Advertisement

Osteoporosis International

, Volume 30, Issue 8, pp 1671–1677 | Cite as

Five-year refracture rates of a province-wide fracture liaison service

  • R. SujicEmail author
  • D.E. Beaton
  • M. Mamdani
  • S.M. Cadarette
  • J. Luo
  • S. Jaglal
  • J.E.M. Sale
  • R. Jain
  • E. Bogoch
  • the Ontario Osteoporosis Strategy Fracture Screening and Prevention Program Evaluation Team
Original Article
  • 173 Downloads

Abstract

Summary

We examined the 5-year refracture rate of 6543 patients and found an overall rate of 9.7%. Adjusted analysis showed that presenting with multiple fractures was an indicator of a higher refracture risk; while presenting with an ankle fracture was associated with a lower refracture risk.

Introduction

To examine refractures among patients screened in a province-wide fracture liaison service (FLS).

Methods

We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates.

Results

The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50–65 age group, refracture risk increased monotonically with age group (66–70 years: HR = 1.3, CI 95%, 1.0–1.7; 71–80 years: HR = 1.7, CI 1.4–2.1; 81+ years: HR = 3.0, CI 2.4–3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6–3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6–0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0–1.5).

Conclusions

One in ten patients in our cohort refractured within 5 years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.

Keywords

Fragility fracture Fracture liaison service Refracture rates Refracture risk 

Notes

Acknowledgments

The views expressed are those of the researchers and do not necessarily reflect those of the Ontario Ministry of Health and Long Term Care. The data used in this study were linked using unique encoded identifiers and analyzed at the Institute for Clinical Evaluative Sciences. The authors gratefully acknowledge the support of Osteoporosis Canada and the Fracture Screening and Prevention Program Evaluation Team for their contribution to the overall evaluation of the program.

Funding information

This study was supported by funding from the Ontario Ministry of Health and Long Term Care (MOHLTC) through the Ontario Osteoporosis Strategy.

Compliance with ethical standards

Conflicts of interest

Rebeka Sujic: no disclosures. Dorcas E Beaton: no disclosures. Muhammad Mamdani: received Honoraria and served as a consultant/advisory board of Novo Nordisk, Allergan, and Amgen. Suzanne M Cadarette: no disclosures. Jin Luo: no disclosures. Susan Jaglal: no disclosures. Joanna EM Sale: no disclosures. Ravi Jain: no disclosures.

Earl R Bogoch received an unrestricted research grant and speaker fees from Amgen Canada Inc., and is an Editorial Board member for the Journal of Rheumatology.

References

  1. 1.
    Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17:1726–1733CrossRefGoogle Scholar
  2. 2.
    Haentjens P, Magaziner J, Colon-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B, Boonen S (2010) Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 152:380–390CrossRefGoogle Scholar
  3. 3.
    Adachi JD, Loannidis G, Berger C, Joseph L, Papaioannou A, Pickard L, Papadimitropoulos EA, Hopman W, Poliquin S, Prior JC, Hanley DA, Olszynski WP, Anastassiades T, Brown JP, Murray T, Jackson SA, Tenenhouse A (2001) The influence of osteoporotic fractures on health-related quality of life in community-dwelling men and women across Canada. Osteoporos Int 12:903–908CrossRefGoogle Scholar
  4. 4.
    Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jonsson B (2004) Fracture risk following an osteoporotic fracture. Osteoporos Int 15:175–179CrossRefGoogle Scholar
  5. 5.
    Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR (2009) Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA 301:513–521CrossRefGoogle Scholar
  6. 6.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739CrossRefGoogle Scholar
  7. 7.
    Bynum JPW, Bell JE, Cantu RV, Wang Q, McDonough CM, Carmichael D, Tosteson TD, Tosteson ANA (2016) Second fractures among older adults in the year following hip, shoulder, or wrist fracture. Osteoporos Int 27:2207–2215CrossRefGoogle Scholar
  8. 8.
    Van Helden S, Cals J, Kessels F, Brink P, Dinant GJ, Geusens P (2006) Risk of new clinical fractures within 2 years following a fracture. Osteoporos Int 17:348–354CrossRefGoogle Scholar
  9. 9.
    Hutjens KM, van Geel TA, Van Helden S et al (2013) The role of the combination of bone and fall related risk factors on short-term subsequent fracture risk and mortality. BMC Musculoskelet Disord 14:121CrossRefGoogle Scholar
  10. 10.
    Huntjens KM, Kosar S, van Geel TA, Geusens PP, Willems P, Kessels A, Winkens B, Brink P, van HS (2010) Risk of subsequent fracture and mortality within 5 years after a non-vertebral fracture. Osteoporos Int 21:2075–2082CrossRefGoogle Scholar
  11. 11.
    Center JR, Bliuc D, Nguyen TV, Eisman JA (2007) Risk of subsequent fracture after low-trauma fracture in men and women. JAMA 297:387–394CrossRefGoogle Scholar
  12. 12.
    Bliuc D, Nguyen ND, Nguyen TV, Eisman JA, Center JR (2013) Compound risk of high mortality following osteoporotic fracture and refracture in elderly women and men. J Bone Miner Res 28:2317–2324CrossRefGoogle Scholar
  13. 13.
    Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C (2002) Meta-analyses of therapies for postmenopausal osteoporosis. IX: summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev 23:570–578CrossRefGoogle Scholar
  14. 14.
    Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski K, Leslie WD (2010) (2010) clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 182:1864–1873CrossRefGoogle Scholar
  15. 15.
    Hopkins RB, Goeree R, Pullenayegum E, Adachi JD, Papaioannou A, Xie F, Thabane L (2011) The relative efficacy of nine osteoporosis medications for reducing the rate of fractures in post-menopausal women. BMC Musculoskelet Disord 12:209CrossRefGoogle Scholar
  16. 16.
    Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35:293–305CrossRefGoogle Scholar
  17. 17.
    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778CrossRefGoogle Scholar
  18. 18.
    Marsh D, Akesson K, Beaton DE, Bogoch ER, Boonen S, Brandi ML, McLellan AR, Mitchell PJ, Sale JE, Wahl DA (2011) Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int 22:2051–2065CrossRefGoogle Scholar
  19. 19.
    Jaglal SB, Hawker G, Cameron C, Canavan J, Beaton DE, Bogoch E, Jain R, Papaioannou A, and members of the Osteoporosis Research MaEWG (2010) The Ontario osteoporosis strategy: implementation of a population-based osteoporosis action plan in Canada. Osteoporos Int 21:903–908CrossRefGoogle Scholar
  20. 20.
    Hawley S, Javaid MK, Prieto-Alhambra D, Lippett J, Sheard S, Arden NK, Cooper C, Judge A (2016) Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study. Age Ageing 45:236–242CrossRefGoogle Scholar
  21. 21.
    Astrand J, Nilsson J, Thorngren KG (2012) Screening for osteoporosis reduced new fracture incidence by almost half: a 6-year follow-up of 592 fracture patients from an osteoporosis screening program. Acta Orthop 83:661–665CrossRefGoogle Scholar
  22. 22.
    Axelsson KF, Jacobsson R, Lund D, Lorentzon M (2016) Effectiveness of a minimal resource fracture liaison service. Osteoporos Int 27:3165–3175CrossRefGoogle Scholar
  23. 23.
    Nakayama A, Major G, Holliday E, Attia J, Bogduk N (2016) Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int 27:873–879CrossRefGoogle Scholar
  24. 24.
    Van der Kallen J, Giles M, Cooper K, Gill K, Parker V, Tembo A, Major G, Ross L, Carter J (2014) A fracture prevention service reduces further fractures two years after incident minimal trauma fracture. Int J Rheum Dis 17:195–203CrossRefGoogle Scholar
  25. 25.
    Lih A, Nandapalan H, Kim M, Yap C, Lee P, Ganda K, Seibel MJ (2011) Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int 22:849–858CrossRefGoogle Scholar
  26. 26.
    Huntjens KM, van Geel TA, van den Bergh JP, van HS, Willems P, Winkens B, Eisman JA, Geusens PP, Brink PR (2014) Fracture liaison service: impact on subsequent nonvertebral fracture incidence and mortality. J Bone Joint Surg Am 96:e29CrossRefGoogle Scholar
  27. 27.
    Beaton DE, Mamdani M, Zheng H, Jaglal S, Cadarette SM, Bogoch ER, Sale JEM, Sujic R, Jain R (2017) Improvements in osteoporosis testing and care are found following the wide scale implementation of the Ontario Fracture Clinic Screening Program: an interrupted time series analysis. Medicine (Baltimore) 96:e9012CrossRefGoogle Scholar
  28. 28.
    Beaton DE, Vidmar M, Pitzul KB, Sujic R, Rotondi NK, Bogoch ER, Sale JEM, Jain R, Weldon J (2017) Addition of a fracture risk assessment to a coordinator's role improved treatment rates within 6 months of screening in a fragility fracture screening program. Osteoporos Int 28:863–869CrossRefGoogle Scholar
  29. 29.
    Cadarette SM, Jaglal SB, Raman-Wilms L, Beaton DE, Paterson JM (2010) Osteoporosis quality indicators using healthcare utilization data. Osteoporos Int 22:1335–1342CrossRefGoogle Scholar
  30. 30.
    Lix LM, Azimaee M, Osman BA, Caetano P, Morin S, Metge C, Goltzman D, Kreiger N, Prior J, Leslie WD (2012) Osteoporosis-related fracture case definitions for population-based administrative data. BMC Public Health 12:301CrossRefGoogle Scholar
  31. 31.
    O'Donnell S (2013) Use of administrative data for national surveillance of osteoporosis and related fractures in Canada: results from a feasibility study. Arch Osteoporos 8:143CrossRefGoogle Scholar
  32. 32.
    Hasselman CT, Vogt MT, Stone KL, Cauley JA, Conti SF (2003) Foot and ankle fractures in elderly white women. Incidence and risk factors. J Bone Joint Surg Am 85-A:820–824CrossRefGoogle Scholar
  33. 33.
    Ismail AA, O’Neill TW, Cockerill W, Finn JD, Cannata JB, Hoszowski K, Johnell O, Matthis C, Raspe H, Raspe A, Reeve J, Silman AJ (2000) Validity of self-report of fractures: results from a prospective study in men and women across Europe. EPOS Study Group European Prospective Osteoporosis Study Group. Osteoporos Int 11:248–254CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  • R. Sujic
    • 1
    Email author
  • D.E. Beaton
    • 1
    • 2
    • 3
  • M. Mamdani
    • 2
    • 4
    • 5
    • 6
  • S.M. Cadarette
    • 5
    • 6
    • 7
  • J. Luo
    • 5
  • S. Jaglal
    • 5
    • 8
    • 9
  • J.E.M. Sale
    • 1
    • 2
  • R. Jain
    • 10
  • E. Bogoch
    • 11
    • 12
  • the Ontario Osteoporosis Strategy Fracture Screening and Prevention Program Evaluation Team
  1. 1.Musculoskeletal Health and Outcomes ResearchLi Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada
  2. 2.Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  3. 3.Institute for Work & HealthTorontoCanada
  4. 4.Li Ka Shing Centre for Healthcare Analytics Research & TrainingLi Ka Shing Knowledge Institute of St. Michael’s HospitalTorontoCanada
  5. 5.Institute for Clinical Evaluative SciencesTorontoCanada
  6. 6.Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoCanada
  7. 7.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  8. 8.Toronto Rehabilitation Institute – University Health NetworkTorontoCanada
  9. 9.Department of Physical TherapyUniversity of TorontoTorontoCanada
  10. 10.Ontario Osteoporosis Strategy, Osteoporosis CanadaTorontoCanada
  11. 11.Division of Orthopaedic Surgery, Department of SurgeryUniversity of TorontoTorontoCanada
  12. 12.Mobility Program, St. Michael’s HospitalTorontoCanada

Personalised recommendations