Long-term persistence of treatment after hip fracture in a fracture liaison service

Abstract

Long-term adherence to antiosteoporosis medication (AOM) in the setting of a fracture liaison service (FLS) are not well known. Patients ≥ 50 with hip fracture seen in an FLS and recommended for treatment to prevent new fractures were analyzed. Baseline data included demographics, identification mode, previous treatment and FRAX items. Patient records were reviewed 3–8 years later, and these data were collected: (1) survival; (2) major refracture; (3) initiation of treatment, proportion of days covered (PDC) and persistence with AOM. 372 patients (mean age, 79 years; 76% women) were included. Mean follow-up was 47 months, 52 patients (14%) had a refracture (22 hip) and 129 (34.5%) died. AOM was started in 283 patients (76.0%). Factors associated with initiation of AOM were previous use of bisphosphonate (OR 9.94; 95% CI 1.29–76.32) and a lower T-score lumbar (OR 0.80; 95% CI 0.65–0.99). Persistence decreased to 72.6%, 60% and 47% at 12, 36 and 60 months. A PDC > 80% was confirmed in 208 patients (55.7%) and associated with previous use of bisphosphonate (OR 3.38; 95% CI 1.34–8.53), treatment with denosumab (OR 2.69; 95% CI:1.37–5.27), and inpatient identification (OR 2.26; 95% CI 1.18–4.34). Long-term persistence with AOM was optimal in patients with hip fracture seen at an FLS. A PDC > 80% was associated with inpatient identification and prescription of denosumab.

Exploring barriers and opportunities to improve osteoporosis care across the acute-to-primary care interface: a qualitative study

“…More than half the potential economic and clinical benefits of treatment are thought to be lost due to poor medication adherence [18]. Osteoporosis medication persistence declines over time and long-term treatment remains suboptimal: 80% persist with treatment to 1 year, 60% to 2 years, and < 50% to 5 years [19][20][21]. Ongoing specialist management through FLS is more costly and has not been shown to significantly improve medication persistence or adherence rates at 2 years [19].…”

The role of the fracture liaison service in the prevention of atypical femoral fractures

“… 99 FLS has been proven to be efficient and cost-effective. 12 – 32 The efficacy in reducing the treatment gap, and increasing the adherence to the anti-osteoporotic treatment might partly explain the reduced mortality rate reported by González-Quevedo et al after 1 and 2 years of the implementation of their FLS program. 20 , 101 These observations were further confirmed by Li et al in their recent meta-analysis.…”

“… 108 , 109 In fact, as formerly underlined, an effective FLS program should include several phases: case finding; patient general health assessment; bone quality assessment and osteoporosis treatment; fall prevention; patient education; and physical exercises. 12 – 32 The reported most effective approaches in case finding are as follows: manual abstraction of cases; electronic reminder systems in the patient medical record; and electronic case finding diagnosis that automatically refers the patient to the FLS. 110 The patient assessment needs an accurate collection of the present fracture history, including the mechanism of injury, the general bone health, and the prior anti-osteoporotic treatment received, as well as medication history.…”

“… 11 , 12 To reduce the incidence of a second FF, several prevention programs have been proposed, and good outcomes were reported in terms of both mortality and treatment adherence. 12 – 32 The fracture liaison service (FLS) is one of the proposed models to effectively manage a patient with an FF. Generally, FLS refers to a multidisciplinary functional coordination structure established in a third-level hospital.…”

“… 32 , 34 This kind of approach has been proven to be cost-effective, with an average reduction of 20% in the treatment gap, a 20% increase in adherence to anti-fracture treatment, and a 5% reduction in the rate of re-fracture and mortality. 12 – 32 Adherence to anti-fracture treatment is one of the pivotal points in the prevention of FFs. 35 …”