Skip to main content

Advertisement

SpringerLink
Log in

A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program

  • Original Article
  • Published:
Archives of Osteoporosis Aims and scope Submit manuscript

A Correction to this article was published on 27 August 2020

This article has been updated

Abstract

Summary

A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was cost-effective and improved initiation of osteoporosis medication following hip fracture.

Purpose/introduction

To determine cost-effectiveness of a 3i hip fracture liaison service (H-FLS) with 12-month follow-up, co-managed by a nurse and physician, when implemented into standard practice.

Methods

The cost-effectiveness analysis compared those receiving the H-FLS to a simulated usual care group using a decision analytic model that incorporated Markov processes. We estimated incremental costs and effectiveness (based on quality-adjusted life years (QALYs) gained) using a lifetime horizon and a healthcare payer perspective. The H-FLS program provided data regarding population at risk, treatment rates, persistence, and intervention costs. We also performed deterministic and probabilistic sensitivity analyses.

Results

One thousand two hundred fifty-two patients were included in the H-FLS between June 2015 and March 2018; 69% were female; the average age was 80 ± 11 years. Anti-absorptive treatment following fracture was initiated in 59.6% (95% CI: 55.7–63.5) H-FLS patients relative to 20.9% (95% CI: 13.3–28.5%) receiving usual care (from our published work). Based on modeled cohort simulation cost-effectiveness analysis (CEA), every 1000 H-FLS patients would experience 12 fewer hip fractures and 37 fewer total fragility fractures than patients receiving usual care. Over the study horizon, the H-FLS led to only a $54 incremental cost/patient with a modest gain of 8 QALYs/1000 patients. The incremental cost-effectiveness ratio (ICER) of $6750/QALY gained was less than the $27,000 cost-effectiveness threshold. Eliminating the 9-month follow-up resulted in incremental savings of $218/patient while also reducing 6-month follow-ups increased cost-savings to $378/patient. Probabilistic sensitivity analyses suggested that the H-FLS would either be cost-saving (60%) or cost-effective (40%).

Conclusion

A H-FLS implemented into standard practice significantly improved anti-absorptive medication use; a cohort simulation cost-effectiveness analysis (CEA) suggested that the H-FLS was cost-effective with potential to become cost-savings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Change history

  • 27 August 2020

    The original version of this article, published on 22 July 2020, unfortunately contained a mistake.

References

  1. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 22:465–475

    Article  Google Scholar 

  2. Tajeu GS, Delzell E, Smith W et al (2014) Death, debility, and destitution following hip fracture. J Gerontol A Biol Sci Med Sci 69:346–353

    Article  Google Scholar 

  3. Lloyd BD, Williamson DA, Singh NA et al (2009) Recurrent and injurious falls in the year following hip fracture: a prospective study of incidence and risk factors from the sarcopenia and hip fracture study. J Gerontol A Biol Sci Med Sci 64:599–609

    Article  Google Scholar 

  4. Dyer SM, Crotty M, Fairhall N et al (2016) A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr 16:158

    Article  Google Scholar 

  5. Giangregorio LM, Leslie WD (2010) Time since prior fracture is a risk modifier for 10-year osteoporotic fractures. J Bone Miner Res 25:1400–1405

    Article  Google Scholar 

  6. Harvey NC, McCloskey EV, Mitchell PJ et al (2017) Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int 28:1507–1529

    Article  CAS  Google Scholar 

  7. Dreinhofer KE, Mitchell PJ, Begue T et al (2018) A global call to action to improve the care of people with fragility fractures. Injury 49:1393–1397

    Article  CAS  Google Scholar 

  8. Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, Eisman JA, March L, Seibel MJ (2013) Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24:393–406

    Article  CAS  Google Scholar 

  9. Wu CH, Tu ST, Chang YF, Chan DC, Chien JT, Lin CH, Singh S, Dasari M, Chen JF, Tsai KS (2018) Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone 111:92–100

    Article  Google Scholar 

  10. Wu CH, Chen CH, Chen PH, Yang JJ, Chang PC, Huang TC, Bagga S, Sharma Y, Lin RM, Chan DC (2018) Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int 29:1023–1047

    Article  Google Scholar 

  11. Majumdar SR, Lier DA, McAlister FA, Johnson JA, Rowe BH, Beaupre LA (2019) Cost-effectiveness of osteoporosis interventions to improve quality of care after upper extremity fracture: results from a randomized trial (C-STOP trial). J Bone Miner Res 34:1220–1228

    Article  Google Scholar 

  12. Wu CH, Kao IJ, Hung WC, Lin SC, Liu HC, Hsieh MH, Bagga S, Achra M, Cheng TT, Yang RS (2018) Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature. Osteoporos Int 29:1227–1242

    Article  Google Scholar 

  13. Swart E, Vasudeva E, Makhni EC, Macaulay W, Bozic KJ (2016) Dedicated perioperative hip fracture Comanagement programs are cost-effective in high-volume centers: an economic analysis. Clin Orthop Relat Res 474:222–233

    Article  Google Scholar 

  14. Solomon DH, Patrick AR, Schousboe J, Losina E (2014) 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 29:1667–1674

    Article  Google Scholar 

  15. Moriwaki K, Noto S (2017) Economic evaluation of osteoporosis liaison service for secondary fracture prevention in postmenopausal osteoporosis patients with previous hip fracture in Japan. Osteoporos Int 28:621–632

    Article  CAS  Google Scholar 

  16. Majumdar SR, Lier DA, Beaupre LA, Hanley DA, Maksymowych WP, Juby AG, Bell NR, Morrish DW (2009) Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Arch Intern Med 169:25–31

    Article  Google Scholar 

  17. Leal J, Gray AM, Hawley S, Prieto-Alhambra D, Delmestri A, Arden NK, Cooper C, Javaid MK, Judge A, and the REFReSH Study Group (2017) Cost-effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: a population-based study. J Bone Miner Res 32:203–211

    Article  Google Scholar 

  18. Majumdar SR, Beaupre LA, Harley CH et al (2007) Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med 167:2110–2115

    Article  Google Scholar 

  19. Zethraeus N, Borgstrom F, Strom O, Kanis JA, Jonsson B (2007) Cost-effectiveness of the treatment and prevention of osteoporosis--a review of the literature and a reference model. Osteoporos Int 18:9–23

    Article  CAS  Google Scholar 

  20. Tosteson AN, Jonsson B, Grima DT, O'Brien BJ, Black DM, Adachi JD (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857

    Article  CAS  Google Scholar 

  21. Strom O, Zethraeus N, Borgström F, Johnell O, Jönsson B, Kanis J (2018) IOF cost- effectiveness reference model: background document. International Osteoporosis Foundation. 1-11-2016

  22. Johnell O, Jonsson B, Jonsson L, Black D (2003) Cost effectiveness of alendronate (fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 21:305–314

    Article  Google Scholar 

  23. Drummond M, Sculpher M, Torrence G, O'Brien B, Stoddard G (2005) Methods for the economic evaluation of health care programmes, 3rd edn. Oxford University Press, Oxford

    Google Scholar 

  24. Bank of Canada. Monthly exchange rates. (http://www.bankofcanada.ca/rates/exchange/monthly-exchange-rates/#table, Accessed on December 3, 2018)

  25. Claxton K, Martin S, Soares M, Rice N, Spackman E, Hinde S, Devlin N, Smith PC, Sculpher M (2015) Methods for the estimation of the national institute for health and care excellence cost-effectiveness threshold. Health Technol Assess 19:1–504

    Article  Google Scholar 

  26. Canadian Agency for Drugs and Technologies (2017) Guidelines for the Economic Evaluation of Health Technologies, 4th edn. Ottawa:Ottawa, Canada

  27. Majumdar SR, Lier DA, Rowe BH, Russell AS, McAlister FA, Maksymowych WP, Hanley DA, Morrish DW, Johnson JA (2011) Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture. Osteoporos Int 22:1799–1808

    Article  CAS  Google Scholar 

  28. Majumdar SR, Lier DA, Hanley DA, Juby AG, Beaupre LA, for the STOP-PRIHS Team (2017) Economic evaluation of a population-based osteoporosis intervention for outpatients with non-traumatic non-hip fractures: the GÇ£catch a BreakGÇØ 1i [type C] FLS. Osteoporos Int 28:1965–1977

    Article  CAS  Google Scholar 

  29. Leslie WD, LaBine L, Klassen P, Dreilich D, Caetano PA (2012) Closing the gap in postfracture care at the population level: a randomized controlled trial. CMAJ 184:290–296

    Article  Google Scholar 

  30. Hodsman AB, Leslie WD, Tsang JF, Gamble GD (2008) 10-year probability of recurrent fractures following wrist and other osteoporotic fractures in a large clinical cohort: an analysis from the Manitoba bone density program. Arch Intern Med 168:2261–2267

    Article  Google Scholar 

  31. 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 23:570–578

    Article  CAS  Google Scholar 

  32. Bone HG, Hosking D, Devogelaer JP, Tucci JR, Emkey RD, Tonino RP, Rodriguez-Portales JA, Downs RW, Gupta J, Santora AC, Liberman UA (2004) Ten years' experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med 350:1189–1199

    Article  CAS  Google Scholar 

  33. Alberta Health Care Insurance Plan (2017) Schedule of medical benefits (procedures and price list). Edmonton, AB, Canada

  34. Government of Alberta (2017) Drug benefits list. Edmonton, AB, Canada

  35. Schousboe JT, Nyman JA, Kane RL, Ensrud KE (2005) Cost-effectiveness of alendronate therapy for osteopenic postmenopausal women. Ann Intern Med 142:734–741

    Article  Google Scholar 

  36. Canadian Institute for Health Information (2016) CMG+ Client Tables. (https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2544&lang=fr&media=0 accessed on Nov 1, 2016)

  37. Canadian Institute for Health Information (2010) DAD resource intensity weights and expected length of stay. Ottawa, ON, Canada. (http://www.cihi.ca/cihi-ext-portal/internet/en/document/standards and data submission/standards/casemix/bul_31may11_d, last accessed Nov 1, 2016)

  38. Alberta Health and Wellness. Continuing care – Accommodation charges. (http://www.health.alberta.ca/services/continuing-care-accommodation-charges.html, last accessed Nov 1, 2017)

  39. Judge A, Javaid MK, Leal J, Hawley S, Drew S, Sheard S, Prieto-Alhambra D, Gooberman-Hill R, Lippett J, Farmer A, Arden N, Gray A, Goldacre M, Delmestri A, Cooper C (2016) Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England. NIHR Journals Library

  40. Cooper C, Atkinson EJ, O'Fallon WM, Melton LJ III (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Miner Res 7:221–227

    Article  CAS  Google Scholar 

  41. Statistics Canada (2018) Life tables - Canada, provinces and territories, 2014–2016 (84–537- X). Ottawa, Ontario, Canada

  42. Peasgood T, Herrmann K, Kanis JA, Brazier JE (2009) An updated systematic review of health state utility values for osteoporosis related conditions. Osteoporos Int 20:853–868

    Article  CAS  Google Scholar 

  43. MacLean C, Newberry S, Maglione M, McMahon M, Ranganath V, Suttorp M, Mojica W, Timmer M, Alexander A, McNamara M, Desai SB, Zhou A, Chen S, Carter J, Tringale C, Valentine D, Johnsen B, Grossman J (2008) Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med 148:197–213

    Article  Google Scholar 

  44. Bolland MJ, Grey AB, Gamble GD, Reid IR (2010) Effect of osteoporosis treatment on mortality: a meta-analysis. J Clin Endocrinol Metab 95:1174–1181

    Article  CAS  Google Scholar 

  45. Neumann PJ, Cohen JT, Weinstein MC (2014) Updating cost-effectiveness--the curious resilience of the $50,000-per-QALY threshold. N Engl J Med 371:796–797

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We would like to acknowledge the assistance of Katelyn Reczek and Amanda Pellecchia from the Alberta Bone and Joint Health Institute who assisted the data preparation as well as Shannon Falsetti and Joyce Mammel, the FLS RNs, for their input regarding the H-FLS service delivery.

Funding

This study was supported by an Alberta Innovates Partnerships for Research and Innovation in the Health System grant (RES0024l76) as well as substantial in-kind contributions from the Alberta Health Service’s Bone and Joint Health Strategic Clinical Network and the Alberta Bone and Joint Health Institute to initiate and evaluate the clinical program.

LA Beaupre receives salary support as the David Magee Chair in Musculoskeletal Research in the Faculty of Rehabilitation Medicine at the University of Alberta.

SR Majumdar held the Endowed Research Chair in Patient Health Management supported by the Faculties of Medicine and Dentistry and Pharmacy and Pharmaceutical Sciences at the University of Alberta during the term of this study.

C Smith owns personal shares of Amgen Inc.

Author information

Authors and Affiliations

  1. University of Alberta (Physical Therapy), 2-50 Corbett Hall, Edmonton, AB, T6G2G4, Canada

    L. A. Beaupre

  2. University of Alberta (Medicine), Edmonton, AB, Canada

    D. Lier & S. R. Majumdar

  3. Alberta Bone and Joint Health Institute, Calgary, AB, Canada

    C. Smith & L. Evens

  4. Alberta Health Services, Calgary, AB, Canada

    H. M. Hanson

  5. University of Calgary, Calgary, AB, Canada

    H. M. Hanson

  6. University of Alberta (Geriatric Medicine), Edmonton, AB, Canada

    A. G. Juby

  7. University of Alberta (Family Medicine), Edmonton, AB, Canada

    P. Kivi

Author notes

  1. S. R. Majumdar is deceased. This paper is dedicated to his memory.

    • S. R. Majumdar
Authors
  1. L. A. Beaupre
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D. Lier
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. L. Evens
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. H. M. Hanson
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. A. G. Juby
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. Kivi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. S. R. Majumdar
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

On behalf of the STOP-Fracture Team

Corresponding author

Correspondence to L. A. Beaupre.

Ethics declarations

Conflict of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(DOCX 17 kb).

ESM 2

(DOCX 1484 kb).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Beaupre, L.A., Lier, D., Smith, C. et al. A 3i hip fracture liaison service with nurse and physician co-management is cost-effective when implemented as a standard clinical program. Arch Osteoporos 15, 113 (2020). https://doi.org/10.1007/s11657-020-00781-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11657-020-00781-w

Keywords

Search

Navigation