In the JournalsPerspective

Fracture liaison service increases BMD testing, osteoporosis treatment

Adults with osteoporosis who received care from a fracture liaison service program were more likely to undergo bone mineral density testing and initiate and adhere to osteoporosis treatment vs. adults receiving usual care, according to study findings published in Bone.

Fracture liaison services are defined as coordinator-based models of secondary fracture prevention services, designed to identify patients at increased risk for secondary fractures and to ensure the patients initiate appropriate treatment via improved care coordination and communication, Chih-Hsing Wu, MD, associate professor in the department of family medicine at National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan, and colleagues wrote in the study background. In 2013, the International Osteoporosis Foundation initiated the promotion of fracture liaison service programs worldwide, but the literature suggests varied outcomes, the researchers noted.

In a meta-analysis and systematic literature review, Wu and colleagues analyzed data from 16 randomized controlled trials and 58 observational studies conducted in adults with osteoporosis aged at least 50 years between January 2000 and February 2017. Studies assessed patients with osteoporosis-related fractures in a hospital, clinic, community or home-based setting, managed using either a fracture liaison service program or usual care. Researchers assessed measurement of BMD at any site, treatment initiation, adherence to treatment, incidence of refracture and rates of all-cause mortality.

In the 37 studies that reported on BMD testing, researchers found that unweighted average rates of BMD testing were 48% in the fracture liaison service arms and 23.5% in the usual care arms, with follow-up periods ranging from 3 to 26 months. In meta-analysis, patients who participated in fracture liaison service interventions were more likely to undergo BMD testing vs. controls (absolute risk increase, 0.24; 95% CI, 0.18-0.29), with results persisting in separate analyses of randomized controlled trials and observational studies.

In 46 studies reporting on osteoporosis treatment initiation rates, fracture liaison service interventions were associated with a 20% higher absolute risk increase in treatment initiation rates vs. control arms (95% CI, 0.16-0.25). In 25 studies assessing adherence to osteoporosis treatment, researchers found that fracture liaison service interventions were associated with a 22% higher absolute risk increase in adherence to medication (95% CI, 0.13-0.31), with follow-up ranges of 3 to 48 months across studies.

In 11 studies evaluating rates of refracture, fracture liaison service interventions were associated with a 5% reduction in absolute risk for refracture vs. usual care (95% CI, –0.08 to –0.03; number needed to treat = 20), with follow-up ranges of 6 to 72 months.

Mortality among patients in a fracture liaison service intervention was reduced by 3% compared with usual care (95% CI –0.05 to –0.01).

“[Fracture liaison services] are clinically effective across a range of important outcomes in patients with fractures of osteoporosis, indicating that they play a significant role in minimizing the burden of disease,” the researchers wrote. – by Regina Schaffer

Disclosures: Amgen supported this study. One of the study authors reports he received consulting fees from Amgen, and another author reports he served as an advisor to Complete HEOR Solutions, LLC.

Adults with osteoporosis who received care from a fracture liaison service program were more likely to undergo bone mineral density testing and initiate and adhere to osteoporosis treatment vs. adults receiving usual care, according to study findings published in Bone.

Fracture liaison services are defined as coordinator-based models of secondary fracture prevention services, designed to identify patients at increased risk for secondary fractures and to ensure the patients initiate appropriate treatment via improved care coordination and communication, Chih-Hsing Wu, MD, associate professor in the department of family medicine at National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan, and colleagues wrote in the study background. In 2013, the International Osteoporosis Foundation initiated the promotion of fracture liaison service programs worldwide, but the literature suggests varied outcomes, the researchers noted.

In a meta-analysis and systematic literature review, Wu and colleagues analyzed data from 16 randomized controlled trials and 58 observational studies conducted in adults with osteoporosis aged at least 50 years between January 2000 and February 2017. Studies assessed patients with osteoporosis-related fractures in a hospital, clinic, community or home-based setting, managed using either a fracture liaison service program or usual care. Researchers assessed measurement of BMD at any site, treatment initiation, adherence to treatment, incidence of refracture and rates of all-cause mortality.

In the 37 studies that reported on BMD testing, researchers found that unweighted average rates of BMD testing were 48% in the fracture liaison service arms and 23.5% in the usual care arms, with follow-up periods ranging from 3 to 26 months. In meta-analysis, patients who participated in fracture liaison service interventions were more likely to undergo BMD testing vs. controls (absolute risk increase, 0.24; 95% CI, 0.18-0.29), with results persisting in separate analyses of randomized controlled trials and observational studies.

In 46 studies reporting on osteoporosis treatment initiation rates, fracture liaison service interventions were associated with a 20% higher absolute risk increase in treatment initiation rates vs. control arms (95% CI, 0.16-0.25). In 25 studies assessing adherence to osteoporosis treatment, researchers found that fracture liaison service interventions were associated with a 22% higher absolute risk increase in adherence to medication (95% CI, 0.13-0.31), with follow-up ranges of 3 to 48 months across studies.

In 11 studies evaluating rates of refracture, fracture liaison service interventions were associated with a 5% reduction in absolute risk for refracture vs. usual care (95% CI, –0.08 to –0.03; number needed to treat = 20), with follow-up ranges of 6 to 72 months.

Mortality among patients in a fracture liaison service intervention was reduced by 3% compared with usual care (95% CI –0.05 to –0.01).

“[Fracture liaison services] are clinically effective across a range of important outcomes in patients with fractures of osteoporosis, indicating that they play a significant role in minimizing the burden of disease,” the researchers wrote. – by Regina Schaffer

Disclosures: Amgen supported this study. One of the study authors reports he received consulting fees from Amgen, and another author reports he served as an advisor to Complete HEOR Solutions, LLC.

    Perspective

    Michael Lewiecki

    Osteoporosis is a major public health concern with serious clinical consequences and high health care costs due to fractures. Most patients at high risk for fracture, including those with prior fractures, are currently not being treated to prevent future fractures. This grim situation has been identified as a crisis in the care of osteoporosis, with an urgent call to action by professional societies and patient advocacy groups worldwide. We need to explore and evaluate all possible interventions to reduce the osteoporosis treatment gap.

    One approach to the crisis in osteoporosis is a fracture liaison service. This is a systematic strategy for secondary fracture prevention. It involves identifying fracture patients, often in the hospital, entering them in a registry and following their clinical course to ensure that they are appropriately evaluated and treated to reduce fracture risk. To assess the effectiveness of this approach, Wu and colleagues conducted a systematic literature review of 159 publications and meta-analysis of 74 controlled studies (16 randomized controlled trials and 58 observational studies) evaluating fracture liaison service outcomes. It was found that patients entered into a fracture liaison service program had higher rates of bone density testing (48% vs. 23.5%), treatment initiation (38% vs. 17.2%), and greater adherence (57% vs. 34.1%) compared with controls. There was also evidence of fewer re-fractures and reduced mortality associated with the fracture liaison service intervention.

    This study provides additional support for further development of fracture liaison services. Every hospital that cares for fracture patients should consider establishing such a program. Resources for starting and maintaining such a service are available from the National Bone Health Alliance (“Fracture Prevention Central”), the American Orthopaedic Association (“Own the Bone”) and the International Osteoporosis Foundation (“Capture the Fracture”).

    E. Michael Lewiecki, MD, FACP, FACE

    Director, New Mexico Clinical Research and Osteoporosis Center
    Director, Bone Health TeleECHO
    University of New Mexico Health Sciences Center

    Disclosure: Lewiecki reports he has received institutional grant or research support from Amgen, Mereo and PFEnex; has served on scientific advisory boards for Alexion, Amgen, Radius, Sandoz, Shire and Ultragenyx; and serves on speakers bureaus for Alexion, Radius and Shire. He is a board member of the National Osteoporosis Foundation, International Society for Clinical Densitometry and Osteoporosis Foundation of New Mexico.