Systematic review on interventions to improve osteoporosis investigation and treatment in fragility fracture patients

Abstract

This study aims to determine osteoporosis (OP) investigation and treatment within post-fracture initiatives conducted in fracture clinics and other orthopedic environments. A systematic review was conducted. Eligibility criteria were: hip fracture patients plus all other fracture patients presenting with a fragility fracture, orthopedic setting where orthopedic physicians/staff were involved, intervention to improve OP management, primary data on ≥20 patients from randomized controlled trials (RCTs) and other study designs. We calculated outcome data within 6 months of screening from an intention-to-treat principle to derive an equated proportion (EP) across interventions. Outcomes were: (1) proportion of patients investigated with bone densitometry, (2) proportion of patients initiating OP medication, and (3) proportion of patients taking OP medication. We identified 2,259 citations, of which 57 articles that included 64 intervention groups were eligible. The median EP for patients investigated was 43% and the 75th percentile was 71%. The median EP for medication initiation was 22% and the 75th percentile was 34%. The median EP for medication taking was 27.5% and the 75th percentile was 43%. The EPs for all outcomes were higher for interventions with dedicated personnel to implement the intervention and those within which bone mineral density testing and/or treatment were included. In studies with an EP, up to 71% of patients were investigated for OP, but <35% initiated medication, and <45% were taking medication within 6 months of screening. Calculating an EP allowed us to compare outcomes across the studies, therefore capturing both RCTs and other study designs typical of real-world settings.

Closing the gap in postfracture care at the population level: a randomized controlled trial

“…15 A systematic review found that 65% of clinical systems for ensuring appropriate postfracture care include a dedicated case coordinator. 16 In some countries, a liaison service for fractures has been cost-effective.…”

Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

“…95 The current consensus supports more intensive service models of specialist nurse-led services: 10,32 1. Observed differences in hip fracture rates before and after introduction of a fracture prevention service:…”

“…No study has used robust outcomes such as refracture rates as highlighted by recent systematic reviews. 95,99 A recent meta-analysis demonstrated a trend towards improved bone mineral density testing rates and treatment initiation. 10,36 However, data on key clinical outcomes are scarce, 100 especially in the context of actual practice conditions in a NHS setting.…”

“…3,39 Two recent systematic reviews have confirmed that patient/physician education strategies are ineffective. 26,36,95 They identified major deficiencies in current literature, which included (1) using treatment initiation as the primary outcome 97 -this is a poor surrogate given the low adherence to therapy; (2) non-contemporary or estimated control data; 20,25 (3) effect sizes based on randomised controlled trials (RCTs) for the drug; 20,98 and (4) attendee versus non-attendee designs. These are subject to significant selection bias and left censoring.…”

Breaking the fragility fracture cycle

“…The systematic review conducted by Sale and colleagues [11] considered published models of case-finding systems in the orthopaedic environment. The reviewers sought to evaluate the structure, protocols, staffing and outcomes of different models and categorise them by the key elements present in each program.…”