Martin M. Grajower, MD, FACP, FACE. Running title: Fracture Liaison Service Effectiveness, Endocr Pract. 2018;24(No. 8)

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1 ENDOCRINE PRACTICE Rapid Electronic Article in Press Rapid Electronic Articles in Press are preprinted manuscripts that have been reviewed and accepted for publication, but have yet to be edited, typeset and finalized. This version of the manuscript will be replaced with the final, published version after it has been published in the print edition of the journal. The final, published version may differ from this proof. DOI: /EP AACE. Commentary EP WHAT MAKES A FRACTURE LIAISON SERVICE EFFECTIVE AND HOW DO YOU MEASURE ITS SUCCESS? Martin M. Grajower, MD, FACP, FACE Running title: Fracture Liaison Service Effectiveness, Endocr Pract. 2018;24(No. 8) Submitted for publication July 9, 2018 Accepted for publication July 12, 2018 From the Department of Medicine, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, New York. Address correspondence to Dr. Martin M. Grajower, 3736 Henry Hudson Parkway, Riverdale, NY grajower@msn.com Published as a Rapid Electronic Article in Press at DOI: /EP

2 Copyright 2018 AACE.

3 In the United States, hip fractures occur annually in patients over age 65 in an estimated 414 per 100,000 men and 957 per 100,000 women, and they are associated with an excess mortality of around 30% (1). Worldwide, the incidence varies by region but is a major problem all over (2). In addition, the occurrence of a hip fracture increases the risk of a subsequent osteoporotic fracture. In an effort to improve the historically low rate of osteoporosis treatment in patients after a hip fracture, fracture liaison services (FLSs) have been developed around the world. These typically involve coordination among the orthopedic service and other services in the hospital, including internal medicine and endocrinology. What makes for an effective FLS? Wu and co-authors (3) did a systematic literature review to address this question and reported their findings in March Of 7,236 articles, they found 57 that were considered of high quality and analyzed these, looking for which components contributed to a successful FLS. They defined success as the percentage of hip fracture patients that underwent a bone mineral density (BMD) test within 6 months after the fracture and the percentage of patients that were treated with osteoporosis medications. There was a correlation between the FLS arranging a BMD test and the primary care physician subsequently initiating osteoporosis therapy. The most effective FLS components were multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions, and patient education. Of these, the dedicated case manager was the most important component. These resulted in 80% of hip fracture patients receiving a BMD test, compared to 29% with usual care. In addition, 67% received appropriate treatment, compared to 26% in the usual care group.

4 With this metanalysis as a background, let us analyze a report by Rotman-Pikielny et al (4) of an FLS without a dedicated coordinator, published in this issue of Endocrine Practice. Due to budgetary restraints, they developed an interdisciplinary FLS between the orthopedic and endocrine services at their hospital. They compared the results of 219 hip fracture patients over a 1-year interval after the development of the FLS to 218 patients over a similar 1-year interval without the FLS. Their primary endpoint was attendance at the metabolic clinic. Their secondary endpoints included vitamin D measurement, calcium and vitamin D recommendations, initiation of osteoporosis medication, and mortality 1-year postfracture. BMD testing was not assessed at all. The authors concluded that even without a coordinator, the FLS was successful. The attendance at the metabolic clinic increased from 14 to 88. Of the 14 attending the metabolic clinic prior to the FLS, 86% were treated; of the 88 attending post-fls, 46% were treated. The mortality rate went down from 21.8% in the untreated patients to 4.3% in the treated patients, a decrease in mortality of 78%. Several points should be made regarding this study. Firstly, the authors state that BMD testing was not included as an endpoint because of patients limited mobility status. One wonders what made their patients with hip fractures any less mobile that those around the world. Could it be that the availability of bone density machines was not conveniently located, such that the means and cost of getting to these testing sites were the true limiting factors? Furthermore, they analyzed the number of patients that came to the metabolic clinic and what percentage of these patients received osteoporosis medication. Let us look at their data another way. Of the 218 patients with hip fractures prior to the FLS, 12 (86% of 14) received medication (5% of the 218), and of the 219 patients post-fls, 40 (46% of 88) received therapy

5 (20% of the 219). Compare these numbers to 26 and 67%, respectively, described in the metaanalysis by Wu et al (3) above. The FLS did not achieve even the treatment success seen with usual care (i.e., without an FLS). The take away in my opinion is that an FLS without a dedicated coordinator is better than nothing, especially in reducing the excess mortality following hip fracture, but it is hardly a model to be emulated. An effective FLS, led by a dedicated coordinator, should aim for BMD testing in as many patients as possible. With a BMD result on file, the patient is more likely to receive osteoporosis medication by the treating physician. CONCLUSION Hip fractures continue to be a significant source of mortality and morbidity throughout the world. FLSs have been developed to try and increase the percentage of patients with hip fractures that receive osteoporosis therapy. The presence of an FLS coordinator appears to be one of the major determinants of a successful FLS. Coordination between the orthopedic and medical services without a coordinator is better than nothing, but it is not a model to be emulated for a successful FLS. DISCLOSURE The author has no multiplicity of interest to disclose.

6 REFERENCES 1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302: Dhanwal DK, Dennison EM, Harvey NC, Cooper C. Epidemiology of hip fracture: worldwide geographic variation. Indian J Orthop. 2011;45: Wu CH, Chen CH, Chen PH, et al. Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int. 2018;29: Rotman-Pikielny P, Frankel M, Lebanon OT, et al. Orthopedic-metabolic collaborative management for osteoporotic hip fracture. Endocr Pract. 2018;24:xxx-xxx.