Citation

Majumdar SR, McAlister FA, Johnson JA, Rowe BH, Bellerose D, Hassan I, Lier DA, Li S, Maksymowych WP, Menon M, Russell AS, Wirzba B, Beaupre LA. J. Bone Miner. Res. 2018; 33(12): 2114-2121.

Affiliation

Department of Physical Therapy, University of Alberta, Edmonton, Alberta Canada, T6G 2G4.

Copyright

(Copyright © 2018, American Society for Bone and Mineral Research)

DOI

10.1002/jbmr.3557

PMID

30040140

Abstract

We compared osteoporosis care after upper extremity fragility fracture using a low-intensity Fracture Liaison Service (FLS) versus a high-intensity FLS in a pragmatic patient-level parallel-arm comparative effectiveness trial undertaken at a Canadian academic hospital. A low-intensity FLS (active-control) that 'identified' patients and notified primary care providers was compared to a high-intensity FLS (case manager) where a specially-trained nurse 'identified' patients, 'investigated' bone health and 'initiated' appropriate treatment. 361 community-dwelling participants 50 years or older with upper extremity fractures who were not on bisphosphonate treatment were included; 350 (97%) participants completed 6-month follow-up undertaken by assessors blinded to group allocation. The primary outcome was difference in bisphosphonate treatment between groups 6-months post-fracture; secondary outcomes included differences in bone mineral density (BMD) testing and a pre-defined composite measure termed "appropriate care" (taking or making an informed decision to decline medication for those with low BMD; not taking bisphosphonate treatment for those with normal BMD). Absolute differences (%), relative risks (RR with 95% confidence intervals [CI]), number-needed-to-treat (NNT) and direct costs were compared. 181 participants were randomized to active-control and 180 to case-manager using computer-generated randomization; the groups were similar on study entry. At 6 months, 51 (28%) active-control vs 86 (48%) case-manager participants started bisphosphonate treatment (20% absolute difference; RR 1.70 [95%CI 1.28-2.24]; p < 0.0001; NNT = 5). Of active-controls, 108 (62%) underwent BMD testing compared to 128 (73%) case-managed patients (11% absolute difference; RR 1.17 [95%CI 1.01-1.36]; p = 0.03). Appropriate care was received by 76 (44%) active-controls and 133 (76%) case-managed participants (32% absolute difference; RR 1.73, [95%CI 1.43-2.09]; p < 0.0001). The direct cost per participant was $18 Canadian (CDN) for the active-control intervention compared to $66 CDN for the case-manager intervention. In summary, case-management led to substantially greater improvements in bisphosphonate treatment and appropriate care within 6-months of fracture than the active control. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

Language: en

Keywords

Aging; Clinical Trials; Fracture Prevention; Injury/Fracture Healing; Osteoporosis