The Cost-Effectiveness of Fragility-Fracture Screening and Prevention

After nearly 2 decades, the orthopaedic community has made a good start on assuming our responsibility in the diagnosis of osteoporosis after a patient’s initial low-energy fracture. We are seeing a positive impact from programs such as the American Orthopaedic Association’s “Own the Bone” initiative as well as from the expanded creation of multidisciplinary fracture liaison services, through which patients who sustain a fragility fracture can receive appropriate follow-up to reduce the risk of subsequent injury.   

There is still work to do to convince the wider orthopaedic surgeon community that leadership on this issue falls in our area. Primary care, rheumatology, and physiatrist practices are overwhelmed with patients with other clinical issues that require their resources. At the same time, it is easier to identify patients who may need treatment for low bone density during their initial encounter in the orthopaedist’s office or during a hospital admission. There is good evidence to suggest that patients are much more receptive to following through with laboratory testing and bone-density screening when they are being treated for a serious metaphyseal fracture.  

In the July 7 issue of JBJS, Saunders et al. examine the cost-effectiveness of a fracture liaison service, presenting their findings of a cost analysis of the Fracture Screening and Prevention Program (FSPP) of Ontario, Canada. Established in 2007, the FSPP was gradually implemented in 37 outpatient fracture clinics in the province; in 2011, the initial education-communication model was replaced by a more intensive strategy, with fracture risk assessment and referrals to specialists being added.  

The researchers’ goal was to determine the cost-effectiveness of the current FSPP compared with usual care (no program). They developed a Markov model and simulated a cohort of patients with a fragility fracture starting at 71 years of age, with model parameters obtained from the published literature and the FSPP.  

The authors concluded that, from the public health-payer perspective, the program is indeed less costly (by $274) and more effective (by 0.018 quality-adjusted life-year) over the lifetime of the patient. Read the full report here.  

We have seen that fracture liaison services can be beneficial to the individual patient. Data such as those from Saunders et al. can help to quantify—for payers and health systems—the value of those services, as our specialty takes on the responsibility of ensuring that patients receive appropriate screening for fracture risk and prevention.

Marc Swiontkowski, MD 
JBJS Editor-in-Chief 

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One thought on “The Cost-Effectiveness of Fragility-Fracture Screening and Prevention

  1. Sometimes when we are mystified by a treatment not being more widely adopted (by physicians and patients), it is helpful to look at the number needed to treat. For patients with prior fragility fractures or very low bone mineral density – the highest risk group, those patients that many think should absolutely go on some kind of anti-resorptive treatment – the number needed to treat to prevent a vertebral fracture is 20, and the number needed to prevent a hip fracture is 100.

    For 100 people getting treatment, 95 get no benefit at all. 5 prevent a vertebral fracture, and one prevents a hip fracture as well. If the medicine is at all unpleasant, expensive, or inconvenient, many patients don’t consider this a very good deal, and avoid it. Throw in the occasional harm, and the decision is easy, from many a patient’s perspective.

    (https://www.thennt.com/nnt/bisphosphonates-for-fracture-prevention-in-post-menopausal-women-with-prior-fractures-or-very-low-bone-density/)

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