Fracture Liaison Service Program Research Articles

Risk factors for mortality, fractures and falls among patients participating in a Fracture Liaison Service program: a machine learning approach

Risk factors for mortality, fractures and falls among patients participating in a Fracture Liaison Service program: a machine learning approach

FRI678 Baseline Characteristics Of Fracture Liaison Service In Ajou University Hospital

Abstract Disclosure: Y. Chung: None. J. Kim: None. S. Lee: None. Y. Choi: None. Introduction: Fracture Liaison Service (FLS) had been set-up in many countries and regions. The Ajou University Hospital (tertiary care academic medical center in South Korea) has launched FLS program mainly composed of femoral fragility fractures. Methods: The baseline characteristics of study subjects were recorded on their initial admission. Data were derived from Ajou University Hospital from April 2019 to August 2022 for hip fracture patients aged 50 or older. Results: The average age was 78.4 years old (range 55 ∼ 98), with 68 male patients and 203 female patients (total 271 subjects). Area of fractures are intertrochanter 120, neck 102, subtrochanter 16, diaphysis 16, and unknown 13 subjects. Fracture type are fragility (osteoporosis) 209, atypical (antiresoprtive drug associated) 15, periprosthetic 17, cancer-related 10, osteomalacia 1, high-energy trauma 6, and unknown 13 subjects. Location of fall were 153 indoor, 73 outdoor, and 45 unknown. Bathrooms and bedrooms accounted for the largest portion of indoor falls. The bone mineral density (BMD) were tested in 215 subjects before discharge. Among them 132 were osteoporosis, 77 were osteopenia or normal, and 6 were undetermined in BMD. Of the 245 subjects who measured the serum 25-OH-Vitamin D, 206 were lower than the normal reference range. Among 244 subjects who measured serum PTH, 64 were higher than the normal reference range. The serum CTX and P1NP were also measured in 240 and 234 subjects, respectively. Among them, 52 subjects and 68 subjects revealed higher than the normal reference range of CTX and P1NP, respectively. Conclusion: Baseline characteristics of study subjects were evaluated in the Ajou University Hospital FLS Program. A significant number of patients included in the FLS were confirmed to have osteopenia or normal BMD. The majority of fracture patients had vitamin D deficiency, and a significant number of fracture patients had elevated serum CTX and P1NP levels. Presentation: Friday, June 16, 2023

Patients undergoing surgical treatment for low-energy distal radius fractures are more likely to receive a referral and participate in a fracture liaison service program.

Patients often do not receive osteoporosis screening after a low-energy distal radius fracture (DRF). The effect of osteoporosis on the healing of DRFs remains a debate, and it is unclear if surgical treatment of this injury affects the referral and participation rates in a fracture liaison service (FLS) program. The purpose of this study is to report on a large cohort of low-energy DRFs and identify demographic, clinical, and treatment factors that affect referral and participation rates in an FLS program. A retrospective review identified patients over 50years old who sustained a low-energy DRF between 2013 and 2018. Patients with high-energy or unknown injury mechanisms were excluded. The primary outcome was the effect of DRF surgical treatment on referral and participation rates in an FLS program. Secondary outcomes included patient demographic and clinical characteristic effects on referral and participation rates in an FLS program. In total, 950 patients met inclusion criteria. Two hundred thirty patients (24.2%) were referred and 149 (15.7%) participated in the FLS program. Patients who underwent surgery were more likely to be referred to the FLS (OR 1.893, CI 1.403-2.555, p < 0.001) and participate in the FLS program (OR 2.47, CI 1.723-3.542, p < 0.001) compared to patients who received non-operative treatment of their DRF. Patients who undergo surgical treatment of a low-energy DRF are more likely to be referred and participate in a FLS program. Further study is needed to identify why surgical treatment may affect referral and participation rates.

Multipronged Programmatic Strategy for Preventing Secondary Fracture and Facilitating Functional Recovery in Older Patients after Hip Fractures: Our Experience in Taipei Municipal Wanfang Hospital.

Background and Objectives: The study assessed the effectiveness of a fracture liaison service (FLS) after 1 year of implementation in improving the outcomes of hip fracture surgery in older adult patients at Taipei Municipal Wanfang Hospital. Materials and Methods: The Wanfang hospital’s FLS program was implemented using a multipronged programmatic strategy. The aims were to encourage the screening and treatment of osteoporosis and sarcopenia, to take a stratified care approach for patients with a high risk of poor postoperative outcomes, and to offer home visits for the assessment of environmental hazards of falling, and to improve the patient’s adherence to osteoporosis treatment. The clinical data of 117 and 110 patients before and after FLS commencement, respectively, were collected from a local hip fracture registry; the data were analyzed to determine the outcomes 1 year after hip fracture surgery in terms of refracture, mortality, and activities of daily living. Results: The implementation of our FLS significantly increased the osteoporosis treatment rate after hip fracture surgery from 22.8% to 72.3%, significantly decreased the 1-year refracture rate from 11.8% to 4.9%, non-significantly decreased 1-year mortality from 17.9% to 11.8%, and improved functional outcomes 1 year after hip fracture surgery. Conclusions: Implementation of our FLS using the multipronged programmatic strategy effectively improved the outcomes and care quality after hip fracture surgery in the older adult population, offering a successful example as a valuable reference for establishing FLS to improve the outcomes in vulnerable older adults.

Secondary fracture prevention: global approaches

Osteoporotic fractures, a major cause of disability and associated medical care expenditures, are expected to continue to increase worldwide. Adults who sustain primary osteoporotic fractures are more likely to sustain additional subsequent fractures, but few receive interventions to prevent those secondary fractures. Fracture liaison service models have been developed to systematically streamline preventative care for patients who have sustained a primary fragility fracture, proving cost-effective and efficacious. These programs have been developed in many countries, with varying degrees of success. There continues to be a need to better understand the various approaches to fracture liaison service programs in different regions enabling best practices to be adopted, successful approaches to be shared, and common obstacles to be addressed. The reports in this supplement address the status of fracture liaison service programs in different countries, focusing on national standards and guidelines, successes and barriers, and future directions. This work represents a collaborative effort of member societies of the International Orthopaedic Trauma Association (IOTA), an international association of orthopaedic societies dedicated to the promotion of musculoskeletal trauma care through advancements in patient care, research, and education. The expectation is that the information in these reports will aid efforts to address the growing need for fragility fracture programs.

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.

SummaryOsteoporosis is an underdiagnosed disease that results in bone fragility and risk of fractures. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of a FLS protocol showed an increase of anti-osteoporotic drug prescription and significant reduction of all-cause mortality.Introduction Hip fractures are the most severe osteoporotic fracture due to their associated disability and elevated risk of mortality. FLS programs have enhanced the management of osteoporosis-related fractures. Our objective is to analyze the effect of the FLS model over survival and 2-year mortality rate following a hip fracture.MethodsWe conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during 3 consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2018). Patients’ information was withdrawn from our local computerized database. Patients were followed for 2 years after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model.ResultsA total of 1101 patients were included in this study (i.e., 357 before FLS implementation and 744 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (583 (78.4%) vs 44 (12.3%); p < 0.01). There was an increase of adherence to treatment after FLS implementation (227 (38.9%) vs 12 (3.3%); p = 0.03). A total of 222 (29.8%) patients after FLS implementation and 114 (31.9%) individuals before FLS implementation (p = 0.44) died during the follow-up period. A second fracture occurred in 49 (6.6%) patients after FLS implementation and in 26 (7.3%) individuals before FLS implementation (p = 0.65). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower all-cause 1-year and 2-year mortality compared with patients managed before the implementation of the FLS protocol (adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59–0.96; HR 0.87, 95% CI 0.69–1.09, respectively).ConclusionsThe implementation of a FLS protocol was associated with an increase of anti-osteoporotic treatment, higher adherence, and greater survival in elderly hip fracture patients. There was a significant reduction of all-cause mortality in the FLS patients treated with anti-osteoporotic. However, the application of the FLS did not affect the risk of suffering a second fragility fracture.

Fracture Liaison Service (FLS) for secondary prevention of fragility fractures: the Italian IMPACT Project

Osteoporosis and subsequent fragility fractures are an important public health issue since this is a common disease that leads to disability, and increased mortality, and therefore has a significant social and economic impact. Several studies have highlighted a dramatic diagnostic-therapeutic gap. A coordinated multidisciplinary system, known as the fracture liaison service (FLS) model, is the most appropriate approach for osteoporosis management and secondary prevention. Developed by the International Osteoporosis Foundation (IOF) through its Capture the Fracture campaign, the FLS model aims to avoid fragmentation of the care pathway by facilitating communication and coordination between primary care and medical specialists. The approach also involves patient identification and education, risk evaluation, the approval of treatments, and long-term follow up. The development of FLS programs has been strongly supported by the IOF. In Italy’s case, the primary recommendations made by the IOF in order to improve the management of patients with fragility fractures, and reverse the expected increase in the number of such fractures and their relative cost over the next 10 years, include the development of dedicated multidisciplinary care pathways, based on the FLS model. In order to make an effective contribution to the organizational needs in this regard, the primary objective of the IMPACT Project is to support the implementation and customization, in selected pilot centers in Italy, of an FLS model in line with the IOF recommendations and coherent with the Italian National Health Service (SNN), and to identify connection points with the territory, the activities of new healthcare professionals, and digital touchpoints in the care pathway.

Role of Fracture Liaison Service Program in Reducing Refracture Rate in the Elderly Osteoporotic Trauma Patients Presenting With Vertebral Compression Fracture: A Six-Year Study.

As the elderly population of the United States and the world increases, so does the incidence of osteoporotic fragility fractures from a fall or minor injury. This results in a large cost to the health care system. This cost is further increased as more than 50% of individuals will have refractures within the first year. In order to reduce the refracture rate in such patients, we enrolled our elderly trauma patients with vertebral compression fractures and vertebral augmentation in a Fracture Liaison Service (FLS) clinic for two years and reevaluated their refracture rate. This is a retrospective analysis of 720 patients. 142 patients (Group A) were seen between 2012 and 2014 before establishing the FLS program and 578 patients (Group B) were seen between 2015 and 2020 after implementation of the FLS program. The patients enrolled in the FLS program were followed for two years after sustaining a vertebral compression fracture. The data collected included age, sex, serum calcium and vitamin D levels, dual energy X-ray absorptiometry (DXA) scan, 10-year fracture risk (FRAX) score, pressure measurements in PSI taken during vertebral augmentation, as well as the refracture rate. The data collected were analyzed and compared between the two groups using the Student's t-test and chi-square test. There was significant reduction in the refracture rate of pre-FLS vs post-FLS vertebral, as well as other fractures in the FLS group (pre-FLS: 48.9% vs post-FLS: 37.0%; P = .01). There was no significant difference between groups A and B in regard to the mean serum level of calcium (9.44mg/dL vs 9.53mg/dL), vitamin D level (35.04ng/mL vs 41.39ng/mL), DXA scan for spine (-.52 vs -.76) and for femur (-1.77 vs -1.52), and 10-year refracture risk for osteoporotic major fracture (FRAX score-mean: 22.6% vs 19.2%) and for hip fracture (9.18% vs 7.53%). There was a significant difference in the mean age between the groups (79.5 vs 73.5 years; P = .01). Of those who underwent vertebral augmentation, 235 had Pressure Scale Index (PSI) measurements taken. There was a trend in increasing refracture rate when PSI ≤199 compared with those who had PSI ≥200, although statistical significance was not met (33.9% vs 27.0%, P = .21). A Fracture Liaison Service program will improve the bone health of geriatric osteoporotic patients presenting to the trauma service with vertebral compression fractures and thus reduces the subsequent refracture rate. Further study is needed to evaluate the best PSI used to impact reduction in refracture rate.

Efficacy of orthopaedic-inspired osteoporosis management: a secondary fracture prevention program after a fracture of the hip in a prospective randomized study.

Aims:Patients who present with fragility fractures are consistently under-evaluated and under-treated for underlying osteoporosis. This point-of-care represents a lost opportunity to prevent future fractures. This 2-arm study evaluated the success by an orthopaedic department in osteoporosis evaluation and initiating treatment.Methods:Patients over the age of 50 years with a fragility fracture of the hip were candidates for inclusion. Exclusion criteria included end-of-life care and moderate or severe dementia. Patients were prospectively randomized into 1 of 2 groups. The Letter group received a letter at the time of discharge encouraging their primary care physician to start medication for osteoporosis (Letter group). The intervention group had 4 interventions including printed information, a DEXA scan, a specific treatment recommendation, and monthly phone calls for 4 months (Intervention group). The primary outcome measure was whether the patient was on recommended treatment at 4 months from the fracture.Results:There were 200 patients in the study, 100 in the Letter, and 100 in the Intervention group. Sixteen patients were removed from the study since they either died (9) within 4 months of their fracture, were transferred for end-of-life care (7), and 4 dropped out. This left 180 patients for analysis. The Letter group had only 6 patients (6.2%) on recommended treatment compared with the Intervention group with 64 patients (77.1%). This was statistically significant (P < 0.0001).Conclusion:Osteoporosis is a worldwide epidemic. Internationally, only about 20% of patients after a hip fracture are treated for their underlying weak bone. The most effective systems use a fracture liaison service (FLS) model. We present a 4-part intervention program that uses an FLS coordinator within the orthopaedic department. We encourage orthopaedic programs to adopt this or other models with the goal of taking the first step toward responsibility for bone health.An FLS program within an orthopaedic department can successfully initiate treatment for underlying osteoporosis.

Barriers and Resources to Optimize Bone Health in Orthopaedic Education: Own the Bone (OTB): Bone Health Education in Residency.

Introduction:Osteoporosis is a critical public health issue with substantial morbidity and healthcare costs. Resident education on osteoporosis is not standardized. Little is known about the barriers to osteoporosis treatment and the usefulness of educational programming from the perspective of orthopaedic residency program directors (PDs).Methods:This study aims to evaluate the current state and perception of bone health education from the perspective of orthopaedic residency PDs. Therefore, a self-designed 29-question online survey was sent to 129 PDs in the United States to assess bone health education. The information, collected from August to October 2020, included program characteristics, participation in the American Orthopaedic Association’s Own the Bone (AOA/OTB) program or any fracture liaison service (FLS) program, availability of faculty, potential barriers, and educational resources. Data collection was performed anonymously with a 47% response rate.Results:The results were compared between programs that used the AOA/OTB program (30%) or any FLS program (28%) (58% OTB or any FLS) vs. programs that did not have any program (42%). Subsequent subanalysis was performed comparing AOA/OTB vs. any FLS vs. no program. Programs that did not have any FLS were least likely to have a formal education syllabus (p = 0.01). When comparing clinical education of residents on bone health, 64% of programs without any system did not provide any formal clinical exposure such as a bone health clinic vs. assessment in patients with fracture compared with 24% of OTB programs and 44% of programs with any FLS (p = 0.02). When asked about desired resources, 47% would find a bone health rotation useful. Among all PDs, 60% support the concept of a 5-year AOA Council of Orthopaedic Residency Directors (CORD)/OTB osteoporosis curriculum.Discussion:The key findings were that institutions including OTB or any FLS in their programs had better availability of specialty consultants, faculty, and a FLS coordinator.

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Background The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.Methods A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.Results At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.ConclusionsThe coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

A scorecard for osteoporosis in Canada and seven Canadian provinces

SummaryThe scorecard evaluates the burden and management of osteoporosis in Canada and how care pathways differ across Canadian provinces. The results showed there are inequities in patients’ access to diagnosis, treatment, and post-fracture care programs in Canada. Interventions are needed to close the osteoporosis treatment gap and minimize these inequities.IntroductionThe purpose of this study was to develop a visual scorecard that assesses the burden of osteoporosis and its management within Canada and seven Canadian provinces.MethodsWe adapted the Scorecard for Osteoporosis in Europe (SCOPE) to score osteoporosis indicators for Canada and seven provinces (British Columbia, Alberta, Saskatchewan, Ontario, Quebec, New Brunswick, and Newfoundland). We obtained data from a comprehensive literature review and interviews with osteoporosis experts. We scored 20 elements across four domains: burden of disease, policy framework, service provision, and service uptake. Each element was scored as red, yellow, or green, indicating high, intermediate, or low risk, respectively. Elements with insufficient data were scored black.ResultsCanada performed well on several elements of osteoporosis care, including high uptake of risk assessment algorithms and minimal wait times for hip fracture surgery. However, there were no established fracture registries, and reporting on individuals with high fracture risk who remain untreated was limited. Furthermore, osteoporosis was not an official health priority in most provinces. Government-backed action plans and other osteoporosis initiatives were primarily confined to Ontario and Alberta. Several provinces (Saskatchewan, New Brunswick, Newfoundland) did not have any registered fracture liaison service (FLS) programs. Access to diagnosis and treatment was also inconsistent and reimbursement policies did not align with clinical guidelines.ConclusionGovernment-backed action plans are needed to address provincial inequities in patients’ access to diagnosis, treatment, and FLS programs in Canada. Further characterization of the treatment gap and the establishment of fracture registries are critical next steps in providing high-quality osteoporosis care.

Fragility Vertebral Compression Fractures in Postmenopausal Women: The Role of a Fracture Liaison Service Program.

As the aging population increases in the United States, so has the prevalence of osteoporosis (10.2 million adults aged 50 years and older in 2010). Programs to manage the increased incidence of fragility fractures in such patients particularly the postmenopausal women are the priority. Programs such as the Fracture Liaison Service (FLS) might be the answer. Data of 256 postmenopausal women with vertebral compression fractures treated with vertebroplasty between 2012 and 2017 were divided into 2 groups. Group A were patients seen between 2012 and 2014 before the establishment of the FLS program at the clinic. Group B were patients seen between 2015 and 2017 who presented to the FLS program in our clinic. Data collected included demographics, refracture rates, dual-energy X-ray absorptiometry (DEXA) scan T-scores, fracture risk score (FRAX), serum calcium and vitamin D levels, and comorbid conditions. There were 103 female patients with a mean age of 79.75 years (standard deviation [SD] ± 10.86) in group A, while group B had 153 patients with a mean age of 75.66 years (SD ± 10.78). There was no significant difference in the DEXA scan T-scores, FRAX scores, and mean serum calcium and vitamin D levels; however, there was a significant reduction in the refracture rate for vertebral compression fractures (P = .003). FLS programs, when implemented, will have a beneficial effect in reducing refracture rates of postmenopausal women with osteoporotic fragility fractures.

Incorporation of a patient navigator into a secondary fracture prevention program identifies barriers to patient care.

Patient navigation improves outcomes in various clinical contexts, but has not been evaluated in secondary fracture prevention. We retrospectively reviewed charts of patients, age 50 + from April to October, 2016 hospitalized with fragility fracture contacted by a patient navigator. Patients were identified using an electronic tool extracting data from electronic medical records which alerted the patient navigator to contact patients by phone post-discharge to schedule appointments to "High-Risk Osteoporosis Clinic" (HiROC) and Dual-energy X-ray Absorptiometry (DXA) scan. Primary outcome was transition from hospital to HiROC. We also compared completion of DXA, five osteoporosis-associated in-hospital laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal, and liver function), osteoporosis medication prescription and adherence, and other patient characteristics to historical controls (2014-2015) without patient navigation. Comparisons were made using Chi-square, Fisher's Exact, two-sample t test or Wilcoxon Rank Sum test, as appropriate. The proportion of patients transitioning to HiROC with and without patient navigation was not different (53% vs. 48%, p = 0.483), but DXA scan completion was higher (90% vs. 67%, p = 0.006). No difference in medication initiation within 3months post discharge (73% vs. 65%, p = 0.387) or adherence at 6months (68% vs. 71%, p = 0.777) was found. Patients attending HiROC lived closer (11 vs. 43 miles, p < 0.001) and more likely to follow-up in surgery clinic (95% vs. 61%, p < 0.001). Patient navigation did not improve transition to HiROC. Longer travel distance may be a barrier-unaffected by patient navigation. Identifying barriers may inform best practices for Fracture Liaison Service programs.

Adherence to fracture liaison service programs in patients over 70: the hidden part of the iceberg.

FLS programs are considered the most effective interventions for secondary prevention of osteoporotic fractures. Our objective was to identify risk factors for non-adherence to an FLS program set up specifically for patients over 70. Our multifaceted, intensive program included five appointments over a 2-year period. One hundred sixty-seven patients (mean age 83.5years) who presented with a recent fragility fracture were enrolled. Multivariable analysis was conducted to determine whether the demographic, clinical, frailty, and osteoporotic risk factors of the patients influenced their adherence to the program. About half of the patients did not attend the follow-up visits. According to the regression analysis, non-initiation of osteoporosis treatment was associated with poor adherence to the program (aHR 3.66). Demographic, clinical, dwelling, frailty factors, osteoporotic risk factors, fracture type, or densitometric scores were not associated with adherence. The first self-reported reason for withdrawal was the difficulty of attending several follow-up visits, and the second was the feeling of not being concerned. We observed that non-initiation of osteoporosis treatment was the only factor correlated with non-adherence to an FLS program. Thus, neither age nor frailty factors should result in patients not being included in FLS. Beyond the necessity of the osteoporosis treatment, good patient understanding of the relevance of all the interventions included in the program is the key.

Fragility Fractures in the Elderly Osteoporotic Patient and the Efficacy of Fracture Liaison Service Programs

Fragility Fractures in the Elderly Osteoporotic Patient and the Efficacy of Fracture Liaison Service Programs

Does a Fracture Liaison Service Program Minimize Recurrent Fragility Fractures in the Elderly With Osteoporotic Vertebral Compression Fractures?

Abstract INTRODUCTION There is a sizable proportion of elderly, both men and women, with fragility fractures, approximately 2 million fractures per year in the United States. METHODS A retrospective chart review of 365 patient presented between January 2012 and December 2017 with vertebral compression fractures. Prepost study design to determine refracture between group A (before Fracture Liaison Service (FLS)) and group B, after calcium, vitamin D, DEXA scans, FRAX scores, and refracture rates were measured. RESULTS Mean age for group A and B were 79.0 and 74.9 yr, respectively, and predominantly females. Serum calcium was higher in group B (9.51 mg/DL) but not significan (P = .19). Fracture score among the groups was similar (20% vs 22%; P = .44). The total refracture rate for both vertebral and other fracture was significantly less in the post FLS patients, 36.5% vs 56% P-value = .01. CONCLUSION FLS program benefited patients with fragility fractures by decreasing the incidence of all refracture rates.

Does a fracture liaison service program minimize recurrent fragility fractures in the elderly with osteoporotic vertebral compression fractures

Does a fracture liaison service program minimize recurrent fragility fractures in the elderly with osteoporotic vertebral compression fractures

Risk Factors for Poor Functional Recovery, Mortality, Recurrent Fractures, and Falls Among Patients Participating in a Fracture Liaison Service Program

ObjectiveA fracture liaison service (FLS) for patients with fractures is a promising approach for improving outcomes, but barriers to the successful implementation of an FLS remain. The factors influencing the outcomes of patients already receiving FLS care are unclear. DesignA prospective multicenter cohort study. Settings and participantsPatients with incident hip and clinical vertebral fractures treated at 2 institutions between January 2014 and June 2016 were prospectively enrolled. Demographic profiles, comorbidities, prior fracture experiences, T scores, Fracture Risk Assessment Tool (FRAX) scores, and serum markers were examined. MeasuresSelf-reported functional status (at the 4th month), mortality, recurrent fractures, and falls (at the 2-year follow-up). ResultsOf 712 patients screened for eligibility, 600 (84%) participants (age 78 ± 10 years) were enrolled in the FLS program. At 4 months, 58%, 53%, and 60% of the participants reported improved mobility, self-care, and daily activities after FLS care, respectively. After 2 years, 85 (14%) died, 36 (6%) developed recurrent fractures, and 199 (33%) had 1 or more fall episodes. Multivariate logistic regression showed that neurologic disorders, heart disease, and diabetes were associated with a decreased probability of functional recovery. Cox regression showed that older age and chronic kidney disease (CKD) were predictive of increased mortality, whereas heart disease was correlated with an increased refracture risk. Older age and cancer or osteoarthritis were associated with a higher risk of falls. Importantly, a higher body mass index predicted a lower risk of mortality and a higher probability of improved self-care but a higher risk of fall at follow-up. Conclusions/ImplicationsWe discovered that comorbidities including CKD, heart disease, cancer, and osteoarthritis could influence short-term functional changes, survival, and the risk of refractures or falls among patients participating in FLSs. These factors are expected to aid in prognosis estimation and management planning for those with fractures.

Chronic kidney disease predicts a lower probability of improvement in patient-reported experience measures among patients with fractures: a prospective multicenter cohort study.

Assessing PREM can assist physicians in improving patients' experiences. Patients with CKD are at an increased risk of exhibiting poor PREM and developing fractures. We aimed to assess whether CKD influences the probability of PREM improvement during follow-up among patients with fractures. We prospectively enrolled patients with hip or vertebral fractures from different institutes into a fracture liaison service program. After registering clinical histories, they received a baseline PREM assessment based on EuroQol group-5 dimension content, including self-care, daily activity, and pain severity using a 5-point Likert scale. A follow-up PREM assessment was arranged 4months later, and we evaluated whether baseline CKD was predictive of PREM improvement. Among 593 fracture patients (18% with CKD), 37.3% and 62.7% presented with hip and vertebral fractures, respectively. Self-care, daily activity, and pain severity improved after follow-up in 32%, 27%, and 43% participants; those with CKD exhibited worse self-care ability and daily activity than those without. Multivariate logistic regression analyses showed that baseline CKD was significantly associated with lower possibility of improvement in daily activity (odds ratio [OR] 0.58, p = 0.049) and pain severity (OR 0.52, p = 0.01), and an insignificant change in the possibility of improvement in self-care ability (OR 0.61, p = 0.09). The presence of CKD predicts a significantly lower probability of PREM improvement among fracture patients. An early emphasis on renal function during fracture care should be considered.