Cost Analysis of a Fracture Liaison Service: A Randomized Controlled Trial for the Secondary Prevention After Fragility Fractures of the Hip.

OBJECTIVE: Fracture liaison services (FLSs) have proven to be effective for secondary fracture prevention. In this study, we evaluated the essential factors in determining whether the FLS saves or loses more than it costs. METHODS: A randomized controlled trial was performed in patients with hip fragility fractures using a hospital-based FLS program in parallel with a cost analysis. Data were generated from a cohort of patients using actual data for FLS effectiveness, individual costs of hip fracture treatment, and medication costs based on an accepted treatment algorithm. RESULTS: A total of 200 patients were randomized, and 180 were analyzed for costs. The FLS program had an overall cost despite the savings in reducing secondary fractures. Medication was 89% of the costs and was the main factor for the FLS costs exceeding the savings. Specifically, using the medication algorithm in this study, the overall cost per patient enrolled in the FLS was $1189 for a 2-year period. If intravenous zoledronic acid had been used, then the overall cost would have been $489. If only oral bisphosphonates had been used, then the FLS would have cost $159 per patient for a 2-year period. CONCLUSION: The present analysis shows that medication cost is the critical component in cost-effectiveness of an FLS program. The FLS program costs would be significantly lower if patients are prescribed less expensive drugs to treat osteoporosis. Additional work needs to be performed refining the medication algorithm considering medication costs but individualized to patient needs based on fracture risk.

Early benefits of a secondary fracture prevention programme.

INTRODUCTION: The most successful programme for secondary fracture prevention is the FLS (fracture liaison service) model. Our orthopaedic department carried out a prospective randomised study to measure the effectiveness of a 4-step intervention programme. The findings in this study reveal important additional clinical benefits to having an orthopaedic-based FLS programme and evaluates the usefulness of fracture risk tools. METHODS: We carried out a prospective study to evaluate patients with a fragility fracture of the hip. There were 2 groups, intervention and control (each 100 patients). Of these, 20 were either removed from the study or dropped out, leaving 180 for analysis. In addition to routine preoperative blood tests, albumin and thyroid function levels were obtained and PTH (parathyroid hormone) levels when indicated.The intervention group (83 patients) had a dual-energy x-ray absorptiometry (DEXA) scan performed and fracture risk (FRAX) was calculated. RESULTS: 12 patients (6.7%) had blood results which showed a potentially treatable cause for osteoporosis and 36 (20%) had blood results that changed their medical care.FRAX scores (180 patients) showed that the major osteoporotic fracture score correctly predicted the hip fracture in only 49%. The hip fracture score correctly predicted the hip fracture in 83%.DEXA scores (65 patients) showed osteoporosis in only 46% of hips and in only 26% of spines.An abnormal FRAX score or DEXA scan would have predicted a fragility fracture 93% of the time. CONCLUSIONS: In addition to reducing secondary fractures, FLS programmes can provide fundamental benefits to the health of the patient. The intervention programme in this study identified patients with underlying treatable causes, correctable clinical conditions and patients with an unusually low bone density. When used together, FRAX and DEXA are more sensitive predictors for hip fracture risk than either are individually. TRIAL REGISTRY: 201497CTIL (https://clinicaltrials.gov/ct2/show/NCT02239523).

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

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

[MONITORING UNITS IN DEPARTMENTS OF INTERNAL MEDICINE: FREQUENCY, IMPACT AND SATISFACTION].

BACKGROUND: Due to increasing numbers of elderly, seriously ill patients and shortage of ICU beds, many hospitals have established monitoring units (MU) in their medical departments. OBJECTIVES: (1) To assess the national prevalence of MUs in medical departments; (2) to determine the outcome of consecutively admitted MU patients; (3) to evaluate patient/ family satisfaction with care. METHODS: The case control study included all 123 patients hospitalized in the MU during a 5-month period, compared with two control groups: (1) 123 patients admitted to medical departments, matched at a ratio of 1:1 by gender, age±10 years and mechanical ventilation; (2) all 52 medical patients treated in the ICU. The main endpoint was 28-day survival. RESULTS: A total of 76/99 (77%) directors of medical departments in Israel responded: 70 (92%) reported the presence of a MU, 64 (92%) have 5-7 beds and 47 (67%) have one nurse per shift. Baseline characteristics of enrolled MU and medical department patients were similar, although 52 medical ICU patients were younger (56±21 vs. 73±14, p<0.001) and had a lower incidence of kidney failure (11.5% vs. 41.5%, p<0.001). The predicted mortality rates were higher for MU patients compared to medical department patients, but 28-day survival rates were similar (64-70%, NS). The questionnaire showed high rates of satisfaction (from 0=low to 5=high): highest with MU care: (4.79±0.48), followed by ICU (4.41±1.06) and lowest for medical department nursing care (4.27±0.84)(p=0.017). CONCLUSIONS: Monitoring units are ubiquitous in Israeli hospitals and contribute to survival and satisfaction with care.

[Impact of a monitoring unit in the medical department on patient outcome].

PURPOSE: Many hospitals have established monitoring units (MU) in their medical departments, with operating costs that are significantly lower than Intensive Care Units, but with no data on their effectiveness. We determined the outcome of patients, who were treated in a new MU during their hospitalization, compared with that of a control group. METHODS: We included all patients, who were admitted to the MU during a five months period. The control group consisted of patients, who were admitted to medical departments and did not stay in the MU during their hospitalization. Patients and controls were matched according to gender, age +/- 10 years, and need for mechanical ventilation. The main endpoint was the 28-day survival rate. RESULTS: There were minor differences between baseline characteristics of patients and controls. The patient cohort included a higher rate of acute renal failure (20/100, 20%) and chronic renal failure (23/100, 23%), compared to the control group (respectively, 10/100, 10%, p < 0.05 and 8/100, 8%, p < 0.05), and a higher rate of respiratory support (83/94, 82% and 72/99, 72%, p < 0.05). Contrarily, a GLasgow coma scale of 3-5 was found in 10/100 (10%) of MU patients and in 20/100 (20%) of control patients (p < 0.05). Despite these differences, there was no difference in predicted mortality score. Nevertheless, the observed survival rate of patients who stayed in the monitoring unit (76/100, 76%) was higher than that of the control group (64/100, 64%) (p < 0.05). CONCLUSIONS: The results of this pilot study indicate that a monitoring unit may contribute to improved survival.

Bacteremia due to beta-hemolytic Streptococcus group G: increasing incidence and clinical characteristics of patients.

PURPOSE: To describe the epidemiology and clinical characteristics of patients diagnosed with Streptococcus group G bacteremia from 1990 to 1999 at a community teaching hospital in Israel. SUBJECTS AND METHODS: We calculated the annual rate of bacteremia with Streptococcus group G, expressed as a percentage of positive blood cultures (after excluding contaminants) and per 1000 admissions. Medical records of patients with Streptococcus group G were reviewed. RESULTS: During the 10-year study period, there was a total of 7415 positive blood cultures, 327 (4.4%) of which were beta-hemolytic Streptococcus species, of which 49 (15%) were group G. The rate of Streptococcus group G bacteremia per 1000 admissions increased from zero (0/18,783) in 1990 to 0.41 (13/31,440) in 1999 (P = 0.001), surpassing Streptococcus group A in frequency. Of the 47 patients with Streptococcus group G, 40 medical records were available for review: 25 patients (63%) were older than 75 years and 32 (80%) were men. The probable source of Streptococcus group G bacteremia was a skin or soft tissue infection in 37 patients (93%). Six of the 40 patients died. CONCLUSION: Community-acquired group G streptococcal bacteremia occurred with increasing frequency from 1990 to 1999 at our hospital. Most patients were elderly men, and the portal of entry was usually the skin or soft tissue. Our findings suggest a change in the epidemiology of bacteremia due to beta-hemolytic streptococci.