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A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture., Purpose/introduction: To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice., Methods: The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses., Results: One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7-63.5) H-FLS patients relative to 20.9% (95% CI: 13.3-28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%)., Conclusion: A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture., Purpose: To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance)., Methods: Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital., Results: Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance)., Conclusions: An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.

Fracture liaison services (FLS) are advocated to improve osteoporosis treatment after fragility fracture, but there are few economic analyses of different models. A population-based 1i [=type C] FLS for non-hip fractures was implemented and it costs $44 per patient and it was very cost-effective ($9200 per QALY gained). Small operational changes would convert it from cost-effective to cost-saving., Introduction: After fragility fracture, <20% of patients receive osteoporosis treatment. FLS are recommended to address this deficit but there are very few economic analyses of different FLS models. Therefore, we conducted an economic analysis of a 1i (=type C) FLS called "Catch a Break (CaB).", Methods: CaB is a population-based FLS in Alberta, Canada, that case-finds older outpatients with non-traumatic upper extremity, spine, pelvis, or "other" non-hip fractures and provides telephonic outreach and printed educational materials to patients and their physicians. Cost-effectiveness was assessed using Markov decision-analytic models. Costs were expressed in 2014 Canadian dollars and effectiveness based on model simulations of recurrent fractures and quality-adjusted life years (QALYs). Perspective was healthcare payer; horizon was lifetime; and costs and benefits were discounted 3%., Results: Over 1 year, CaB enrolled 7323 outpatients (mean age 67 years, 75% female, 69% upper extremity) at average cost of $44 per patient. Compared with usual care, CaB increased rates of bisphosphonate treatment by 4.3 to 17.5% (p < 0.001). Over their lifetime, for every 10,000 patients enrolled in CaB, 4 hip fractures (14 fractures total) would be avoided and 12 QALYs gained. Compared with usual care, incremental cost-effectiveness of CaB was estimated at $9200 per QALY. CaB was cost-effective in 85% of 10,000 probabilistic simulations. Sensitivity analyses showed if "other" fractures were excluded and intervention costs reduced 25% that CaB would become cost-saving., Conclusions: A relatively inexpensive population-based 1i (=type C) FLS was implemented in Alberta and it was very cost-effective. If CaB excluded "other" fractures and decreased intervention costs by 25%, it would be cost-saving, as would any FLS that was more effective and less expensive.

We aimed to understand how patients 50 years and older decided to persist with or stop osteoporosis (OP) treatment. Processes related to persisting with or stopping OP treatments are complex and dynamic. The severity and risks and harms related to untreated clinical OP and the favorable benefit-to-risk profile for OP treatments should be reinforced., Introduction: Older adults with fragility fracture and clinical OP are at high risk of recurrent fracture, and treatment reduces this risk by 50 %. However, only 20 % of fracture patients are treated for OP and half stop treatment within 1 year. We aimed to understand how older patients with new fractures decided to persist with or stop OP treatment over 1 year., Methods: We conducted a grounded theory study of patients 50 years and older with upper extremity fracture who started bisphosphonates and then reported persisting with or stopping treatment at 1 year. We used theoretical sampling to identify patients who could inform emerging concepts until data saturation was achieved and analyzed these data using constant comparison., Results: We conducted 21 interviews with 12 patients. Three major themes emerged. First, patients perceived OP was not a serious health condition and considered its impact negligible. Second, persisters and stoppers differed in weighting the risks vs benefits of treatments, where persisters perceived less risk and more benefit. Persisters considered treatment "required" while stoppers often deemed treatment "optional." Third, patients could change treatment status even 1-year post-fracture because they re-evaluated severity and impact of OP vs risks and benefits of treatments over time., Conclusions: The processes and reasoning related to persisting with or stopping OP treatments post-fracture are complex and dynamic. Our findings suggest two areas of leverage for healthcare providers to reinforce to improve persistence: (1) the severity and risks and harms related to untreated clinical OP and (2) the favorable benefit-to-risk profile for OP treatments., Competing Interests: None

Summary: Bisphosphonate treatment rates were examined before and after admission to long-term residential care. Bisphosphonate treatment rates were low (16%) pre-admission but doubled after long-term residential care admission (30%). Men were very undertreated for osteoporosis, while a history of falls with injury was not associated with treatment., Introduction: To determine the rates and independent correlates of bisphosphonate treatment in elderly residents before and after admission to long-term care (LTC) institutions., Methods: Information was collected from records of 421 residents of four LTC institutions in Edmonton, Alberta, Canada. Osteoporosis-related diagnoses, treatments, and risk factors including falls in LTC and any adulthood fractures were abstracted. Osteoporosis was defined by physician diagnosis or documented fractures of the hip, spine, or upper extremity. Multivariable analyses were undertaken to determine factors independently associated with bisphosphonate treatment., Results: Mean age was 84 ± 8 years and 290 (70%) were female. Overall, 142 (34%) had previous fractures, 170 (41%) had physician-diagnosed osteoporosis, and 227 (54%) residents met the study's clinical definition of osteoporosis. Of those with osteoporosis, 44 (19%) were men. Before admission, 36 (16%) patients with osteoporosis were treated with bisphosphonates; after admission another 31 (14%) were started on bisphosphonates by LTC physicians. Women were far more likely than men to start bisphosphonate treatment [30 (97%) women vs. 1 (3%) man, adjusted odds ratio (aOR) = 9.20 (95% confidence intervals 1.2,70.5)]. Falls with injury were common [72/227 (31%)] but not associated with bisphosphonate treatment (adjusted p value > 0.5)., Conclusion: Rates of pre-admission bisphosphonate treatment were low, but did double after LTC admission. Women were almost ten times more likely to start bisphosphonate treatment than men, although one fifth of those with documented osteoporosis were men. Although falls cause most fractures, a history of falls with injury was not associated with bisphosphonate treatment. Our findings suggest that targeting men and residents with falls for treatment with bisphosphonates might be warranted.

Unlabelled: Intravenous bisphosphonates reduce mortality following hip fracture. We determined whether new use of oral bisphosphonates was also associated with reductions in mortality in 209 hip fracture patients. Oral bisphosphonate exposure led to relative reduction of 8% per month of use (p = 0.001) or about a 60% reduction in mortality per year of use., Introduction: Intravenous bisphosphonates reduce mortality following hip fracture. Using prospectively collected long-term data from a randomized trial of osteoporosis quality improvement for hip fracture, we determined whether new use of oral bisphosphonates was associated with reductions in mortality or the composite outcome of death or new fracture., Methods: Originally, 220 hip fracture patients were randomized to case manager (n = 110) or usual care followed by facilitated bone mineral density (BMD) testing (n = 110) interventions. All were eligible for bisphosphonate treatment. Post-randomization, we followed patients for 3 years and ascertained bisphosphonate treatment, medication adherence and persistence, all-cause mortality, and new clinical fractures. Proportional hazards analyses with time-varying treatment status were undertaken., Results: The final study cohort included 209 patients: 136 (65%) females, 104 (50%) older than 75 years, 90 (43%) with poor self-reported health, and 38 (18%) underweight. Of these, 76 (36%) had a previous fracture before hip fracture and 132 (81%) had low BMD. A total of 101 (46%) patients started oral bisphosphonates and 65 (64%) remained on treatment at the final evaluation. Overall, 24 (11%) patients died, 19 (9%) had new fractures, and 42 (20%) reached the composite outcome of death or fracture. Compared to no treatment, bisphosphonate exposure was independently associated with reduced mortality (17[16%] vs. 7[7%]; adjusted hazard ratio (aHR) = 0.92 per month treated; 95%CI, 0.88-0.97) and composite endpoints (28[26%] vs. 5[15%]; aHR = 0.94 per month treated; 95%CI, 0.91-0.97)., Conclusion: Like intravenous bisphosphonates after hip fracture, our study suggests that oral bisphosphonates may be associated with reductions in all-cause mortality.

Summary: Despite their proven efficacy for secondary fracture prevention, long-term adherence with oral bisphosphonates is poor.Introduction: To compare the effectiveness of two interventions on long-term oral bisphosphonate adherence after an upper extremity fragility fracture.Methods: Community-dwelling participants 50 years or older with upper extremity fragility fractures not previously treated with bisphosphonates were randomized to either a multi-faceted patient and physician educational intervention (the active control arm) vs. a nurse-led case manager (the study arm). Primary outcome was adherence (taking > 80% of prescribed doses) with prescribed oral bisphosphonates at 12 months postfracture between groups; secondary outcomes included rates of primary non-adherence and 24-month adherence. We also compared quality of life between adherent and non-adherent patients.Results: By 12 months, adherence with the initially prescribed bisphosphonate was similar (p = 0.96) in both groups: 38/48 (79.2%) in the educational intervention group vs. 66/83 (79.5%) in the case manager arm. By 24 months, adherence rates were 67% (32/48) in the educational intervention group vs. 53% (43/81) in case managed patients (p = 0.13). Primary non-adherence was 6% (11 patients) in the educational intervention group and 12% (21 patients) in the case managed group (p = 0.07). Prior family history of osteoporosis (aOR 2.1, 95% CI 1.0 to 4.4) and being satisfied with current medical care (aOR 2.3, 95% CI 1.1 to 4.8) were associated with better adherence while lower income (aOR 0.2, 95% CI 0.1 to 0.6, for patients with income < $30,000 per annum) was associated with poorer rates of adherence. There were no differences in health-related quality of life scores at baseline or during follow-up between patients who were adherent and those who were not.Conclusion: While both interventions achieved higher oral bisphosphonate adherence compared to previously reported adherence rates in the general population, primary non-adherence and long-term adherence to bisphosphonates were similar in both arms. Adherence was influenced by family history of osteoporosis, satisfaction with current medical care, and income.Trial registration: ClinicalTrials.gov: NCT01401556 [ABSTRACT FROM AUTHOR]