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Tahmasbi F, Sadoughi F, Sheikhtaheri A, Zabihiyeganeh M, Ameri F. Developing fracture liaison service framework based on comparative analysis and scoping review. Osteoporos Int 2024; 35:1513-1571. [PMID: 38831198 DOI: 10.1007/s00198-024-07091-8] [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: 12/18/2023] [Accepted: 04/16/2024] [Indexed: 06/05/2024]
Abstract
This research conducts a comparative analysis and scoping review of 105 studies in the field of Fracture Liaison Service (FLS). The resulting two-dimensional framework represents a significant step toward FLS implementation. PURPOSE The primary goal is to review interventions in real world settings in order to provide the FLS framework that specifies the essential elements of its implementation and offers different perspectives on that. METHOD This study encompasses two phases: a comparative analysis of existing FLS models, including "Capture the Fracture," "5IQ," and "Ganda," and a scoping review from 2012 to 2022 in PubMed, Web of Science, Scopus, ProQuest, and IEEE databases limited to publications in English. RESULTS The resulting model of comparative analysis identifies patient identification, investigation, intervention and integration or continuity of care as the four main stages of FLS. Additionally, the elements of quality and information span across all stages. Following comparative analysis, the framework is designed to be used for content analysis of the included studies in the scoping review. The intersection of columns (Who, Where, When, What, How, Quality) with rows (Identification, Investigation, Intervention, and continuity of care) yields a set of questions, answered in tabular form based on the scoping review. CONCLUSION The framework offers potential benefits in facilitating the adoption of effective approaches for FLS implementation. It is recommended to undertake an in-depth review of each of these components in order to uncover novel and innovative approaches for improving their implementation.
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Affiliation(s)
- Foziye Tahmasbi
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Farahnaz Sadoughi
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Abbas Sheikhtaheri
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mozhdeh Zabihiyeganeh
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Ameri
- School of Manufacturing Systems and Networks, Arizona State University, Arizona, AZ, USA
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Le HV, Van BW, Shahzad H, Teng P, Punatar N, Agrawal G, Wise B. Fracture liaison service-a multidisciplinary approach to osteoporosis management. Osteoporos Int 2024:10.1007/s00198-024-07181-7. [PMID: 39020092 DOI: 10.1007/s00198-024-07181-7] [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: 01/09/2024] [Accepted: 07/03/2024] [Indexed: 07/19/2024]
Abstract
A fracture liaison service is a systems-level multidisciplinary approach designed to reduce subsequent fracture risk in patients who recently sustained fragility fractures. It is estimated that one in three women and one in five men over the age of 50 years old have osteoporosis. Nonetheless, only 9 to 20% of patients who sustain an initial fragility fracture eventually receive any osteoporosis treatment. With the aim of preventing subsequent fractures, a fracture liaison service (FLS) works through identifying patients presenting with fragility fractures to the hospital and providing them with easier access to osteoporosis care through referrals for bone health and fracture risk assessment and recommendation or initiation of osteoporosis treatment. Currently, there are four major types of FLS models ranging from services that only identify at-risk patients and inform and educate the patient but take no further part in communicating their findings to other stakeholders in patients' care, to services that identify, investigate, and initiate treatment at the other end of the spectrum. In this article, we review the benefits, challenges, and outcomes of FLS in the American healthcare system with further exploration of the roles each member of the multidisciplinary team can play in improving patients' bone health.
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Affiliation(s)
- Hai V Le
- Department of Orthopaedic Surgery, University of California Davis School of Medicine, 4860 Y St #1700, Sacramento, CA, 95817, USA.
| | - Benjamin W Van
- Department of Orthopaedic Surgery, University of California Davis School of Medicine, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Hania Shahzad
- Department of Orthopaedic Surgery, University of California Davis School of Medicine, 4860 Y St #1700, Sacramento, CA, 95817, USA
| | - Polly Teng
- Department of Orthopaedic Surgery, University of California Davis School of Medicine, 4860 Y St #1700, Sacramento, CA, 95817, USA
- Department of Endocrinology, University of California Davis School of Medicine, Sacramento, USA
| | - Nisha Punatar
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, USA
| | - Garima Agrawal
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, USA
| | - Bart Wise
- Department of Orthopaedic Surgery, University of California Davis School of Medicine, 4860 Y St #1700, Sacramento, CA, 95817, USA
- Department of Rheumatology, University of California Davis School of Medicine, Sacramento, USA
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3
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Danazumi MS, Lightbody N, Dermody G. Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis. Osteoporos Int 2024; 35:1133-1151. [PMID: 38536447 PMCID: PMC11211169 DOI: 10.1007/s00198-024-07052-1] [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: 02/23/2023] [Accepted: 03/01/2024] [Indexed: 06/28/2024]
Abstract
To determine and appraise the certainty of fracture liaison service (FLS) in reducing the risk of secondary fragility fractures in older adults aged ≥ 50 years and to examine the nature of the FLS and the roles of various disciplines involved in the delivery of the FLS. Medline, EMBASE, PubMed, CINAHL, SCOPUS, and The Cochrane Library were searched from January 1st, 2010, to May 31st, 2022. Two reviewers independently extracted data. The risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies and the PEDro scale for randomized trials, while the GRADE approach established the certainty of the evidence. Thirty-seven studies were identified of which 34 (91.9%) were rated as having a low risk of bias and 22 (59.5%) were meta-analyzed. Clinically important low certainty evidence at 1 year (RR 0.26, CI 0.13 to 0.52, 6 pooled studies) and moderate certainty evidence at ≥ 2 years (RR 0.68, CI 0.55 to 0.83, 13 pooled studies) indicate that the risk of secondary fragility fracture was lower in the FLS intervention compared to the non-FLS intervention. Sensitivity analyses with no observed heterogeneity confirmed these findings. This review found clinically important moderate certainty evidence showing that the risk of secondary fragility fracture was lower in the FLS intervention at ≥ 2 years. More high-quality studies in this field could improve the certainty of the evidence. Review registration: PROSPERO-CRD42021266408.
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Affiliation(s)
- Musa Sani Danazumi
- Discipline of Physiotherapy, College of Science, Health & Engineering, La Trobe University, Bundoora, VIC, Australia
- Department of Physiotherapy, Federal Medical Centre Nguru, 02 Machina Road, Nguru, 630101, Yobe, Nigeria
| | - Nicol Lightbody
- Queensland Government Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia
| | - Gordana Dermody
- School of Health, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD, 4556, Australia.
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Xu L, Zhao T, Perry L, Frost SA, Di Tanna GL, Wang S, Chen M, Kolt GS, Jan S, Si L. Return on investment of fracture liaison services: a systematic review and analysis. Osteoporos Int 2024; 35:951-969. [PMID: 38300316 DOI: 10.1007/s00198-024-07027-2] [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: 07/17/2023] [Accepted: 01/12/2024] [Indexed: 02/02/2024]
Abstract
Fracture liaison services (FLS) have been proven clinically effective and cost-effective in preventing subsequent fractures among patients with an existing fragility fracture. Little is known about their monetary benefits such as their return on investment (ROI). This systematic review aimed to investigate the ROI of FLS and identify the FLS characteristics with better ROI. Studies on the cost-effectiveness of FLS published between January 2000 and December 2022 were searched from MEDLINE, EMBASE, PubMed, and Cochrane Central. Two independent reviewers conducted study selection and data extraction. ROI was calculated based on the difference between monetary benefits and FLS costs divided by the FLS costs. Subgroup analysis of ROI was performed across FLS types and FLS design details. A total of 23 FLS were included in this review. The majority of them were targeting patients aged over 50 years having fractures without identified sites. The mean ROI of these FLS was 10.49 (with a median ROI of 7.57), and 86.96% of FLS had positive ROI. FLS making treatment recommendations yielded the highest ROI (with a mean ROI of 18.39 and a median of 13.60). Incorporating primary care providers (with a mean ROI of 16.04 and a median of 13.20) or having them as program leaders (with a mean ROI of 12.07 and a median of 12.07) has demonstrated a high ROI. FLS for specific fracture sites had great monetary return. Intensive FLS such as type A and B FLS programs had higher ROI than non-intensive type C and D FLS. This review revealed a 10.49-fold monetary return of FLS. Identified characteristics contributing to greater economic return informed value-for-money FLS designs. Findings highlight the importance of FLS and the feasibility of expanding their contribution in mitigating the economic burden of osteoporotic fracture and are conducive to the promotion of FLS internationally.
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Affiliation(s)
- L Xu
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - T Zhao
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - L Perry
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- South Eastern Sydney Local Health District, Randwick, New South Wales, Australia
| | - S A Frost
- University of Wollongong and South Western Sydney Local Health District, Wollongong, New South Wales, Australia
| | - G L Di Tanna
- Department of Business Economics, Health & Social Care, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - S Wang
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - M Chen
- School of Health Policy and Management, Nanjing Medical University, No. 101, Longmian Avenue, Nanjing, 211166, China.
| | - G S Kolt
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | - S Jan
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - L Si
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
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Billups SJ, Fixen DR, Schilling LM, El-Sheikh A, Marcus AM, Rothman MS. Lessons Learned: Evaluation of Fracture Liaison Service Quality Improvement Efforts in a Large Academic Healthcare System. J Gen Intern Med 2024; 39:1407-1413. [PMID: 38100010 PMCID: PMC11169298 DOI: 10.1007/s11606-023-08568-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 12/04/2023] [Indexed: 06/13/2024]
Abstract
BACKGROUND The Fracture Liaison Service (FLS) care model, a care coordination program for patients experiencing a fragility fracture, is proven to improve management of patients with an osteoporotic fracture, but treatment initiation gaps persist. OBJECTIVE We describe the evolution of a centralized FLS within a university-based healthcare system, including impact of adding clinical pharmacist consultation, and describe circumstances surrounding continued care gaps. DESIGN Cohort analysis of osteoporosis medication initiation before FLS, after initial implementation, and after addition of pharmacist consultation. PATIENTS Individuals aged 65 and older experiencing any fragility fracture between 7/1/16 and 3/31/22. INTERVENTION A centralized team outreached eligible patients, ordered dual x-ray absorptiometry and laboratory tests as needed, and scheduled an osteoporosis-focused primary care appointment. Three years after FLS implementation, clinical pharmacist consultative review was added prior to the primary care visit. MAIN MEASURES Initiation of osteoporosis pharmacologic therapy, completion of DXA, primary care follow-up rate, and description of circumstances where therapy was not initiated. KEY RESULTS Of 1204 new fractures between 7/1/16 and 3/31/22, 315 patients were enrolled in one of two FLS phases, and 89 eligible historical controls were identified. Medication initiation rates went from 22/89 (25%) pre-FLS to 201/428 (47%) after-FLS phase 1 [POST1] (p<0.001) and to 106/187 (57%) after FLS phase 2 (POST2), when clinical pharmacist consultation was added (p=0.03 versus POST1). DXA was completed in 56/89 (67%) of pre-FLS patients, 364/428 (85%) POST1 patients (p<0.001 versus pre), and 163/187 (87%) POST2 (p< 0.001 versus PRE, p=0.59 versus POST1). Of 375 patients who did not initiate osteoporosis medication, more in the combined post-FLS cohorts attended a follow-up primary care appointment (233/308, 76% attended, versus pre-FLS 41/67, 61%, p=0.016). CONCLUSION An FLS including centralized outreach and care coordination significantly improved patient follow-up, DXA, and medication initiation. Addition of de-centralized pharmacist consultation further improved medication initiation rates.
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Affiliation(s)
- Sarah J Billups
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
| | - Danielle R Fixen
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | | | - Arwa El-Sheikh
- University of Colorado School of Medicine, Aurora, CO, USA
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6
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Bendtsen MG, Hitz MF. Opportunistic Identification of Vertebral Compression Fractures on CT Scans of the Chest and Abdomen, Using an AI Algorithm, in a Real-Life Setting. Calcif Tissue Int 2024; 114:468-479. [PMID: 38530406 PMCID: PMC11061033 DOI: 10.1007/s00223-024-01196-2] [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: 12/22/2023] [Accepted: 02/13/2024] [Indexed: 03/28/2024]
Abstract
This study evaluated the performance of a vertebral fracture detection algorithm (HealthVCF) in a real-life setting and assessed the impact on treatment and diagnostic workflow. HealthVCF was used to identify moderate and severe vertebral compression fractures (VCF) at a Danish hospital. Around 10,000 CT scans were processed by the HealthVCF and CT scans positive for VCF formed both the baseline and 6-months follow-up cohort. To determine performance of the algorithm 1000 CT scans were evaluated by specialized radiographers to determine performance of the algorithm. Sensitivity was 0.68 (CI 0.581-0.776) and specificity 0.91 (CI 0.89-0.928). At 6-months follow-up, 18% of the 538 patients in the retrospective cohort were dead, 78 patients had been referred for a DXA scan, while 25 patients had been diagnosed with osteoporosis. A higher mortality rate was seen in patients not known with osteoporosis at baseline compared to patients known with osteoporosis at baseline, 12.8% versus 22.6% (p = 0.003). Patients receiving bisphosphonates had a lower mortality rate (9.6%) compared to the rest of the population (20.9%) (p = 0.003). HealthVCF demonstrated a poorer performance than expected, and the tested version is not generalizable to the Danish population. Based on its specificity, the HealthVCF can be used as a tool to prioritize resources in opportunistic identification of VCF's. Implementing such a tool on its own only resulted in a small number of new diagnoses of osteoporosis and referrals to DXA scans during a 6-month follow-up period. To increase efficiency, the HealthVCF should be integrated with Fracture Liaison Services (FLS).
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Affiliation(s)
| | - Mette Friberg Hitz
- Research Unit, Medical Department, Zealand University Hospital, Koege, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Koege, Denmark
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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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Sabri SA, Chavarria JC, Ackert-Bicknell C, Swanson C, Burger E. Osteoporosis: An Update on Screening, Diagnosis, Evaluation, and Treatment. Orthopedics 2023; 46:e20-e26. [PMID: 35876780 PMCID: PMC10084730 DOI: 10.3928/01477447-20220719-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Osteoporosis screening, diagnosis, and treatment have gained much attention in the health care community over the past 2 decades. During this time, creation of multispecialty awareness programs (eg, "Own the Bone," American Orthopedic Association; "Capture the Fracture," International Osteoporosis Foundation) and improvements in diagnostic protocols have been evident. Significant advances in technology have elucidated elements of genetic predisposition for decreased bone mineral density in the aging population. Additionally, several novel drug therapies have entered the market and provide more options for primary care and osteoporosis specialists to medically manage patients at risk for fragility fractures. Despite this, adherence to osteoporosis screening and treatment protocols has been surprisingly low by health care practitioners, including orthopedic surgeons. Continued awareness and education of this skeletal disorder is crucial to effectively care for our aging population. [Orthopedics. 2023;46(1):e20-e26.].
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Affiliation(s)
- Shahbaaz A. Sabri
- University of Colorado School of Medicine, Department of
Orthopedic Surgery, Denver, CO
| | - Joseph C. Chavarria
- University of Colorado School of Medicine, Department of
Orthopedic Surgery, Denver, CO
| | | | - Christine Swanson
- University of Colorado School of Medicine, Department of
Endocrinology, Metabolism and Diabetes Denver, CO
| | - Evalina Burger
- University of Colorado School of Medicine, Department of
Orthopedic Surgery, Denver, CO
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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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10
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A model-based cost-effectiveness analysis of fracture liaison services in China. Arch Osteoporos 2022; 17:132. [PMID: 36195760 PMCID: PMC9532296 DOI: 10.1007/s11657-022-01170-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 09/23/2022] [Indexed: 02/03/2023]
Abstract
This study is a model-based cost-effectiveness analysis of fracture liaison services (FLS) in China, suggesting that FLS could potentially lead to lifetime cost-saving in patients who have experienced a fracture. However, Chinese-specific real-world data is needed to confirm the results of our study. PURPOSE The study aimed to assess the potential cost-effectiveness of fracture liaison services (FLS) from the Chinese healthcare perspective with a lifetime horizon. METHODS A previously validated Markov microsimulation model was adapted to estimate the cost-effectiveness of FLS compared to no-FLS. The evaluation was conducted in patients aged 65 years with a recent fracture. Treatment pathways were differentiated by gender, FLS attendance, osteoporosis diagnosis, treatment initiation, and adherence. Given the uncertainty in FLS cost, the cost in the base-case analysis was assumed at US$200. Analyses were also performed to determine the maximum cost for making the FLS cost-saving and cost-effective at the Chinese willingness-to-pay (WTP) threshold. One-way sensitivity analyses were conducted. RESULTS When compared with no-FLS, the FLS was dominant (lower costs, higher quality-adjusted life years) in our target population at the FLS cost of US$200 per patient. For every 100 patients who were admitted to the FLS, approximately four hip fractures, nine clinical vertebral fractures, and three wrist fractures would be avoided over their lifetimes. Our findings were robust to numerous one-way sensitivity analyses; however, the FLS was not cost-effective in patients aged 80 years and older. CONCLUSION FLS could potentially lead to lifetime cost-saving in patients who have experienced a fracture. Our study informs the potential cost-effectiveness of FLS and the knowledge gap in China; more future research incorporating Chinese-specific real-world data are needed to confirm the results of our study and to better evaluate the cost-effectiveness of FLS in China.
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11
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Moral-Cuesta D, Gutiérrez-Misis A, Veloz BAC, Matovelle-Ochoa P, Epelde IM, Alarcón TA, Díez-Sebastián J, Galbete A, Maestre IM, Velilla NM, González-Montalvo JI. Profile and 3-month evolution of geriatric patients after a hip fracture followed-up at a Fracture Liaison Service (FLS). Rev Esp Geriatr Gerontol 2022; 57:205-211. [PMID: 35872030 DOI: 10.1016/j.regg.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 05/29/2022] [Accepted: 06/23/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION There are few studies on Fracture Liaison Service (FLS) that evaluate older patients after a hip fracture (HF) through comprehensive geriatric assessment. We aim to determine these patients' characteristics, outcomes, and prescribed treatments. METHODS A retrospective observational study of a cohort of patients older than 65 years admitted with HFs to an orthogeriatric unit between February 25th (2013) and December 16th (2016). After hospitalization, those patients with a good baseline social, functional, and cognitive situation were referred to the FLS. A comprehensive geriatric assessment and treatment adjustment were conducted. A comparison between FLS patients and HF patients non-referred was made. RESULTS From 1887 patients admitted to the orthogeriatric unit, 469 (23%) were referred to the FLS. Of those, 335 were women (77.2%) and 337 (77.6%) lived in the community. The FLS patients had a better functional status (97.1% of the patients with independent gait versus 79.2%) than non-FLS patients (p<0.001). After 3 months in the FLS, 356 (82%) patients had independent gait and had improved their analytical values. Antiosteoporotic treatment was prescribed to 322 patients (74%), vitamin D supplements to 397 (91.5%), calcium to 321 (74%), and physical exercise to 421 (97%). CONCLUSIONS Patients referred to an FLS were younger, with a better functional and cognitive situation. At hospital discharge, they frequently presented gait impairment and laboratory abnormalities (anemia, hypoproteinemia, vitamin D deficiency) that presented good recovery due to the patient's previous baseline. These patients benefit from comprehensive treatment (pharmacological and non-pharmacological).
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Affiliation(s)
- Debora Moral-Cuesta
- Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain.
| | - Alicia Gutiérrez-Misis
- Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Instituto de Investigación Biomédica del Hospital Universitario La Paz (IdiPaz), Madrid, Spain
| | - Bernardo Abel Cedeño Veloz
- Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain; Centro de Investigación Biomédica de Navarra (Navarrabiomed), Pamplona, Spain
| | | | - Itxaso Marin Epelde
- Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain
| | - Teresa Alarcón Alarcón
- Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Instituto de Investigación Biomédica del Hospital Universitario La Paz (IdiPaz), Madrid, Spain; Servicio de Geriatría, Hospital Universitario La Paz, Madrid, Spain
| | - Jesús Díez-Sebastián
- Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Sección de Epidemiología Clínica del Servicio de Medicina Preventiva, Madrid, Spain
| | - Arkaitz Galbete
- Centro de Investigación Biomédica de Navarra (Navarrabiomed), Pamplona, Spain
| | | | - Nicolás Martínez Velilla
- Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (Idisna), Pamplona, Spain; Centro de Investigación Biomédica de Navarra (Navarrabiomed), Pamplona, Spain
| | - Juan Ignacio González-Montalvo
- Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain; Instituto de Investigación Biomédica del Hospital Universitario La Paz (IdiPaz), Madrid, Spain; Servicio de Geriatría, Hospital Universitario La Paz, Madrid, Spain
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12
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Gregson CL, Armstrong DJ, Bowden J, Cooper C, Edwards J, Gittoes NJL, Harvey N, Kanis J, Leyland S, Low R, McCloskey E, Moss K, Parker J, Paskins Z, Poole K, Reid DM, Stone M, Thomson J, Vine N, Compston J. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2022; 17:58. [PMID: 35378630 PMCID: PMC8979902 DOI: 10.1007/s11657-022-01061-5] [Citation(s) in RCA: 163] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023]
Abstract
The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management. INTRODUCTION The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. METHODS Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement. CONCLUSION The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.
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Affiliation(s)
- Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK.
- Royal United Hospital NHS Foundation Trust, Bath, UK.
| | - David J Armstrong
- Western Health and Social Care Trust (NI), Nutrition Innovation Centre for Food and Health, Ulster University, and Visiting Professor, Belfast, Northern Ireland
| | - Jean Bowden
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, 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
| | - John Edwards
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, and Wolstanton Medical Centre, Newcastle under Lyme, UK
| | - Neil J L Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital, University Hospitals Birmingham & University of Birmingham, Birmingham, UK
| | - Nicholas Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia and Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
| | | | - Rebecca Low
- Abingdon and Specialty Doctor in Metabolic Bone Disease, Marcham Road Health Centre, Nuffield Orthopaedic Centre, Oxford, UK
| | - Eugene McCloskey
- Department of Oncology & Metabolism, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - Katie Moss
- St George's University Hospital, London, UK
| | - Jane Parker
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Zoe Paskins
- School of Medicine, Keele University, Keele, Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | - Kenneth Poole
- Department of Medicine, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | - Mike Stone
- University Hospital Llandough, Cardiff and Vale University Health Board, Llandough, UK
| | | | - Nic Vine
- Musculoskeletal Research Unit, Bristol Medical School, Learning and Research Building, University of Bristol, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Juliet Compston
- University of Cambridge, School of Clinical Medicine, Cambridge, UK
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13
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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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14
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Ahmed S, Zehra N, Noordin S, Sadruddin A, Khan AH. Bridging the gaps in secondary fracture prevention at a single center in Pakistan-compliance with the IOF best practice framework. Arch Osteoporos 2021; 16:158. [PMID: 34698959 DOI: 10.1007/s11657-021-01032-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/19/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The International Osteoporosis Foundation (IOF) formulated a set of best practice framework as an international benchmark for secondary fracture prevention (SFP) and fracture liaison services (FLS), delineating essential elements of service delivery. The aim of this audit was to assess compliance with the IOF standards for patients ≥ 50 years presenting with fragility hip fractures at a tertiary care center in Pakistan. METHODS A retrospective sample of hip fracture cases from Jan 2019 to Dec 2019, treated at the section of Orthopedic Surgery, Aga Khan University, Karachi, was conducted. After excluding high energy trauma cases and patients younger than 50 years of age, medical records were audited, using a pre-structured Performa based on IOF standards. Compliance level of 0, 1, 2, and 3 was recorded as defined by IOF. Microsoft excel was used for data analysis. RESULTS A compliance level of 3 was recorded for patient identification and fall prevention services, whereas level 1 was attained for database maintenance for 25 (100%) cases. For medication initiation, level 0 was recorded for all the cases; however, 8 (32%) cases were prescribed calcium and vitamin D supplements. For the standards, including post-fracture assessment timing, evaluation of secondary causes of osteoporosis, multifaceted assessment, medication review, communication strategy, and long-term management, a level 0 was noted for 25 (100%) cases. Moreover, no recommended assessment guidelines were followed uniformly. CONCLUSION The care gaps identified require substantial efforts to ensure adequate implementation of the overall best practice standards for SFP, necessitating the need for FLS initiation and establishment of fracture care pathway.
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Affiliation(s)
- Sibtain Ahmed
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Nawazish Zehra
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Shahryar Noordin
- Musculoskeletal and Sports Medicine, Department of Surgery, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Anum Sadruddin
- Department of Surgery, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan
| | - Aysha Habib Khan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
- Chemical Pathology & Bone, Departments of Pathology and Laboratory Medicine, Medicine Aga Khan University, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan.
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15
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Olmo-Montes FJ, Hernández-Cruz B, Miranda MJ, Jimenez-Moreno MD, Vázquez-Gámez MÁ, Giner M, Colmenero MA, Pérez-Venegas JJ, Montoya-García MJ. The Fracture Liaison Service of the Virgen Macarena University Hospital Reduces the Gap in the Management of Osteoporosis, Particularly in Men. It Meets the International Osteoporosis Foundation Quality Standards. J Clin Med 2021; 10:jcm10184220. [PMID: 34575331 PMCID: PMC8465304 DOI: 10.3390/jcm10184220] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/13/2021] [Accepted: 09/15/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To describe the Fracture Liaison Service (FLS), to know the characteristics of the patients attended with emphasis on sex differences, and to know the compliance of International Osteoporosis Foundation (IOF) quality standards. METHODS Observational, prospective research. All the consecutive patients that attended in usual clinical practice from May 2018 to October 2019, were over 50 years, and with a fragility fracture (FF), were included. RESULTS Our FLS is a type A multidisciplinary unit. We included 410 patients, 80% women. FF recorded in 328 women were: Hip (132, 40%), Clinical Vertebral (81, 25%) and No hip No vertebral (115, 35%). Those in 82 men were: Hip (53, 66%), Clinical Vertebral (20, 24%) and No hip No vertebral (9, 10%), p = 0.0001. Men had more secondary osteoporosis (OP). The most remarkable result was the low percentage of patients with OP receiving treatment and the differences between sex. Forty-nine (16%) women versus nine (7%) men had received it at some point in their lives, p = 0.04. The probability of a man not receiving prior treatment was 2.5 (95%CI 1.01-6.51); p = 0.04, and after the FF was 0.64 (0.38-1.09). Treatment adherence in the first year after the FLS was 96% in both sexes. The completion of IOF quality standards was bad for patient identification and reference time. It was poor for initial OP screening standard and good for the remaining ten indicators. CONCLUSIONS the FLS narrowed the gap in diagnosis, treatment, and follow-up of fragility fracture patients, especially men. The FLS meets the IOF quality standards.
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Affiliation(s)
- Francisco-Jesús Olmo-Montes
- Internal Medicine Department, Virgen Macarena University Hospital, Dr Fedriani Avenue No 3, 41009 Seville, Spain; (F.-J.O.-M.); (M.J.M.); (M.D.J.-M.); (M.-A.C.)
| | - Blanca Hernández-Cruz
- Rheumatology Department, Virgen Macarena University Hospital, Dr Fedriani Avenue No 3, 41009 Seville, Spain;
- Correspondence: ; Tel.: +34-954-78-22-06
| | - Mª José Miranda
- Internal Medicine Department, Virgen Macarena University Hospital, Dr Fedriani Avenue No 3, 41009 Seville, Spain; (F.-J.O.-M.); (M.J.M.); (M.D.J.-M.); (M.-A.C.)
| | - Mª Dolores Jimenez-Moreno
- Internal Medicine Department, Virgen Macarena University Hospital, Dr Fedriani Avenue No 3, 41009 Seville, Spain; (F.-J.O.-M.); (M.J.M.); (M.D.J.-M.); (M.-A.C.)
| | - Mª Ángeles Vázquez-Gámez
- PAIDI Research Group CTS/211, Medicine Department, School of Medicine, Seville University, Sanchez Pizjuan SN, 41009 Seville, Spain; (M.Á.V.-G.); (M.G.); (M.-J.M.-G.)
| | - Mercè Giner
- PAIDI Research Group CTS/211, Medicine Department, School of Medicine, Seville University, Sanchez Pizjuan SN, 41009 Seville, Spain; (M.Á.V.-G.); (M.G.); (M.-J.M.-G.)
| | - Miguel-Angel Colmenero
- Internal Medicine Department, Virgen Macarena University Hospital, Dr Fedriani Avenue No 3, 41009 Seville, Spain; (F.-J.O.-M.); (M.J.M.); (M.D.J.-M.); (M.-A.C.)
| | - José Javier Pérez-Venegas
- Rheumatology Department, Virgen Macarena University Hospital, Dr Fedriani Avenue No 3, 41009 Seville, Spain;
| | - María-José Montoya-García
- PAIDI Research Group CTS/211, Medicine Department, School of Medicine, Seville University, Sanchez Pizjuan SN, 41009 Seville, Spain; (M.Á.V.-G.); (M.G.); (M.-J.M.-G.)
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16
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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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17
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Chandran M, Mitchell PJ, Amphansap T, Bhadada SK, Chadha M, Chan DC, Chung YS, Ebeling P, Gilchrist N, Habib Khan A, Halbout P, Hew FL, Lan HPT, Lau TC, Lee JK, Lekamwasam S, Lyubomirsky G, Mercado-Asis LB, Mithal A, Nguyen TV, Pandey D, Reid IR, Suzuki A, Chit TT, Tiu KL, Valleenukul T, Yung CK, Zhao YL. Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region. Osteoporos Int 2021; 32:1249-1275. [PMID: 33502559 PMCID: PMC8192320 DOI: 10.1007/s00198-020-05742-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/11/2020] [Indexed: 01/07/2023]
Abstract
UNLABELLED Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care. PURPOSE Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development. METHODS We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards. RESULTS Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines. CONCLUSION The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.
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Affiliation(s)
- M Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, 20, College Road, Academia, Singapore, 169856, Singapore.
| | - P J Mitchell
- Synthesis Medical NZ Limited, Pukekohe, Auckland, New Zealand
| | - T Amphansap
- Department of Orthopedics, Police General Hospital, Bangkok, Thailand
| | - S K Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M Chadha
- Department of Endocrinology, Hinduja Hospital and Research Centre, Mumbai, India
| | - D-C Chan
- Internal Medicine, National University Hospital Chu-Tung Branch, Chinese Taipei, Taiwan
| | - Y-S Chung
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, South Korea
| | - P Ebeling
- Department of Medicine in the School of Clinical Sciences, Monash Health, Melbourne, Australia
| | - N Gilchrist
- Canterbury District Health Board, Christchurch, New Zealand
| | - A Habib Khan
- Section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - F L Hew
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | - H-P T Lan
- Musculoskeletal and Metabolic Unit, Biomedical Research Center, Pham Ngoc Thach University of Medicine, Bone and Muscle Research Group, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - T C Lau
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - J K Lee
- Department of Orthopedics, Beacon International Specialist Centre, Petaling Jaya, Malaysia
| | - S Lekamwasam
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | | | - L B Mercado-Asis
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - A Mithal
- Endocrinology, Diabetes Division, Mithal, M. Max Healthcare - Pan-Max, Gurgaon, India
| | - T V Nguyen
- Genetics and Epidemiology of Osteoporosis Laboratory, Bone Biology Division, Garvan Institute of Medical Reseach, Sydney, Australia
| | - D Pandey
- Department of Orthopaedics, National Trauma Centre, Kathmandu, Nepal
| | - I R Reid
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Suzuki
- Department of Endocrinology, School of Medicine, Fujita Health University, Toyoake, Japan
| | - T T Chit
- East Yangon General Hospital, Yangon, Myanmar
| | - K L Tiu
- Polytrauma and Fragility Fracture team, Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - T Valleenukul
- Department of Orthopedics, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - C K Yung
- Department of Endocrinology and Patient Safety Unit, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam
| | - Y L Zhao
- Department of Obstetrics and Gynecology, Beijing United Family Hospital, Beijing, China
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Improving Secondary Fracture Prevention After Vertebroplasty: Implementation of a Fracture Liaison Service. J Am Coll Radiol 2021; 18:1235-1238. [PMID: 34166641 DOI: 10.1016/j.jacr.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of our study was to evaluate a multidisciplinary fracture liaison service (FLS) to improve osteoporosis treatment and secondary fracture prevention for patients after vertebroplasty. METHODS A retrospective chart review of consecutive vertebroplasty patients from January 2016 to January 2020. FLS began in December 2016 allowing for before-and-after comparison. Statistical analysis included patient demographics and procedure characteristics. Proportion of patients evaluated by the FLS clinic and treatment modification were evaluated. Opt-in versus opt-out referral strategies were compared. Dual energy x-ray absorptiometry scans or vitamin D levels within 3 months before or after vertebroplasty were assessed. Time to event analysis was used to evaluate secondary fracture occurrence. RESULTS There were 137 vertebroplasty patients, 39 before FLS and 98 after FLS, included. Only 15% of all patients were already being treated in a bone health clinic. Of those referred and evaluated by the FLS, 73.0% had their osteoporosis treatment modified. Patients evaluated by the FLS were more likely to have a dual energy x-ray absorptiometry scan or a vitamin D level drawn (P < .001 for both). The opt-out referral was more effective with a 75.0% referral rate (P = .71). Secondary fracture of any kind occurred in 23.4% of all patients. Time to event analysis demonstrated a trend toward a reduced risk of secondary spinal fractures in the fracture prevention group with an adjusted hazard ratio of 0.39 (0.13-1.11, 95% confidence interval). DISCUSSION A multidisciplinary FLS can be implemented for patients after vertebroplasty to evaluate osteoporotic risk factors and optimize osteoporosis therapy, both of which are important factors in preventing secondary vertebral fractures.
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Adams J, Wilson N, Hurkmans E, Bakkers M, Balážová P, Baxter M, Blavnsfeldt AB, Briot K, Chiari C, Cooper C, Dragoi RG, Gäbler G, Lems W, Mosor E, Pais S, Simon C, Studenic P, Tilley S, de la Torre-Aboki J, Stamm TA. 2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. Ann Rheum Dis 2021; 80:57-64. [PMID: 32332077 PMCID: PMC7788058 DOI: 10.1136/annrheumdis-2020-216931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older. METHODS Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated. RESULTS Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6. CONCLUSION These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.
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Affiliation(s)
- Jo Adams
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Nicky Wilson
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Emalie Hurkmans
- Department Care I, Musculoskeletal System & Neurology, Dutch National Health Care Institute, Diemen, The Netherlands
| | - Margot Bakkers
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Petra Balážová
- EULAR Young PARE, Zurich, Switzerland
- Slovak League Against Rheumatism, Piestany, Slovakia
| | - Mark Baxter
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Karine Briot
- INSERM U1153, Paris Descartes University, Reference Center for Genetic Bone Diseases - Department of Rheumatology, Cochin Hospital, Paris, France
| | - Catharina Chiari
- Department of Orthopedics and Trauma-Surgery, Medical University of Vienna, Vienna, Austria
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Razvan Gabriel Dragoi
- Rehabilitation, Physical Medicine and Rheumatology, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
| | - Gabriele Gäbler
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Willem Lems
- Department of Rheumatology, VU University Medical Centre Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Erika Mosor
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Sandra Pais
- Centre for Biomedical Research, Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Cornelia Simon
- Department of Balneology, Rehabilitation and Rheumatology, 'Victor Babes' University of Medicine and Pharmacy, Timisoara, Timisoara, Romania
| | - Paul Studenic
- Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Vienna, Austria
| | - Simon Tilley
- Medicine for Older People, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Trauma & Orthopaedics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Arthritis and Rehabilitation, Vienna, Austria
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Leopold SS. Editorial: Secondary Fracture Prevention-What's Your System? Clin Orthop Relat Res 2020; 478:1703-1705. [PMID: 32732553 PMCID: PMC7371035 DOI: 10.1097/corr.0000000000001276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Seth S Leopold
- S. S. Leopold, Editor-in-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA
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21
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A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program. Arch Osteoporos 2020; 15:113. [PMID: 32699946 DOI: 10.1007/s11657-020-00781-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/30/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture. PURPOSE/INTRODUCTION To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice. METHODS The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses. RESULTS One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%). CONCLUSION A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.
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Javaid MK, Sami A, Lems W, Mitchell P, Thomas T, Singer A, Speerin R, Fujita M, Pierroz DD, Akesson K, Halbout P, Ferrari S, Cooper C. A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: a position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network. Osteoporos Int 2020; 31:1193-1204. [PMID: 32266437 PMCID: PMC7280347 DOI: 10.1007/s00198-020-05377-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/03/2020] [Indexed: 12/23/2022]
Abstract
The International Osteoporosis Foundation (IOF) Capture the Fracture® Campaign with the Fragility Fracture Network (FFN) and National Osteoporosis Foundation (NOF) has developed eleven patient-level key performance indicators (KPIs) for fracture liaison services (FLSs) to guide quality improvement. INTRODUCTION Fracture Liaison Services (FLSs) are recommended worldwide to reduce fracture risk after a sentinel fracture. Given not every FLS is automatically effective, the IOF Capture the Fracture working group has developed and implemented the Best Practice Framework to assess the organisational components of an FLS. We have now developed a complimentary KPI set that extends this assessment of performance to the patient level. METHODS The Capture the Fracture working group in collaboration with the Fragility Fracture Network Secondary Fragility Fracture Special Interest Group and National Osteoporosis Foundation adapted existing metrics from the UK-based Fracture Liaison Service Database Audit to develop a patient-level KPI set for FLSs. RESULTS Eleven KPIs were selected. The proportion of patients: with non-spinal fractures; with spine fractures (detected clinically and radiologically); assessed for fracture risk within 12 weeks of sentinel fracture; having DXA assessment within 12 weeks of sentinel fracture; having falls risk assessment; recommended anti-osteoporosis medication; commenced of strength and balance exercise intervention within 16 weeks of sentinel fracture; monitored within 16 weeks of sentinel fracture; started anti-osteoporosis medication within 16 weeks of sentinel fracture; prescribed anti-osteoporosis medication 52 weeks after sentinel fracture. The final KPI measures data completeness for each of the other KPIs. For these indicators, levels of achievement were set at the < 50%, 50-80% and > 80% levels except for treatment recommendation where a level of 50% was used. CONCLUSION This KPI set compliments the existing Best Practice Framework to support FLSs to examine their own performance using patient-level data. By using this KPI set for local quality improvement cycles, FLSs will be able to efficiently realise the full potential of secondary fracture prevention and improved clinical outcomes for their local populations.
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Affiliation(s)
- M K Javaid
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK.
| | - A Sami
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK
| | - W Lems
- VU University Medical Center, Amsterdam, The Netherlands
| | - P Mitchell
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK
- School of Medicine, Sydney Campus, The University of Notre Dame Australia, 140 Broadway, Sydney, NSW, 2007, Australia
| | - T Thomas
- Department of Rheumatology, Hôpital Nord, CHU de Saint-Etienne, and INSERM U1059, University of Lyon, Saint-Etienne, France
| | - A Singer
- Department of Medicine, MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA
- Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital and Georgetown University Medical Center, Washington, DC, USA
| | - R Speerin
- Fragility Fracture Network, Zürich, Switzerland
- Musculoskeletal Network, NSW Agency for Clinical Innovation, Chatswood, Australia
| | - M Fujita
- International Osteoporosis Foundation, Nyon, Switzerland
| | - D D Pierroz
- International Osteoporosis Foundation, Nyon, Switzerland
| | - K Akesson
- Department of Orthopaedics, Skane University Hospital, Malmö, Sweden
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - S Ferrari
- Division of Bone Disease, Department of Internal Medicine Specialties, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - C Cooper
- The Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Orthopaedic Sciences, University of Oxford, Oxford, OX4 7LD, UK
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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Beaupre LA, Moradi F, Khong H, Smith C, Evens L, Hanson HM, Juby AG, Kivi P, Majumdar SR. Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework. Arch Osteoporos 2020; 15:83. [PMID: 32488730 DOI: 10.1007/s11657-020-00751-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/05/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture. PURPOSE To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance). METHODS Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital. RESULTS Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance). CONCLUSIONS An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.
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Affiliation(s)
- L A Beaupre
- University of Alberta (Physical Therapy), 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada.
| | - F Moradi
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - H Khong
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - C Smith
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - L Evens
- Alberta Bone and Joint Health Institute, Calgary, AB, Canada
| | - H M Hanson
- Seniors Health Strategic Clinical Network™, Alberta Health Services and University of Calgary (Medicine), Calgary, AB, Canada
| | - A G Juby
- University of Alberta (Geriatric Medicine), Edmonton, AB, Canada
| | - P Kivi
- University of Alberta (Family Medicine), Edmonton, AB, Canada
| | - S R Majumdar
- University of Alberta (Medicine), Edmonton, AB, Canada
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Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. J Orthop Trauma 2020; 34:e125-e141. [PMID: 32195892 DOI: 10.1097/bot.0000000000001743] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).
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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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Senay A, Perreault S, Delisle J, Morin SN, Fernandes JC. Performance of a Fracture Liaison Service in an Orthopaedic Setting: A Report of Key Indicators and Improvement of Longitudinal Outcomes. J Bone Joint Surg Am 2020; 102:486-494. [PMID: 31714470 DOI: 10.2106/jbjs.19.00185] [Citation(s) in RCA: 10] [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 Many Fracture Liaison Services (FLSs) have been successfully implemented, but very few incorporate systematic longitudinal follow-up. The objective of this study was to report on the performance of such an FLS using key performance indicators and longitudinal clinical outcomes. METHODS An FLS was implemented in 2 outpatient orthopaedic clinics. Men and women who were ≥40 years of age and had a recent fragility fracture were recruited. Participants were evaluated, treated when appropriate, and systematically followed over a 2-year period. Clinical data including chart review and questionnaires were collected. Medical services and hospitalization claims data were retrieved from administrative databases. The primary outcomes were the following key performance indicators: the numbers of investigated and treated patients, follow-up attendance, and the incidence of subsequent fractures. Secondary outcomes were the changes in bone turnover markers and quality of life, physical capacity, and pain scores between baseline and follow-up visits. RESULTS A total of 532 subjects with a mean age of 63.4 years were recruited; 85.7% were female. Bone mineral density results were collected for 472 subjects (88.7%) and a prescription for anti-osteoporosis medication was given to 86.6% of patients. Overall, 83.6% of patients attended at least 1 follow-up visit. The subsequent fracture incidence rate was 2.6 per 100 person-years (23 fractures). The mean level of type-I collagen C-telopeptide (CTX-1), a bone resorption marker, decreased >35%. Clinically important improvements of functional capacity scores (by 14.4% to 63.7%) and pain level (by 19.3% to 35.7%) were observed over time; however, the increase in quality-of-life scores was not clinically important (by 3% to 15.2%). CONCLUSIONS In this FLS, the rates of investigation, treatment, and participation were >80% over a 2-year period. The subsequent fragility fracture incidence rate was <3 per 100 person-years. These results suggest that an intensive FLS model of care, with a systematic longitudinal follow-up, is effective. A randomized controlled trial is needed to support these results. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andréa Senay
- Faculties of Pharmacy (A.S. and S.P.) and Medicine (J.C.F.), Université de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Sylvie Perreault
- Faculties of Pharmacy (A.S. and S.P.) and Medicine (J.C.F.), Université de Montréal, Montréal, Québec, Canada
| | - Josée Delisle
- CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital Jean-Talon, Montréal, Montréal, Québec, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Center for Outcomes and Evaluation, Montréal, Québec, Canada
| | - Julio C Fernandes
- Faculties of Pharmacy (A.S. and S.P.) and Medicine (J.C.F.), Université de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital Jean-Talon, Montréal, Montréal, Québec, Canada
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27
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Conley RB, Adib G, Adler RA, Åkesson KE, Alexander IM, Amenta KC, Blank RD, Brox WT, Carmody EE, Chapman-Novakofski K, Clarke BL, Cody KM, Cooper C, Crandall CJ, Dirschl DR, Eagen TJ, Elderkin AL, Fujita M, Greenspan SL, Halbout P, Hochberg MC, Javaid M, Jeray KJ, Kearns AE, King T, Koinis TF, Koontz JS, Kužma M, Lindsey C, Lorentzon M, Lyritis GP, Michaud LB, Miciano A, Morin SN, Mujahid N, Napoli N, Olenginski TP, Puzas JE, Rizou S, Rosen CJ, Saag K, Thompson E, Tosi LL, Tracer H, Khosla S, Kiel DP. Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. J Bone Miner Res 2020; 35:36-52. [PMID: 31538675 DOI: 10.1002/jbmr.3877] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/08/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022]
Abstract
Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early post-fracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease). © 2019 American Society for Bone and Mineral Research.
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Affiliation(s)
| | | | | | | | - Ivy M Alexander
- UConn School of Nursing, University of Connecticut, Storrs, CT, USA
| | - Kelly C Amenta
- Department of Physician Assistant Studies, Mercyhurst University, Erie, PA, USA
| | - Robert D Blank
- Department of Endocrinology, Metabolism and Clinical Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA.,Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | | | - Emily E Carmody
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Bart L Clarke
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Douglas R Dirschl
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL, USA
| | | | - Ann L Elderkin
- American Society for Bone and Mineral Research, Washington, DC, USA
| | - Masaki Fujita
- Science Department, International Osteoporosis Foundation, Nyon, Switzerland
| | - Susan L Greenspan
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Marc C Hochberg
- Division of Rheumatology, University of Maryland School of Medicine and VA Maryland Health Care System, Baltimore, MD, USA
| | - Muhammad Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, USA
| | - Kyle J Jeray
- Prisma Health - Upstate (formerly Greenville Health System), Greenville, SC, USA
| | - Ann E Kearns
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Toby King
- US Bone and Joint Initiative, Rosemont, IL, USA
| | | | - Jennifer Scott Koontz
- Orthopedics & Sports Medicine, Newton Medical Center, Newton, KS, USA.,Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, KS, USA
| | - Martin Kužma
- 5th Department of Internal Medicine, University Hospital, Comenius University, Bratislava, Slovakia
| | - Carleen Lindsey
- Bones, Backs and Balance, LLC, Bristol Physical Therapy, LLC, Bristol, CT, USA
| | - Mattias Lorentzon
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia.,Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.,Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Nadia Mujahid
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Nicola Napoli
- Department of Nutrition and Metabolic Disorders, Campus Bio-Medico University of Rome, Rome, Italy.,Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - J Edward Puzas
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Clifford J Rosen
- Tufts University School of Medicine, Boston, MA, USA.,Maine Medical Center Research Institute, Portland, ME, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Laura L Tosi
- Department of Orthopaedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC, USA
| | - Howard Tracer
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Sundeep Khosla
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas P Kiel
- Harvard Medical School, Musculoskeletal Research Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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28
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Pennestrì F, Corbetta S, Favero V, Banfi G. Fragility Fracture Prevention-Implementing a Fracture Liaison Service in a High Volume Orthopedic Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16244902. [PMID: 31817294 PMCID: PMC6950760 DOI: 10.3390/ijerph16244902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/28/2019] [Accepted: 12/01/2019] [Indexed: 11/16/2022]
Abstract
Fragility fractures pose a serious threat to patient health, quality of life, and healthcare sustainability. In order to reduce their clinical, social, and economic burden, a Fracture Liaison Service (FLS) was introduced in a high volume orthopedic hospital in 2017. The purpose of this retrospective observational study is to describe the FLS protocol, introduce its preliminary outcomes, and provide an early evaluation in light of international guidelines and recommendations. All the performances suggested by the International Osteoporosis Foundation (IOF) are provided under the same institution by which a patient is admitted for surgery. Clinical indicators from patient history and administrative indicators from the hospital database have been used to estimate the spread of fragility fracture prevention and the degree of patient compliance to these programs. The research included 403 patients. Although, almost 1/3 were admitted for the second fragility fracture, only half received anti-osteoporotic treatment before it. The degree of prevention was even lower in the case of patients admitted for the first fragility fracture. The risk of being affected by a secondary fracture was seven times higher when patients did not attend any follow-up or diagnostic exam. In order to identify the main determinants of compliance with FLS and perform a cost-effectiveness analysis on a larger sample, it is fundamental to integrate data from different providers.
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Affiliation(s)
- Federico Pennestrì
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, 20161 Milan, Italy;
- Correspondence: ; Tel.: +39-02-66214850
| | - Sabrina Corbetta
- IRCCS Orthopedic Institute Galeazzi, Endocrinology and Diabetology Service, 20161 Milan, Italy; (S.C.); (V.F.)
- Department of Biomedical, Surgical and Odontoiatric Services, University of Milan, 20122 Milan, Italy
| | - Vittoria Favero
- IRCCS Orthopedic Institute Galeazzi, Endocrinology and Diabetology Service, 20161 Milan, Italy; (S.C.); (V.F.)
- Department of Biomedical, Surgical and Odontoiatric Services, University of Milan, 20122 Milan, Italy
| | - Giuseppe Banfi
- IRCCS Orthopedic Institute Galeazzi, Scientific Direction, 20161 Milan, Italy;
- Università Vita-Salute San Raffaele, Scientific Direction, 20132 Milan, Italy
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29
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Yoo JI, Ha YC, Park KS, Kim RB, Seo SH, Koo KH. Incidence and Mortality of Osteoporotic Refractures in Korea according to Nationwide Claims Data. Yonsei Med J 2019; 60:969-975. [PMID: 31538432 PMCID: PMC6753341 DOI: 10.3349/ymj.2019.60.10.969] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/16/2019] [Accepted: 08/09/2019] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Studies on the incidence and mortality of refractures after primary osteoporotic fracture are limited by the relatively rare incidence of such refractures and small sample sizes. The objectives of this research were: 1) to determine the incidence of osteoporotic refractures and fracture locations and 2) to assess mortality rates associated with osteoporotic refracture over a median follow up of 3 years using nationwide claim database. MATERIALS AND METHODS Patients over 50 years of age who had an osteoporotic fracture that was confirmed operationally were enrolled. Refracture was defined as that after 6 months of an untreated period. Mortality rate was calculated using the Charlson comorbidity index and was analyzed using Cox proportional hazards regression analysis. RESULTS A total of 18956 first-time instances of osteoporotic fracture were reported between 2007 and 2012 after a median follow up of 3.1 years (range, 1 to 7 years). Among 18956 patients, 2941 (15.50%) experienced refracture. After follow up for 1 year, cumulative mortality rates for re-fracture and non-refracture groups were 9.1% and 7.2%, respectively. After adjusting for covriates, mortality rate was 1.2 times greater in patients with re-fracture than in patients without re-fracture over a median follow up of 3 years (hazard ratio: 1.20, 95% confidence interval: 1.08-1.34, p<0.001). CONCLUSION The incidence of osteoporotic re-fracture in this nationwide study was 15.5%, and the mortality rate of re-fracture patients was 1.2 times higher than that of non-refracture patients over a median follow up of 3 years.
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Affiliation(s)
- Jun Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Yong Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea.
| | - Ki Soo Park
- Institute of Health Science, Gyeongsang National University, Jinju, Korea
- Department of Preventive Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Rock Beum Kim
- Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Sung Hyo Seo
- Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Kyung Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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30
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Kwok TSH, Gakhal N, Ruban TN. The Evaluation of an Osteoporosis Clinic in a Community Hospital Setting: a Retrospective Chart Review and Telephone Survey. Can Geriatr J 2019; 22:143-147. [PMID: 31565110 PMCID: PMC6715410 DOI: 10.5770/cgj.22.359] [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] [Indexed: 11/24/2022] Open
Abstract
Background Patients who have suffered fragility fractures are at an increased risk for subsequent fractures. The Osteoporosis (OP) Clinic at Markham Stouffville Hospital (MSH) was set up in July 2015 to screen, diagnose, and treat patients with fragility fractures. The goal of this study was to identify differences in OP screening and treatment initiation between patients seen in the OP clinic versus usual care. Methods A retrospective cohort study and telephone interview was conducted on 40 patients who had sustained a hip fragility fracture between September 2015 and July 2016. 20 of those patients were referred to the OP clinic, while the remaining patients received usual care. Results At the end of the intervention, 16/20 patients in the OP clinic group were appropriately placed on a bisphosphonate/RANKL inhibitor versus only 6/20 patients in the usual care group (p < .01). Conclusions A significant care gap exists in secondary fracture prevention between the osteoporosis clinic and usual care groups. Better screening and subsequent intervention are needed for patients with fragility fractures. This study highlights the efficacy of an outpatient OP clinic in a community hospital setting.
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Affiliation(s)
- Timothy S H Kwok
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Natasha Gakhal
- Women's College Hospital, Toronto, ON, Canada.,Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thanu N Ruban
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Markham Stouffville Hospital, Markham, ON, Canada
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31
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Sanclemente-Boli T, Ponce-Ruiz S, Álvarez-Lorenzo C, Zuriguel-Pérez E, Tapia-Melenchon R, Ramentol-Sintas M, Villar-Casares MDM, Teixidor-Serra J, Molero-García V, Sánchez-Raya J, Lalueza-Broto P, Ginés-Puertas À, Garrido-Clua M, Mestre-Torres J. Effectiveness of a multidisciplinary educational intervention in patients with hip fracture: SWEET HOME study. Med Clin (Barc) 2019; 153:446-453. [PMID: 31320135 DOI: 10.1016/j.medcli.2019.02.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Hip fracture is a common injury among elderly patients. The main goal of our study was to assess the effectiveness of a multidisciplinary educational intervention aimed at hip fracture patients to promote home discharges and reduce in-hospital complications. MATERIAL AND METHOD A quasi-experimental study was performed by taking repeated measurements at hospital admission, at hospital discharge, and at both 30days and one year of discharge. Patients aged ≥65years with hip fracture who were admitted to the Orthogeriatric Service between February 2016 and January 2017 were included in the study. The educational intervention consisted in two coordinated actions: patient education administered during their hospitalization and multimodal support provided during their discharge home. RESULTS A total of 67 patients were included in the study (77.6% of whom were women; 84.19±7,78 years old). Of these, 70.1% were discharged home, which doubles the figures recorded in the 2014-2015 period. The rate of readmission at 30days and one year of the discharge was 8.5%. At the one-year follow-up, the patient's dependence to perform basic activities of daily living was nearer to the pre-fracture level (Barthel: 86.67±19.31; 94.33±14.66), their mobility had improved in comparison with the time of discharge (Parker: 4.73±1.84; 6.73±2.76; Timed Up and Go Test: 38.29±21.27; 21.91±10.97), and their cognitive function had not worsened significantly. The patient education measures improved the patients' autonomy as perceived by the patients, the caregivers, and the healthcare providers. Satisfaction with the healthcare received was high. CONCLUSIONS As a novelty to the already described benefits in orthogeriatric care models, this study would contribute by proving an increase of the number of patients discharged home in a safe condition.
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Affiliation(s)
- Teresa Sanclemente-Boli
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d'Hebron, Barcelona, España.
| | - Sandra Ponce-Ruiz
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Consuelo Álvarez-Lorenzo
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | | | - Raquel Tapia-Melenchon
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Marc Ramentol-Sintas
- Servicio de Medicina Interna, Hospital Universitari Vall d'Hebron, Barcelona, España
| | | | - Jordi Teixidor-Serra
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Vicente Molero-García
- Servicio de Cirugía Ortopédica y Traumatológica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Judith Sánchez-Raya
- Servicio de Medicina Física i Rehabilitación, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Pilar Lalueza-Broto
- Servicio de Farmacia, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - Àlex Ginés-Puertas
- Servicio de Medicina Física i Rehabilitación, Hospital Universitari Vall d'Hebron, Barcelona, España
| | | | - Jaume Mestre-Torres
- Servicio de Medicina Interna, Hospital Universitari Vall d'Hebron, Barcelona, España
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Metasynthesis of Patient Attitudes Toward Bone Densitometry. J Gen Intern Med 2018; 33:1796-1804. [PMID: 30054881 PMCID: PMC6153231 DOI: 10.1007/s11606-018-4587-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/09/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Bone densitometry (e.g., dual-energy X-ray absorptiometry or "DXA") is strongly associated with osteoporosis treatment; however, rates of DXA are low. While studies have demonstrated a continued need for primary care provider education on the role of DXA in preventive care, little is known about the role of patient attitudes toward DXA. This review's purpose is to synthesize the evidence about the effects of patient perceptions and experiences of DXA on osteoporosis prevention. METHODS A metasynthesis was conducted of English language, peer-reviewed publications, searching relevant databases: MEDLINE, CINAHL, Web of Science Social Science Citation Index, PsycINFO, and Sociological Abstracts. Identified articles' quality was appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist, and an iterative process of data evaluation, integration, and synthesis was used to develop the findings. RESULTS Thirteen articles from ten studies were identified, composing an aggregated sample of 265 people (231 women). Participant attitudes toward screening ranged from receptive to ambivalent to concerned about results. Participants' understandings of DXA and its role in clinical care were limited. Knowledge of osteoporosis was also partial and influenced by lay sources, the media, and health care providers. Primary care providers strongly influenced participant behavior, especially if participants had a more passive approach to health care. Participants reported less concern about expected barriers of health care access and cost. CONCLUSION Minimal knowledge exists of patient perceptions and experiences of DXA among those who are fracture naïve: Prior research has focused primarily on secondary fracture prevention contexts. Our metasynthesis reveals patients' significant reliance, given their limited risk appraisal and knowledge, upon primary care providers in decision-making. We urge colleagues to conduct qualitative research on DXA barriers among general primary care population in order to facilitate health care delivery systems better equipped to diagnose and treat patients before their first fracture.
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