Treating osteoporosis in Canada: what clinical efficacy data should be considered by policy decision makers?

Effects of Fracture Liaison Service on Outcomes of Patients with Hip Fracture in Rural Area of an Asian Country

Introduction

Fracture Liaison Services (FLS) has been proven effective in reducing subsequent fractures and related mortality. However, more research is needed on the impact of FLS on the 30-day readmission rate and its effectiveness in rural hospitals. This study aims to assess the impact of FLS on clinical outcomes including readmission rates, subsequent fractures, and fracture-related mortality in rural areas of an Asain country.

Materials and methods

In a rural hospital in Taiwan, we conducted a two-year prospective cohort study on elderly individuals with fragility hip fractures. The study compared the clinical outcomes between the control group and the FLS-cohort group. Logistic regression analysis was used to identify factors contributing to 1-year mortality after injury.

Results

556 patients were enrolled. (304 in the control group and 252 in the FLS group) The mean age was 79.8 years. The findings revealed that the introduction of FLS did not result in significant differences in mortality, readmission, complication, subsequent fractures, or secondary hip fractures. However, there were notable improvements in the length of hospital stay and the proportion of patients receiving surgery within 48 h following the implementation of FLS. Subgroup analysis showed that FLS patients who received anti-osteoporotic treatment had lower mortality and 30-day readmission rates. Factors associated with higher 1-year mortality included male, high ASA level, and delayed surgery.

Discussion

This study provides the real-life evidence of the effect of intensive FLS model in a rural hospital in an Asian country.

Conclusion

While FLS did not show significant differences in certain clinical outcomes, it led to shorter hospital stays and increased timely surgeries. FLS patients receiving anti-osteoporotic treatment had better mortality and readmission rates. Further research is necessary to gain a comprehensive understanding of the impact of FLS care in rural areas of Asia.

Efficacy and Safety of Denosumab in Osteoporosis or Low Bone Mineral Density Postmenopausal Women

Denosumab, a human monoclonal antibody, acts against the receptor activator of nuclear factor-κB ligand and is a promising antiresorptive agent in patients with osteoporosis. This study aimed to update the efficacy and safety of denosumab vs. placebo in osteoporosis or low bone mineral density (BMD) postmenopausal women. PubMed, Embase, Cochrane library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) reporting the efficacy and safety data of denosumab vs. placebo in osteoporosis or low BMD postmenopausal women. A random-effects model was used to calculate pooled weight mean differences (WMDs) or relative risks (RRs) with corresponding 95% confidence intervals (CIs) for treatment effectiveness of denosumab vs. placebo. Eleven RCTs including 12,013 postmenopausal women with osteoporosis or low BMD were preferred for the final meta-analysis. The summary results indicated that the percentage change of BMD in the denosumab group was greater than that of BMD in placebo at 1/3 radius (WMD: 3.43; 95%CI: 3.24–3.62; p < 0.001), femoral neck (WMD: 3.05; 95%CI: 1.78–4.33; p < 0.001), lumbar spine (WMD: 6.25; 95%CI: 4.59–7.92; p < 0.001), total hip (WMD: 4.36; 95%CI: 4.07–4.66; p < 0.001), trochanter (WMD: 6.00; 95%CI: 5.95–6.05; p < 0.001), and total body (WMD: 3.20; 95%CI: 2.03–4.38; p < 0.001). Moreover, denosumab therapy significantly reduced the risk of clinical fractures (RR: 0.57; 95%CI: 0.51–0.63; p < 0.001), nonvertebral fracture (RR: 0.83; 95%CI: 0.70–0.97; p = 0.018), vertebral fracture (RR: 0.32; 95%CI: 0.25–0.40; p < 0.001), and hip fracture (RR: 0.61; 95%CI: 0.37–0.98; p = 0.042). Finally, denosumab did not cause excess risks of adverse events. These findings suggested that postmenopausal women receiving denosumab had increased BMDs and reduced fractures at various sites without inducing any adverse events.

Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate

SUMMARY

We assessed the ability of a fracture liaison service (FLS) to directly reduce re-fracture risk. Having a FLS is associated with a ∼40% reduction in the 3-year risk of major bone and ∼30% of any bone re-fracture. The number needed to treat to prevent a re-fracture is 20.

INTRODUCTION

FLS have been promoted as the most effective interventions for secondary fracture prevention, and while there is evidence of increased rate of investigation and treatment at institutions with a FLS, only a few studies have considered fracture outcomes directly. We therefore sought to evaluate the ability of our FLS to reduce re-fracture risk.

METHODS

Historical cohort study of all patients ≥50 years presenting over a 6-month period with a minimal trauma fracture (MTF) to the emergency departments of a tertiary hospital with a FLS, and one without a FLS. Baseline characteristics, mortality and MTFs over a 3-year follow-up were recorded.

RESULTS

Five hundred fifteen patients at the FLS hospital and 416 patients at the non-FLS hospital were studied. Over 3 years, 63/515 (12%) patients at the FLS hospital and 70/416 (17%) at the non-FLS hospital had a MTF. All patients were analysed in an intention-to-treat analysis regardless of whether they were seen in the FLS follow-up clinic. Statistical analysis using Cox proportional hazard models in the presence of a competing risk of death from any cause was used. After adjustment for baseline characteristics, there was a ∼30% reduction in rate of any re-fracture at the FLS hospital (hazard ratio (HR) 0.67, confidence interval (CI) 0.47-0.95, p value 0.025) and a ∼40% reduction in major re-fractures (hip, spine, femur, pelvis or humerus) (HR 0.59, CI 0.39-0.90, p value 0.013).

CONCLUSIONS

We found a ∼30% reduction in any re-fractures and a ∼40% reduction in major re-fractures at the FLS hospital compared with a similar non-FLS hospital. The number of patients needed to treat to prevent one new fracture over 3 years is 20.

A fracture prevention service reduces further fractures two years after incident minimal trauma fracture

AIM

To evaluate the impact of a fracture prevention clinic service on initiation of treatment, continuing treatment and subsequent minimal trauma fractures (MTF).

METHOD

Participants were people aged 50 and over, with a minimal trauma fracture presenting to the Emergency Department (ED) in a large tertiary referral hospital in New South Wales, Australia, between February 2007 and March 2009. A cohort of patients who attended a Fracture Prevention Clinic (clinic group) were compared with a cohort who did not attend the clinic (non-clinic group). A telephone questionnaire was conducted with participants or their carers between December 2010 and April 2011 at least 12 months post-fracture presentation. Questionnaire items included demographics, fracture types, osteoporosis treatment, recurrent fractures and smoking and dietary habits. Data were compared using chi-squared test for categorical variables and Student's t-test or Mann-Whitney U-test for continuous variables.

RESULTS

Two hundred and fourteen clinic attendees and 220 non-clinic attendees were surveyed between 12 and 40 months (mean 24 months) post-initial fracture. New fracture rates were lower in the clinic group (5.1%) than the non-clinic group (16.4%, P < 0.001). Treatment rates for bone fragility were higher in the clinic group (81.3%) than in the non-clinic group (54.1%, P < 0.001) with 66.8% of the clinic group and 34.1% of the non-clinic group on a bisphosphonate or strontium ranelate at the time of the survey (P < 0.001).

CONCLUSION

Patients managed by a fracture prevention clinic service following a MTF have fewer new fractures and are more likely to be on treatment for bone fragility.

Clinical efficacy and safety of denosumab in postmenopausal women with low bone mineral density and osteoporosis: a meta-analysis

OBJECTIVE

Clinical trials indicate that denosumab could be a potential treatment for postmenopausal osteoporosis. The objective of this meta-analysis was to assess the clinical efficacy and safety of offering denosumab to postmenopausal women with low bone mass.

METHODS

Data sources included MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to February 3, 2010 and bibliographies of reviews. Randomized controlled trials comparing the efficacy and safety of denosumab to placebo for treatment of low bone mass (low bone mineral density or osteoporosis) in postmenopausal women were selected. Two reviewers independently abstracted data on study general characteristics and outcomes. Review Manager 5.0 software was used for data syntheses and meta-analysis.

RESULTS

The database search revealed 4 studies (comprising 8864 patients randomized) that met the inclusion criteria and contributed to some or all of the meta-analysis outcomes. Relative risk (95% CI) of fractures for the denosumab compared with placebo group was 0.58 (0.52 to 0.66); relative risk (95% CI) of serious adverse events was 1.33 (0.83 to 2.14); relative risk (95% CI) of serious adverse events related to infection was 2.10 (0.64 to 6.90); relative risk (95% CI) of neoplasm was 1.11 (0.91 to 1.36); relative risk (95% CI) of study discontinuation due to adverse events was 1.10 (0.83 to 1.47); and relative risk (95% CI) of death was 0.78 (0.57 to 1.06). Findings remained robust to sensitivity analyses.

CONCLUSION

Our analysis found a significant reduction in relative fracture risk in the denosumab compared with the placebo group.