Taking the Skeleton out of the Closet: Performance and Cost-effectiveness of a ‘Fracture Capture’ Service (#112)
A 2009 hospital orthopaedic unit audit identified that amongst patients over 50 years of age who were discharged directly from the emergency department after sustaining a fragility fracture, only 2% subsequently had a DXA scan and 6% were treated with an osteoporosis agent. One year later, a follow-up audit demonstrated that the introduction of an osteoporosis policy that guided investigation and referral significantly improved investigation rates, however did not alter treatment rates. Therefore in 2010 with funding from the pharmaceutical industry, a ‘Fracture Capture’ service was established to improve osteoporosis detection and management in outpatients over 50 years of age who had sustained a fragility fracture. A nurse-coordinator (0.3 EFT) screened patients attending orthopaedic clinics and arranged pathology and DXA testing before physician review (0.1 EFT).
This study aimed to assess the performance and cost-effectiveness of the ‘Fracture Capture’ Service over the inaugural two-years from April 2010 to April 2012.
Performance analysis included a clinic database audit and a patient quality assurance questionnaire. Cost-effectiveness analysis assumed a 5-year treatment duration with no mortality. Medication and investigations costs were taken from the Pharmaceutical Benefits Scheme and Medicare Benefits Schedule respectively. Staffing costs were derived from employment contracts while the direct medical costs associated with fractures were taken from published Australian data1. Five-year fracture risk was calculated using the Garvan Fracture Risk Calculator and the fracture risk reduction assigned to each osteoporosis agent was the published non-vertebral fracture risk reduction2-6. Published utility values for osteoporotic fractures were used to calculate Quality-Adjusted Life Years (QALYs) lived7. The study was approved by the Melbourne Health Research Ethics Committee.
Table 1. Baseline Patient Characteristics
Osteoporosis agents were prescribed to 124 patients (61%): 44 risedronate, 32 alendronate, 27 strontium ranelate, 16 zoledronic acid, 2 teriparatide, 1 denosumab, 1 pamidronate, 1 testosterone. Ninety questionnaires were returned: 94% very satisfied/satisfied with the service; 74% reviewed by the physician within 2 months, 84% maintained medication compliance. We estimated that with treatment as above for 5 years, ‘Fracture Capture’ would reduce the number of refractures from 59 to 50, improving QALYs by 0.056 with net cost $1500 per patient. This equates to an incremental cost-effectiveness ratio of $26806/QALY gained, within a reasonable Australian cost per QALY threshold of <$50000. Although excluded from the cost-effectiveness analysis, 'Fracture Capture' also led to the identification and treatment of 6 cases of primary hyperparathyroidism, 3 cases of thyrotoxicosis, 4 cases of hypogonadism and 2 cases of monoclonal gammopathy of unknown significance.
‘Fracture Capture’ is a popular, cost-effective model to improve outpatient osteoporosis management.
- Harris A, Watts J, Ebeling P, Crowely S (1998) The burden of illness and the cost of osteoporosis in Australia. Centre for Health Program Evaluation, Monash University, Victoria
- Wells G, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1)
- Wells GA, Cranney A, Peterson J, Boucher M, Shea B, Robinson V, Coyle D, Tugwell P. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1)
- O'Donnell S, Cranney A, Wells GA, Adachi JD, Reginster JY. Strontium ranelate for preventing and treating postmenopausal osteoporosis. Cochrane Database Syst Rev. 2006 Oct 18;(4)
- Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR, Delmas P, Zoog HB, Austin M, Wang A, Kutilek S, Adami S, Zanchetta J, Libanati C, Siddhanti S, Christiansen C; FREEDOM Trial. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009 Aug 20;361(8):756-65.
- Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR; HORIZON Pivotal Fracture Trial. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007 May 3;356(18):1809-22.
- Hiligsmann M, Ethgen O, Richy F, Reginster JY. Utility values associated with osteoporotic fracture: a systematic review of the literature. Calcif Tissue Int. 2008 Apr;82(4):288-92.