Health-related quality of life of patients with a recent fracture attending a fracture liaison service: a 3-year follow-up study

Cost-effectiveness of a multicomponent-adherence intervention in fracture liaison services

BACKGROUND

This study aims to assess the lifetime cost-effectiveness of a multi-component adherence intervention (MCAI), including a patient decision aid and motivational interviewing, compared to usual care in patients with a recent fracture attending fracture liaison services (FLS) and eligible for anti-osteoporosis medication (AOM).

RESEARCH DESIGN AND METHODS

Data on AOM initiation and one-year persistence were collected from a quasi-experimental study conducted between 2019 and 2023 in two Dutch FLS centers. An individual level, state-transition Markov model was used to simulate lifetime costs and quality-adjusted life years (QALYs) with a societal perspective of MCAI vs usual care. One-way and probabilistic sensitivity analyses were conducted including variation in additional FLS and MCAI costs (no MCAI cost in baseline).

RESULTS

MCAI was associated with gain in QALYs (0.0012) and reduction in costs (-€16) and is therefore dominant. At the Dutch willingness-to-pay threshold of €50,000/QALY, MCAI remained cost-effective when increasing costs of the FLS visit or the yearly maintenance cost for MCAI up to +€60. Probabilistic sensitivity analysis demonstrated MCAI to be dominant in 54% of the simulations and cost-effective in 87% with a threshold of €50,000/QALY.

CONCLUSIONS

A MCAI implemented in FLS centers may lead to cost-effective allocation of resources in FLS care, depending on extra costs.

Cost-effectiveness analysis of fracture liaison services: a Markov model using Dutch real-world data

This study assessed the lifetime cost-effectiveness of a fracture liaison service (FLS) compared to no-FLS in the Netherlands from a societal perspective and suggested that FLS was cost-effective in patients with a recent fracture aged 50 years and older. The implementation of FLS could lead to lifetime health-economic benefits.

INTRODUCTION

The objective of this study was to investigate the lifetime cost-effectiveness of a fracture liaison service (FLS) compared to no-FLS in the Netherlands from a societal perspective and using real-world data.

METHODS

Annual fracture incidence, treatment scenarios as well as treatment initiation in the years 2017-2019 were collected from a large secondary care hospital in the Netherlands. An individual-level, state transition model was designed to simulate lifetime costs and quality-adjusted life years (QALYs). Treatment pathways were differentiated by gender, presence of osteoporosis and/or prevalent vertebral fracture, and treatment status. Results were presented as incremental cost-effectiveness ratios (ICER). Both one-way and probabilistic sensitivity analyses were conducted.

RESULTS

For patients with a recent fracture aged 50 years and older, the presence of an FLS was associated with a lifetime €45 higher cost and 0.11 additional QALY gained leading to an ICER of €409 per QALY gained, indicating FLS was cost-effective compared to no-FLS at the Dutch threshold of €20,000/QALY. The FLS remained cost-effectiveness across different age categories. Our findings were robust in all one-way sensitivity analyses, the higher the treatment initiation rate in FLS, the greater the cost-effective of FLS. Probabilistic sensitivity analyses revealed that FLS was cost-effective in 90% of the simulations at the threshold of €20,000/QALY, with women 92% versus men 84% by gender.

CONCLUSION

This study provides the first health-economic analysis of FLS in the Netherlands, suggesting the implementation of FLS could lead to lifetime health-economic benefits.

Characterization and effectiveness of a Fracture Liaison Services program in Colombia

PURPOSE

Fracture Liaison Services programs reduce mortality and the risk of refracture and increase treatment and adherence rates. Greater coverage is an important priority for the future. The aim was to determine the characteristics of patients over 50 years old who suffered fractures and the effectiveness of a Fracture Liaison Services program in a health care institution in Colombia.

METHODS

This was a retrospective follow-up study of a cohort of patients with vertebral and nonvertebral fractures managed in a Fracture Liaison Services program. Sociodemographic, clinical and pharmacological variables were identified. Key performance indicators were used to evaluate the effectiveness of the program. Descriptive and bivariate analysis was performed.

RESULTS

A total of 438 patients were analyzed. The average age was 77.5 years, and 78.5% were women. Hip and vertebral fractures were the most common (25.3% and 24.9%, respectively). Vertebral fractures prevailed in men (33.0% vs 22.7%; p = 0.041) and those of the radius/ulna in women (20.3% vs 10.6%; p = 0.031). A total of 29.7% had experienced a previous fracture, and 16.7% had received antiosteoporosis drugs. A total of 63.5% of the cases were managed surgically. At discharge, 58.8% received prescriptions for calcium/vitamin D, and 50.7% with prescriptions of antiosteoporotic therapy, especially teriparatide (21.2%) and denosumab (16.4%), without significant differences by sex. However, in women with hip fractures, anti-osteoporotic management prevailed (83.7% vs 64.0; p = 0.032). The effectiveness of the overall program per year was 74.6%. On follow-up, only 9.1% of patients had experienced a new fall, and of those 3.7% presented a new fracture. A total of 4.3% died during follow-up.

CONCLUSIONS

Good adherence to the recommendations of the country's clinical practice guidelines was found, and overall, the effectiveness of the program was very satisfactory, with a low incidence of new fractures during follow-up. Fracture Liaison Services programs reduce mortality and the risk of refracture. A retrospective follow-up study of a cohort of patients with vertebral and nonvertebral fractures managed in a Fracture Liaison Services, showed that the effectiveness was 73.6%. On follow-up, 9.1% of patients had experienced a new fall, and of those 3.7% presented a new fracture.

The effectiveness of fracture liaison services in patients with hip fractures: A systematic review and meta-analysis of randomized controlled trials

Background

In recent years, fracture liaison services (FLS) have been applied for hip fractures; however, their effectiveness remains uncertain.

Objective

To evaluate the effectiveness of FLS in patients with hip fractures.

Design

A systematic review and meta-analysis of randomized controlled trials.

Data sources

Embase, PubMed, Cochrane Library, Ebsco, Ovid, Web of Science, Medline, CNKI, Wangfang, and Vip were searched from their date of inception to March 2023. Two researchers screened the literature based on the inclusion and exclusion criteria, evaluated the quality, extracted data, and conducted a meta-analysis using ReviewManager 5.4.

Results

After screening, 12 randomised controlled trials (RCT) including 2136 patients were used in the meta-analysis. The primary outcomes were hip function rate of recurrent fracture, medication adherence, and degree of weakness. FLS improved hip function in patients with hip fractures [MD = 9.37, 95 % CI (7.69, 11.06), P < 0.0001], P < 0.0001], medication adherence [OR = 10.59, 95 % CI (1.64, 68.41), P＜0.0001], degree of weakness [MD = -1.45, 95%CI (-1.68，-1.23), P＜0.0001], and reduced the rate of recurrent fractures [OR = 0.60, 95 % CI (0.44, 0.82).

Conclusion

Implementation of the FLS management model was beneficial for patients with hip fractures. It can positively impact the prognosis of patients with hip fractures by improving hip function, reducing the rate of recurrent fractures, and improving medication adherence and degree of weakness.

Effectiveness of fracture liaison services in osteoporosis

BACKGROUND

In response to the gradual decline in the number of prescriptions for anti-osteoporosis medication (AOM) following fragility fractures, fracture liaison services (FLSs) have been set up around the world with the aim of filling this treatment gap. Several studies have already reported the benefits of such organizations, particularly in reducing fracture risk, mortality rates and healthcare costs, and literature on FLSs has increased at a steady pace over time.

METHODS

A narrative review was conducted on the latest available findings on the effectiveness of FLSs. Various approaches to implementing an effective FLS program are discussed.

RESULTS

FLS programs have enhanced the management of osteoporosis-related fractures. However, several studies have highlighted that not all FLSs are necessarily effective in reducing subsequent fracture risk and mortality. Long-term AOM persistence and monitoring are another critical issue in FLS programs. A few studies have reported that FLSs are associated with an improvement in AOM persistence, regardless of the type of AOM. Practitioners in the FLS setting need to be aware of the impact of recency of fracture and fracture recurrence rates, and the need for timely interventions. The administration of zoledronic acid in an in-patient setting may improve AOM treatment rates in patients, who often encounter obstacles to outpatient follow-up. Introducing 'vertebral fracture identification services' in FLS programs is also an option. However, doing so leads to an increase in workload and this would need to be considered by any FLS that is considering introducing such a service. Evidence suggests that digital technologies can support (i) multidisciplinary teams in providing the best possible patient care based on current evidence, and (ii) patient self-management. However, as the methodological quality of many of the studies evaluating these technologies was poor, their validity of their results is limited.

CONCLUSION

Further research should focus on the optimal implementation of post-fracture care using automated systems, and standardized reporting of patient's characteristics and outcome measures using key performance indicators.

Factors affecting the quality of life in the chronic phase of thoracolumbar osteoporotic vertebral fracture managed conservatively with a brace

BACKGROUND CONTEXT

Although osteoporotic vertebral fractures (OVFs) are the most common type of osteoporotic fracture, few reports have closely investigated the factors contributing to the quality of life (QOL) in the chronic phase after thoracolumbar OVFs using detailed radiographic evaluation.

PURPOSE

This study aimed to identify factors associated with the QOL in the chronic phase after thoracolumbar OVF.

DESIGN

Post hoc analysis of a prospective randomized study.

PATIENT SAMPLE

Participants included 195 patients with fresh thoracolumbar OVF managed conservatively with a brace who were available for radiographic analysis 48 weeks after injury.

OUTCOME MEASURES

The degree of QOL impairment at 48 weeks after thoracolumbar OVF was assessed using the Japanese three-level version of the EuroQol five-dimensional questionnaire (EQ-5D) score.

METHODS

Univariate and multivariate regression analyses were used to evaluate the relationships between the QOL and radiographic factors.

RESULTS

The univariate analysis showed that age, analgesic use, T10/L5 Cobb angle on magnetic resonance imaging (MRI), subsequent vertebral fracture, and nonunion were significantly associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. The multiple regression analysis showed that nonunion, analgesic use, subsequent vertebral fracture, and sacral slope on MRI were independently associated with the EQ-5D score at 48 weeks after thoracolumbar OVF. Receiver operating characteristic analysis for the deterioration of QOL showed that the cutoff value for sacral slope on MRI was 35 degrees.

CONCLUSIONS

This study demonstrated that nonunion, subsequent vertebral fracture, and lower sacral slope were independently associated with poorer QOL in the chronic phase of thoracolumbar OVF managed conservatively with a brace. Therefore, improving or preventing these factors in patients with thoracolumbar OVF in the chronic phase may improve the QOL of the affected patients.

Closing the gap in osteoporosis management: the critical role of primary care in bone health

OBJECTIVE

The World Health Organization issued a call to action for primary care to lead efforts in managing noncommunicable diseases, including osteoporosis. Although common, osteoporosis remains underdiagnosed and undertreated. Primary care practitioners (PCPs) are critical in identifying individuals at risk for osteoporosis and osteoporotic fractures; however, recent advances in assessment, diagnosis, and treatment of osteoporosis have not been incorporated into clinical practice in primary care due to numerous reasons including time constraints and insufficient knowledge. To close this gap in clinical practice, we believe PCPs need a practical strategy to facilitate osteoporosis assessment and management that is easy to implement.

METHODS

In this article, we consolidate information from various global guidelines and highlight areas of agreement to create a streamlined osteoporosis management strategy for a global audience of PCPs.

RESULTS

We present a systematic approach to facilitate osteoporosis assessment and management that includes four steps: (1) identifying patients at risk through proactive screening strategies, (2) investigating and diagnosing patients, (3) intervening with personalized treatment plans, and (4) implementing patient-centered strategies for long-term management and monitoring of patients.

CONCLUSION

Primary care has a central role in ensuring the incorporation of key elements of holistic care as outlined by the World Health Organization in managing noncommunicable diseases including osteoporosis; namely, a people-centered approach, incorporation of specialist services, and multidisciplinary care. This approach is designed to strengthen the health system's response to the growing osteoporosis epidemic.

Inpatient Zoledronic Acid and Integrated Orthopedic and Fracture Liaison Services Improve Osteoporosis Treatment Rates

CONTEXT

Fragility fractures increase risks for future fractures, morbidity, and mortality. Available pharmacotherapy for underlying osteoporosis is safe and effective but underused.

OBJECTIVE

To improve pharmacotherapy rate representing secondary prevention of osteoporotic fractures.

METHODS

This single-center, observational, follow-up study included patients with fragility fractures admitted to the Massachusetts General Hospital between February 2016 and December 2019. For patients admitted to the orthopedics service with fragility fracture, the Massachusetts General Hospital Fracture Liaison Service (FLS) was systematically consulted. Initial outpatient follow-up with FLS was established in conjunction with the orthopedic postoperative follow-up visit. Patients at risk for failing timely outpatient follow-up were administered zoledronic acid (ZA) during the index fracture hospitalization. The main outcome measures were percentage of patients with fragility fracture(s) started on pharmacotherapy for osteoporosis and average length of stay and 30-day readmission rate of patients treated with ZA.

RESULTS

Compared with baseline (8-11%) and reference (5-20%) rates, integration of FLS to the orthopedics service, along with appropriate inpatient administration of ZA, increased the pharmacotherapy rate to 70% (412/589) among eligible patients with verified treatment status. Inpatient ZA administration neither affected the average length of stay nor 30-day readmission rate. Treatment status of 37.9% (471/1240) of the study patients remained unknown due to lack of or unknown follow-up.

CONCLUSION

Integration of a FLS and orthopedics services along with inpatient ZA administration improved the osteoporosis pharmacotherapy rate among patients with fragility fracture(s) who often had obstacles for outpatient follow-up.

Relationship between oseteoporosis with fatty infiltration of paraspinal muscles based on QCT examination

INTRODUCTION

To investigate the correlation between paraspinal muscles features and osteoporosis in lumbar spine.

MATERIALS AND METHODS

A total of 367 subjects who underwent quantitative computed tomography (QCT) examination were enrolled in this study. QCT pro workstation was used to obtain the mean bone mineral density (BMD) of the lower lumbar spine. Fat fraction (FF) and cross-section area (CSA) of the paraspinal muscles at the corresponding levels were measured. All participants were divided into normal, osteopenia, and osteoporosis groups. One-way ANOVA and independent samples t tests were performed to compare differences between groups. Pearson and Spearman correlation coefficients and partial correlation analysis after controlling for confounding factors were used to analyze the correlation between BMD and paraspinal muscles measurements.

RESULTS

Among the 367 participants included, 116 were in the normal group, 130 in the osteopenia group and 121 in the osteoporosis group. There were significant differences among the three groups for the mean and multifidus FF. BMD showed negative correlations with the FF of the paraspinal muscles. Multifidus and mean FF showed the best correlation (r = - 0.654, - 0.777). There were also significant differences in the mean and multifidus FF between different age groups, while after controlling for confounding factors, there was no correlation between age and FF of the paraspinal muscles.

CONCLUSION

This preliminary study demonstrated the association of BMD with fatty infiltration of paraspinal muscles. Different muscles might have specific effects in different sex and age groups.

A head-to-head comparison of EQ-5D-5L and SF-6D in Dutch patients with fractures visiting a Fracture Liaison Service

AIMS

This study compared the psychometric properties of EQ-5D-5L and SF-6D to assess the interchangeability of both instruments in patients with a recent fracture presenting at a Fracture Liaison Service (FLS).

MATERIALS AND METHODS

Data from a prospective observational study in a Dutch FLS clinic were used. Over 3 years, subjects were interviewed at several time points using EQ-5D-5L and SF-36. Floor and ceiling effects were evaluated. Agreement was evaluated by intra-class correlation coefficients and visualized in Bland-Altman plots. Spearman's rank correlation coefficients were applied to assess convergent validity. Mann-Whitney U test or Kruskal-Wallis H test as well as effect size (ES) were used to explore known-groups validity. Responsiveness was explored using standardized response mean (SRM) and ES. For each measurement property, hypotheses on direction and magnitude of effects were formulated.

RESULTS

A total of 499 patients were included. EQ-5D-5L had a considerable ceiling effect in comparison to SF-6D (21 vs. 1.2%). Moderate agreement between the (UK and Dutch) EQ-5D-5L and SF-6D was identified with intra-class correlation coefficients of 0.625 and 0.654, respectively. Bland-Altman plots revealed proportional bias as the differences in utilities between two instruments were highly dependent on the health states. High correlation between instruments was found (UK: rho = 0.758; Dutch: rho = 0.763). EQ-5D-5L and SF-6D utilities showed high correlation with physical component score but low correlation with mental component score of SF-36. Both instruments showed moderate discrimination (ES > 0.5) for subgroup by baseline fracture type, and moderate responsiveness (SRM > 0.5) in patients that sustained a subsequent fracture.

CONCLUSION

Both EQ-5D-5L and SF-6D appeared to be valid utility instruments in patients with fractures attending the FLS. However, they cannot be used interchangeably given only moderate agreement was identified, and differences in utilities and ceiling effect were revealed. Comparable construct validity and responsiveness were indicated, and neither instrument was found to be clearly superior.