The impact of fracture liaison services on subsequent fractures and mortality: a systematic literature review and meta-analysis

Abstract

This systematic review and meta-analysis suggests that fracture liaison service (FLS) is associated with a significantly lower probability of subsequent fractures and mortality although the latter was only found in studies comparing outcomes before and after the introduction of an FLS. Introduction To systematically review and evaluate the impact of fracture liaison services (FLSs) on subsequent fractures and mortality using meta-analysis. Methods A literature search was performed within PubMed and Embase to identify original articles published between January 1, 2010, and April 30, 2020, reporting the effect of FLSs on subsequent fractures and/or mortality. Only studies comparing FLS to no-FLS were included. A meta-analysis using random-effects models was conducted. The quality of studies was appraised after combining and modifying criteria of existing quality assessment tools. Results The search retrieved 955 published studies, of which 16 studies fulfilled the inclusion criteria. Twelve studies compared outcomes before (pre-FLS) and after (post-FLS) FLS implementation, two studies compared outcomes between hospitals with and without FLS, and two other studies performed both comparisons. In total, 18 comparisons of FLS and no-FLS care were reported. Follow-up time varied from 6 months to 4 years. Sixteen comparisons reported on subsequent fractures and 12 on mortality. The quality assessment revealed methodological issues in several criteria. Excluding studies with very high selection bias, the meta-analysis of nine comparisons (in eight papers) revealed that the FLS care was associated with a significantly lower probability of subsequent fractures (odds ratio: 0.70, 95% CI: 0.52-0.93, P=0.01). In studies with a follow-up > 2 years, a significantly lower probability of subsequent fractures was captured for FLS care (odds ratio: 0.57, 95% CI: 0.34-0.94, P=0.03), while in studies ≤ 2 years, there was no difference in the odds of subsequent fractures. No significant difference in the odds of mortality was observed (odds ratio: 0.73, 95% CI: 0.49-1.09, P=0.12) in the meta-analysis of eight comparisons (in seven papers). However, a significantly lower probability of mortality was identified in the six pre-post FLS comparisons (odds ratio: 0.65, 95% CI: 0.44-0.95, P=0.03), but not in studies comparing hospitals with and without FLS. No difference was observed in mortality stratified by follow-up time. Conclusion This systematic review and meta-analysis suggests that FLS care is associated with a significantly lower probability of subsequent fractures and mortality although the latter was only found in studies comparing outcomes before and after the introduction of an FLS. The quality assessment revealed that some important methodological issues were unmet in the currently available studies. Recommendations to guide researchers to design high-quality studies for evaluation of FLS outcomes in the future were provided.

A 2-year follow-up of a novel Fracture Liaison Service: can we reduce the mortality in elderly hip fracture patients? A prospective cohort study

“…Furthermore, hip fracture patient survival is related with the presence of comorbidities at 2 years of follow-up [ 13 ]. A recent systematic review and meta-analysis conducted on Fracture Liaison Services demonstrated a lower probability or subsequent fractures and mortality [ 14 ].…”

Osteoporosis in 10 years time: a glimpse into the future of osteoporosis

“… 53 It is now clear that high-intensity FLS (which comprise identification, investigation, and initiation of therapy) have been successful in reducing the incidence of new fractures. 54 Moreover, cost-effectiveness analyses of FLS showed gains in quality-adjusted life years (QALY) for expenses below the willingness to pay thresholds. 55 A recently published meta-analysis showed that the implementation of FLS is associated with lower probability of subsequent fractures with a trend toward mortality reduction.…”

“… 55 A recently published meta-analysis showed that the implementation of FLS is associated with lower probability of subsequent fractures with a trend toward mortality reduction. 54 Evidence mostly came from indirect comparisons between hospitals with and without FLS and from the comparison between pre-FLS versus post-FLS periods in the same hospital. Majumdar et al 56 in 2018 conducted a pragmatic randomized controlled trial comparing two different FLS strategies.…”

Fractura subsecuente y reingreso hospitalario relacionado a fracturas por fragilidad en Unidad de Coordinación de Fracturas de Ortogeriatría

“…8,9 Se ha reportado internacionalmente una tasa de fractura subsecuente de 7.7% posterior a la implementación del modelo FLS comparado con la tasa de 10.9% previo a su establecimiento. 10 En algunos estudios disminuye hasta 5% la presentación de fractura subsecuente en un periodo de cinco años después de presentar la fractura inicial. 11 Una fractura previa es un fuerte predictor de fractura posterior; sin embargo, las tasas de tratamiento postfractura son bajas.…”