Risk stratification improves outcomes in an osteoporosis fracture liaison service

Abstract

Summary

Selecting patients at higher baseline risk of fragility fracture may optimise clinical outcomes and cost-effectiveness of hospital fracture liaison services (FLS). In this cohort study, we found a risk-stratified approach led to a higher rate of treatment initiation and estimated number of fractures prevented compared to the traditional FLS strategy.

Purpose

Hospital-based fracture liaison services (FLS) are cost-effective and reduce refracture risk. However, optimal FLS characteristics to maximise clinical and cost-effectiveness are uncertain.

Methods

We reviewed data for FLS patients at Royal North Shore Hospital, Sydney (2015–2023). In 2018, the patient selection strategy was adjusted from a traditional approach (any fragility fracture, ≥ 50 years) to preferentially invite those either ≥ 60 years with any fragility fracture, or any presenting with hip and/or vertebral fractures. Cohorts entering the service pre-(FLS1) and post-this timepoint (FLS2) were compared regarding clinical characteristics, estimated fracture risk and pharmacotherapy initiation. Modelling was performed to estimate fractures averted.

Results

The total cohort (n = 1903) was median 68-years-old and predominantly female (77%). Both cohorts were similar in sex distribution and prevalence of various fracture risk factors. The FLS2 cohort was older (median 69 vs 65 years, p < 0.001), more frequently presented with hip/vertebral fracture (21.4% vs 13.8%, p < 0.001), had higher Garvan-estimated 10-year fracture-risk (median 36.0% vs 27.4%, p < 0.001) and more frequently initiated pharmacotherapy (79.0% vs 64.6%, p < 0.001). In the overall cohort, strongest predictors of treatment initiation were older age, osteoporotic bone density, hip/vertebral fracture and female sex. Over 5 years, risk-stratified FLS was estimated to avert more osteoporotic (72 vs 44, p < 0.001) and hip fractures (20 vs 10, p < 0.001) per 1000 patients compared with traditional FLS.

Conclusion

In this large hospital-based FLS study, a risk-stratified selection strategy was associated with more frequent pharmacotherapy initiation and estimated to avert more fractures; however, longitudinal assessment of treatment adherence and refracture rates is required to confirm utility.