Cost-Effectiveness Analysis of Fracture Liaison Services Compared with Standard of Care in the Secondary Prevention of Fragility Fractures in Spain

Abstract

Purpose To assess the cost-effectiveness of a Fracture Liaison Service (FLS) compared with standard care for the secondary prevention of fragility fractures in Spain. Methods Patients with osteoporosis and an initial fragility fracture who were candidates to initiate osteoporosis treatment (mean age 65 years, 90.7% female) were included in the model. Disease progression was simulated with a Markov model through seven health states (with and without osteoporosis treatment, subsequent hip, vertebral, forearm and humerus fracture, and death). A time horizon of 10 years and a 6-month duration per cycle was set. Clinical, economic, and quality of life parameters were estimated from the literature and Spanish clinical practice. Resource use and treatment patterns were validated by an expert panel. The Spanish National Health System (SNS) perspective was adopted, taking direct costs (€; 2020) into account. Effectiveness was measured in life-years gained (LYG) and quality-adjusted life years gained (QALYs). A discount rate of 3% was applied to costs and outcomes. The uncertainty of the parameters was assessed using deterministic, scenario and probabilistic sensitivity analyses (1000 iterations). Results Setting up a FLS for the secondary prevention of fragility fractures in Spain would provide better osteoporosis treatment initiation and persistence. This would reduce subsequent fragility fractures, disutilities and deaths. FLS would have greater clinical benefits (0.008 and 0.082 LYG and QALY gained per patient, respectively) and higher costs (€563.69 per patient) compared with standard care, leading to an incremental cost-utility ratio of €6855.23 per QALY gained over the 10 years horizon. The sensitivity analyses showed limited dispersion of the base case results, corroborating their robustness. Conclusion From the SNS perspective and considering Spanish willingness-to-pay thresholds, the introduction of FLS for the secondary prevention of fragility fractures would be a cost-effective strategy.

Perspectives on Fracture Liaison Service in Austria: clinical and economic considerations

“…FLS represents a systematic, structured approach to prevent subsequent fractures. Evidence indicates that FLS also increases QALYs (19)(20)(21). FLS are implemented in hospitals with trauma surgery and are already established internationally in more than 50 countries.…”

The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis

“…Nonetheless, the proposal has arisen because of the failure of many clinicians and healthcare systems to identify and manage future fracture risk in patients who have already sustained fractures in whom undetected osteoporosis has also remained un-investigated and untreated [1,29,30]. This failure can be addressed, and is being addressed, without the need to alter the definition of osteoporosis [31][32][33][34][35][36][37][38].…”

Spanish National Registry of Major Osteoporotic Fractures (REFRA) seen at Fracture Liaison Services (FLS): objectives and quality standards

“…This initiative was first introduced in university hospitals in Scotland and gained considerable attention upon demonstrating lower rates of secondary fractures [15]. There is mounting evidence showing that FLS multidisciplinary approach provides a tailored model of care for these patients, with improved relevant patient outcomes such as new fracture rate, treatment coverage, and treatment adherence, along with demonstrated cost-effectiveness [16][17][18].…”