement in DXA scanning rates (Figure 1). Six studies reported, on average, a 3-fold improvement in antiresorptive therapy rates (Figure 2). Four large studies reported significant reductions in the rate of new fractures using time-dependent Cox proportional hazards models at 12 months (HR = 0.84, 0.95), 24 months (HR = 0.44, 0.65), and 36 months (HR = 0.67). Five large studies reported mortality improvements using time-dependent Cox proportional hazards models at 12 months (HR = 0.88, 0.84, 0.81) and 24 months (HR = 0.65, 0.67). Conclusions: The findings suggest that fracture liaison services improve rates of DXA scanning and antiresorptive therapy as well as reductions in the rates of new fractures and mortality among patients seen following minimum trauma fractures across many time points.
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Affiliation(s)
- David W Barton
- Department of Orthopaedic Surgery, University of Florida College of Medicine, Jacksonville, Florida, FL, USA
| | - Amit S Piple
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - C Taylor Smith
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Sterling A Moskal
- Department of Biology, Wake Forest University, Winston-Salem, NC, USA
| | - Jonathan J Carmouche
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Department of Orthopaedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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25
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Cha YH, Ha YC, Park KS, Yoo JI. What is the Role of Coordinators in the Secondary Fracture Prevention Program? J Bone Metab 2020; 27:187-199. [PMID: 32911583 PMCID: PMC7571241 DOI: 10.11005/jbm.2020.27.3.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
Background The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs. Methods A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study. Results At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families. Conclusions The coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.
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Affiliation(s)
- Yong Han Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ki-Soo Park
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Jun-Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
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26
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Ebeling PR, Chan DC, Lau TC, Lee JK, Songpatanasilp T, Wong SH, Hew FL, Sethi R, Williams M. Secondary prevention of fragility fractures in Asia Pacific: an educational initiative. Osteoporos Int 2020; 31:805-826. [PMID: 31788717 DOI: 10.1007/s00198-019-05197-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
Abstract
The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.
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Affiliation(s)
- P R Ebeling
- Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash Health, Translational Research Facility, Level 7, 246 Clayton Rd, Clayton, VIC, 3168, Australia.
| | - D-C Chan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Superintendent Office, Chutung Branch, National Taiwan University Hospital, Hsinchu, Taiwan
| | - T C Lau
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - J K Lee
- Department of Orthopedic Surgery, Beacon International Specialist Centre, Petaling Jaya, Selangor, Malaysia
| | - T Songpatanasilp
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - S H Wong
- Department of Orthopaedics, International Medical Centre, Central, Hong Kong
| | - F L Hew
- Puchong Medical Specialist Centre, Puchong, Selangor, Malaysia
- Sime Darby Medical Centre, Subang Jaya, Selangor, Malaysia
| | - R Sethi
- Amgen Asia Holding Limited, Hong Kong, Hong Kong
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Mugnier B, Daumas A, Doddoli S, Belmeliani S, Couderc AL, Mizzi B, Lévêque P, Villani P. Adherence to fracture liaison service programs in patients over 70: the hidden part of the iceberg. Osteoporos Int 2020; 31:765-774. [PMID: 31927612 DOI: 10.1007/s00198-020-05290-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/06/2020] [Indexed: 10/25/2022]
Abstract
UNLABELLED Significant dropout rates have been observed throughout Fracture Liaison Service (FLS) programs, especially for elderly patients. In an FLS program set up specifically for patients over 70, the non-initiation of osteoporosis treatment was the only factor associated with poor adherence to the program. Neither age nor frailty factors affected adherence. INTRODUCTION FLS programs are considered the most effective interventions for secondary prevention of osteoporotic fractures. Our objective was to identify risk factors for non-adherence to an FLS program set up specifically for patients over 70. METHODS Our multifaceted, intensive program included five appointments over a 2-year period. One hundred sixty-seven patients (mean age 83.5 years) who presented with a recent fragility fracture were enrolled. Multivariable analysis was conducted to determine whether the demographic, clinical, frailty, and osteoporotic risk factors of the patients influenced their adherence to the program. RESULTS About half of the patients did not attend the follow-up visits. According to the regression analysis, non-initiation of osteoporosis treatment was associated with poor adherence to the program (aHR 3.66). Demographic, clinical, dwelling, frailty factors, osteoporotic risk factors, fracture type, or densitometric scores were not associated with adherence. The first self-reported reason for withdrawal was the difficulty of attending several follow-up visits, and the second was the feeling of not being concerned. CONCLUSION We observed that non-initiation of osteoporosis treatment was the only factor correlated with non-adherence to an FLS program. Thus, neither age nor frailty factors should result in patients not being included in FLS. Beyond the necessity of the osteoporosis treatment, good patient understanding of the relevance of all the interventions included in the program is the key.
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Affiliation(s)
- B Mugnier
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France.
| | - A Daumas
- APHM, Hôpital La Timone, Service de Médecine Interne Gériatrie et Thérapeutique, 264 rue Saint Pierre, 13005, Marseille, France
| | - S Doddoli
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France
| | - S Belmeliani
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France
| | - A-L Couderc
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France
| | - B Mizzi
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France
| | - P Lévêque
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France
| | - P Villani
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, 270 Bd de Sainte Marguerite, 13009, Marseille, France
- APHM, Hôpital La Timone, Service de Médecine Interne Gériatrie et Thérapeutique, 264 rue Saint Pierre, 13005, Marseille, France
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Frost SA, Kelly A, Gaudin J, Evoy LM, Wilson C, Marov L, El Haddad C, Center J, Eisman JA, Nguyen TV, Hassett G. Establishing baseline absolute risk of subsequent fracture among adults presenting to hospital with a minimal-trauma-fracture. BMC Musculoskelet Disord 2020; 21:133. [PMID: 32111200 PMCID: PMC7049191 DOI: 10.1186/s12891-020-3161-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 02/24/2020] [Indexed: 11/16/2022] Open
Abstract
Background One in three women and one in five men are expected to experience a minimal-trauma-fracture after the age of 50-years, which increases the risk of subsequent fracture. Importantly, timely diagnosis and optimal treatment in the form of a fracture liaison service (FLS), has been shown to reduce this risk of a subsequent fracture. However, baseline risk of subsequent fracture among this group of FLS patients has not been well described. Therefore, this study aims to estimate absolute risk of subsequent fracture, among women and men aged 50-years or more, presenting to hospital with a minimal-trauma-fracture. Methods Women and men aged 50-years or more with a minimal-trauma-fracture, presenting to hospitals across the South Western Sydney Local Health District between January 2003 and December 2017 were followed to identify subsequent fracture presentations to hospital. Absolute risk of subsequent fracture was estimated, by taking into account the competing risk of death. Results Between January 2003 and December 2017–15,088 patients presented to the emergency departments of the five hospitals in the SWSLHD (11,149, women [74%]), with minimal-trauma-fractures. Subsequent fractures identified during the follow-up period (median = 4.5 years [IQR, 1.6–8.2]), occurred in 2024 (13%) patients. Death during the initial hospital stay, or during a subsequent hospital visit was recorded among 1646 patients (11%). Women were observed to have 7.1% risk of subsequent fracture after 1-year, following an initial fracture; and, the risk of subsequent fracture after 1-year was 6.2% for men. After 5-years the rate among women was 13.7, and 11.3% for men, respectively. Cumulative risk of subsequent fracture when initial fractures were classified as being at proximal or distal sites are also presented. Conclusion This study has estimated the baseline risk of subsequent fracture among women and men presenting to hospital with minimal trauma fractures. Importantly, this information can be used to communicate risk to patients deciding to attend an osteoporosis refracture prevention clinic, and highlight the need for screening, and initial of treatment when indicated, once a minimal-trauma-fracture has occurred.
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Affiliation(s)
- Steven A Frost
- SPHERE MSK Clinical Academic Group, Sydney, Australia. .,South Western Sydney Centre for Applied Nursing Research, Ingham Institute of Applied Medical Research, Sydney, NSW, Australia. .,Western Sydney University, Sydney, Australia. .,Faculty of Medicine, UNSW Sydney, Sydney, Australia. .,Garvan Institute of Medical Research, Darlinghurst, Australia. .,Centre for Applied Nursing Research, Ingham Institute of Applied Medical Research, South Western Sydney Local Health District (SWSLHD), Sydney, Australia.
| | - Ayano Kelly
- SPHERE MSK Clinical Academic Group, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
| | - Julia Gaudin
- SPHERE MSK Clinical Academic Group, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
| | | | | | | | - Carlos El Haddad
- Western Sydney University, Sydney, Australia.,Liverpool Hospital, Sydney, Australia.,Campbelltown Hospital, Sydney, Australia
| | - Jacqueline Center
- SPHERE MSK Clinical Academic Group, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia.,Garvan Institute of Medical Research, Darlinghurst, Australia
| | - John A Eisman
- SPHERE MSK Clinical Academic Group, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia.,Garvan Institute of Medical Research, Darlinghurst, Australia.,St Vincent's Hospital, Sydney, Australia.,School of Medicine, University of Notre Dame Australia, Sydney, Australia.,Visiting Professor, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, Netherlands
| | - Tuan V Nguyen
- SPHERE MSK Clinical Academic Group, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia.,Garvan Institute of Medical Research, Darlinghurst, Australia.,University of Technology Sydney, Sydney, NSW, Australia
| | - Geraldine Hassett
- SPHERE MSK Clinical Academic Group, Sydney, Australia.,Faculty of Medicine, UNSW Sydney, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
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MacRae T, Shofler DW. Integration of Podiatric Medicine Within the Fracture Liaison Services Model. J Am Podiatr Med Assoc 2020; 110:Article6. [PMID: 32073324 DOI: 10.7547/18-118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Underlying bone metabolic disorders are often neglected when managing acute fractures. The term fracture liaison services (FLS) refers to models of care with the designated responsibility of comprehensive fracture management, including the diagnosis and treatment of osteoporosis. Although there is evidence of the effectiveness of FLS in reducing health-care costs and improving patient outcomes, podiatric practitioners are notably absent from described FLS models. The integration of podiatric practitioners into FLS programs may lead to improved patient care and further reduce associated health-care costs.
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Affiliation(s)
| | - David W. Shofler
- Western University of Health Sciences, College of Podiatric Medicine, Pomona, CA
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Mitchell PJ, Cooper C, Fujita M, Halbout P, Åkesson K, Costa M, Dreinhöfer KE, Marsh DR, Lee JK, Chan DCD, Javaid MK. Quality Improvement Initiatives in Fragility Fracture Care and Prevention. Curr Osteoporos Rep 2019; 17:510-520. [PMID: 31734907 DOI: 10.1007/s11914-019-00544-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This review sought to describe quality improvement initiatives in fragility fracture care and prevention. RECENT FINDINGS A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance. Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.
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Affiliation(s)
- Paul J Mitchell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
- School of Medicine, Sydney Campus, The University of Notre Dame Australia, 140 Broadway, Sydney, NSW, 2007, Australia.
- Fragility Fracture Network, c/o MCI Schweiz AG, Schaffhauserstrasse 550, 8052, Zürich, Switzerland.
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- International Osteoporosis Foundation, 9 rue Juste-Olivier, CH-1260, Nyon, Switzerland
| | - Masaki Fujita
- International Osteoporosis Foundation, 9 rue Juste-Olivier, CH-1260, Nyon, Switzerland
| | - Philippe Halbout
- International Osteoporosis Foundation, 9 rue Juste-Olivier, CH-1260, Nyon, Switzerland
| | - Kristina Åkesson
- International Osteoporosis Foundation, 9 rue Juste-Olivier, CH-1260, Nyon, Switzerland
- Department of Orthopaedics, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Matthew Costa
- Fragility Fracture Network, c/o MCI Schweiz AG, Schaffhauserstrasse 550, 8052, Zürich, Switzerland
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Karsten E Dreinhöfer
- Fragility Fracture Network, c/o MCI Schweiz AG, Schaffhauserstrasse 550, 8052, Zürich, Switzerland
- Department of Musculoskeletal Rehabilitation, Prevention and Health Service Research, Center for Sport Science and Sport Medicine (CSSB), Center for Musculoskeletal Surgery (CMSC), Charité Universitätsmedizin, Berlin, Germany
- Department of Orthopedics and Traumatology, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - David R Marsh
- Fragility Fracture Network, c/o MCI Schweiz AG, Schaffhauserstrasse 550, 8052, Zürich, Switzerland
- University College London, Gower St, Bloomsbury, London, WC1E 6BT, UK
| | - Joon-Kiong Lee
- Department of Orthopedic Surgery, Beacon International Specialist Centre, Petaling Jaya, Selangor, Malaysia
- Advanced Neuroscience and Orthopedic Centre (ANOC), Kuala Lumpur, Malaysia
| | - Ding-Cheng Derrick Chan
- Department of Geriatrics and Gerontology and Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Superintendent Office, Chutung Branch, National Taiwan University Hospital, Hsinchu County, Taiwan
| | - M Kassim Javaid
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- International Osteoporosis Foundation, 9 rue Juste-Olivier, CH-1260, Nyon, Switzerland
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31
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Singh S, Whitehurst DG, Funnell L, Scott V, MacDonald V, Leung PM, Friesen K, Feldman F. Breaking the cycle of recurrent fracture: implementing the first fracture liaison service (FLS) in British Columbia, Canada. Arch Osteoporos 2019; 14:116. [PMID: 31776684 DOI: 10.1007/s11657-019-0662-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 10/21/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Fractures occurring with very little trauma are often caused by osteoporosis and can lead to disability. This study demonstrates that a coordinator working with an orthopaedic team can significantly increase the number of individuals receiving appropriate treatments during their after-fracture care to prevent future fractures from occurring. PURPOSE Well-implemented Fracture Liaison Service (FLS) programs increase appropriate investigation and treatment for osteoporosis after low trauma fracture. This research evaluates the effectiveness of the first FLS program implemented in British Columbia (BC), Canada. METHODS A controlled before-and-after study was conducted. The intervention was an FLS program implemented at an orthopaedic outpatient clinic at Peace Arch Hospital in BC. Eligible patients were those over the age of 50 years with a low trauma fracture of the hip, pelvis, vertebra, wrist or humerus. A nurse practitioner FLS coordinator identified, investigated and initiated treatment in patients based on their future fracture risk. The primary outcome was the percentage of all patients at high-risk to refracture, who achieved at least one of the following outcomes: (1) started on osteoporosis medication, (2) referred to an osteoporosis consultant or (3) assessed for treatment change if they were already on osteoporosis medication at the time of the fracture. Secondary outcomes included the rate of bone density testing, referral to fall prevention programs and change in health-related quality of life over 6 months. RESULTS A total of 195 patients participated in the study (65 in the usual care group, 130 in the FLS group). Average age was 70.5 years (standard deviation 11.5), and 84% of participants were female. In the FLS group, 77.8% of high-risk patients achieved the primary outcome compared with 22.9% in the usual care group. CONCLUSION In BC, the implementation of an FLS program improved investigation and treatment for osteoporosis after low trauma fracture.
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Affiliation(s)
- Sonia Singh
- Fraser Health Authority, Surrey, British Columbia, Canada. .,Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada. .,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - David Gt Whitehurst
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | | | - Vicky Scott
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Pet-Ming Leung
- Fraser Health Authority, Surrey, British Columbia, Canada
| | | | - Fabio Feldman
- Fraser Health Authority, Surrey, British Columbia, Canada.,Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
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Sujic R, Beaton DE, Mamdani M, Cadarette SM, Luo J, Jaglal S, Sale JEM, Jain R, Bogoch E. Five-year refracture rates of a province-wide fracture liaison service. Osteoporos Int 2019; 30:1671-1677. [PMID: 31152183 DOI: 10.1007/s00198-019-05017-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 05/14/2019] [Indexed: 11/26/2022]
Abstract
UNLABELLED We examined the 5-year refracture rate of 6543 patients and found an overall rate of 9.7%. Adjusted analysis showed that presenting with multiple fractures was an indicator of a higher refracture risk; while presenting with an ankle fracture was associated with a lower refracture risk. INTRODUCTION To examine refractures among patients screened in a province-wide fracture liaison service (FLS). METHODS We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates. RESULTS The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50-65 age group, refracture risk increased monotonically with age group (66-70 years: HR = 1.3, CI 95%, 1.0-1.7; 71-80 years: HR = 1.7, CI 1.4-2.1; 81+ years: HR = 3.0, CI 2.4-3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6-3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6-0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0-1.5). CONCLUSIONS One in ten patients in our cohort refractured within 5 years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.
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Affiliation(s)
- R Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
| | - D E Beaton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Work & Health, Toronto, ON, Canada
| | - M Mamdani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Centre for Healthcare Analytics Research & Training, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - S M Cadarette
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - J Luo
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - S Jaglal
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Toronto Rehabilitation Institute - University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - R Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
| | - E Bogoch
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Mobility Program, St. Michael's Hospital, Toronto, ON, Canada
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Ma X, Xia H, Wang J, Zhu X, Huang F, Lu L, He L. Re-fracture and correlated risk factors in patients with osteoporotic vertebral fractures. J Bone Miner Metab 2019; 37:722-728. [PMID: 30465091 DOI: 10.1007/s00774-018-0974-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023]
Abstract
Re-fracture risk is higher following osteoporotic fracture. However, there is no accurately reported rate of re-fracture incidence in southwest China. The purpose of this study was to describe the osteoporotic vertebral fracture (OVF) survival for re-fracture state and analyze the risk of re-fracture. This historical cohort study was conducted in four hospitals in southwest China. Patients aged ≥ 50 years (n = 586) with OVF who were supposed to receive anti-osteoporosis drugs after the fracture were included (2012-2017). Telephone follow-up and referring case files were used to estimate the survival for re-fracture and identify the determinants of re-fracture. A total of 555 patients completed the follow-up investigation. Overall, 285 patients experienced a re-fracture, and the longest follow-up investigation time was 72 months. The survival rates for re-fracture at 12 months, 24 months, 36 months, and 48 months were 82.0%, 71.5%, 61.7%, and 34.0%, respectively. The factors correlated with re-fracture hazard were advanced age [hazard ratio (HR) = 1.996], being female (HR = 1.342), smoking (HR = 1.435), history of hypertension (HR = 1.219) and diabetes (HR = 3.271), and persistence of taking anti-osteoporosis drugs after fracture [0-3 months, 4-6 months, 7-12 months, and more than 12 months (HR = 0.703)]. OVF patients with advanced age, who were female, smoked, had fracture with hypertension or diabetes, and who complied poorly with anti-osteoporosis drug treatment presented higher prevalence of re-fracture and low anti-osteoporosis adherence in southwest China. The management of anti-osteoporosis after fracture is necessary in this area.
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Affiliation(s)
- Xinling Ma
- School of Nursing, Fudan University, Shanghai, 200032, China
| | - Haiou Xia
- School of Nursing, Fudan University, Shanghai, 200032, China.
| | - Jinhua Wang
- Youjiang Medical University for Nationalities, Baise, 533000, China
- West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Sichuan, 610041, China
| | - Xiaoxiao Zhu
- School of Nursing, Fudan University, Shanghai, 200032, China
| | - Fangyan Huang
- Youjiang Medical University for Nationalities, Baise, 533000, China
| | - Liuxue Lu
- The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China
| | - Lanyan He
- The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, 533000, China
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Evaluation of the need for a fracture liaison service in a patient-centered medical home. J Am Pharm Assoc (2003) 2019; 59:565-569. [PMID: 30948237 DOI: 10.1016/j.japh.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the need for a fracture liaison service (FLS) based on postfracture care in a patient-centered medical home (PCMH). METHODS Patients in a PCMH who presented to a local 763-bed community teaching hospital with fragility fracture of the hip, spine, or forearm between January 1, 2013, and December 31, 2014, were identified using ICD-9 codes. A retrospective chart review of inpatient and outpatient medical records 2 years before the fracture and 1 year afterward was conducted. The primary outcome was dual X-ray absorptiometry (DXA) scan utilization or pharmacotherapy for osteoporosis 6 months after fracture. RESULTS One hundred eighty-two patients were identified, and 75 patients were included in the analysis. The median age of the cohort was 84 years, and 70.7% of patients were white women. Fragility fractures included hip fracture (42.7%), vertebral fracture (40.0%), and forearm fracture (17.3%). Six months after fracture, 30.7% of patients were prescribed prescription therapy for osteoporosis, and 6.7% had received a DXA scan. Although nearly all patients had a follow-up visit in the PCMH during the year after fracture, only 8.3% were seen in an established osteoporosis clinic. Twenty-three percent of patients were deceased at 1 year. CONCLUSIONS More patients in this PCMH received a DXA scan or pharmacotherapy, or both, for osteoporosis 6 months after fragility fracture than observed nationally. However, approximately 70% of patients were undertreated. Incorporating principles of an FLS into an existing osteoporosis clinic is warranted.
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35
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Parreco J, Eidelson SA, Revell S, Zakrison TL, Schulman CI, Rattan R. Nationwide risk factors for hospital readmission for subsequent injury after motor vehicle crashes. TRAFFIC INJURY PREVENTION 2018; 19:S127-S132. [PMID: 30543465 DOI: 10.1080/15389588.2018.1540866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 10/06/2018] [Accepted: 10/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Some drivers involved in motor vehicle crashes across the United States may be identified as at risk of subsequent injury by a similar mechanism. The purpose of this study was to perform a national review of the risk factors for hospitalization for a new injury due to a subsequent motor vehicle crash. It was hypothesized that presenting to a different hospital after subsequent injury would result in worse patient outcomes when compared to presentation at the same hospital. METHODS The Nationwide Readmissions Database for 2010-2014 was queried for all inpatient hospitalizations with injury related to motor vehicle traffic. The primary patient outcome of interest was subsequent motor vehicle crash-related injury within 1 year. The secondary patient outcomes were different hospital subsequent injury presentation, higher Injury Severity Score (ISS), longer length of stay (LOS), and in-hospital death after subsequent injury. The analysis of secondary patient outcomes was performed only on patients who were reinjured. Univariable analysis was performed for each outcome using all variables during the index admission. Multivariable logistic regression was performed using all significant (P < .05) variables on univariate analysis. Results were weighted for national estimates. RESULTS During the study period, 1,008,991 patients were admitted for motor vehicle-related injury; 12,474 patients (1.2%) suffered a subsequent injury within 1 year. From the reinjured patients, 32.9% presented to a different hospital, 48.9% had a higher ISS, and 22.1% had a longer LOS. The in-hospital mortality rate after subsequent injury was 1.1%. Presentation to a different hospital for subsequent injury was associated with a longer LOS (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.20-1.45; P < .01) and a higher ISS (OR = 1.38; 95% CI, 1.27-1.49; P < .01). Motorcyclists were more likely to suffer subsequent injury (OR = 1.39; 95% CI, 1.32-1.46; P < .01) and motorcycle passengers were more likely to present to a different hospital with a subsequent injury (OR = 2.49; 95% CI, 1.73-3.59; P < .01). Alcohol abuse was associated with subsequent injury (OR = 1.12; 95% CI, 1.07-1.18; P < .01). CONCLUSIONS Nearly a third of patients suffering subsequent motor vehicle crash-related injury after an initial motor vehicle crash in the United States present to a different hospital. These patients are more likely to suffer more severe injuries and longer hospitalizations due to their subsequent injury. Future efforts to prevent these injuries must consider the impact of this fragmentation of care and the implications for quality and cost improvements.
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Affiliation(s)
- Joshua Parreco
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Sarah A Eidelson
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Scott Revell
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Tanya L Zakrison
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Carl I Schulman
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Rishi Rattan
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
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Andreasen C, Solberg LB, Basso T, Borgen TT, Dahl C, Wisløff T, Hagen G, Apalset EM, Gjertsen JE, Figved W, Hübschle LM, Stutzer JM, Elvenes J, Joakimsen RM, Syversen U, Eriksen EF, Nordsletten L, Frihagen F, Omsland TK, Bjørnerem Å. Effect of a Fracture Liaison Service on the Rate of Subsequent Fracture Among Patients With a Fragility Fracture in the Norwegian Capture the Fracture Initiative (NoFRACT): A Trial Protocol. JAMA Netw Open 2018; 1:e185701. [PMID: 30646281 PMCID: PMC6324344 DOI: 10.1001/jamanetworkopen.2018.5701] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Fragility fracture is a major health issue because of the accompanying morbidity, mortality, and financial cost. Despite the high cost to society and personal cost to affected individuals, secondary fracture prevention is suboptimal in Norway, mainly because most patients with osteoporotic fractures do not receive treatment with antiosteoporotic drugs after fracture repair. OBJECTIVES To improve secondary fracture prevention by introducing a standardized intervention program and to investigate the effect of the program on the rate of subsequent fractures. DESIGN, SETTING, AND PARTICIPANTS Trial protocol of the Norwegian Capture the Fracture Initiative (NoFRACT), an ongoing, stepped wedge cluster randomized clinical trial in 7 hospitals in Norway. The participating hospitals were cluster randomized to an intervention starting date: May 1, 2015; September 1, 2015; and January 1, 2016. Follow-up is through December 31, 2019. The outcome data were merged from national registries of women and men 50 years and older with a recent fragility fracture treated at 1 of the 7 hospitals. DISCUSSION The NoFRACT trial is intended to enroll 82 000 patients (intervention period, 26 000 patients; control period, 56 000 patients), of whom 23 578 are currently enrolled by January 2018. Interventions include a standardized program for identification, assessment, and treatment of osteoporosis in patients with a fragility fracture that is led by a trained coordinating nurse. The primary outcome is rate of subsequent fracture (per 10 000 person-years) based on national registry data. Outcomes before (2008-2015; control period) and after (2015-2019; intervention period) the intervention will be compared, and each hospital will act as its own control. Use of outcomes from national registry data means that all patients are included in the analysis regardless of whether they are exposed to the intervention (intention to treat). A sensitivity analysis with a transition window will be performed to mitigate possible within-cluster contamination. RESULTS Results are planned to be disseminated through publications in peer-reviewed journals and presented at local, national, and international conferences. CONCLUSIONS By introducing a standardized intervention program for assessment and treatment of osteoporosis in patients with fragility fractures, we expect to document reduced rates of subsequent fractures and fracture-related mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02536898.
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Affiliation(s)
- Camilla Andreasen
- Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - Lene B. Solberg
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Trude Basso
- Department of Orthopedic Surgery, St Olav’s University Hospital, Trondheim, Norway
| | - Tove T. Borgen
- Department of Rheumatology, Vestre Viken Hospital Trust, Hospital of Drammen, Drammen, Norway
| | - Cecilie Dahl
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Torbjørn Wisløff
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, Oslo, Norway
| | - Gunhild Hagen
- Department of Reviews and Health Technology Assessments, Norwegian Institute of Public Health, Oslo, Norway
| | - Ellen M. Apalset
- Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease, Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Wender Figved
- Department of Orthopedic Surgery, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Lars M. Hübschle
- Department of Orthopedic Surgery, Vestre Viken Hospital Trust, Hospital of Drammen, Drammen, Norway
| | - Jens M. Stutzer
- Department of Orthopedic Surgery, Møre and Romsdal Hospital Trust, Molde Hospital, Molde, Norway
| | - Jan Elvenes
- Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - Ragnar M. Joakimsen
- Department of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
- Department of Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Unni Syversen
- Department of Endocrinology, St Olav’s University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik F. Eriksen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Nordsletten
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Frede Frihagen
- Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Tone K. Omsland
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Åshild Bjørnerem
- Department of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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Senay A, Delisle J, Banica A, Laflamme GY, Leduc S, Mac-Thiong JM, Ranger P, Rouleau D, Fernandes JC. Barriers to the identification of fragility fractures for secondary fracture prevention in an orthopaedic clinic-based fracture liaison service: a prospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mugnier B, Daumas A, Couderc AL, Mizzi B, González T, Amrani A, Lévêque P, Aymes B, Argenson JN, Villani P. Clinical effectiveness of osteoporosis treatment in older patients: A fracture liaison service-based prospective study. J Women Aging 2018; 31:553-565. [PMID: 30295566 DOI: 10.1080/08952841.2018.1529473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The clinical efficacy of anti-osteoporotic treatments in old patients is discussed. The aim of this study was to assess if the use of anti-osteoporotic treatments for the secondary prevention of osteoporotic fractures could reduce the risk of refractures in patients over 75 years old in a Fracture Liaison Service. In this population of frail, elderly patients presenting with a recent osteoporotic fracture, we observed that the refracture incidence was similar in the treated group and the untreated group during the first year. However, 30 months after the index fracture, the osteoporosis medication for a year or more reduced the incidence of refractures by 70%.
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Affiliation(s)
- Bénédicte Mugnier
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Aurélie Daumas
- APHM, Hôpital La Timone, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Anne-Laure Couderc
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Barbara Mizzi
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Thomas González
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Anne Amrani
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Pierre Lévêque
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Brice Aymes
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
| | - Jean-Nöel Argenson
- APHM, Hôpital Sainte Marguerite, Service de Chirurgie Orthopédique et Traumatologie, Marseille, France
| | - Patrick Villani
- APHM, Hôpital Sainte Marguerite, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France.,APHM, Hôpital La Timone, Service de Médecine Interne Gériatrie et Thérapeutique, Marseille, France
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Inderjeeth CA, Raymond WD, Briggs AM, Geelhoed E, Oldham D, Mountain D. Implementation of the Western Australian Osteoporosis Model of Care: a fracture liaison service utilising emergency department information systems to identify patients with fragility fracture to improve current practice and reduce re-fracture rates: a 12-month analysis. Osteoporos Int 2018; 29:1759-1770. [PMID: 29704027 DOI: 10.1007/s00198-018-4526-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
UNLABELLED Fracture liaison service linked to an emergency department database effectively identifies patients with OP, improves best practice care, reduces recurrent fractures, and improves quality of life (QoL). The next step is to establish cost-effectiveness. This should be seen as the standard model of care. INTRODUCTION The Western Australian Osteoporosis Model of Care recommends implementation of a fracture liaison service (FLS) to manage patients with minimal trauma fractures (MTFs). This study evaluates the efficacy of a FLS linked to a tertiary hospital emergency department information system (EDIS) in reducing recurrent fractures. METHODS Patients aged ≥ 50 years with MTF identified from EDIS were invited to the FLS. Patient outcomes were compared to routine care (retrospective group-same hospital, and prospective group-other hospital) at 3- and 12-month follow-up. RESULTS Two hundred forty-one of 376 (64.1%) eligible patients participated in the FLS with 12 months of follow-up. Absolute risk of recurrent MTF at 12 months was reduced by 9.2 and 10.2% compared with the prospective and retrospective controls, respectively. After age/sex adjustment, FLS participants had less MTF at 12 months vs. the retrospective controls, OR 0.38 (95%CI 0.18-0.79), but not the prospective controls, OR 0.40 (95%CI 0.16-1.01). FLS patients were more likely to receive the 'best practice' care, i.e. awareness of osteoporosis, investigations, and treatment (all p < 0.05). 'Fallers' (OR 0.48 (95%CI 0.24, 0.96)) and fall rates were lower in the FLS (p = 0.001) compared to the prospective control. FLS experienced the largest improvement in QoL from 3 to 12 months as measured by the EuroQoL 5-domain (EQ-5D) UK weighted score (+ 15 vs. - 11 vs. - 16%, p < 0.001) and EQ-5D Health State visual analogue scale (+ 29 vs. - 2 vs. + 1%, p < 0.001). CONCLUSION Patients managed in a linked EDIS-FLS were more likely to receive the 'best practice' care and had lower recurrent MTF and improved QoL.
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Affiliation(s)
- C A Inderjeeth
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia.
- School of Medicine, The University of Western Australia, Perth, Australia.
- Arthritis and Osteoporosis Foundation of Western Australia, Shenton Park, Australia.
| | - W D Raymond
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
| | - A M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, Australia
| | - E Geelhoed
- School of Population Health, The University of Western Australia, Perth, Australia
| | - D Oldham
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
| | - D Mountain
- Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
- School of Medicine, The University of Western Australia, Perth, Australia
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40
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Reduced mortality and subsequent fracture risk associated with oral bisphosphonate recommendation in a fracture liaison service setting: A prospective cohort study. PLoS One 2018; 13:e0198006. [PMID: 29856795 PMCID: PMC5983426 DOI: 10.1371/journal.pone.0198006] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 05/12/2018] [Indexed: 11/24/2022] Open
Abstract
Objective Osteoporotic fragility fractures, that are common in men and women, signal increased risk of future fractures and of premature mortality. Less than one-third of postmenopausal women and fewer men are prescribed active treatments to reduce fracture risk. Therefore, in this study the association of oral bisphosphonate recommendation with subsequent fracture and mortality over eight years in a fracture liaison service setting was analysed. Materials and methods In this prospective cohort study, 5011 men and women aged >50 years, who sustained a clinical fracture, accepted the invitation to attend the fracture liaison service of the West Glasgow health service between 1999 and 2007. These patients were fully assessed and all were recommended calcium and vitamin D. Based on pre-defined fracture risk criteria, 2534 (50.7%) patients were additionally also recommended oral bisphosphonates. Mortality and subsequent fracture risk were the pre-defined outcomes analysed using Cox proportional hazard models. Results Those recommended bisphosphonates were more often female (82.9 vs. 72.4%), were older (73.4 vs. 64.4 years), had lower bone mineral density T-score (-3.1 vs. -1.5) and more had sustained hip fractures (21.7 vs. 6.2%; p < 0.001). After adjustments, patients recommended bisphosphonates had lower subsequent fracture risk (Hazard Ratio (HR): 0.60; 95% confidence interval (CI): 0.49–0.73) and lower mortality risk (HR: 0.79, 95%CI: 0.64–0.97). Conclusion Of the patients, who are fully assessed after a fracture at the fracture liaison service, those with higher fracture risk and a recommendation for bisphosphonates had worse baseline characteristics. However, after adjusting for these differences, those recommended bisphosphonate treatment had a substantially lower risk for subsequent fragility fracture and lower risk for mortality. These community-based data indicate the adverse public health outcomes and mortality impacts of the current low treatment levels post fracture could be improved by bisphosphonate recommendation for both subsequent fracture and mortality.
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Wu CH, Chen CH, Chen PH, Yang JJ, Chang PC, Huang TC, Bagga S, Sharma Y, Lin RM, Chan DC. Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int 2018. [PMID: 29525971 DOI: 10.1007/s00198-017-4370-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Fracture liaison services (FLS) have been demonstrated to improve outcomes following osteoporotic fracture. The aim of this systematic literature review (SLR) was to determine the characteristics of an FLS that lead to improved patient outcomes. We conducted a SLR, including articles published between 2000 and February 2017, using global (Medline, EMBASE, PubMed and Cochrane Library) and local databases. Studies including patients aged ≥ 50 years with osteoporotic fractures enrolled in an FLS were assessed. Information extracted from each article included key person coordinating the FLS (physician, nurse or other healthcare professional), setting (hospital vs community), intensity (single vs multiple), duration (long vs short term), fracture type and gender. A meta-analysis of randomised controlled trials was conducted based on the key person coordinating the FLS. Out of 7236 articles, 57 were considered to be high quality and identified for further analysis. The SLR identified several components which contributed to FLS success, including multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions and patient education. Meta-analytic data confirm the effectiveness of an FLS following an osteoporotic fracture: approximate 27% increase in the likelihood of BMD testing and up to 21% increase in the likelihood of treatment initiation compared with usual care. The balance of evidence indicates that the multifaceted FLS and dedicated coordination are important success factors that contribute to effective FLS interventions which reduce fracture-related morbidity and mortality.
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Affiliation(s)
- C-H Wu
- Department of Family Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
- Institute of Gerontology, National Cheng Kung University College of Medicine, Tainan, Taiwan
| | - C-H Chen
- Orthopaedic Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Orthopaedics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Adult Reconstruction Surgery, Department of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - P-H Chen
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - J-J Yang
- Department of Internal Medicine, Po Jen General Hospital, Taipei City, Taiwan
| | - P-C Chang
- Department of Orthopedics, An Nan Hospital, China Medical University, Tainan, Taiwan
| | - T-C Huang
- National Taiwan University Hospital Chu-Tung Branch, Hsinchu, Taiwan
| | - S Bagga
- Complete HEOR Solutions LLC, 1046 Knapp Road, North Wales, PA, 19454, USA
| | - Y Sharma
- Complete HEOR Solutions LLC, 1046 Knapp Road, North Wales, PA, 19454, USA
| | - R-M Lin
- Tainan Municipal An-Nan Hospital-China Medical University, Tainan, Taiwan
| | - D-C Chan
- National Taiwan University Hospital Chu-Tung Branch, Hsinchu, Taiwan.
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Reber KC, König HH, Becker C, Rapp K, Büchele G, Mächler S, Lindlbauer I. Development of a risk assessment tool for osteoporotic fracture prevention: A claims data approach. Bone 2018; 110:170-176. [PMID: 29421456 DOI: 10.1016/j.bone.2018.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 01/30/2018] [Accepted: 02/03/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND In aging societies osteoporotic fractures are a major health problem with high economic costs. Targeting prevention at individuals at high risk is important to reduce the future burden of fractures. Available risk assessment tools (e.g., FRAX®, QFracture, the algorithm provided by the German Osteology Society (DVO-Tool)) rely on self-reported patient information to predict fracture risk. Time and resource constraints, limited access to clinical data, and (un)willingness to participate may hamper the use of these tools. To overcome such obstacles, the aim is to develop a fracture risk assessment tool based on claims data that may be directly used on an institutional level. METHODS Administrative claims data of an elderly (≥65years) population (N=298,530) for the period from 2006 through 2014 was used. Major osteoporotic fractures (MOF) were identified based on hospital diagnoses. We applied Cox proportional hazard regression to determine the association of individual risk factors and fracture risk. Hazard ratios were used to construct a risk score. The discriminative ability of the score was evaluated using C-statistics. RESULTS We identified 7864 MOF during follow-up. The median time to first fracture during follow-up was 371.5days. Individuals with a MOF during follow-up had a higher mean and median risk score (mean: 4.53; median: 4) than individuals without MOF (mean: 3.07; median: 3). Adding drug-related risk factors slightly improved discrimination compared to a simple model with age, gender, and prior fracture. CONCLUSION We developed a fracture risk score model based on in-hospital treated subjects to predict MOF that can be used on an institutional level. The score included age, sex and prior fracture as risk factors. Adding other risk factors involved very small improvement in discrimination.
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Affiliation(s)
- Katrin C Reber
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Germany.
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Germany
| | - Clemens Becker
- Department of Clinical Gerontology, Robert-Bosch-Hospital Stuttgart, Germany
| | - Kilian Rapp
- Department of Clinical Gerontology, Robert-Bosch-Hospital Stuttgart, Germany
| | - Gisela Büchele
- Institute of Epidemiology and Medical Biometry, Ulm University, Germany
| | - Sarah Mächler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Germany
| | - Ivonne Lindlbauer
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Germany
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Dirschl DR, Rustom H. Practice Patterns and Performance in U.S. Fracture Liaison Programs: An Analysis of >32,000 Patients from the Own the Bone Program. J Bone Joint Surg Am 2018; 100:680-685. [PMID: 29664856 DOI: 10.2106/jbjs.17.00665] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We are not aware of any previous investigation assessing a national cohort of patients enrolled in a fracture liaison service (FLS) program in an open health-care system to ascertain prevalent practice patterns. The objective of this investigation was to determine, in a geographically diverse group of centers in a single FLS program, the percentage of patients for whom anti-osteoporosis treatment was recommended or started as well as to identify associations between patient and fracture variables and the likelihood of treatment being recommended. METHODS The study utilized the Own the Bone program registry, which included 32,671 unique patient records with the required data. The primary outcome measure was whether a recommendation to start anti-osteoporosis treatment was made to the patient at the time of program enrollment. The associations between patient and fracture variables and the likelihood of having treatment recommended were calculated. RESULTS Anti-osteoporosis treatment was recommended to 72.8% of patients and was initiated for 12.1%. A sedentary lifestyle and a parent who had sustained a hip fracture increased the likelihood of a treatment recommendation by 10% and 12%, respectively. While patients with a spinal fracture were 11% more likely to have received a treatment recommendation, those with a hip fracture were 2% less likely to have received such a recommendation. Age was not strongly associated with the likelihood of receiving a treatment recommendation but was associated with the initiation of treatment. CONCLUSIONS Practitioners at sites in the Own the Bone program recommend anti-osteoporosis treatment, at the time of initial evaluation, to about three-quarters of patients who present with a fragility fracture. This is a very strong improvement over previously reported national data. The findings that a hip fracture had the lowest association and age had very little association with the likelihood of recommending treatment were unexpected and perhaps deserve further investigation. CLINICAL RELEVANCE FLS programs and sites as well as all those who manage patients with a fragility fracture can utilize the information derived from this study to improve practice patterns for the care of these patients.
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Affiliation(s)
- Douglas R Dirschl
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago School of Medicine and Biological Sciences, Chicago, Illinois
| | - Hani Rustom
- College of Osteopathic Medicine, Des Moines University, Des Moines, Iowa
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Major G, Ling R, Searles A, Niddrie F, Kelly A, Holliday E, Attia J, Bogduk N. The Costs of Confronting Osteoporosis: Cost Study of an Australian Fracture Liaison Service. JBMR Plus 2018; 3:56-63. [PMID: 30680364 PMCID: PMC6339551 DOI: 10.1002/jbm4.10046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 11/11/2022] Open
Abstract
Fracture liaison services (FLS) are an accepted approach to lowering rates of osteoporotic refractures. However, resource allocations to FLS are open to challenge, as most relevant cost analyses are based on anticipated, rather than observed, benefits. To support informed decision making, we have estimated the cost of operating an FLS, from the perspective of the Australian health system, with real life costs. On the basis of hospital records, we compared total costs of two cohorts of patients presenting with minimal trauma fractures (MTFs) at two hospital emergency departments (EDs) across a 6‐month period (July to December 2010). The treatment cohort (FLS Cohort, n = 515) attended an ED at a hospital offering FLS post‐fracture care; the Usual Care Cohort (n = 416) attended an ED at a hospital without an FLS. Hospital records were reviewed for further attendance of both groups at their respective hospitals’ EDs with refractures for the subsequent 3 years. Costs were constructed from “bottom up” with a “microcosting” approach. Total costs for both cohorts included any FLS and the costs of refractures. Cohort costs were estimated for every 1000 patients over the 3 observed years. Compared with the Usual Care Cohort, the FLS Cohort had 62 fewer fractures per 1000 patients and $617,275 lower costs over 3 years. In a sensitivity analysis, where 20% of the Usual Care Cohort received FLS preventative treatment, FLS Cohort costs were lower by $880,154. As both hospitals consistently process around 2000 patients per year, the estimated annual saving is $1.2 million to $1.8 million (Australian dollars). From the perspective of the Australian public health system, investment in FLS can be a financially effective way of reducing the cost of osteoporotic fracture management. © 2018 The Authors JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Gabor Major
- Bone and Joint Centre John Hunter Hospital New Lambton Australia.,University of Newcastle Faculty of Health and Medicine Callaghan Australia
| | - Rod Ling
- University of Newcastle Faculty of Health and Medicine Callaghan Australia.,Hunter Medical Research Institute (HMRI) New Lambton Heights Australia
| | - Andrew Searles
- University of Newcastle Faculty of Health and Medicine Callaghan Australia.,Hunter Medical Research Institute (HMRI) New Lambton Heights Australia
| | - Fiona Niddrie
- Bone and Joint Centre John Hunter Hospital New Lambton Australia
| | - Ayano Kelly
- Canberra Hospital Rheumatology Department Woden Australia
| | - Elizabeth Holliday
- University of Newcastle Faculty of Health and Medicine Callaghan Australia.,Hunter Medical Research Institute (HMRI) New Lambton Heights Australia
| | - John Attia
- University of Newcastle Faculty of Health and Medicine Callaghan Australia.,Hunter Medical Research Institute (HMRI) New Lambton Heights Australia
| | - Nikolai Bogduk
- University of Newcastle Faculty of Health and Medicine Callaghan Australia
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Chang YF, Huang CF, Hwang JS, Kuo JF, Lin KM, Huang HC, Bagga S, Kumar A, Chen FP, Wu CH. Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review. Osteoporos Int 2018; 29:779-792. [PMID: 29285627 DOI: 10.1007/s00198-017-4347-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
The analysis aimed to identify the treatment gaps in current fracture liaison services (FLS) and to provide recommendations for best practice establishment of future FLS across the Asia-Pacific region. The findings emphasize the unmet need for the implementation of new programs and provide recommendations for the refinement of existing ones. The study's objectives were to evaluate fracture liaison service (FLS) programs in the Asia-Pacific region and provide recommendations for establishment of future FLS programs. A systematic literature review (SLR) of Medline, PubMed, EMBASE, and Cochrane Library (2000-2017 inclusive) was performed using the following keywords: osteoporosis, fractures, liaison, and service. Inclusion criteria included the following: patients ≥ 50 years with osteoporosis-related fractures; randomized controlled trials or observational studies with control groups (prospective or retrospective), pre-post, cross-sectional and economic evaluation studies. Success of direct or indirect interventions was assessed based on patients' understanding of risk, bone mineral density assessment, calcium intake, osteoporosis treatment, re-fracture rates, adherence, and mortality, in addition to cost-effectiveness. Overall, 5663 unique citations were identified and the SLR identified 159 publications, reporting 37 studies in Asia-Pacific. These studies revealed the unmet need for public health education, adequate funding, and staff resourcing, along with greater cooperation between departments and physicians. These actions can help to overcome therapeutic inertia with sufficient follow-up to ensure adherence to recommendations and compliance with treatment. The findings also emphasize the importance of primary care physicians continuing to prescribe treatment and ensure service remains convenient. These findings highlight the limited evidence supporting FLS across the Asia-Pacific region, emphasizing the unmet need for new programs and/or refinement of existing ones to improve outcomes. With the continued increase in burden of fractures in Asia-Pacific, establishment of new FLS and assessment of existing services are warranted to determine the impact of FLS for healthcare professionals, patients, family/caregivers, and society.
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Affiliation(s)
- Y -F Chang
- Department of Family Medicine, National Cheng Kung University College of Medicine and Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan
| | - C -F Huang
- Department of Family Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
| | - J -S Hwang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - J -F Kuo
- Division of Endocrinology and Metabolism, Changhua Christian Hospital, Changhua, Taiwan
| | - K -M Lin
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - H -C Huang
- Department of Orthopaedics, Tainan Municipal Hospital, Tainan, Taiwan
| | - S Bagga
- Complete HEOR Solutions LLC, 1046 Knapp Road, North Wales, PA, 19454, USA
| | - A Kumar
- Complete HEOR Solutions LLC, 1046 Knapp Road, North Wales, PA, 19454, USA
| | - F -P Chen
- Keelung Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - C -H Wu
- Department of Family Medicine, National Cheng Kung University College of Medicine and Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan.
- Institute of Gerontology, National Cheng Kung University College of Medicine, Tainan, Taiwan.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to report the evidence of beneficial effects of Fracture Liaison Service (FLS) including data regarding their impact on subsequent fracture, mortality risk and cost-effectiveness. This review also discusses the limitations of these data and the challenges faced during the implementation of FLS. RECENT FINDINGS Recent studies showed the beneficial impact of implementation of FLS on the prevention of subsequent fracture risk, reduced mortality and cost-effectiveness. However, heterogeneity of FLS models and small number of studies limited the conclusion about the impact of FLS on secondary fracture prevention. SUMMARY Patients with osteoporosis-related fractures are at higher risk of subsequent refractures. These subsequent fractures are associated with increased morbidity and premature mortality. However, there is a gap between evidence-based recommendations for postfracture care and actual clinical practice. FLS care is recommended for the management of the prevention of secondary fracture. FLS implementation reduces the risk of subsequent fracture, but the level of evidence is low as the interpretation of data is limited by the number of studies and their heterogeneity. FLS care significantly reduces the postfracture mortality, especially in patients with hip fractures. FLS implementation is cost-effective compared with usual care. Additional studies (with large sample and long-term follow-up) are needed to assess the impact of FLS care on subsequent fracture risk.
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Alibhai SMH, Breunis H, Timilshina N, Hamidi MS, Cheung AM, Tomlinson GA, Manokumar T, Samadi O, Sandoval J, Durbano S, Warde P, Jones JM. Improving bone health in men with prostate cancer receiving androgen deprivation therapy: Results of a randomized phase 2 trial. Cancer 2017; 124:1132-1140. [PMID: 29211305 DOI: 10.1002/cncr.31171] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/06/2017] [Accepted: 11/10/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Strategies to improve bone health care in men receiving androgen deprivation therapy (ADT) are not consistently implemented. The authors conducted a phase 2 randomized controlled trial of 2 education-based models-of-care interventions to determine their feasibility and ability to improve bone health care. METHODS A single-center parallel-group randomized controlled trial of men with prostate cancer who were receiving ADT was performed. Participants were randomized 1:1:1 to 1) a patient bone health pamphlet and brief recommendations for their family physician (BHP+FP); 2) a BHP and support from a bone health care coordinator (BHP+BHCC); or 3) usual care. The primary efficacy outcome was receipt of a bone mineral density (BMD) test within 6 months. Secondary efficacy outcomes included guideline-appropriate calcium and vitamin D use and bisphosphonate prescriptions for men at high fracture risk. Feasibility endpoints included recruitment, retention, satisfaction, contamination, and outcome capture. The main analysis used logistic regression with a 1-sided P of .10. The trial is registered at ClinicalTrials.gov (identifier NCT02043236). RESULTS A total of 119 men were recruited. The BHP+BHCC strategy was associated with a greater percentage of men undergoing a BMD test compared with the usual-care group (78% vs 36%; P<.001). BMD ordering also was found to be increased with the BHP+FP strategy (58% vs 36%; P = .047). Both strategies were associated with higher percentages of patients using calcium and vitamin D, but only the BHP+FP arm was statistically significant (P = .039). No men were detected to be at high fracture risk. All but one feasibility endpoint was met. CONCLUSIONS Educational strategies to improve bone health care appear feasible and are associated with improved BMD ordering in men receiving ADT. Cancer 2018;124:1132-40. © 2017 American Cancer Society.
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Affiliation(s)
- Shabbir M H Alibhai
- Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Henriette Breunis
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Narhari Timilshina
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Maryam S Hamidi
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Angela M Cheung
- Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George A Tomlinson
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Tharsika Manokumar
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Osai Samadi
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Joanna Sandoval
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Sara Durbano
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Padraig Warde
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Jennifer M Jones
- Department of Psychosocial Oncology, University Health Network, Toronto, Ontario, Canada
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Beaton DE, Mamdani M, Zheng H, Jaglal S, Cadarette SM, Bogoch ER, Sale JEM, Sujic R, Jain R. Improvements in osteoporosis testing and care are found following the wide scale implementation of the Ontario Fracture Clinic Screening Program: An interrupted time series analysis. Medicine (Baltimore) 2017; 96:e9012. [PMID: 29310418 PMCID: PMC5728819 DOI: 10.1097/md.0000000000009012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We evaluated a system-wide impact of a health intervention to improve treatment of osteoporosis after a fragility fracture. The intervention consisted of assigning a screening coordinator to selected fracture clinics to identify, educate, and follow up with fragility fracture patients and inform their physicians of the need to evaluate bone health. Thirty-seven hospitals in the province of Ontario (Canada) were assigned a screening coordinator. Twenty-three similar hospitals were control sites. All hospitals had orthopedic services and handled moderate-to-higher volumes of fracture patients. Administrative health data were used to evaluate the impact of the intervention.Fragility fracture patients (≥50 years; hip, humerus, forearm, spine, or pelvis fracture) were identified from administrative health records. Cases were fractures treated at 1 of the 37 hospitals assigned a coordinator. Controls were the same types of fractures at the control sites. Data were assembled for 20 quarters before and 10 quarters after the implementation (from January 2002 to March 2010). To test for a shift in trends, we employed an interrupted time series analysis-a study design used to evaluate the longitudinal effects of interventions, through regression modelling. The primary outcome measure was bone mineral density (BMD) testing. Osteoporosis medication initiation and persistence rates were secondary outcomes in a subset of patients ≥66 years of age.A total of 147,071 patients were used in the analysis. BMD testing rates increased from 17.0% pre-intervention to 20.9% post-intervention at intervention sites (P < .01) compared with no change at control sites (14.9% and 14.9%, P = .33). Medication initiation improved significantly at intervention sites (21.6-23.97%; P = .02) but not at control sites (17.5-18.5%; P = .27). Persistence with bisphosphonates decreased at all sites, from 59.9% to 56.4% at intervention sites (P = .02) and more so from 62.3% to 54.2% at control sites (P < .01) using 50% proportion of days covered (PDC 50).Significant improvements in BMD testing and treatment initiation were observed after the initiation of a coordinator-based screening program to improve osteoporosis management following fragility fracture.
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Affiliation(s)
- Dorcas E. Beaton
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Occupational Sciences and Occupational Therapy, University of Toronto
- Institute for Work & Health
| | - Muhammad Mamdani
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Li Ka Shing Centre for Healthcare Analytics Research & Training, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Institute for Clinical Evaluative Sciences
- Leslie Dan Faculty of Pharmacy, University of Toronto
| | - Hong Zheng
- Institute for Clinical Evaluative Sciences
| | - Susan Jaglal
- Institute for Clinical Evaluative Sciences
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy, University of Toronto
| | - Suzanne M. Cadarette
- Institute for Clinical Evaluative Sciences
- Leslie Dan Faculty of Pharmacy, University of Toronto
| | - Earl R. Bogoch
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto
| | - Joanna E. M. Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Rebeka Sujic
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute of St. Michael's Hospital
| | - Ravi Jain
- Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ON, Canada
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Mendis AS, Ganda K, Seibel MJ. Barriers to secondary fracture prevention in primary care. Osteoporos Int 2017; 28:2913-2919. [PMID: 28664275 DOI: 10.1007/s00198-017-4131-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/14/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED This study of current osteoporosis management patterns in general practice found that the majority of patients presenting to their local health practitioner with a recent low-trauma fracture was not managed appropriately. The analysis demonstrated that failure to investigate was highly predictive of failure to treat and that one of the major barriers to effective osteoporosis management is a lack of specific knowledge about who to investigate and treat. INTRODUCTION Osteoporotic fractures are associated with significant morbidity and mortality. The current study aimed (i) to determine the number of patients with osteoporotic fractures who were not investigated or treated for osteoporosis by their primary care physician and (ii) to identify factors that contribute to the ongoing gap in osteoporosis care. METHODS We conducted an observational retrospective study (2012-2014) using explicit medical record review at three major general practices in metropolitan Sydney. Patients aged 55 years or older who had a documented minimal trauma fracture (MTF) were identified. Data collected included demographics, prior fractures, testing for vitamin D/bone mineral density and initiation of osteoporosis pharmacotherapy. The main outcome measures included the number of patients who did not undergo the following: (i) a bone density scan, (ii) vitamin D measurement and/or (iii) initiation of osteoporosis pharmacotherapy. RESULTS Of the 87 patients (69% female; mean age 71.7 years) with prevalent MTF, 55 (63%) were not referred for a bone density scan. Vitamin D levels were not measured in 36 patients (41%) and 55 patients (63%) did not receive specific osteoporosis pharmacotherapy. Failure to investigate was highly predictive of failure to treat (p < 0.001). The presence of major osteoporotic risk factors did not affect the likelihood of investigation or treatment, indicating that a major barrier to effective osteoporosis management was a lack of knowledge. CONCLUSION Management of patients with MTF's in primary care is poor. Systems aimed at improving the identification and treatment of patients with osteoporotic fractures in this setting is required in order to close the osteoporosis care gap.
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Affiliation(s)
- A S Mendis
- Department of Endocrinology and Metabolism, Level 6 Concord Medical Centre, Concord Repatriation General Hospital, Hospital Road, Concord West, NSW, 2139, Australia
| | - K Ganda
- Department of Endocrinology and Metabolism, Level 6 Concord Medical Centre, Concord Repatriation General Hospital, Hospital Road, Concord West, NSW, 2139, Australia
| | - M J Seibel
- Department of Endocrinology and Metabolism, Level 6 Concord Medical Centre, Concord Repatriation General Hospital, Hospital Road, Concord West, NSW, 2139, Australia.
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Bachour F, Rizkallah M, Sebaaly A, Barakat A, Razzouk H, El Hage R, Nasr R, El Khoury M, Maalouf G. Fracture liaison service: report on the first successful experience from the Middle East. Arch Osteoporos 2017; 12:79. [PMID: 28929307 DOI: 10.1007/s11657-017-0372-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/25/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study aims to assess for the first time in the Middle East, the clinical benefits of an FLS model established in a hospital in Beirut, Lebanon. It shows a significant 54% relative risk reduction in re-fracture incidence, confirming the patient-oriented benefit of diffusing this system in the Middle East region. PURPOSE/INTRODUCTION Few hospitals in Lebanon applied Fracture Liaison Service (FLS) program. A type A FLS is established at Bellevue hospital in Beirut in July 2013. This study aims to assess its clinical benefits and efficacy. METHODS Patients aged 50 years and above presenting to our hospital with minimal trauma fracture from July 2012 till June 2014 are enrolled. These are divided into two groups, before (group A) and after (group B) FLS implementation. Both groups are compared for re-fracture incidence, bone health assessment; osteoporosis treatment maintenance, and death in a 2-year follow-up. RESULTS Nighty-eight patient composing group B are compared to 100 patients in the group A. Around 65% of patients in the FLS group underwent Dexa osteodensitometry following their fracture compared to 28% in the comparator group (p < 0.001). About 54% of patients in group B maintained osteoporosis treatment compared to 26% in group A (p < 0.001). Sixteen percent of patients died in the FLS study group compared to 16% of patients in the comparator group (p = 0.950). A second fracture, happened in 8.2% of patients in the FLS study group compared to 18% of the patients in the comparator group p = 0.004. Number needed to treat reached 10.2 patients. CONCLUSIONS The statistical analysis results go with the overwhelming evidence concerning FLS importance in promoting bone health assessment and osteoporosis treatment in fracture patients. It also confirms the clinical value and the patient-oriented benefit of an implementation of such a system.
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Affiliation(s)
- Falah Bachour
- Musculoskeletal Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon
| | - Maroun Rizkallah
- Musculoskeletal Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon.
| | - Amer Sebaaly
- Musculoskeletal Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon
| | - Angelique Barakat
- Laboratory Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon
| | - Hiba Razzouk
- Family Medicine Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon
| | - Rawad El Hage
- Department of Physical Education, Faculty of Arts and Social Sciences, University of Balamand, El-Koura, Lebanon
| | - Riad Nasr
- Department of Physical Education, Faculty of Arts and Social Sciences, University of Balamand, El-Koura, Lebanon
| | - Mirvat El Khoury
- Musculoskeletal Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon
| | - Ghassan Maalouf
- Musculoskeletal Department, Bellevue University Medical Center, Saint Joseph University School of Medicine, Beirut, Lebanon
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