Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study

Abstract

In patients presenting with a minimal trauma non-vertebral fracture, active identification and management significantly reduces the risk of refracture (Australian New Zealand Clinical Trials Registry ACTRN 12606000108516).

Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England

“…25 However, the strongest evidence on effectiveness has recently been provided by an Australian study that was designed as a prospective observational trial with a concurrent control group in which, compared with standard care, targeted identification and management significantly reduced the risk of refracture by > 80%. 26 Across the UK there is variation in the care pathway of the treatment and management of hip fracture patients and in the way secondary fracture prevention services are structured and organised. Even with a co-ordinator-based system in place, the structure of services can vary between hospitals.…”

“…Using observed fracture rates from patients who did or did not attend a specialist service: the Concord study, Australia, demonstrated an 80% reduction in fractures over 5 years. 26 However, using patients who did not attend the specialist clinic as the 'comparator' group resulted in significant immortal time bias and selection bias in those who attended were more likely to be healthier and have fewer comorbidities. Finally, only 20% of all fragility fracture patients attend the specialist service, as those with cognitive impairment and other serious comorbidities were excluded; this is an important limit to generalisability of the service in terms of extension to all fragility fracture patients.…”

“…3,39 Two recent systematic reviews have confirmed that patient/physician education strategies are ineffective. 26,36,95 They identified major deficiencies in current literature, which included (1) using treatment initiation as the primary outcome 97 -this is a poor surrogate given the low adherence to therapy; (2) non-contemporary or estimated control data; 20,25 (3) effect sizes based on randomised controlled trials (RCTs) for the drug; 20,98 and (4) attendee versus non-attendee designs. These are subject to significant selection bias and left censoring.…”

“…101 Similarly, fracture patients receiving care within the intervention programme at Concord Repatriation General Hospital (Sydney, NSW, Australia) were found to be at 80% reduced risk of subsequent fracture, compared with patients electing standard care. 26 It is likely, however, that a proportion of the difference reported reflects selection bias with worse comorbidities in those who did not attend and better health-seeking behaviour in those who did (95% remained on initial treatment throughout the study period). It is also important to note that these previous analyses considered refracture after any index fragility non-vertebral fracture as opposed to our focus on hip fracture.…”

“…101 Recent studies have also reported that co-ordinator-based programmes can significantly reduce the rate of total hip fracture admissions 96 and refracture rate after a non-vertebral fracture. 26,101 Despite these data, a recent audit in the UK found that only 37% of local health services provide any kind of FLS.40 Importantly for both orthogeriatric and FLS services, significant variation exists in how such services are structured. …”