Long-term persistence of treatment after hip fracture in a fracture liaison service; recommending treatment during admission is more efficient

Background Long-term adherence to antiosteoporosis medication (AOM) in the setting of a fracture liaison service (FLS) are not well known. Methods Patients ≥50 with hip fracture seen in an FLS and recommended for treatment to prevent new fractures were analyzed. Baseline data included demographics, identification mode, previous treatment and FRAX® items. Patient records were reviewed 3-8 years later, and these data were collected: 1) survival; 2) major refracture; 3) initiation of treatment, proportion of days covered (PDC) and persistence with AOM. Results 372 patients (mean age, 79 years; 76% women) were included. Mean follow-up was 47 months, 52 patients (14%) had a refracture (22 hip) and 129 (34.5%) died. AOM was started in 283 patients (76.0%). Factors associated with initiation of AOM were previous use of bisphosphonate (OR9.94;95%CI:1.29-76.32) and a lower T-score lumbar (OR 0.80;95%CI:0.65-0.99). Persistence decreased to 72.6%, 60% and 47% at 12, 36 and 60 months. A PDC>80% was confirmed in 208 patients (55.7%) and associated with previous use of bisphosphonate (OR3.38;95%CI:1.34-8.53), treatment with denosumab (OR2.69;95%CI:1.37-5.27), and inpatient identification (OR2.26; 95%CI:1.18-4.34). Conclusions Long-term persistence with AOM was optimal in patients with hip fracture seen at an FLS. A PDC>80% was associated with inpatient identification and prescription of denosumab.

Improvement of osteoporosis Care Organized by Nurses: ICON study - Protocol of a quasi-experimental study to assess the (cost)-effectiveness of combining a decision aid with motivational interviewing for improving medication persistence in patients with a recent fracture being treated at the fracture liaison service

Background Given the health and economic burden of fractures related to osteoporosis, suboptimal adherence to medication and the increasing importance of shared-decision making, the Improvement of osteoporosis Care Organized by Nurses (ICON) study was designed to evaluate the effectiveness, cost-effectiveness and feasibility of a multi-component adherence intervention (MCAI) for patients with an indication for treatment with anti–osteoporosis medication, following assessment at the Fracture Liaison Service after a recent fracture. The MCAI involves two consultations at the FLS. During the first consultation, a decision aid is will be used to involve patients in the decision of whether to start anti-osteoporosis medication. During the follow-up visit, the nurse inquires about, and stimulates, medication adherence using motivational interviewing techniques. Methods A quasi-experimental trial to evaluate the (cost-) effectiveness and feasibility of an MCAI, consisting of a decision aid (DA) at the first visit, combined with nurse-led adherence support using motivational interviewing during the follow-up visit, in comparison with care as usual, in improving adherence to oral anti-osteoporosis medication for patients with a recent fracture two Dutch FLS. Medication persistence, defined as the proportion of patients who are persistent at one year assuming a refill gap < 30 days, is the primary outcome. Medication adherence, decision quality, subsequent fractures and mortality are the secondary outcomes. A lifetime cost-effectiveness analysis using a model-based economic evaluation and a process evaluation will also be conducted. A sample size of 248 patients is required to show an improvement in the primary outcome with 20%. Study follow-up is at 12 months, with measurements at baseline, after four months, and at 12 months. Discussion We expect that the ICON-study will show that the MCAI is a (cost-)effective intervention for improving persistence with anti-osteoporosis medication and that it is feasible for implementation at the FLS. Trial registration This trial has been registered in the Netherlands Trial Registry, part of the Dutch Cochrane Centre (Trial NL7236 (NTR7435)). Version 1.0; 26-11-2020.

SP9.1.12 Bone protection in neck of femur fracture patients in a DGH without a fracture liaison service

Introduction In England and Wales, there are approximately 75,000 proximal femoral fractures per year. Bone protection is vital in these patients and a key recommendation of NICE guidelines (CG124) for multidisciplinary approach in hip fracture management. Method Data were collected retrospectively using clinical portal, admission records and medication charts. The data were inputted into the FRAX calculator to calculate a patient’s risk of developing an osteoporotic fracture; depending on their risk they would be appropriate for bone protection or DEXA scanning for further assessment. As certain data criteria were not available for the FRAX calculation, risk calculation was underscored i.e. if parental hip fracture status was not known. Results A total of 59 patients were audited between July and October 2019. Of those patients, 25 were calculated as high risk, however, only 6 patients had adequate bone protection. 19 patients were deemed intermediate risk and would benefit from a DEXA scan for further assessment. Of those 19 patients, only 8 had adequate bone protection. DEXA scan was only requested for 2 of the patients who were intermediate or high risk. In the year following, 4 patients have had another fracture, with 3 of those patients not on any bone protection medication and had a high risk FRAX calculation. Conclusion Following a local meeting; a proforma was piloted to identify patients at risk and requiring bone protection. With the help of a dedicated orthopaedic pharmacist and nurse practitioners, continuity of care can be achieved to aid patients long-term wellbeing.

Does Fracture Liaison Service Improves Fracture Risk Assessment among Patients with Fragility Fractures? A Systematic Review

Background: The fragility fractures can cause substantial pain, disability, reduced quality of life and mortality. The probability of sustaining subsequent fractures increases up to five times after an initial fragility fracture. The Fracture Liaison Service is a coordinated model of care that aims to bridge the post-fracture care gap by improving subsequent fracture risk assessment and post-fracture management. However, there are very few studies that included fracture risk assessment as a significant outcome of an FLS program. This systematic review aims to evaluate the available evidence on the effect of FLS in improving fracture risk assessment among fragility fracture patients Method: A systematic literature search will be carried out on the major electronic databases including PubMed, Embase, CINAHL Plus, and Cochrane to identify the outcomes of Fracture Liaison Service. The literature search will not be restricted to the context and year of publication. Two researchers will independently conduct the databases search. We will pilot the search strategy to ensure sufficient sensitivity and specificity. The JBI critical appraisal tools will be used to assess methodological quality of all the included studies. Discussion: This review will highlight an urgent need for more studies from different geographical areas to determine best practices for implementing fracture risk assessment globally and guiding clinical decision making for osteoporosis management. The findings of this systematic review will highlight the importance of including fracture risk assessment as a significant parameter to evaluate FLS programs implemented across the globe. Conclusion: This systematic review will provide more information about fracture risk assessments and its reporting. It will also highlight the variations in the methods of performing a fracture risk assessment with and without BMD testing and the impact of the FLS program in improving fracture risk assessment.