Cost-utility analysis of coordinator services (FLS) in patients with femur fractures.

Bridging the Osteoporosis Treatment Gap: Performance and Cost-Effectiveness of a Fracture Liaison Service

<p class="abstract"><strong>Background:</strong> Proximal femoral fractures are very common in elderly patients. These fractures are thought to be associated with osteoporosis. Vitamin D is a possible risk factor for osteoporosis. So, this study was done to evaluate the association of serum vitamin D level with types of femoral fractures in elderly patients.</p><p class="abstract"><strong>Methods:</strong> The study was done between September 2013 to August 2016, 75 patients with age >60 years (male and female both) with proximal femoral fractures were studied. Serum 25-hydroxy vitamin D, calcium, phosphate, alkaline phosphatase levels, liver function test, renal function test, hemoglobin and complete blood counts of all the patients were assessed.<strong></strong></p><p class="abstract"><strong>Results:</strong> On assessment of serum vitamin D in proximal femoral fracture in elderly patients, it shows an increase incidence of proximal femoral fractures in patients with low serum vitamin D level. Fracture of neck of femur was most common among all. Type of fracture has no significant statistical relationship with serum vitamin D levels.</p><p class="abstract"><strong>Conclusions:</strong> Osteoporosis and serum vitamin D level depends on age and sex of the patient. But type of proximal femoral osteoporotic fracture has no association with either grade of osteoporosis or serum vitamin D level.</p>

SummaryThis study assessed the lifetime cost-effectiveness of a fracture liaison service (FLS) compared to no-FLS in the Netherlands from a societal perspective and suggested that FLS was cost-effective in patients with a recent fracture aged 50 years and older. The implementation of FLS could lead to lifetime health-economic benefits.IntroductionThe objective of this study was to investigate the lifetime cost-effectiveness of a fracture liaison service (FLS) compared to no-FLS in the Netherlands from a societal perspective and using real-world data.MethodsAnnual fracture incidence, treatment scenarios as well as treatment initiation in the years 2017–2019 were collected from a large secondary care hospital in the Netherlands. An individual-level, state transition model was designed to simulate lifetime costs and quality-adjusted life years (QALYs). Treatment pathways were differentiated by gender, presence of osteoporosis and/or prevalent vertebral fracture, and treatment status. Results were presented as incremental cost-effectiveness ratios (ICER). Both one-way and probabilistic sensitivity analyses were conducted.ResultsFor patients with a recent fracture aged 50 years and older, the presence of an FLS was associated with a lifetime €45 higher cost and 0.11 additional QALY gained leading to an ICER of €409 per QALY gained, indicating FLS was cost-effective compared to no-FLS at the Dutch threshold of €20,000/QALY. The FLS remained cost-effectiveness across different age categories. Our findings were robust in all one-way sensitivity analyses, the higher the treatment initiation rate in FLS, the greater the cost-effective of FLS. Probabilistic sensitivity analyses revealed that FLS was cost-effective in 90% of the simulations at the threshold of €20,000/QALY, with women 92% versus men 84% by gender.ConclusionThis study provides the first health-economic analysis of FLS in the Netherlands, suggesting the implementation of FLS could lead to lifetime health-economic benefits.

We evaluated the cost-effectiveness of a fracture liaison service prospectively designed to have a parallel control group treated by standard care. The clinical effectiveness of this service was associated with an incremental cost-effectiveness ratio versus standard care of Australian dollars (AUD) 17,291 per quality-adjusted life year (QALY) gained. Osteoporotic fractures are a major burden for national health services. The risk of re-fracture following an osteoporotic fracture is particularly high. In a study unique in prospectively having a control group treated by standard care, we recently demonstrated that a Minimal Trauma Fracture Liaison (MTFL) service significantly reduces the risk of re-fracture by 80%. Since the service involves greater use of resources, we have now evaluated whether it is cost-effective. A Markov model was developed that incorporated fracture probabilities and resource utilization data (expressed in AUD) obtained directly from the 4-year MTFL service clinical study. Resource utilization, local cost and mortality data and fracture-related health utility data were used to calculate QALYs with the MTFL service and standard care. Main outcome measures were: additional costs of the MTFL service over standard care, the financial savings achieved through reduced fractures and changes in QALYs associated with reduced fractures calculated over a 10-year simulation period. Costs and QALYs were discounted at 5% annually. Sensitivity analyses quantified the effects of different assumptions of effectiveness and resource utilization associated with the MTFL service. The MTFL service improved QALYs by 0.089 years and led to increased costs of AUD 1,486 per patient versus standard care over the 10-year simulation period. The incremental cost-effectiveness ratio versus standard care was AUD 17,291 per QALY gained. Results were robust under all plausible assumptions. The MTFL service is a cost-effective intervention to reduce recurrent osteoporotic fractures.

The cost-effectiveness of a less intensive fracture liaison service is unknown. We evaluated a fracture liaison service that had been educating and referring patients for secondary prevention of osteoporotic fractures for 6 years. Our results suggest that a less intensive fracture liaison service, with moderate effectiveness, can still be worthwhile. Fragility fractures are common among older patients; the risk of re-fracture is high but could be reduced with treatments; different versions of fracture liaison service have emerged to reduce recurrent osteoporotic fractures. But the cost-effectiveness of a less intensive model is unknown. The objective of this study was to assess the cost-effectiveness of the Ontario Fracture Clinic Screening program, a fracture liaison service that had been educating and referring fragility fracture patients across Ontario, Canada to receive bone mineral density testing and osteoporosis treatments since 2007. We developed a Markov model to assess the cost-effectiveness of the program over the patients' remaining lifetime, using rates of bone mineral density testing and osteoporosis treatment and cost of intervention from the program, and supplemented it with the published literature. The analysis took the perspective of a third-party health-care payer. Costs and benefits were discounted at 5 % per year. Sensitivity analyses assessed the effects of different assumptions on the results. The program improved quality-adjusted life-years (QALYs) by 4.3 years and led to increased costs of CAD $83,000 for every 1000 patients screened, at a cost of $19,132 per QALY gained. The enhanced model, the Bone Mineral Density (BMD) Fast Track program that includes ordering bone mineral density testing, was even more cost-effective ($5720 per QALY gained). The Ontario Fracture Clinic Screening program appears to be a cost-effective way to reduce recurrent osteoporotic fractures.

SummaryWe analyzed 5396 patients with fragility fracture, their inclusion by the FLS, and prescription of treatment. Thirty-four percent of potential cases were attended by the FLS, and at the healthcare level, the impact of FLS model resulted in an increase of treated patients from 20% in standard care to 41%.IntroductionPatients with fragility fractures are at high risk of new fractures, with a negative impact on their quality of life, as well as higher mortality and costs for the health system, especially for hip fractures. Less than 20% of patients receive treatment (lifestyle advice, calcium, vitamin D, and bisphosphonate) after a fracture. The fracture liaison service (FLS) is the most effective model for secondary prevention.ObjectivesTo analyze the incidence of fragility fractures in the area of Gran Canaria North and the impact of the FLS unit on the prevention of new fractures.MethodsPatients > 50 years were attended at the emergency department for fractures of the proximal femur, proximal humerus, distal forearm, pelvis, or vertebra during the period 2018–2022 were included. A file was constructed containing demographic data, type of fracture, inclusion in the FLS, and the initiation of treatment to prevent new fractures. A sample of patients not treated at the FLS was selected for estimating the prophylaxis of fractures under standard care management.ResultsA total of 5396 patients were included, 74.2% women, with a mean age of 74 years. After excluding 558 traumatic fractures (10.3%), 318 (5.9%) deaths, and 167 (3.1%) cases due to a lack of criteria, the sample of potential patients who were candidates for FLS was 4353. This represented 80.6% of the initial sample, of which 1497 patients (34.4%) were attended at the unit. Factors independently associated with referral to the FLS were younger age (OR 0.97; 95% CI 0.97–0.98), female sex (OR 2.24; 95% CI 1.91–2.61), and humerus fracture (OR 1.34; 95% CI 1.16–1.55). Treatment to prevent fractures was verified in 1189 patients (79.4%) in the FLS group and in 585 (20.4%) of those with fragility fractures who were not included. At the healthcare level, the services provided by the FLS resulted in an increase in treated patients from 20% in standard care to 41% with the FLS model.ConclusionsIn terms of treatment initiation to new fracture prevention at the healthcare level, the FLS achieved a twofold increase. The high incidence of fractures and the progressive aging of the population underline the effectiveness of the FLS secondary prevention model.

SummaryThis study is a model-based cost-effectiveness analysis of fracture liaison services (FLS) in China, suggesting that FLS could potentially lead to lifetime cost-saving in patients who have experienced a fracture. However, Chinese-specific real-world data is needed to confirm the results of our study.PurposeThe study aimed to assess the potential cost-effectiveness of fracture liaison services (FLS) from the Chinese healthcare perspective with a lifetime horizon.MethodsA previously validated Markov microsimulation model was adapted to estimate the cost-effectiveness of FLS compared to no-FLS. The evaluation was conducted in patients aged 65 years with a recent fracture. Treatment pathways were differentiated by gender, FLS attendance, osteoporosis diagnosis, treatment initiation, and adherence. Given the uncertainty in FLS cost, the cost in the base-case analysis was assumed at US$200. Analyses were also performed to determine the maximum cost for making the FLS cost-saving and cost-effective at the Chinese willingness-to-pay (WTP) threshold. One-way sensitivity analyses were conducted.ResultsWhen compared with no-FLS, the FLS was dominant (lower costs, higher quality-adjusted life years) in our target population at the FLS cost of US$200 per patient. For every 100 patients who were admitted to the FLS, approximately four hip fractures, nine clinical vertebral fractures, and three wrist fractures would be avoided over their lifetimes. Our findings were robust to numerous one-way sensitivity analyses; however, the FLS was not cost-effective in patients aged 80 years and older.ConclusionFLS could potentially lead to lifetime cost-saving in patients who have experienced a fracture. Our study informs the potential cost-effectiveness of FLS and the knowledge gap in China; more future research incorporating Chinese-specific real-world data are needed to confirm the results of our study and to better evaluate the cost-effectiveness of FLS in China.

Objective To compare the clinical effects of locking gamma nail (LGN) with modified gamma nail (MGN) in the management of unstable intertrochanteric femoral fractures in elderly patients. Methods A total of 143 elderly patients with unstable intertrochanteric femoral fractures who were treated with LGN (n = 67) or MGN (n = 76) at the 118th Hospital of PLA from January 2008 to May 2012 and had complete clinical data were retrospectively studied. We compare the two groups in terms of fracture healing time, Harris hip score, degree of fracture compression, and variation of Neck shaft angle. Continuous variables (fracture healing time, Harris hip score, and the degree of fracture compression) were compared using the paired t-test, and comparison of categorical variables (the change of Neck shaft angle) was performed using the chi-squared test. Results All of the patients were followed successfully. Compared with the MGN group, the LGN group had significantly longer fracture healing time [(16.8 ± 7.4) weeks vs (14.4 ± 6.6) weeks], less variation of neck-shaft angle (3.0% vs 14.5%), lower degree of fracture compression [(4.4 ± 2.5) mm vs (7.3 ± 3.1) mm], and higher Harris hip score [(86.6 ± 6.3) scores vs (83.1 ± 6.7) scores] (P < 0.05 for all). Conclusion Both LGN and MGN are effective in the management of unstable intertrochanteric femoral fractures in elderly patients, but LGN has more advantages in preventing compression of fracture end and recovery of hip joint function compared to MGN. Key words: Intertrochanteric femoral fractures; Unstable; Elderly patients; Locking gamma nail; Internal fixation

Objective: To evaluate the treatment effect of total hip arthroplasty (THA) for intertrochanteric femur fractures (IFF) in elderly patients. Methods: Thirty-two elderly patients with IFF admitted to the hospital from August 2021 to August 2024 were selected and randomly divided into two groups using a random number table. The experimental group (16 patients) underwent THA surgery, while the control group (16 patients) underwent proximal femoral nail antirotation (PFNA) surgery. Hip joint function and quality of life indicators were compared between the two groups. Results: Before surgery, there was no significant difference in hip joint function and quality of life scores between the two groups (P &gt; 0.05). However, at six months postoperatively, the experimental group had higher hip joint function and quality of life scores compared to the control group (P &lt; 0.05). The total effective rate was higher in the experimental group than in the control group (P &lt; 0.05). The complication rate in the experimental group was similar to that in the control group (P &gt; 0.05). Conclusion: THA can improve the clinical efficacy of elderly patients with IFF, minimize postoperative complications, effectively restore hip joint function, and optimize postoperative quality of life.

EVOLUTION OF THE INTERNAL FIXATION OF LONG BONE FRACTURES

This study aimed to assess the cost-utility of a Fracture Liaison Service (FLS) with a systematic follow-up according to patients' follow-up compliance trajectories. The Lucky Bone™ FLS is a prospective cohort study conducted on women and men (≥40 years) with fragility fractures. Dedicated personnel of the program identified fractures, investigated, treated, and followed patients systematically over 2 years. Groups of follow-up compliance trajectories were identified, and Markov decision models were used to assess the cost-utility of each follow-up trajectory group compared to usual care. A lifetime horizon from the perspective of the healthcare payer was modeled. Costs were converted to 2018 Canadian dollars and incremental cost-utility ratios (ICURs) were measured. Costs and benefits were discounted at 1.5%. A total of 532 participants were followed in the FLS (86% women, mean age of 63 years). Three trajectories were predicted and interpreted; the high followers (HFs, 48.4%), intermediate followers (IFs, 28.1%), and low followers (LFs, 23.5%). The costs of the interventions per patient varied between $300 and $446 for 2 years, according to the follow-up trajectory. The FLS had higher investigation, treatment, and persistence rates compared to usual care. Compared to usual care, the ICURs for the HF, IF, and LF trajectory groups were $4250, $21,900, and $72,800 per quality-adjusted life year (QALY) gained, respectively ($9000 per QALY gained for the overall FLS). Sensitivity analyses showed that the HF and IF trajectory groups, as well as the entire FLS, were cost-effective in >67% of simulations with respect to usual care. In summary, these results suggest that a high-intensity FLS with a systematic 2-year follow-up can be cost-effective, especially when patients attend follow-up visits. They also highlight the importance of understanding the behaviors and factors that surround follow-up compliance over time as secondary prevention means that they are at high risk of re-fracture. © 2020 American Society for Bone and Mineral Research (ASBMR).

Nondisplaced femoral neck fractures constitute a substantial portion of these injuries. The optimal treatment strategy between internal fixation (IF) and hemiarthroplasty (HA) remains debated, particularly concerning cost-effectiveness. We conducted a cost-effectiveness analysis using a Markov decision model to compare HA and IF in treating nondisplaced femoral neck fractures in elderly patients in China. The analysis was performed from a payer perspective with a 5-year time horizon. Costs were measured in 2020 USD, and effectiveness was measured in quality-adjusted life-years (QALYs). Sensitivity analyses, including one-way and probabilistic analyses, were conducted to assess the robustness of the results. The willingness-to-pay threshold for incremental cost-effectiveness ratio (ICER) was set at $11,083/QALY following the Chinese gross domestic product in 2020. HA demonstrated higher cumulative QALYs (2.94) compared to IF (2.75) but at a higher total cost ($13,324 vs. $12,167), resulting in an ICER of $6,128.52/QALY. The one-way sensitivity analysis identified the costs of HA and IF as the most influential factors. Probabilistic sensitivity analysis indicated that HA was more effective in 69.3% of simulations, with an ICER below the willingness-to-pay threshold of $11,083 in 58.8% of simulations. HA is a cost-effective alternative to IF for treating nondisplaced femoral neck fractures in elderly patients in mainland China.

Introduction:Neck of femur fractures is the most common fractures in elderly people as they present with osteoporosis. There is a higher chance of proximal femur fracture in a schizophrenic patient as there is a loss of bone mineral density due to a drug-induced increase in the level of prolactin and immobility. Patients with Parkinson’s disease were at higher risk for the development of hip fractures due to gait disturbances and instability.Case Report:A 63-year-old male patient presented with complaints of the right arm pain, swelling, deformity of the right arm, and difficulty in extending the wrist for 3 days. The patient had a history of falls and trauma to the left arm at home. X-ray right arm showed distal one-third spiral humerus fracture for which intramedullary nailing was done. X-ray of the pelvis with both hips showed right neck of femur fracture with associated greater trochanter (GT) fracture. We managed with total hip replacement using a dual mobility cup and tension band wiring for GT fracture. Postoperatively, the patient has a good range of motion at the hip. The functional outcome is good as per Harris’s hip score.Conclusion:Neck femur fractures in elderly patients with associated comorbidities such as schizophrenia and parkinsonism are best managed with total hip replacement using a dual mobility cup. It avoids the risk of dislocation in high-risk patients and prevents secondary procedures. Careful clinical and radiological examination of the pelvis is very essential even in asymptomatic patients with a history of trauma to prevent delayed diagnosis of these types of fractures in patients with schizophrenia and parkinsonism.

Objective To investigate the value of enhanced recovery after surgery(ERAS)in the perioperative period of intertrochanteric femoral fractures in elderly patients. Methods A retrospective analysis of 100 elderly patients with intertrochanteric femoral fractures at Shenyang Shengjing Hospital from January 2014 to January 2017 was conducted.According to the treatment, patients were divided into two groups: an ERAS group and a routine group(n=50, each). Hospitalization times, postoperative pain visual analogue scales(VAS), complication rates, operation times, evaluated byHarris hip scores and other parameters were compared between the two groups. Results All patients were followed up for 20 months(mean=18.7 months). The hospitalization time and postoperative pain VAS score were shorter or lower in the ERAS group than in the routine group[(6.06±1.89)d vs.(8.02±1.89)d, 3.02±1.79 vs.3.66±1.06, both P 0.05). Conclusions ERAS in treating intertrochanteric femoral fractures in the elderly can significantly reduce the length of hospital stay, postoperative pain and complications, and should be recommended. Key words: Rehabilitation; Hip fracture; Perioperative

There is an enormous humanitarian and socioeconomic need to improve the quality and effectiveness of care for patients with hip fracture. To reduce mechanical complications in the osteosynthesis of proximal femoral fractures, improved fixation techniques have been developed including blade or screw-anchor devices, locked minimally invasive or cement augmentation strategies. However, despite numerous innovations and advances regarding implant design and surgical techniques, systemic and mechanical complication rates remain high. Treatment success depends on secure implant fixation in often-osteoporotic bone as well as on patient-specific factors (fracture stability, bone quality, comorbidity, and gender) and surgeon-related factors (experience, correct reduction, and optimal screw placement in the head/neck fragment). For fracture fixation, the anchorage of the lag screw within the femoral head plays a crucial role depending on the implant’s design. Meta-analyses and randomized controlled studies demonstrate that there is a strong trend towards arthroplasty treating geriatric femoral neck fractures. However, for young adults as well as older patients with less compromised bone quality, or in undisplaced fractures, head-preserving therapy is preferred as it is less invasive and associated with good functional results. This review summarizes the evidence for the internal fixation of femoral neck fractures and trochanteric femoral fractures in elderly patients. In addition, biomechanical considerations regarding implant anchorage in the femoral head including rotation, migration, and femoral neck shortening are made. Finally, cement augmentation strategies for hip fracture implants are evaluated critically.