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Wang M, Seibel MJ. Secondary fracture prevention in primary care: a narrative review. Osteoporos Int 2024:10.1007/s00198-024-07036-1. [PMID: 38652313 DOI: 10.1007/s00198-024-07036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/28/2024] [Indexed: 04/25/2024]
Abstract
The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.
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Affiliation(s)
- Mawson Wang
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia.
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia.
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord Campus, Hospital Rd, Gate 3, Concord, NSW, Australia
- Department of Endocrinology and Metabolism, Concord Hospital, Sydney Local Health District, Concord, NSW, Australia
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Foo CD, Yan JY, Chan ASL, Yap JCH. Identifying Key Themes of Care Coordination for Patients with Chronic Conditions in Singapore: A Scoping Review. Healthcare (Basel) 2023; 11:healthcare11111546. [PMID: 37297686 DOI: 10.3390/healthcare11111546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
A projected rise in patients with complex health needs and a rapidly ageing population will place an increased burden on the healthcare system. Care coordination can bridge potential gaps during care transitions and across the care continuum to facilitate care integration and the delivery of personalised care. Despite having a national strategic vision of improving care integration across different levels of care and community partners, there is no consolidation of evidence specifically on the salient dimensions of care coordination in the Singapore healthcare context. Hence, this scoping review aims to uncover the key themes that facilitate care coordination for patients with chronic conditions in Singapore to be managed in the community while illuminating under-researched areas in care coordination requiring further exploration. The databases searched were PubMed, CINAHL, Scopus, Embase, and Cochrane Library. Results from Google Scholar were also included. Two independent reviewers screened articles in a two-stage screening process based on the Cochrane scoping review guidelines. Recommendation for inclusion was indicated on a three-point scale and rating conflicts were resolved through discussion. Of the 5792 articles identified, 28 were included in the final review. Key cross-cutting themes such as having standards and guidelines for care programmes, forging stronger partnerships across providers, an interoperable information system across care interfaces, strong programme leadership, financial and technical resource availabilities and patient and provider-specific factors emerged. This review also recommends leveraging these themes to align with Singapore's national healthcare vision to contain rising healthcare costs.
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Affiliation(s)
- Chuan De Foo
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore
| | - Jia Yin Yan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore
| | - Audrey Swee Ling Chan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore
| | - Jason C H Yap
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore 117549, Singapore
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Cheah MH, Lai PSM, Khor HM, Ratnasingam J, Chandrasekaran CSK, Singh S, Zakaria MIB, Ong T. Fragility fracture care gap at a tertiary teaching hospital in Malaysia. Arch Osteoporos 2023; 18:63. [PMID: 37148374 DOI: 10.1007/s11657-023-01256-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/21/2023] [Indexed: 05/08/2023]
Abstract
Fracture begets fracture, pharmacological treatment is needed to prevent secondary fractures. This study found that there was a fragility fracture care gap where both bone health investigations and treatment initiation rates were low. Strategies such as Fracture Liaison Service is needed to address the care gap. PURPOSE This study aimed to investigate the clinical burden and secondary fracture prevention of fragility fractures at a tertiary teaching hospital in Malaysia. METHODS Electronic medical records of all patients admitted with fragility fractures between 1 January 2017-31 December 2018 were reviewed. Patients < 50 years old, with non-fragility fractures, restricted access to medical records, transferred to another hospital or who passed away during admission were excluded. Descriptive statistics were used to summarise patients' characteristics, frequency of fragility fractures, and secondary fracture prevention details. Binomial logistic regression was performed to analyse predictive factors for post-fracture bone health assessments and treatment initiation. RESULTS 1030 patients [female (767/1030, 74.5%)] presented with 1071 fractures [hip fractures (378/1071, 35.3%)]. 170/993 (17.1%) patients were initiated on anti-osteoporosis medications (AOMs) and 148/984 (15.0%) had bone mineral density (BMD) performed within 1-year post-fracture. Less than half (42.4%) of the patients remained on treatment at 1-year post-fracture. Older patients [65-74 years old: odds ratio (OR) = 2.18, 95%CI 1.05-4.52, p = 0.04; ≥ 75 years: OR = 3.06, 95%CI 1.54-6.07, p < 0.01], hip fractures (OR = 1.95, 95%CI 1.23-3.11, p < 0.01), Chinese ethnicity (OR = 1.90, 95%CI 1.07-3.35, p = 0.03),previously diagnosed with osteoporosis (OR = 2.65, 95%CI:1.32-5.31, p < 0.01) and a BMD test performed (OR = 12.48, 95%CI 8.04-19.37, p < 0.01) were found to have higher AOM initiation. Patients with past diagnosis of osteoporosis (OR = 4.45, 95%CI 2.25-8.81, p < 0.01) and initiated on AOM (OR = 11.34, 95%CI 7.57-16.97, p < 0.01) had a higher likelihood to undergo BMD testing. CONCLUSION The AOM initiation and BMD testing rates were low. There is a need to address the fragility fracture care gap with strategies such as Fracture Liaison Service.
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Affiliation(s)
- Min Hui Cheah
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Hui Min Khor
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | | | - Simmrat Singh
- Department of Orthopaedic Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mohd Idzwan Bin Zakaria
- Academic Unit Trauma and Emergency, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Terence Ong
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
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Ding BTK, Lim HF, Johari F, Kunnasegaran R. An Orthopaedic Surgeon Led Osteoporosis (OSLO) Model of Care reduces early recurrent fracture rates and improves treatment compliance in patients treated for osteoporotic fractures. Osteoporos Int 2023; 34:299-307. [PMID: 36409358 DOI: 10.1007/s00198-022-06595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/31/2022] [Indexed: 11/22/2022]
Abstract
UNLABELLED This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) in improving care of patients with primary osteoporotic fractures. The OSLO-MOC has shown to be effective in improving osteoporotic medication initiation and compliance and reducing secondary fracture rates in patients. PURPOSE This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) as compared to a Case Manager Led Osteoporosis Model of Care (CMLO-MoC) in reducing early osteoporotic re-fracture rates and treatment compliance in patients. METHODS This was a single centre, retrospective, comparative cohort study of all patients screened and treated for secondary osteoporotic fracture prevention from the 2008 to 2018 at an orthopaedic surgical unit. From the 2008 to 2013, patients were recruited under the CMLO-MoC and from 2014 to 2018, under the OSLO-MOC. Logistics regression analysis was used to identify significant predictors such as OSLO-MOC implementation, gender, ethnicity, marital status and education level for patient recruitment, treatment compliance and secondary fracture rates at 12-month follow-up. RESULTS Over a 10-year period, 7388 patients were screened of which 2855 patients were eligible for analysis. A total of 1234 patients were recruited under CMLO-MoC and 1621 patients under OSLO-MOC. Implementation of the OSLO-MOC was associated with greater patient recruitment, OR 1.26 (95%CI 1.06-1.49, P = 0.007). Of the 2855 patients recruited, OSLO-MOC implementation, OR 2.61 (95%CI 2.03-3.36, P < 0.001), and a higher level of education, OR 1.428 (95%CI 1.02-1.43, P = 0.037), were associated with improved compliance to medication at 12 months. OSLO-MOC implementation was the only factor associated with reduced risk of secondary fractures at 12 months, OR 0.14 (95%CI 0.03-0.66, P = 0.013). CONCLUSION The OSLO-MOC has shown to be effective in reducing the rate of re-fracture and osteoporotic medication initiation and compliance of patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benjamin Tze Keong Ding
- Department of Orthopaedic Surgery, Woodlands Health, 2 Yishun Central 2, Tower E, S768024, Singapore, Singapore.
| | - Hai Fon Lim
- Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, S768828, Singapore, Singapore
| | - Fadzleen Johari
- Nursing Specialty, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, S308433, Singapore, Singapore
| | - Remesh Kunnasegaran
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, S308433, Singapore, Singapore
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Chong B, Ganesan G, Lau TC, Tan KB. Cost-effectiveness of selective bone densitometry using the osteoporosis self-assessment tool for Asians in multi-ethnic Asian population. Arch Osteoporos 2022; 18:10. [PMID: 36515739 DOI: 10.1007/s11657-022-01200-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
Early detection and treatment of osteoporosis can help to prevent debilitating fractures in the elderly. The osteoporosis self-assessment tool for Asians can be used as a screening tool to stratify patients for bone densitometry. It is most cost-effective for post-menopausal women aged 70 and males aged 75. PURPOSE To determine the cost-effectiveness of selective bone densitometry (SBD) using the Osteoporosis Self-Assessment Tool for Asians (OSTA) as a risk-stratifying tool for the three predominant races (Chinese, Malay and Indian) in Singapore. METHODS Decision analytical models were developed using a Markov model. Three scenarios were compared: no bone densitometry, SBD using the OSTA as a pre-screening tool and universal bone densitometry. Those diagnosed with osteoporosis were treated with five years of alendronate therapy. Data sources were from Singapore epidemiological studies, healthcare cost figures and published literature. Measurements include life years, quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratios (ICER). RESULTS Compared to no bone densitometry, SBD using the OSTA would cost between $40,679 and $73,909 per QALY gained for men aged 75-80 and $22,386 to $58,185 per QALY gained for post-menopausal women aged 70-80. Universal bone densitometry would cost $157,955 to $177,127 per QALY gained for men aged 75-80 and $40,179 to $66,112 per QALY gained for post-menopausal women aged 70 to 80 compared to SBD. CONCLUSION In general, osteoporosis screening was the most cost-effective for Malays and the least cost-effective for Indians. However, a general guideline should still be applied to the Singaporean population, as further explained later. Overall, the most cost-effective strategy for males would be using OSTA as a risk-stratifying tool at age 75. For post-menopausal women, SBD should be used for women aged 70, while universal bone densitometry should be used for women aged 75-80.
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Affiliation(s)
- Bryan Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Ganga Ganesan
- Data Analytics Division, Ministry of Health, Singapore, Singapore
| | - Tang Ching Lau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kelvin Bryan Tan
- Future Systems Office, Ministry of Health, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
- Centre of Regulatory Excellence, Duke-NUS Medical School, Singapore, Singapore.
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Jones AR, Herath M, Ebeling PR, Teede H, Vincent AJ. Models of care for osteoporosis: A systematic scoping review of efficacy and implementation characteristics. EClinicalMedicine 2021; 38:101022. [PMID: 34345811 PMCID: PMC8319463 DOI: 10.1016/j.eclinm.2021.101022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Osteoporosis affects over half of adults over 50 years worldwide. With an ageing population, osteoporosis, fractures and their associated costs are increasing. Unfortunately, despite effective therapies, many with osteoporosis remain undiagnosed and untreated. Models of care (MoC) to improve outcomes include fracture liaison services, screening, education, and exercise programs, however efficacy for these is mixed. The aim of this study is to summarise MoC in osteoporosis and describe implementation characteristics and evidence for improving outcomes. METHODS This systematic scoping review identified articles via Ovid Medline and Embase, published in English between 01/01/2009 and 15/06/2021, describing MoC for adults aged ≥18 years with, or at risk of, osteoporosis and / or health professionals caring for this group. All included at least one of clinical, consumer or clinician outcomes, with fractures and bone mineral density (BMD) change the primary clinical outcomes. Exclusion criteria were studies assessing pharmaceuticals or procedures without other interventions, or insufficient operational details. All study designs were included, with no comparator necessary. Title and abstract were reviewed by two reviewers. Full text review and data extraction was performed by these reviewers for 20% of article and, thereafter by a single author. As the review was predominantly descriptive, no comparator statistics were used. FINDINGS 314 articles were identified describing 289 MoC with fracture liaison services (n=89) and education programs (n=86) predominating. The population had prior fragility fracture in 77 studies, the median (IQR) patient number was 210 (87, 667) and the median (IQR) follow-up duration for outcome assessment was 12 (6, 12·5) months. Fracture reduction was reported by 65 studies, with 16 (37%) graded as high quality, and 19 / 47 studies with a comparator group found a reduction in fractures. BMD change was reported by 73 studies, with 41 finding improved BMD. Implementation characteristics including reach, fidelity and loss to follow-up were under-reported, and consumer and clinician perspectives rare. INTERPRETATION This comprehensive review of MoC for osteoporosis demonstrated inconsistent evidence for improving outcomes despite similar types of models. Future studies should include implementation outcomes, consumer and clinician perspectives, and fracture or BMD outcomes with sufficient duration of follow-up. Authors should consider pragmatic trial designs and co-design with clinicians and consumers.
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Affiliation(s)
- Alicia R Jones
- Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia
- Department of Endocrinology, Monash Health, Melbourne, Australia
| | - Madhuni Herath
- Department of Endocrinology, Monash Health, Melbourne, Australia
- Hudson Institute of Medical Research, Melbourne, Australia
| | - Peter R Ebeling
- Department of Endocrinology, Monash Health, Melbourne, Australia
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia
- Department of Endocrinology, Monash Health, Melbourne, Australia
| | - Amanda J Vincent
- Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia
- Department of Endocrinology, Monash Health, Melbourne, Australia
- Corresponding author at: Monash Centre for Health Research and Implementation, Monash University, Locked Bag 29, Clayton, Vic 3168, Australia.
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7
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Chandran M, Mitchell PJ, Amphansap T, Bhadada SK, Chadha M, Chan DC, Chung YS, Ebeling P, Gilchrist N, Habib Khan A, Halbout P, Hew FL, Lan HPT, Lau TC, Lee JK, Lekamwasam S, Lyubomirsky G, Mercado-Asis LB, Mithal A, Nguyen TV, Pandey D, Reid IR, Suzuki A, Chit TT, Tiu KL, Valleenukul T, Yung CK, Zhao YL. Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region. Osteoporos Int 2021; 32:1249-1275. [PMID: 33502559 PMCID: PMC8192320 DOI: 10.1007/s00198-020-05742-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/11/2020] [Indexed: 01/07/2023]
Abstract
UNLABELLED Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care. PURPOSE Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development. METHODS We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards. RESULTS Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines. CONCLUSION The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.
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Affiliation(s)
- M Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, 20, College Road, Academia, Singapore, 169856, Singapore.
| | - P J Mitchell
- Synthesis Medical NZ Limited, Pukekohe, Auckland, New Zealand
| | - T Amphansap
- Department of Orthopedics, Police General Hospital, Bangkok, Thailand
| | - S K Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M Chadha
- Department of Endocrinology, Hinduja Hospital and Research Centre, Mumbai, India
| | - D-C Chan
- Internal Medicine, National University Hospital Chu-Tung Branch, Chinese Taipei, Taiwan
| | - Y-S Chung
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, South Korea
| | - P Ebeling
- Department of Medicine in the School of Clinical Sciences, Monash Health, Melbourne, Australia
| | - N Gilchrist
- Canterbury District Health Board, Christchurch, New Zealand
| | - A Habib Khan
- Section of Chemical Pathology, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - F L Hew
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | - H-P T Lan
- Musculoskeletal and Metabolic Unit, Biomedical Research Center, Pham Ngoc Thach University of Medicine, Bone and Muscle Research Group, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - T C Lau
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - J K Lee
- Department of Orthopedics, Beacon International Specialist Centre, Petaling Jaya, Malaysia
| | - S Lekamwasam
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | | | - L B Mercado-Asis
- Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
| | - A Mithal
- Endocrinology, Diabetes Division, Mithal, M. Max Healthcare - Pan-Max, Gurgaon, India
| | - T V Nguyen
- Genetics and Epidemiology of Osteoporosis Laboratory, Bone Biology Division, Garvan Institute of Medical Reseach, Sydney, Australia
| | - D Pandey
- Department of Orthopaedics, National Trauma Centre, Kathmandu, Nepal
| | - I R Reid
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Suzuki
- Department of Endocrinology, School of Medicine, Fujita Health University, Toyoake, Japan
| | - T T Chit
- East Yangon General Hospital, Yangon, Myanmar
| | - K L Tiu
- Polytrauma and Fragility Fracture team, Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - T Valleenukul
- Department of Orthopedics, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - C K Yung
- Department of Endocrinology and Patient Safety Unit, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan, Brunei Darussalam
| | - Y L Zhao
- Department of Obstetrics and Gynecology, Beijing United Family Hospital, Beijing, China
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Chandran M, Mitchell PJ. Tackling osteoporosis and fragility fractures in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:291-293. [PMID: 33990815 DOI: 10.47102/annals-acadmedsg.2021119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore
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Elements and Performance Indicators of Integrated Healthcare Programmes on Chronic Diseases in Six Countries in the Asia-Pacific Region: A Scoping Review. Int J Integr Care 2021; 21:3. [PMID: 33613135 PMCID: PMC7879996 DOI: 10.5334/ijic.5439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background and Aims: Globally, hospital-based healthcare models targeting acute care, are not effective in addressing chronic conditions. Integrated care programmes for chronic diseases have been widely developed and implemented in Europe and North America and to a much lesser extent in the Asia-Pacific region to meet such challenges. We completed a scoping review aiming to examine the elements of programmes identified in the literature from select study countries in the Asia-Pacific, and discuss important facilitators and barriers for design and implementation. Methods: The study design adopted a scoping review approach. Integrated care programmes in the study countries were searched in electronic databases using a developed search strategy and key words. Elements of care integration, barriers and facilitators were identified and charted following the Chronic Care Model (CCM). Results: Overall the study found a total of 87 integrated care programmes for chronic diseases in all countries, with 44 in China, 21 in Singapore, 12 in India, 5 in Vietnam, 4 in the Philippines and 1 in Fiji. Financial incentives were found to play a crucial role in facilitating integrated care and ensuring the sustainability of programmes. In many cases, the performance of programmes was found not to have been adequately assessed. Conclusion: Integrated care is important for addressing the challenges surrounding the delivery of long-term care and there is an increasing trend of integrated care programmes for chronic diseases in the Asia-Pacific. Evaluating the performance of integrated care programmes is crucial for developing strategies for implementing future programmes and improving already existing programmes.
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Fuggle NR, Kassim Javaid M, Fujita M, Halbout P, Dawson-Hughes B, Rizzoli R, Reginster JY, Kanis JA, Cooper C. Fracture Risk Assessment and How to Implement a Fracture Liaison Service. PRACTICAL ISSUES IN GERIATRICS 2021. [DOI: 10.1007/978-3-030-48126-1_14] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ong T, Khor HM, Kumar CS, Singh S, Chong E, Ganthel K, Lee JK. The Current and Future Challenges of Hip Fracture Management in Malaysia. Malays Orthop J 2020; 14:16-21. [PMID: 33403058 PMCID: PMC7751988 DOI: 10.5704/moj.2011.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/01/2020] [Indexed: 12/27/2022] Open
Abstract
By 2050, it is predicted that six million hip fractures will occur each year of which the majority will happen in Asia. Malaysia is not spared from this predicted rise and its rate of increase will be one of the highest in this region. Much of this is driven by our unprecedented growth in the number of older people. Characteristics of individuals with hip fractures in Malaysia mirror what has been reported in other countries. They will be older multimorbid people who were already at risk of falls and fractures. Outcomes were poor with at least a quarter do not survive beyond 12 months and in those that do survive have limitation in their mobility and activities of daily living. Reviewing how these fractures are managed and incorporating new models of care, such as orthogeriatric care, could address these poor outcomes. Experts have warned of the devastating impact of hip fracture in Malaysia and that prompt action is urgently required. Despite that, there remains no national agenda to highlight the need to improve musculoskeletal health in the country.
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Affiliation(s)
- T Ong
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - H M Khor
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - C S Kumar
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - S Singh
- Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - Egm Chong
- Department of Geriatric Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - K Ganthel
- Department of Orthopaedics, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - J K Lee
- Department of Orthopaedics, Beacon Hospital, Petaling Jaya, Malaysia
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Speerin R, Needs C, Chua J, Woodhouse LJ, Nordin M, McGlasson R, Briggs AM. Implementing models of care for musculoskeletal conditions in health systems to support value-based care. Best Pract Res Clin Rheumatol 2020; 34:101548. [PMID: 32723576 PMCID: PMC7382572 DOI: 10.1016/j.berh.2020.101548] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.
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Affiliation(s)
- Robyn Speerin
- The Sydney University, Level 7, Department of Rheumatology, Royal North Shore Hospital, Reserve Road, ST LEONARDS, NSW, 2065, Australia.
| | - Christopher Needs
- Department of Rheumatology, Level 4, QEII Building, Royal Prince Alfred Hospital, 59 Missenden Road, Camperdown, NSW, 2050, Australia.
| | - Jason Chua
- Centre for Musculoskeletal Outcomes Research, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - Linda J Woodhouse
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
| | - Margareta Nordin
- Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center (OIOC), New York University, New York, NY, USA.
| | - Rhona McGlasson
- Bone & Joint Canada, P.O. Box 1036, Toronto, ON, M5K 1P2, Canada.
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987, Perth, WA, 6845, Australia.
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13
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Cha YH, Ha YC, Park KS, Yoo JI. What is the Role of Coordinators in the Secondary Fracture Prevention Program? J Bone Metab 2020; 27:187-199. [PMID: 32911583 PMCID: PMC7571241 DOI: 10.11005/jbm.2020.27.3.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
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. Conclusions The 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.
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Affiliation(s)
- Yong Han Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ki-Soo Park
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Jun-Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
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14
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Undertreatment of osteoporosis following hip fracture: a retrospective, observational study in Singapore. Arch Osteoporos 2020; 15:141. [PMID: 32918196 DOI: 10.1007/s11657-020-00816-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/01/2020] [Indexed: 02/03/2023]
Abstract
UNLABELLED Undertreatment of osteoporosis after hip fracture increases the risk of death, disability, recurrent osteoporotic fractures, and financial burden. Only half were compliant with osteoporosis medications. Elderly patients were less persistent and compliant to treatment. Denosumab was associated with a higher proportion of days covered by osteoporosis medications than oral bisphosphonates. PURPOSE The aim of this study was to identify factors that contributed to the initiation of osteoporosis medications following hip fracture as well as the compliance and persistence to osteoporosis medications. METHODS Clinical data of 532 patients older than 50 years old admitted for surgical fixation of hip fractures were reviewed. Three hundred forty-seven had sufficient data for analysis after excluding patients with non-fragility fractures. Prescription for any osteoporosis medication in the year following hip fracture as well as compliance to treatment was evaluated. RESULTS Only 40.3% of patients were prescribed with osteoporosis medication within 1 year post-hip fracture. Females (p = 0.020) performing dual-energy x-ray absorptiometry scan (p < 0.001) and 25 hydroxyvitamin D levels testing post-hip fracture (p < 0.027) were independent determinants of increased likelihood of being prescribed with osteoporosis medication. Patients with proportion of days covered (PDC) ≥ 0.8 (or 80% of days covered in a year) were defined as compliant. Overall, only 49.7% of the patients were compliant with osteoporosis medications. Elderly patients aged 70-79 years (p = 0.002) and males (p = 0.017) were less persistent with osteoporosis treatment when compared with patients aged < 69 years and females. The compliance was poorer in patients aged 70-79 years (p = 0.026) as compared with those under 69 years of age. Statistically significant difference (p = 0.032) was observed between mean PDC of oral bisphosphonates (0.66) and denosumab (0.83). Only 39.3% of patients were persistent with treatment at 1 year. CONCLUSION Our findings demonstrate the urgent need to increase awareness through a structured protocol of osteoporosis treatment. A multi-disciplinary Fracture Liaison Service should be set up to ensure compliance to osteoporosis medication post-hip fracture.
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15
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Ebeling PR, Chan DC, Lau TC, Lee JK, Songpatanasilp T, Wong SH, Hew FL, Sethi R, Williams M. Secondary prevention of fragility fractures in Asia Pacific: an educational initiative. Osteoporos Int 2020; 31:805-826. [PMID: 31788717 DOI: 10.1007/s00198-019-05197-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
Abstract
The Asia -Pacific Bone Academy (APBA) Fracture Liaison Service (FLS) Focus Group educational initiative has stimulated activity across the Asia -Pacific region with the intention of supporting widespread implementation of new FLS. In 2017, the APBA FLS Focus Group developed a suite of tools to support implementation of FLS across the Asia-Pacific region as a component of a multi-faceted educational initiative. This article puts this initiative into context with a narrative review describing the burden of fragility fractures in the region, the current secondary fracture prevention care gap and a summary of emerging best practice. The results of a survey to evaluate the impact of the APBA educational initiative is presented, in addition to commentary on recent activities intended to improve the care of individuals who sustain fragility fractures across the Asia -Pacific. A FLS Toolbox for Asia-Pacific was developed which included the following sections:1. The burden of fragility fractures in the Asia-Pacific region.2. A summary of evidence for FLS in the Asia-Pacific.3. A generic, fully referenced FLS business plan template.4. Potential cost savings accrued by each country, based on a country-specific FLS Benefits Calculator.5. How to start and expand FLS programmes in the Asia-Pacific context.6. A step-by-step guide to setting up FLS in countries in the Asia-Pacific region.7. Other practical tools to support FLS establishment.8. FLS online resources and publications.The FLS Toolbox was provided as a resource to support FLS workshops immediately following the 5th Scientific Meeting of the Asian Federation of Osteoporosis Societies (AFOS) held in Kuala Lumpur in October 2017. The FLS workshops addressed three key themes:• The FLS business case.• Planning the FLS patient pathway.• The role of the FLS coordinator in fragility fracture care management.A follow-up survey of 142 FLS workshop participants was conducted in August-September 2018. The survey included questions regarding how FLS were developed, funded, the scope of service provision and the support provided by the educational initiative. Almost one-third (30.3%) of FLS workshop participants completed the survey. Survey responses were reported for those who had established a FLS at the time the survey was conducted and, separately, for those who had not established a FLS. Findings for those who had established a FLS included:• 78.3% of respondents established a multidisciplinary team to develop the business case for their FLS.• 87.0% of respondents stated that a multidisciplinary team was established to design the patient pathway for their FLS.• 26.1% of respondents stated that their FLS has sustainable funding.• The primary source of funding for FLS was from public hospitals (83.3%) as compared with private hospitals (16.7%).Most hospitals that had not established a FLS at the time the survey was conducted were either in the process of setting-up a FLS (47%) or had plans in place to establish a FLS for which approval is being sought (29%). The primary barrier to establishing a new FLS was lack of sustainable funding. The APBA FLS Focus Group educational initiative has stimulated activity across the Asia-Pacific region with the intention of supporting widespread implementation of new FLS. A second edition of the FLS Toolbox is in development which is intended to complement ongoing efforts throughout the region to expedite widespread implementation of FLS.
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Affiliation(s)
- P R Ebeling
- Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash Health, Translational Research Facility, Level 7, 246 Clayton Rd, Clayton, VIC, 3168, Australia.
| | - D-C Chan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Superintendent Office, Chutung Branch, National Taiwan University Hospital, Hsinchu, Taiwan
| | - T C Lau
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - J K Lee
- Department of Orthopedic Surgery, Beacon International Specialist Centre, Petaling Jaya, Selangor, Malaysia
| | - T Songpatanasilp
- Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - S H Wong
- Department of Orthopaedics, International Medical Centre, Central, Hong Kong
| | - F L Hew
- Puchong Medical Specialist Centre, Puchong, Selangor, Malaysia
- Sime Darby Medical Centre, Subang Jaya, Selangor, Malaysia
| | - R Sethi
- Amgen Asia Holding Limited, Hong Kong, Hong Kong
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16
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Senay A, Perreault S, Delisle J, Morin SN, Fernandes JC. Performance of a Fracture Liaison Service in an Orthopaedic Setting: A Report of Key Indicators and Improvement of Longitudinal Outcomes. J Bone Joint Surg Am 2020; 102:486-494. [PMID: 31714470 DOI: 10.2106/jbjs.19.00185] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Many Fracture Liaison Services (FLSs) have been successfully implemented, but very few incorporate systematic longitudinal follow-up. The objective of this study was to report on the performance of such an FLS using key performance indicators and longitudinal clinical outcomes. METHODS An FLS was implemented in 2 outpatient orthopaedic clinics. Men and women who were ≥40 years of age and had a recent fragility fracture were recruited. Participants were evaluated, treated when appropriate, and systematically followed over a 2-year period. Clinical data including chart review and questionnaires were collected. Medical services and hospitalization claims data were retrieved from administrative databases. The primary outcomes were the following key performance indicators: the numbers of investigated and treated patients, follow-up attendance, and the incidence of subsequent fractures. Secondary outcomes were the changes in bone turnover markers and quality of life, physical capacity, and pain scores between baseline and follow-up visits. RESULTS A total of 532 subjects with a mean age of 63.4 years were recruited; 85.7% were female. Bone mineral density results were collected for 472 subjects (88.7%) and a prescription for anti-osteoporosis medication was given to 86.6% of patients. Overall, 83.6% of patients attended at least 1 follow-up visit. The subsequent fracture incidence rate was 2.6 per 100 person-years (23 fractures). The mean level of type-I collagen C-telopeptide (CTX-1), a bone resorption marker, decreased >35%. Clinically important improvements of functional capacity scores (by 14.4% to 63.7%) and pain level (by 19.3% to 35.7%) were observed over time; however, the increase in quality-of-life scores was not clinically important (by 3% to 15.2%). CONCLUSIONS In this FLS, the rates of investigation, treatment, and participation were >80% over a 2-year period. The subsequent fragility fracture incidence rate was <3 per 100 person-years. These results suggest that an intensive FLS model of care, with a systematic longitudinal follow-up, is effective. A randomized controlled trial is needed to support these results. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andréa Senay
- Faculties of Pharmacy (A.S. and S.P.) and Medicine (J.C.F.), Université de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Sylvie Perreault
- Faculties of Pharmacy (A.S. and S.P.) and Medicine (J.C.F.), Université de Montréal, Montréal, Québec, Canada
| | - Josée Delisle
- CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital Jean-Talon, Montréal, Montréal, Québec, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Center for Outcomes and Evaluation, Montréal, Québec, Canada
| | - Julio C Fernandes
- Faculties of Pharmacy (A.S. and S.P.) and Medicine (J.C.F.), Université de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.,CIUSSS du Nord-de-l'Île-de-Montréal, Hôpital Jean-Talon, Montréal, Montréal, Québec, Canada
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17
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The health and economic burden of osteoporotic fractures in Singapore and the potential impact of increasing treatment rates through more pharmacological options. Arch Osteoporos 2019; 14:114. [PMID: 31773442 DOI: 10.1007/s11657-019-0664-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/24/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE This study aims to estimate the health and economic burden of osteoporosis in Singapore from 2017 to 2035, and to quantify the impact of increasing the treatment rate of osteoporosis. METHODS Population forecast data of women and men aged 50 and above in Singapore from 2017 to 2035 was used along with prevalence rates of osteoporosis to project the osteoporosis population over time. The population projections by sex and age group were used along with osteoporotic fracture incidence rates by fracture type (hip, vertebral, other), and average direct and indirect costs per case to forecast the number of fractures, the total direct health care costs, and the total indirect costs due to fractures in Singapore. Data on treatment rates and effects were used to model the health and economic impact of increasing treatment rate of osteoporosis, using different hypothetical levels. RESULTS Between 2017 and 2035, the incidence of osteoporotic fractures is projected to increase from 15,267 to 24,104 (a 57.9% increase) F 10,717 to 17,225 (a 60.7% increase) and M 4550 to 6878 (a 51.2% increase). The total economic burden (including direct costs and indirect costs to society) associated with these fractures is estimated at S$183.5 million in 2017 and is forecasted to grow to S$289.6 million by 2035. However, increasing the treatment rate for osteoporosis could avert up to 29,096 fractures over the forecast period (2017-2035), generating cumulative total cost savings of up to S$330.6 million. CONCLUSION Efforts to improve the detection, diagnosis, and treatment of osteoporosis are necessary to reduce the growing clinical, economic, and societal burden of fractures in Singapore.
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18
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Yong EL, Ganesan G, Kramer MS, Logan S, Lau TC, Cauley JA, Tan KB. Hip fractures in Singapore: ethnic differences and temporal trends in the new millennium. Osteoporos Int 2019; 30:879-886. [PMID: 30671610 DOI: 10.1007/s00198-019-04839-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 01/03/2019] [Indexed: 12/17/2022]
Abstract
UNLABELLED Despite an increase in absolute numbers, the age-standardized incidence of hip fractures in Singapore declined in the period 2000 to 2017. Among the three major ethnic groups, Chinese women had the highest fracture rates but were the only group to show a temporal decline. INTRODUCTION A study published in 2001 predicted a 30-50% increase in Singapore hip fracture incidence rates over the ensuing 30 years. To test that prediction, we examined the incidence of hip fracture in Singapore from 2000 to 2017. METHODS We carried out a population-based study of hip fractures among Singapore residents aged ≥ 50 years. National medical insurance claims data were used to identify admissions with a primary discharge diagnosis of hip fracture. Age-adjusted rates, based on the age distribution of the Singapore population of 2000, were analyzed separately by sex and ethnicity (Chinese, Malay, or Indian). RESULTS Over the 18-year study period, 36,082 first hip fractures were recorded. Total hip fracture admissions increased from 1487 to 2729 fractures/year in the years 2000 to 2017. Despite this absolute increase, age-adjusted fracture rates declined, with an average annual change of - 4.3 (95% CI - 5.0, - 3.5) and - 1.1 (95% CI - 1.7, - 0.5) fractures/100,000/year for women and men respectively. Chinese women had 1.4- and 1.9-fold higher age-adjusted rates than Malay and Indian women: 264 (95% CI 260, 267) versus 185 (95% CI 176, 193) and 141 (95% CI 132, 150) fractures/100,000/year, respectively. Despite their higher fracture rates, Chinese women were the only ethnic group exhibiting a decline, most evident in those ≥ 85 years, in age-adjusted fracture rate of - 5.3 (95% CI - 6.0, - 4.5) fractures/100,000/year. CONCLUSION Although the absolute number of fractures increased, steep drops in elderly Chinese women drove a reduction in overall age-adjusted hip fracture rates. Increases in the older population will lead to a rise in total number of hip fractures, requiring budgetary planning and new preventive strategies.
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Affiliation(s)
- E L Yong
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore, Singapore.
| | - G Ganesan
- Division of Policy, Research and Evaluation, Ministry of Health, Singapore, Singapore
| | - M S Kramer
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore, Singapore
- Departments of Epidemiology, Biostatistics & Occupational Health and of Pediatrics, McGill University Faculty of Medicine, Montreal, Quebec, H3G 1Y6, Canada
| | - S Logan
- Department of Obstetrics and Gynecology, National University of Singapore, Singapore, Singapore
| | - T C Lau
- Department of Medicine, National University Hospital, National University of Singapore, Singapore, 119228, Singapore
| | - J A Cauley
- Graduate School of Public Health, Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - K B Tan
- Division of Policy, Research and Evaluation, Ministry of Health, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
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19
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Senay A, Perreault S, Delisle J, Morin SN, Raynauld JP, Banica A, Troyanov Y, Beaumont P, Jodoin A, Laflamme GY, Leduc S, Mac-Thiong JM, Nguyen H, Ranger P, Rouleau DM, Fernandes JC. Rationale, study design, and descriptive data of the Lucky Bone™ Fracture Liaison Service. Arch Osteoporos 2019; 14:19. [PMID: 30756193 DOI: 10.1007/s11657-019-0571-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 01/27/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED The study design of a multidisciplinary Fracture Liaison Service (2-year follow-up) aiming to optimize fragility fracture management in an outpatient setting is presented. Patient characteristics, investigation, and treatment initiation data at baseline were recorded. Results corroborate the care gap in osteoporosis management, reinforcing the need for secondary fracture prevention programs. PURPOSE This paper describes the study design, implementation, and baseline characteristics of a multidisciplinary Fracture Liaison Service (FLS) in Quebec (Canada). METHODS A FLS was implemented as a prospective cohort study. After identification, fracture risk was assessed and patients were started on treatment or referred, according to guidelines and risk assessment. Thereafter, patients were systematically followed over 2 years. Clinical data (fractures, bone density, blood testing (bone turnover markers), quality of life, physical disability) as well as administrative data (pharmacological, health services, hospitalization) was collected. Baseline descriptive data was analyzed and presented. RESULTS Of 542 recruited participants, 532 underwent baseline assessment (85.7% female, mean age 63.4 years). Overall, 29.7% of participants either withdrew from the study or were lost to follow-up. Almost 27% were referred to a specialist, while > 70% received anti-osteoporosis medication prescriptions through the FLS at baseline. Mean femoral T-score was - 1.6 ± 1.0 and vertebral T-score was - 1.7 ± 1.4. Nearly 19% of subjects reported being under anti-osteoporosis medication at the time of incident fracture. Thirty-three percent of participants reported a prior fracture history, of which 29.7% reported being given anti-osteoporosis therapy. Most fracture sites were to the wrist and ankle, while < 19% were hip/femur or vertebral fractures. CONCLUSIONS These results highlight the important care gap in fragility fracture management and reinforce the need for secondary fracture prevention programs. This prospective study will allow the evaluation of key performance indicators for outpatient clinic-based FLS, such as medication usage, by combining prospective clinical and administrative data.
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Affiliation(s)
- Andréa Senay
- Faculty of Pharmacy, Université de Montréal, 2900 bl. Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada
| | - Sylvie Perreault
- Faculty of Pharmacy, Université de Montréal, 2900 bl. Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Sanofi Aventis endowment Research Chair in Optimal Drug Use, Université de Montréal, Montreal, Canada
| | - Josée Delisle
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada
| | - Suzanne N Morin
- McGill University Health Centre, Montreal General Hospital, 1650 Cedar avenue, Room B2.118, Montreal, QC, H3G 1A4, Canada
| | - Jean-Pierre Raynauld
- Institut de rhumatologie de Montréal, 1551 rue Ontario est, Montreal, QC, H2L 1S6, Canada
| | - Andreea Banica
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada
| | - Yves Troyanov
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada
| | - Pierre Beaumont
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada
| | - Alain Jodoin
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada
| | - G Yves Laflamme
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada
| | - Stéphane Leduc
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada
| | - Jean-Marc Mac-Thiong
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada
| | - Hai Nguyen
- CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada
| | - Pierre Ranger
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada.,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada
| | - Dominique M Rouleau
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada
| | - Julio C Fernandes
- CIUSSS Nord de l'Ile de Montréal, Hôpital du Sacré-Coeur de Montréal, 5400 bl. Gouin ouest, Montreal, QC, H4J 1C5, Canada. .,CIUSSS Nord de l'Ile de Montréal, Hôpital Jean-Talon, 1385 rue Jean-Talon est, Montreal, QC, H2E 1S6, Canada. .,Faculty of Medicine, Université de Montréal, 2900 bl. Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada. .,Chaire de recherche en orthopédie de l'UdeM au CIUSS NIM, 5400 boul. Gouin ouest, Montreal, QC, H4J 1C5, Canada.
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20
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Dirschl DR, Rustom H. Practice Patterns and Performance in U.S. Fracture Liaison Programs: An Analysis of >32,000 Patients from the Own the Bone Program. J Bone Joint Surg Am 2018; 100:680-685. [PMID: 29664856 DOI: 10.2106/jbjs.17.00665] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We are not aware of any previous investigation assessing a national cohort of patients enrolled in a fracture liaison service (FLS) program in an open health-care system to ascertain prevalent practice patterns. The objective of this investigation was to determine, in a geographically diverse group of centers in a single FLS program, the percentage of patients for whom anti-osteoporosis treatment was recommended or started as well as to identify associations between patient and fracture variables and the likelihood of treatment being recommended. METHODS The study utilized the Own the Bone program registry, which included 32,671 unique patient records with the required data. The primary outcome measure was whether a recommendation to start anti-osteoporosis treatment was made to the patient at the time of program enrollment. The associations between patient and fracture variables and the likelihood of having treatment recommended were calculated. RESULTS Anti-osteoporosis treatment was recommended to 72.8% of patients and was initiated for 12.1%. A sedentary lifestyle and a parent who had sustained a hip fracture increased the likelihood of a treatment recommendation by 10% and 12%, respectively. While patients with a spinal fracture were 11% more likely to have received a treatment recommendation, those with a hip fracture were 2% less likely to have received such a recommendation. Age was not strongly associated with the likelihood of receiving a treatment recommendation but was associated with the initiation of treatment. CONCLUSIONS Practitioners at sites in the Own the Bone program recommend anti-osteoporosis treatment, at the time of initial evaluation, to about three-quarters of patients who present with a fragility fracture. This is a very strong improvement over previously reported national data. The findings that a hip fracture had the lowest association and age had very little association with the likelihood of recommending treatment were unexpected and perhaps deserve further investigation. CLINICAL RELEVANCE FLS programs and sites as well as all those who manage patients with a fragility fracture can utilize the information derived from this study to improve practice patterns for the care of these patients.
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Affiliation(s)
- Douglas R Dirschl
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago School of Medicine and Biological Sciences, Chicago, Illinois
| | - Hani Rustom
- College of Osteopathic Medicine, Des Moines University, Des Moines, Iowa
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Chang YF, Huang CF, Hwang JS, Kuo JF, Lin KM, Huang HC, Bagga S, Kumar A, Chen FP, Wu CH. Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review. Osteoporos Int 2018; 29:779-792. [PMID: 29285627 DOI: 10.1007/s00198-017-4347-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
The analysis aimed to identify the treatment gaps in current fracture liaison services (FLS) and to provide recommendations for best practice establishment of future FLS across the Asia-Pacific region. The findings emphasize the unmet need for the implementation of new programs and provide recommendations for the refinement of existing ones. The study's objectives were to evaluate fracture liaison service (FLS) programs in the Asia-Pacific region and provide recommendations for establishment of future FLS programs. A systematic literature review (SLR) of Medline, PubMed, EMBASE, and Cochrane Library (2000-2017 inclusive) was performed using the following keywords: osteoporosis, fractures, liaison, and service. Inclusion criteria included the following: patients ≥ 50 years with osteoporosis-related fractures; randomized controlled trials or observational studies with control groups (prospective or retrospective), pre-post, cross-sectional and economic evaluation studies. Success of direct or indirect interventions was assessed based on patients' understanding of risk, bone mineral density assessment, calcium intake, osteoporosis treatment, re-fracture rates, adherence, and mortality, in addition to cost-effectiveness. Overall, 5663 unique citations were identified and the SLR identified 159 publications, reporting 37 studies in Asia-Pacific. These studies revealed the unmet need for public health education, adequate funding, and staff resourcing, along with greater cooperation between departments and physicians. These actions can help to overcome therapeutic inertia with sufficient follow-up to ensure adherence to recommendations and compliance with treatment. The findings also emphasize the importance of primary care physicians continuing to prescribe treatment and ensure service remains convenient. These findings highlight the limited evidence supporting FLS across the Asia-Pacific region, emphasizing the unmet need for new programs and/or refinement of existing ones to improve outcomes. With the continued increase in burden of fractures in Asia-Pacific, establishment of new FLS and assessment of existing services are warranted to determine the impact of FLS for healthcare professionals, patients, family/caregivers, and society.
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Affiliation(s)
- Y -F Chang
- Department of Family Medicine, National Cheng Kung University College of Medicine and Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan
| | - C -F Huang
- Department of Family Medicine, National Yang-Ming University Hospital, Yilan, Taiwan
| | - J -S Hwang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - J -F Kuo
- Division of Endocrinology and Metabolism, Changhua Christian Hospital, Changhua, Taiwan
| | - K -M Lin
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - H -C Huang
- Department of Orthopaedics, Tainan Municipal Hospital, Tainan, Taiwan
| | - S Bagga
- Complete HEOR Solutions LLC, 1046 Knapp Road, North Wales, PA, 19454, USA
| | - A Kumar
- Complete HEOR Solutions LLC, 1046 Knapp Road, North Wales, PA, 19454, USA
| | - F -P Chen
- Keelung Chang Gung Memorial Hospital, Chang Gung University, Keelung, Taiwan
| | - C -H Wu
- Department of Family Medicine, National Cheng Kung University College of Medicine and Hospital, 138 Sheng-Li Road, Tainan, 70428, Taiwan.
- Institute of Gerontology, National Cheng Kung University College of Medicine, Tainan, Taiwan.
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Chandran M, Tay D, Huang XF, Hao Y. The burden of inpatient care for diabetic and non-diabetic patients with osteoporotic hip fractures-does it differ? An analysis of patients recruited into a fracture liaison service in Southeast Asia. Arch Osteoporos 2018; 13:27. [PMID: 29546650 DOI: 10.1007/s11657-018-0440-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/26/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hospital care and mortality of diabetic and non-diabetic osteoporotic Asian patients undergoing hip fracture surgery were explored with no difference in length of hospitalization, incidence of post-operative complications, or mortality between diabetics and non-diabetics seen. Time to operation correlated with post-operative complications occurrence and therefore surgery should be expeditiously done. INTRODUCTION Whether burden of inpatient care, problems after admission, and mortality rates differ between diabetics and non-diabetics undergoing surgery for osteoporotic hip fractures has not been explored in Asian populations. METHOD Three hundred eighty-nine multi-ethnic diabetic and non-diabetic patients recruited into a FLS at a large Asian hospital with new osteoporotic hip fractures requiring operative repair were analyzed. RESULTS 87.9% were Chinese, 6.4% Malay, and 3.6% Indians. BMI and age did not significantly differ between diabetics and non-diabetics. Median (IQR) length of hospitalization (LOHS) in days was 12 (9, 17) in diabetics and 11 (8, 14) in non-diabetics (p = 0.011). Median time from admission to operation (TTO) was 3 (2, 5) in diabetics versus 2 (1, 4.5) in the non-diabetics (p = 0.003). Occurrence of aggregate post-operative complications did not differ between diabetics and non-diabetics. No in-hospital mortalities occurred in either group. Thirty-day and 1-year mortality rates did not differ between the two groups. One-year mortality was 2.8% in the entire cohort. On multivariate regression analysis adjusted for age and race, only TTO (β; 1.8, 95% CI 1.5-2.0, p < 0.001) and occurrence of post-operative complications (β; 6.3, 95% CI 3.7-7.9, p < 0.001) correlated with LOHS. TTO and age-adjusted Charlson's Comorbidity Index (CCI) correlated significantly with the development of post-operative complications. CONCLUSIONS Diabetes was not independently associated with LOHS in patients undergoing hip fracture surgery. Aggregate post-operative complications did not differ between diabetics and non-diabetics. TTO and occurrence of post-operative complications significantly affected LOHS. TTO correlated with post-complications development. Surgery should be expeditiously done in both diabetics and non-diabetics to avoid the development of post-operative complications and to prevent prolonged hospital stay.
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Affiliation(s)
- M Chandran
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - D Tay
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - X F Huang
- Department of Endocrinology, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Y Hao
- Health Services Research Unit (HSRU), Division of Medicine, Singapore General Hospital, Singapore, Singapore
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Chan BH, Yee R, Puvanendran R, Ang SB. Medication-related osteonecrosis of the jaw in osteoporotic patients: prevention and management. Singapore Med J 2018; 59:70-75. [PMID: 29568850 PMCID: PMC6119741 DOI: 10.11622/smedj.2018014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Osteoporosis is a major, growing healthcare issue. This is especially of concern in an ageing population like that of Singapore. Osteoporotic patients are at risk of fractures, which can result in increased morbidity and mortality. The use of antiresorptive therapy with bisphosphonates or denosumab has been proven to reduce fracture risk. However, the use of these medications has rarely been associated with the development of osteonecrosis of the jaw, a potentially debilitating condition affecting one or both jaws. Appropriate understanding of the patient's antiresorptive therapy regime, as well as early institution of preventive dental measures, can play an important role in preventing medication-related osteonecrosis of the jaw (MRONJ). Regular monitoring and prompt referral to specialist care is warranted for patients with established MRONJ.
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Affiliation(s)
- Boon Hui Chan
- Dental Service, KK Women’s and Children’s Hospital, Singapore
| | - Ruixiang Yee
- Dental Service, KK Women’s and Children’s Hospital, Singapore
| | | | - Seng Bin Ang
- Family Medicine Service, KK Women’s and Children’s Hospital, Singapore
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High prevalence of missed opportunities for secondary fracture prevention in a regional general hospital setting in Singapore. Arch Osteoporos 2017; 12:60. [PMID: 28656564 DOI: 10.1007/s11657-017-0356-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/14/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study aims at assessing the gap in secondary fracture prevention at a regional general hospital setting in Singapore. Male patients have significantly lower rate of being investigated and treated for osteoporosis than their female counterparts. Vitamin D deficiency is prevalent in our population. PURPOSE Secondary fracture prevention services are not routine in Singapore; we seek to assess the treatment gap that exists in the lack of diagnosis and treatment of osteoporosis in fragility fracture patients. METHODS We performed a retrospective analysis of all admissions for fragility fractures between December 2013 and December 2014. Demographic data, rates of BMD performance, serum vitamin D investigation and calcium and vitamin D supplementation as well as antiresorptive initiation 1 year post admission were analysed. RESULTS There were 125 fragility fractures in patients below 65 and 615 fractures in older patients. There was a slightly higher proportion of males in the younger population, whereas females predominated in the older population. Median vitamin D levels were low in both younger (19.1 μg/L) and older (22.0 μg/L) groups, but supplementation was lower in younger patients (4.8 versus 16.6%, p = 0.003). Rate of BMD performance was lower in younger patients (34.4 versus 64.6%, p < 0.01); there was a significant difference of BMD performance between male and female patients in the younger population (19.1 versus 52.8%, p < 0.01) which was not present in the older age group. Antiresportive initiation was significantly lower in the younger age group versus older (10.4 versus 31.5%, p < 0.01); male patients in the younger and older age groups had significantly lower antiresorptive initiation rate compared to the females. CONCLUSION There is a significant treatment gap in diagnosis and treatment of osteoporosis in fragility fracture patients in a regional hospital setting in Singapore. Male osteoporosis remains inadequately investigated and treated in both age groups.
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Makras P, Panagoulia M, Mari A, Rizou S, Lyritis GP. Evaluation of the first fracture liaison service in the Greek healthcare setting. Arch Osteoporos 2017; 12:3. [PMID: 28004297 DOI: 10.1007/s11657-016-0299-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/09/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED We evaluated the first implementation of FLS in the Greek healthcare setting, at the 251 Hellenic Air Force and VA General Hospital of Athens. Participation rate was moderate (54.5%) and needs improvement; osteoporosis medication was either suggested or reviewed in 74 out of the 116 patients recruited. PURPOSE The purpose of this study was to evaluate the first implementation of a fracture liaison service (FLS) in Greece, at the 251 Hellenic Air Force and VA General Hospital, Athens. METHODS Single-center, prospective study from May 1, 2013 to April 30, 2015 (first year-second year follow-up) was conducted. Patients of both genders aged 40-90 years old, with a history of a low trauma fracture and willing to participate, were included after identification by an FLS nurse. Following recruitment, osteoporosis risk factors were assessed, FRAX score was calculated for treatment-naïve patients, bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA), and osteoporosis treatment was suggested where applicable. The rate of participation, the indication of osteoporosis treatment, and the difficulties met were evaluated. RESULTS Of the eligible 213 patients, 97 (45.5%) were reluctant to participate for personal reasons. From the 116 initially recruited patients (mean age 74.8 ± 12 years), 77 (66.4%) discontinued their participation at some point for various reasons and 39 patients concluded the study. All 116 patients were assessed for osteoporosis risk factors and given a tailor-made exercise and education program, while FRAX score was assessed in all treatment-naïve patients (74 patients, 63.8%). Osteoporosis medication was suggested or reviewed in 74 patients; however, an adherence rate of 100% is only available for the 24 who concluded the study. CONCLUSIONS We report the first implementation of FLS in the Greek healthcare setting. The participation rate is moderate and definitely needs improvement.
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Affiliation(s)
- Polyzois Makras
- Department of Endocrinology and Diabetes, 251 Hellenic Air Force General Hospital, 3 Kanellopoulou st, 115 25, Athens, Greece.
| | - Maria Panagoulia
- Nursing Sector, 251 Hellenic Air Force General Hospital, Athens, Greece
| | - Andriana Mari
- 2nd Department of Internal Medicine, 251 Hellenic Air Force General Hospital, Athens, Greece
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Noordin S, Allana S, Masri BA. Establishing a hospital based fracture liaison service to prevent secondary insufficiency fractures. Int J Surg 2017; 54:328-332. [PMID: 28919380 DOI: 10.1016/j.ijsu.2017.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 08/08/2017] [Accepted: 09/06/2017] [Indexed: 11/29/2022]
Abstract
In the aging population worldwide, osteoporosis is a relatively common condition and a major cause of long-term morbidity. Initial fragility fractures can lead to subsequent fractures. After a vertebral fracture, the risk of any another fracture increases 200% and that of a subsequent hip fracture increases 300%. For starting a hospital based Fracture Liaison Service (FLS) program, the nucleus is based on a physician champion, a FLS coordinator, and a nurse manager. A Fracture Liaison Service (FLS) is a multidisciplinary system approach to reducing subsequent fracture risk in patients with a recent fragility fracture due to compromised bone health by identifying them at or close to the time when they are treated at the hospital for fracture and providing them with easy access to osteoporosis care. It has been shown that when compared to other models such as referral letters to primary care physicians or endocrinologists, the FLS model results in a higher rate of diagnosis and treatment with less attrition in the posffracture phase. Insufficiency fracture care requires more than surgery to stabilize a fractured bone. The FLS program provides an opportunity to treat osteoporosis from a public health perspective rather than leaving this to the whims of individual physicians. This is achieved by providing a seamless integration of care by health care providers, nursing staff and administration. The FLS can be adapted to any model of care including academic health systems. FLS provides a holistic approach to identify patients as well as to provide evidence-based interventions to prevent subsequent fractures. The long term goal is that internationally FLS will result in in decreased fracture-related morbidity, mortality and overall health care expenditure.
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Affiliation(s)
- Shahryar Noordin
- Associate Professor, Orthopaedic Surgery, Aga Khan University, Karachi, Pakistan.
| | - Salim Allana
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, USA
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vacnouver, Canada
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Mitchell P, Åkesson K, Chandran M, Cooper C, Ganda K, Schneider M. Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture. Best Pract Res Clin Rheumatol 2017; 30:536-558. [PMID: 27886945 DOI: 10.1016/j.berh.2016.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/09/2016] [Accepted: 09/10/2016] [Indexed: 12/29/2022]
Abstract
As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered.
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Affiliation(s)
- Paul Mitchell
- Synthesis Medical NZ Limited, Pukekohe, New Zealand; University of Notre Dame Australia, Sydney, Australia; Osteoporosis New Zealand, Wellington, New Zealand.
| | - Kristina Åkesson
- Department of Orthopaedics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, ACADEMIA, 20 College Road, 169856, Singapore
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; National Institute of Health Research (NIHR) Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, The Botnar Research Centre, University of Oxford, Oxford, UK
| | - Kirtan Ganda
- The University of Sydney, Concord Clinical School and Concord Repatriation General Hospital, 1A Hospital Road, Concord Hospital, NSW, 2139, Australia
| | - Muriel Schneider
- International Osteoporosis Foundation, 9, Rue Juste-Olivier, 1260, Nyon, Switzerland
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Improvement in osteoporosis detection in a fracture liaison service with integration of a geriatric hip fracture care program. Injury 2016; 47:2755-2759. [PMID: 27773370 DOI: 10.1016/j.injury.2016.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/16/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Care gaps have been identified in the treatment of osteoporosis after the occurrence of a fragility hip fracture. HiROC (High Risk Osteoporosis Clinic) is a fracture liaison service implemented at our institution. In ProvenCare geriatric hip fracture care program at our institution pre-set orders for the inpatient HiROC consults were prescribed. We hypothesized that there will be a significant increase in the rate of enrollment of patients in the HiROC program after the integration of the pre-set orders. PATIENTS AND METHODS The trauma database at a level-I trauma center was reviewed retrospectively for the charts of patients >50 years of age with fragility intertrochanteric fractures. Patients not treated under the geriatric hip fracture care program and patients treated under the geriatric hip fracture care program were identified and reviewed for the enrollment in HiROC and subsequent follow up. RESULTS Out of 589 patients treated before the implementation of ProvenCare, 443 patients (75%) were enrolled in HiROC at the index consult. In comparison, out of 153 patients treated after the implementation of ProvenCare, 131 patients (85.6%) were enrolled in HiROC at the index consult. The difference between the two groups was statistically significant (p=0.008). CONCLUSION Our experience shows that the occurrence of a fragility intertrochanteric fracture can be effectively utilized for the detection and initiation of treatment of osteoporosis. With the implementation of pre-set orders in the geriatric hip fracture care program significantly better enrollment can be achieved.
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Chan DC, Chang CHC, Lim LC, Brnabic AJM, Tsauo JY, Burge R, Hsiao FY, Jin L, Gürbüz S, Yang RS. Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database. Osteoporos Int 2016; 27:2855-2865. [PMID: 27172935 PMCID: PMC4981624 DOI: 10.1007/s00198-016-3611-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 04/18/2016] [Indexed: 11/24/2022]
Abstract
UNLABELLED Medication persistence and adherence are critical for osteoporosis outcomes. Using the Taiwan National Health Insurance Research Database, we found that persistence and adherence to teriparatide were low in Taiwanese patients with osteoporosis and that greater persistence and adherence were associated with a lower incidence of hip and other nonvertebral fractures. INTRODUCTION The purpose of this study was to determine the persistence and adherence to teriparatide treatment in Taiwanese patients with osteoporosis, and to examine the association between persistence and adherence to teriparatide with fracture risks. METHODS Medical and pharmacy claims for 4,692 patients with vertebral or hip fractures and teriparatide prescriptions between 2005 and 2008 were identified (Taiwan National Health Insurance Research Database). Persistence was the time from the start of treatment to the first 90-day gap between two teriparatide prescriptions. Adherence was the number of teriparatide pens (each pen is used over 1 month) prescribed over 24 months. Association of persistence and adherence to teriparatide with fracture incidence was assessed using adjusted Cox proportional hazards models. RESULTS The proportion of patients persisting with teriparatide for >6 months and >12 months was 44.6 and 24.9 %, respectively. Over 24 months, 53.6 % of patients were adherent for >6 months and 33.9 % were adherent for >12 months. Patients persisting for >12 months had a significantly lower incidence of hip (adjusted hazard ratio [HR], 0.61 [95 % confidence interval (CI), 0.40-0.93], P = 0.0229) and nonvertebral fracture (HR, 0.79 [95 % CI, 0.63-0.99], P = 0.0462) compared with those who persisted for ≤12 months. Patients adherent for >12 months had a lower incidence of hip (HR, 0.66 [95 % CI, 0.46-0.96], P = 0.0286) and nonvertebral fracture (HR, 0.81 [95 % CI, 0.66-0.99], P = 0.0377) compared with those adherent for ≤12 months. CONCLUSIONS Persistence and adherence to teriparatide over 24 months were low in Taiwanese patients with osteoporosis; greater adherence and persistence were associated with a lower incidence of nonvertebral fractures.
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Affiliation(s)
- D-C Chan
- Superintendent Office, Chu-Tung Branch, National Taiwan University Hospital, Hsinchu County, Taiwan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - L-C Lim
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Orthopaedics, National Taiwan University Hospital, No. 7. Chung-Shan S. Rd., Taipei, 100, Taiwan
| | - A J M Brnabic
- Real World Analytics, Eli Lilly Australia Pty Ltd, Sydney, Australia
| | - J-Y Tsauo
- School and Graduate Institute of Physical Therapy, National Taiwan University, Taipei, Taiwan
| | - R Burge
- Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
| | - F-Y Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - L Jin
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - S Gürbüz
- Eli Lilly and Company, Indianapolis, IN, USA
| | - R-S Yang
- Department of Orthopaedics, National Taiwan University Hospital, No. 7. Chung-Shan S. Rd., Taipei, 100, Taiwan.
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Chandran M, Cheen M, Ying H, Lau TC, Tan M. Dropping the Ball and Falling Off the Care Wagon. Factors Correlating With Nonadherence to Secondary Fracture Prevention Programs. J Clin Densitom 2016. [PMID: 26209018 DOI: 10.1016/j.jocd.2015.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Health care systems and hospitals in several countries have implemented Fracture Liaison Services (FLSs). Success rates of FLSs with regard to osteoporosis assessment and treatment, fracture reduction, and adherence to osteoporosis medications have been reported by several groups including ours. A significant drop-out rate among patients in these programs may occur. This has not been evaluated before. We explored the factors correlating with nonadherence among a multiethnic population of patients in the FLS at our institution, the largest tertiary teaching hospital in South East Asia. Our secondary objective was to explore whether patients who defaulted follow-up visits continued to be compliant with medications. A retrospective analysis of our FLS's computerized database was performed. Of 938 patients followed up more than 2 years, 237 defaulted at various time points. A significant percentage of patients who dropped out of the program opined that it was because the follow-up visits were too time consuming. Non-Chinese patients were more likely than Chinese (adjusted hazard ratio [aHR] = 1.98, 1.33-2.94), patients with primary school education and below were more likely than those with secondary school and above education (aHR = 1.65, 1.11-2.45) and those with nonvertebral and/or multiple fractures were more likely than those with spine fractures (aHR = 1.38, 1.06-1.81) to be nonadherent. A fraction of patients who defaulted continued to fill osteoporosis medication prescriptions. Median medication possession ratio among the patients who defaulted was 12.3% (interquartile range: 4.1%-36.7%) at 2 years. Persistence ranged from 15.1% to 20.8% and from 1.9% to 7.5% at 1 and 2 years, respectively after defaulting from the program. Our study, which to the best of our knowledge is the first of its kind, provides insight into the factors correlating with nonadherence to FLSs. Knowledge of the challenges faced by patients may be of help to health care providers interested in developing FLSs.
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Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore.
| | - Mcvin Cheen
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Hao Ying
- Department of Health Services Research and Biostatistics Unit, Singapore General Hospital, Singapore
| | - Tang Ching Lau
- Division of Rheumatology, National University Hospital, Singapore
| | - Matthew Tan
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore
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Mitchell PJ, Cooper C, Dawson-Hughes B, Gordon CM, Rizzoli R. Life-course approach to nutrition. Osteoporos Int 2015; 26:2723-42. [PMID: 26412214 PMCID: PMC4656714 DOI: 10.1007/s00198-015-3288-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/11/2015] [Indexed: 01/12/2023]
Abstract
This narrative review summarizes the role that nutrition plays in the development and maintenance of a healthy skeleton throughout the life-course. Nutrition has a significant influence on bone health throughout the life cycle. This narrative review summarizes current knowledge and guidance pertaining to the development and maintenance of a healthy skeleton. The primary objectives proposed for good bone health at the various stages of life are the following: Children and adolescents: achieve genetic potential for peak bone mass Adults: avoid premature bone loss and maintain a healthy skeleton Seniors: prevention and treatment of osteoporosis Findings from cohort studies, randomized controlled trials, systematic reviews and meta-analyses, in addition to current dietary guidelines, are summarized with the intention of providing clear nutritional guidance for these populations and pregnant women.
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Affiliation(s)
- P J Mitchell
- Synthesis Medical NZ Ltd, Auckland, New Zealand
- University of Notre Dame Australia, Sydney, Australia
| | - C Cooper
- NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK.
| | - B Dawson-Hughes
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - C M Gordon
- Divisions of Adolescent Medicine and Endocrinology, Hasbro Children's Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Naranjo A, Ojeda-Bruno S, Bilbao-Cantarero A, Quevedo-Abeledo JC, Diaz-González BV, Rodríguez-Lozano C. Two-year adherence to treatment and associated factors in a fracture liaison service in Spain. Osteoporos Int 2015; 26:2579-85. [PMID: 26048675 DOI: 10.1007/s00198-015-3185-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 05/20/2015] [Indexed: 12/22/2022]
Abstract
UNLABELLED A fracture liaison service in Spain is able to maintain 73 % of the patients on antiresorptive 2 years after the fracture. INTRODUCTION The purpose of this study was to evaluate the 2-year effectiveness of a program for the secondary prevention of fractures. METHODS Fragility fractures in patients over 50 attending the emergency room in our centre are captured by the recruitment system of a secondary prevention program. The unit is attended by a nurse, coordinated by two rheumatologists and with the collaboration of primary care consisted of a training program and annual meetings. The outcome of the program was analysed 2 years after implementation, including: (1) percentage of attendees/eligible; (2) percentage of attendees who start treatment with antiresorptive; (3) percentage of patients who retain treatment after 6, 12, 18 and 24 months; and (4) factors associated to adherence. RESULTS After 2 years of implementation, the program detected 1674 patients with fracture, of whom 759 finally entered the program (57 % of eligible). After 3 months, 82 % of patients prescribed an antiresorptive started treatment. After a year, 52 % of the patients in the program, 72 % of those of a prescribed treatment, were taking antiresorptives. Adherence at 24 months among those who had prescribed anti-fracture drugs was 73 %. Factors associated with adherence at 12 months were female sex (76 vs 45 %; p = 0.01) and previous treatment with antiresorptive (86 vs 68 %; p = 0.02). CONCLUSIONS In Spain, a program designed to prevent secondary fragility fractures based on the collaboration between primary care and rheumatology seems effective in terms of recruitment of patients and adherence to treatment in the mid/long-term.
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Affiliation(s)
- A Naranjo
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Barranco de La Ballena s/n, 35011, Las Palmas de Gran Canaria, Spain.
- Medical and Surgical Sciences Department, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - S Ojeda-Bruno
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Barranco de La Ballena s/n, 35011, Las Palmas de Gran Canaria, Spain
| | - A Bilbao-Cantarero
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Barranco de La Ballena s/n, 35011, Las Palmas de Gran Canaria, Spain
| | - J C Quevedo-Abeledo
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Barranco de La Ballena s/n, 35011, Las Palmas de Gran Canaria, Spain
| | - B V Diaz-González
- Primary Care Service, Gerencia de Atención Primaria de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - C Rodríguez-Lozano
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Barranco de La Ballena s/n, 35011, Las Palmas de Gran Canaria, Spain
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Hsu CY, Chiu WC, Chen JF, Chou CL, Su YJ, Yu SF, Cheng TT. Medical specialty-related adherence to anti-osteoporotic regimens in fragility hip fracture patients. J Bone Miner Metab 2015; 33:577-83. [PMID: 25240801 DOI: 10.1007/s00774-014-0621-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/08/2014] [Indexed: 12/31/2022]
Abstract
There is poor adherence in the management of osteoporotic fractures. We designed a study to investigate adherence to osteoporotic regimens among osteoporotic hip fracture patients and to analyze the risk factors associated with poor compliance. This retrospective chart-review study was carried out using a database of osteoporotic hip fracture patients at a medical center in Taiwan for the period 2001-2007. Adherence was assessed using compliance and persistence. Compliance was calculated by the medication possession ratio (MPR) and persistence by the time from treatment initiation to discontinuation. The MPR and corresponding risk factors for poor compliance (MPR < 80 %) were evaluated for year 1. The year 2 results were analyzed only for those subjects with good compliance (MPR ≥ 80 %) at the end of year 1. There were 366 osteoporotic hip fracture patients (323 women, 43 men) with a mean age of 73.9 ± 7.6 years. Of these, 53.8 % had good compliance for year 1 and 68.5 % for year 2. During 2 years of follow-up, the overall persistence ratio was 33.1 %. The risk factor associated with poor compliance in the first year was index prescription by orthopedists [odds ratio (OR) 1.69, 95 % confidence interval (CI) 1.10-2.59]. Subjects with hypertension (OR 0.69, 95 % CI 0.46-0.99) had good compliance. Index prescription by orthopedists (OR 2.44, 95 % CI 1.31-4.51) was the sole risk factor for poor compliance in year 2. In conclusion, although adherence to osteoporotic regimens was sub-optimal in hip fracture patients, the majority of patients' decreased adherence occurred within the first year. Medical specialties showed different adherences in both year 1 and year 2.
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Affiliation(s)
- Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123 Ta-Pei Road, Kaohsiung, 833, Taiwan, China
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Miller AN, Lake AF, Emory CL. Establishing a fracture liaison service: an orthopaedic approach. J Bone Joint Surg Am 2015; 97:675-81. [PMID: 25878314 DOI: 10.2106/jbjs.n.00957] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Bone health evaluations should be incorporated into care pathways for fragility fractures in all patients who are fifty years of age or older.➤ A fracture liaison service (FLS) is an established and proven method to achieve recommended standards of care for fragility fractures, including intervention for osteoporosis, secondary fracture prevention, and bone health evaluation.➤ The FLS facilitates patient care by automatically including all patients with a fragility fracture within a health-care system to provide them with the intervention that they need and to prevent avoidable fracture-related complications or readmissions.➤ An FLS functions with three key personnel: the FLS coordinator (usually an advanced practice provider), a physician champion (usually an orthopaedic surgeon), and a nurse navigator.
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Affiliation(s)
- Anna N Miller
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070. E-mail address for A.N. Miller:
| | - Anne F Lake
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070. E-mail address for A.N. Miller:
| | - Cynthia L Emory
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070. E-mail address for A.N. Miller:
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Wilk A, Sajjan S, Modi A, Fan CPS, Mavros P. Post-fracture pharmacotherapy for women with osteoporotic fracture: analysis of a managed care population in the USA. Osteoporos Int 2014; 25:2777-86. [PMID: 25112720 PMCID: PMC4221620 DOI: 10.1007/s00198-014-2827-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/25/2014] [Indexed: 12/14/2022]
Abstract
UNLABELLED Pharmacologic therapy is recommended to reduce future fracture risk. We examined osteoporosis medications dispensed to older women after first fracture. Only 23 % received therapy during the first year post-fracture. Prior osteoporosis therapy, a prior osteoporosis diagnosis, and older age were good predictors of post-fracture osteoporosis therapy. INTRODUCTION Pharmacologic therapy is recommended after osteoporotic fracture to reduce future fracture risk. The objective of this retrospective study was to examine osteoporosis therapy dispensed to women post-fracture. METHODS We identified women ≥50 years old in a large administrative claims database from 2003 to mid-2012 who were continuously enrolled 2 years before (baseline) and 1 year after first osteoporotic fracture. Exclusions were Paget's disease or malignant neoplasm. Pre- and post-fracture osteoporosis therapies (oral and parenteral) were assessed overall and by fracture site. RESULTS A total of 47,171 women of mean (SD) age of 63 (10) years were eligible; fractures included 8 % hip, 17 % vertebral, 73 % non-hip/non-vertebral, and 3 % multiple fracture sites. Only 18 % received osteoporosis therapy within 90 days and 23 % within 1 year post-fracture. Overall, 19 % of women had a prior osteoporosis diagnosis; 20 % had received osteoporosis therapy during baseline. Of 37,649 (80 %) women without baseline therapy, only 9 % initiated pharmacologic therapy within 1 year. The adjusted odds ratio (OR) of therapy within 1 year post-fracture was significantly greater for women who had received baseline osteoporosis therapy (versus none) and who had vertebral (OR 12.7, 95 % confidence interval (CI) 11.2-14.5), hip (15.2, 12.5-18.7), or non-hip/non-vertebral fracture (34.4, 31.7-37.3). Other significant predictors included pre-fracture osteoporosis diagnosis (1.6, 1.4-1.7) and older age (OR range, 1.3-1.7). Treatment adherence was significantly better among women with baseline osteoporosis diagnosis. CONCLUSIONS The substantial post-fracture treatment gap represents an important unmet need for women with osteoporotic fractures. Fracture liaison or adherence programs could lead to improved post-fracture treatment rates.
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Affiliation(s)
- A. Wilk
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA USA
| | - S. Sajjan
- Center for Observational and Real-World Evidence, Merck & Co., Inc., One Merck Drive, PO Box 100, WS2E-76, Whitehouse Station, NJ 08889-0100 USA
| | - A. Modi
- Center for Observational and Real-World Evidence, Merck & Co., Inc., One Merck Drive, PO Box 100, WS2E-76, Whitehouse Station, NJ 08889-0100 USA
| | | | - P. Mavros
- Center for Observational and Real-World Evidence, Merck & Co., Inc., One Merck Drive, PO Box 100, WS2E-76, Whitehouse Station, NJ 08889-0100 USA
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Dehamchia-Rehailia N, Ursu D, Henry-Desailly I, Fardellone P, Paccou J. Secondary prevention of osteoporotic fractures: evaluation of the Amiens University Hospital's fracture liaison service between January 2010 and December 2011. Osteoporos Int 2014; 25:2409-16. [PMID: 24980182 DOI: 10.1007/s00198-014-2774-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/11/2014] [Indexed: 11/29/2022]
Abstract
SUMMARY The main goal was to assess the performance of the fracture liaison service (FLS) at Amiens University Hospital for 2 years. Osteoporosis medication was prescribed in 182 patients and 67.4 % were still taking treatment 18 months later. Secondary prevention of osteoporotic fractures has improved since the creation of the FLS. INTRODUCTION The main goal of the present study was to assess the performance and results of the FLS at Amiens University Hospital, France. METHODS This was an observational, single-center, ambispective study. All patients admitted to Amiens University Hospital between January 2010 and December 2011 for a low-trauma fracture (vertebral and non-vertebral fractures) were identified by a FLS nurse. Patients willing to enter the study were assessed for their osteoporosis risk factors, daily calcium intake, bone mineral density (BMD) by DXA, and clinical chemistry parameters. When indicated, the patients received a prescription for osteoporosis medication. The participation rate, type of osteoporosis medications, initiation rate, and osteoporosis treatment persistence 12 and 18 months later were assessed. RESULTS Of the 1,439 patients contacted, 872 were eligible for inclusion. A total of 335 patients (participation rate 38.4 %) were included in the study (mean age 63.3 years; 71.9 % female). All patients underwent BMD measurement, and more than 90 % of them were assessed for osteoporosis risk factors and daily calcium intake. Osteoporosis medication was prescribed in 182 (75.5 %) of the patients in whom it was indicated (n = 241). The main class of osteoporosis medications prescribed was bisphosphonates (83.5 %), and 74.1 and 67.4 % of treated patients were still taking treatment 12 and 18 months later, respectively. The main cause of treatment discontinuation was non-renewal of the prescription by the patient's general practitioner. CONCLUSION Secondary prevention of osteoporotic fractures in Amiens University Hospital has improved since the creation of the FLS, with encouragingly high treatment initiation and persistence rates.
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Solomon DH, Patrick AR, Schousboe J, Losina E. The potential economic benefits of improved postfracture care: a cost-effectiveness analysis of a fracture liaison service in the US health-care system. J Bone Miner Res 2014; 29:1667-74. [PMID: 24443384 PMCID: PMC4176766 DOI: 10.1002/jbmr.2180] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/02/2014] [Accepted: 01/10/2014] [Indexed: 01/13/2023]
Abstract
Fractures related to osteoporosis are associated with $20 billion in cost in the United States, with the majority of cost born by federal health-care programs, such as Medicare and Medicaid. Despite the proven fracture reduction benefits of several osteoporosis treatments, less than one-quarter of patients older than 65 years of age who fracture receive such care. A postfracture liaison service (FLS) has been developed in many health systems but has not been widely implemented in the United States. We developed a Markov state-transition computer simulation model to assess the cost-effectiveness of an FLS using a health-care system perspective. Using the model, we projected the lifetime costs and benefits of FLS, with or without a bone mineral density test, in men and women who had experienced a hip fracture. We estimated the costs and benefits of an FLS, the probabilities of refracture while on osteoporosis treatment, as well as the utilities associated with various health states from published literature. We used multi-way sensitivity analyses to examine impact of uncertainty in input parameters on cost-effectiveness of FLS. The model estimates that an FLS would result in 153 fewer fractures (109 hip, 5 wrist, 21 spine, 17 other), 37.43 more quality-adjusted life years (QALYs), and save $66,879 compared with typical postfracture care per every 10,000 postfracture patients. Doubling the cost of the FLS resulted in an incremental cost-effectiveness ratio (ICER) of $22,993 per QALY. The sensitivity analyses showed that results were robust to plausible ranges of input parameters; assuming the least favorable values of each of the major input parameters results in an ICER of $112,877 per QALY. An FLS targeting patients post-hip fracture should result in cost savings and reduced fractures under most scenarios.
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Affiliation(s)
- Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA; Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, MA, USA
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Sale JEM, Beaton D, Bogoch E. Secondary prevention after an osteoporosis-related fracture: an overview. Clin Geriatr Med 2014; 30:317-32. [PMID: 24721371 DOI: 10.1016/j.cger.2014.01.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This article is an overview of the status of postfracture secondary prevention programs. The concept of fracture risk, the inclusion of fracture risk in clinical practice guidelines for osteoporosis, and how fracture risk has contributed to the development of postfracture secondary prevention programs are described. The scope of postfracture secondary prevention programs, the gaps in care that persist despite these initiatives, and the potential reasons for these gaps are also described. Recommendations for future research in the area of postfracture secondary prevention are provided.
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Affiliation(s)
- Joanna E M Sale
- Mobility Program Clinical Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Suite 425, 155 College Street, Toronto, Ontario M5T 3M7, Canada.
| | - Dorcas Beaton
- Mobility Program Clinical Research Unit, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Suite 425, 155 College Street, Toronto, Ontario M5T 3M7, Canada
| | - Earl Bogoch
- Mobility Program, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto, Ontario M5T 1P5, Canada
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Abstract
The key questions addressed in this chapter are: • How can individual risk of fracture be best estimated? • What is the best system to prevent a further fracture? • How to implement systems for preventing further fractures? Absolute fracture risk calculators (FRCs) provide a means to estimate an individual's future fracture risk. FRCs are widely available and provide clinicians and patients a platform to discuss the need for intervention to prevent fragility fractures. Despite availability of effective osteoporosis medicines for almost two decades, most patients presenting with new fragility fractures do not receive secondary preventive care. The Fracture Liaison Service (FLS) model has been shown in a number of countries to eliminate the care gap in a clinically and cost-effective manner. Leading international and national organisations have developed comprehensive resources and/or national strategy documents to provide guidance on implementation of FLS in local, regional and national health-care systems.
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Chandran M, Akesson K. Secondary Fracture Prevention: Plucking The Low Hanging Fruit. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n10p541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
It is well known that one fragility fracture begets another. Fracture Liaison Services have been shown to narrow the care gap that exists in the care of patients with fragility fractures. A secondary fracture prevention programme “OPTIMAL” (Osteoporosis Patient Targeted and Integrated Management for Active Living) has been in existence in the public restructured hospitals and polyclinics of Singapore since 2008 and this is beginning to show significant beneficial results in terms of identification and management of fragility fractures. However, significant obstacles in the path of appropriate management of the patient with a fragility fracture still exist. A concerted, multipronged and interdisciplinary approach is needed to overcome these barriers.
Keywords: Care Gap, Fracture Liaison Service, Osteoporosis, Singapore
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