Abstract
This systematic review and meta-analysis evaluated the outcomes of patients with osteoporosis-related fractures managed through fracture liaison services (FLS) programs. Medline, PubMed, EMBASE, and the Cochrane Library were searched (January 2000-February 2017 inclusive) using the keywords 'osteoporosis', 'fractures', 'liaison', and 'service' to identify randomised controlled trials and observational studies of patients aged ≥50years with osteoporosis-related fractures in hospital, clinic, community, or home-based settings who were managed using FLS. Risk of bias was assessed at outcome level. Meta-analysis followed a random-effects and fixed-effects model. Outcomes of interest were incidence of bone mineral density (BMD) testing, treatment initiation, adherence, re-fractures, and mortality due to osteoporosis treatment. A total of 159 publications were identified for the systematic literature review; 74 controlled studies (16 RCTs; 58 observational studies) were included in the meta-analysis. Overall, 41 of 58 observational studies and 12 of 16 RCTs were considered of high quality. Compared with patients receiving usual care (or those in the control arm), patients receiving care from an FLS program had higher rates of BMD testing (48.0% vs 23.5%) and treatment initiation (38.0% vs 17.2%) and greater adherence (57.0% vs 34.1%). Unweighted average rates of re-fracture were 13.4% among patients in the control arm and 6.4% in the FLS arm. Unweighted average rates of mortality were 15.8% in the control arm and 10.4% in the FLS arm. Meta-analysis revealed significant FLS-associated improvements in all outcomes versus non-FLS controls, with BMD testing increased by 24 percentage points (95% confidence interval [CI] 0.18-0.29), 20 percentage points for treatment rates (95% CI 0.16-0.25), and 22 percentage points for adherence (95% CI 0.13-0.31) and absolute risk of re-fracture reduced by five percentage points (95% CI -0.08 to -0.03) and mortality reduced by three percentage points (95% CI -0.05 to -0.01). FLS programs improved outcomes of osteoporosis-related fractures, with significant increases in BMD testing, treatment initiation, and adherence to treatment and reductions in re-fracture incidence and mortality.
Highlights
Osteoporosis is characterised by a reduction in bone mass and strength, predisposing patients to an increased risk of fragility fractures [1]
A total of 396 publications were excluded from the systematic literature review (SLR) for reasons including duplicates, language, publication type, population not of interest, and irrelevant outcome
Despite the marked improvements to services made available to osteoporosis patients experiencing fragility fractures through Fracture liaison services (FLS), there is still room for improvement: the present study found that adherence to treatment remains rather poor and just under half of the patients in the FLS arm undergo bone mineral density (BMD) testing
Summary
Osteoporosis is characterised by a reduction in bone mass and strength, predisposing patients to an increased risk of fragility fractures [1]. Fracture liaison services (FLS) are coordinator-based models of secondary fracture prevention services with a broad remit. They are designed to identify patients who are at increased risk of secondary fractures and, following a comprehensive assessment, ensure that patients initiate appropriate treatment via improved care coordination and communication [6,7,8]. FLS have made significant contributions towards improving bone mineral density (BMD) testing rates and treatment initiation rates after MTF when FLS have adopted a fully coordinated intensive approach to patient care, as shown in a systematic literature review (SLR) and meta-analysis performed in 2012 covering publications in 1996–2011 [11]. In 2013, the International Osteoporosis Foundation (IOF) initiated the promotion of FLS programs, continually being implemented worldwide, but their outcomes show wide variability in the literature
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