Decreased Mortality and Subsequent Fracture Risk in Patients With a Major and Hip Fracture After the Introduction of a Fracture Liaison Service: A 3-Year Follow-Up Survey

Abstract

Fracture liaison services (FLS) are considered to be the most effective organizational approach for secondary fracture prevention. In this study, we evaluated whether FLS care was associated with reduced subsequent fracture and mortality risk over 3 years of follow-up. In total, 8682 consecutive patients aged 50-90 years with a recent fracture were included. Before FLS introduction, regular fracture treatment procedures were followed (pre-FLS). After FLS introduction, patients were invited to the FLS and FLS attenders were assessed for osteoporosis, prevalent vertebral fractures, metabolic bone disorders, medication use, and fall risk, and treatment for fracture prevention was initiated according to Dutch guidelines. All fractures were radiographically confirmed and categorized into major/hip (pelvis, proximal humerus or tibia, vertebral, multiple rib, distal femur) and non-major/non-hip (all other fractures). Mortality risk was examined using age and sex adjusted Cox proportional hazard models. For subsequent fracture risk, Cox proportional hazard models were adjusted for age, sex, and competing mortality risk (subdistribution hazard [SHR] approach). The pre-FLS group consisted of 2530 patients (72% women), of whom 1188 (46.9%) had major/hip index fractures, the post-FLS group consisted of 6152 patients (69% women), of whom 2973 (48.3%) had major/hip index fractures. In patients with a non-major/non-hip fracture there was no difference in subsequent non-major/non-hip fracture risk or mortality between pre-FLS and post-FLS. In patients with a major/hip index fracture, mortality risk was lower post-FLS (hazard ratio [HR] 0.84; 95% confidence interval [CI], 0.73-0.96) and subsequent major/hip fracture risk was lower in the first 360 days after index fracture post-FLS compared to pre-FLS (SHR 0.67; 95% CI, 0.52-0.87). In conclusion, FLS care was associated with a lower mortality risk in the first 3 years and a lower subsequent major/hip fracture risk in the first year in patients with a major/hip index fracture but not in patients with a non-major/non-hip fracture.

Patients with osteoporosis: children of a lesser god

“…As an example, mortality in the year following hip fracture is close to 20% and most of the survivors will suffer from severe and prolonged disability and/or will refracture within the following year. 3 A substantial proportion of the mortality occurring after fracture is due to refracture. 4 5 Alongside with the clinical burden comes the personal economic cost, which is only partially sustained by the healthcare systems and commonly falls back on caregivers and patients.…”

“… 8 Many fracture liaison services have been established throughout the world to identify, treat and monitor those sustaining fragility fractures. 3 It has been demonstrated that postfracture treatment with anti-osteoporotic medications can reduce mortality and morbidity. 9 10 Nonetheless, efforts to improve the situation are still inadequate.…”

“…Such great disproportion between costs linked to fracture care and costs related to antiosteoporotic medications is surprising when compared with other diseases (eg, cardiovascular diseases (CV)), whereas the clinical burden of fracture can be immense. As an example, mortality in the year following hip fracture is close to 20% and most of the survivors will suffer from severe and prolonged disability and/or will refracture within the following year 3. A substantial proportion of the mortality occurring after fracture is due to refracture 4 5.…”

“…It is worth mentioning the ‘Capture the Fracture’ initiative, promoted by the International Osteoporosis Foundation 8. Many fracture liaison services have been established throughout the world to identify, treat and monitor those sustaining fragility fractures 3. It has been demonstrated that postfracture treatment with anti-osteoporotic medications can reduce mortality and morbidity 9 10.…”

Team Approach: Organizing and Empowering Multidisciplinary Teams in Postfragility Fracture Care

“…Of the 1,240 patients studied, 575 were scheduled for outpatient follow-up, and 307 (53%) kept their appointments. A PFCP was initiated at a single center in the Netherlands in January 2008 14 . The program coordinator was a trained nurse; patients were identified through searching the medical record for qualifying fracture diagnoses and invited by letter to participate in the program.…”