Fracture liaison services and secondary fracture prevention


Service of Bone Diseases
Geneva University Hospitals
and Faculty of Medicine

Fracture liaison services and secondary fracture prevention

“Whoever has a fracture, will fracture again”

Interview wi th R. Rizzol i
and T. Cheval ley,

Strategies for osteoporosis prevention may include a population-based approach through the promotion of modifications in lifestyle habits (including specific exercise regimens, changes in diet, and avoiding risk factors like smoking). Nevertheless, evidence of the efficacy of such a population based approach is still missing. Widespread screening at the menopause on the basis of bone mineral density (BMD) alone is not generally recommended because of its poor sensitivity and specificity when used for screening. Monitoring by a coordinating nurse and better adherence to treatment have been shown to decrease the incidence of fractures over 2 years compared with usual medical care. A prevalent low-trauma fracture is the strongest risk factor, independent of BMD values, to identify patients at increased risk of subsequent fracture. A prevalent vertebral fracture is associated with a 4- to 5-fold increase in the risk of further vertebral fracture, particularly within the first year, while a doubling of the risk of a hip fracture is expected after a vertebral fracture or after a fracture of the proximal humerus or distal forearm. In elderly women, prior wrist fracture is a risk factor for morphometric vertebral fracture independent of BMD, but the association between prior wrist fracture and incident hip fracture is largely explained by hip BMD. Overall, patients with a history of any type of prior fragility fracture have a significantly increased risk of any fracture compared with individuals without a prior fracture. Therefore, patients with a low-trauma fracture should be considered as a high-risk group to be targeted for diagnostic and treatment procedures. Despite this evidence, patients with low-trauma fractures are rarely considered for appropriate measures.

Medicographia. 2014;36:219-224 (see French abstract on page 224)

Do you think that there is a lack of awareness about osteoporosis?

The lack of knowledge about osteoporosis is observed first at the level of the patients and is influenced by age, level of education, level of physical activity, calcium intake, and personal experience. A study showed that women admitted to hospital with a hip fracture were unaware that they had osteoporosis or had never considered treatment for it.1 Moreover, a questionnaire administered within 10 days of a low-trauma fracture to assess patients’ perception of the cause of their fracture showed that although 79% of patients had already heard of osteoporosis, the majority (73%) believed that their fracture was not related to bone fragility (Table I, page 220),2 irrespective of the type of facture. This lack of awareness and knowledge is also observed in orthopedic surgeons, who are usually the first—and often the only—physician seen by the fractured patient. Orthopedic surgeons take care of about 80% of wrist fractures,3 which may occur well before more debilitating fractures. The World Orthopaedic Osteoporosis Organization (WOOO) strongly advocates a leading role for orthopedic surgeons in the management of osteoporosis in patients with fragility fracture. A survey performed by the International Osteroporosis Foundation (IOF) among 3422 orthopedic surgeons in France, Germany, Italy, Spain, the United Kingdom, and New Zealand showed that identification and treatment of the osteoporotic patient were insufficient in many areas.4 This survey clearly indicated that many orthopedic surgeons still neglect to identify, assess, and treat osteoporosis patients with fragility fractures. Primary care physicians are even less likely to recognize and treat osteoporosis than specialist endocrinologists or rheumatologists, as they have less exposure to specific education about osteoporosis. Regarding vertebral fracture recognition, a prospective study carried out in the general internal medicine ward of a large university teaching hospital in Geneva showed that only 22% of patients with vertebral fracture had a diagnosis mentioned in their discharge summary and only 11% benefited from specific osteoporosis management.5 Efficacious treatments (eg, hormone replacement therapy, selective estrogen receptor modifiers, bisphosphonates, denosumab, strontium ranelate, or teriparatide) reduce the risk of fracture by 30% to 60%6-9 and are highly costeffective.10,11 Even simple measures like vitamin D and calcium supplementation can reduce hip fractures, particularly in institutionalized and housebound elderly people. Despite the availability of these effective antiosteoporotic medications and the publication of clinical guidelines (Table II),12-17 more than 75% of women and about 90% of men with a high likelihood of osteoporosis are not investigated and/or treated after a low-trauma fracture.

Table I
Table I. Patient awareness of osteoporosis according to the site
of fracture (personal data).

What are the educational needs of patients and doctors?

In osteoporosis, like in all chronic diseases, persistence and compliance decrease with time, particularly in the first year. Lack of adherence has an impact on the individual since lower adherence to osteoporosis treatment is associated with a significantly greater risk of fracture.

Information about osteoporosis given by general practitioners, especially when supported by a bone mineral density (BMD) measurement, is associated with a 2- to 3-fold greater likelihood of a patient receiving specific antiosteoporotic therapy.18,19 We conducted a prospective study in the service of general internal medicine of a large university teaching hospital in Geneva to evaluate the impact of an educational intervention on the recognition of vertebral fractures and on the prescription of antiosteoporosis treatment among general internists.20 During a 3.5-month observation period (phase 1), all lateral spine or chest radiographs of consecutive inpatients older than 60 years were reviewed by two independent investigators, and vertebral fractures were graded according to their severity. Radiology reports and general internists’ discharge summaries were compared. During the following 2- month intervention period (phase 2), internists were actively educated about vertebral fracture identification by means of lectures, posters, and leaflets. Radiologists did not receive this educational program and served as controls. In the observation phase, the radiologists detected 34%, and the internists 22%, of prevalent vertebral fractures. During the education intervention phase, the radiologists detected 22% of prevalent vertebral fractures, whereas among the internists the detection rate almost doubled (43%; P=0.008 compared with phase 1). The percentage of patients with vertebral fracture who benefited from medical management of their osteoporosis increased from 11% (phase 1) to 40% (phase 2, P<0.03). These findings confirm the large under recognition of vertebral fractures by physicians, irrespective of their severity, and demonstrate that a simple educational program can improve their detection on routine radiographs and, consequently, improve osteoporosis management.

Table II
Table II. Antifracture efficacy of the most
frequently used treatments for postmenopausal
osteoporosis when given with calcium
and vitamin D, as derived from randomized
controlled trials.

Abbreviations: HRT, hormone replacement therapy;
NA, no evidence available; PTH, parathyroid hormone.
After reference 17: Kanis et al. Osteoporos Int.
2013;24:23-57. © 2013, International Osteoporosis
Foundation and National Osteoporosis Foundation.

Why is a Fracture Liaison Service a good option for osteoporotic patient management?

Orthopedic surgeons are at the forefront for the identification and treatment of patients with fragility fracture, though general practitioners may also play a central role in referral and management. Another option is to use a nurse-led service to evaluate all patients with a recent fragility fracture. The interventions comprise three components: (i) prevention of falls; (ii) nutritional deficit correction; and (iii) pharmaceutical treatment of osteoporosis. An effective osteoporosis service requires a multidisciplinary team of health professionals, headed by a clinician with expertise in osteoporosis to ensure consistent management of osteoporosis.

Clinical pathways are already applied to surgical diagnosis and postsurgical care, particularly in orthopedics, cardiac surgery, and urology, and for nonsurgical patients (such as those with inflammatory arthritis, or infectious or thrombotic diseases). These pathways allow for a reduction in the length of hospital stays and a decrease in health care costs.21-24 As the risk of fracture increases after the first fracture and the latter often goes undiagnosed and untreated, education and awareness increasing programs are an essential strategy to increase the rate of treatment in people who have already sustained an osteoporotic fracture and who do not realize that they are at major risk of subsequent fracture. By taking an active role in managing or referring patients with osteoporosis, the orthopedic surgeon can ensure that patients with fractures are adequately investigated and treated in order to improve the long-term outcome of these individuals.

A study compared the investigation and treatment of osteoporosis offered to fractured patients at two orthopedic centers in the UK25; one center had an established fracture liaison service, while the other center relied upon individual clinicians to initiate investigation or treatment for osteoporosis in patients following fracture. In the center with a fracture liaison service, 85% of patients with a proximal humeral fracture and 20% of those with a hip fracture had been offered a dual-energy x-ray absorptiometry (DXA) scan. Approximately 50% and 85%, respectively, were receiving treatment for osteoporosis 6 months following their fracture. This compared with DXA examination being offered to only 6% and 9.7% of humeral and hip fracture patients, respectively, and 20% (hip) and 27% (proximal humerus) of patients receiving osteoporosis treatment in the other center. Based on this observation, all patients admitted for fragility fractures in Glasgow are now offered evaluation and treatment of their underlying osteoporosis.

In elderly patients presenting to the orthopedic unit with low energy hip or distal radius fractures at Manchester Royal Infirmary, an initial retrospective survey demonstrated that only 16% of elderly female patients with low-energy hip fractures and none of those (0%) with distal radius fractures were given a treatment or referred for further investigation for possible osteoporosis.26 Nevertheless, after changes in their practice, 76% (P<0.00001) of patients with hip fractures and 81% (P<0.00001) of those with distal radius fractures were investigated, given a treatment, or referred to a consultant physician for the management of osteoporosis. A recent randomized study showed that the offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone, but this investigation did not affect the treatment rate, which reflected significant participant and doctor-related barriers to osteoporosis management. Recently, barriers encountered in setting up these clinical pathways were reviewed and proven solutions to overcome them were identified. Thus, treatment of diagnosed vertebral fractures in primary care is becoming more common. A prospective randomized intervention study has recently shown that, following distal radius fractures, BMD tests and initiation of treatments were more frequent in patients for whom the orthopedic surgeon ordered the tests and forwarded the results to the primary care physician than in those for whom he/ she sent a letter to the primary care physician outlining guidelines for osteoporosis screening. In another randomized clinical trial including 62 patients, management initiated by the orthopedic surgeon improved the rate of early osteoporosis treatment after hip fracture compared with osteoporosis management initiated by the primary care physician (58% vs 29%, P=0.04).27 A recent systematic review and meta-analysis on models of care for the secondary prevention of osteoporotic fractures has confirmed that in all models—model A (identification, assessment, and treatment initiation), model B (identification and assessment), and model C (alerting patients plus primary care physician)—the percentage of patients that had a BMD test and received treatment was higher in the intervention group.28 Adherence after intervention varied between 34% and 95% at 12 months among type A studies. In one type B study, there was 86% adherence at 12 months.29

A recent UK study reported an improvement in adherence to 57% at 1 year through patient support in the form of treatment monitoring by nurses, and there was a trend for the monitored group to persist with therapy for 25% longer compared with no monitoring.30 In this study, monitoring by nurses had a greater impact on adherence and persistence than the provision of bone marker results to patients. Adherence to various osteoporosis medications has also been shown to result in a 16% to 36% lower fracture rate over 2 years. A correct understanding of DXA results may lead to higher treatment rates and better adherence to treatment among patients with low BMD. One year after initiating treatment for osteoporosis, 45.2% of 40 002 patients were not continuing to fill their prescriptions; although several patient characteristics significantly correlated with compliance, adjusted models explained little of the variation. As the patients, their relatives, and primary care physicians became more informed and engaged in treatment decisions, compliance with therapy improved. Indeed, in this study, a telephone survey of 50 randomly selected patients with hip fracture revealed that 82% (41/50) remained on antiosteoporotic treatment at least 6 months after discharge from the hospital.

How effective is a fracture liaison service from the patient’s point of view?

To improve knowledge of the disease and adherence to osteoporosis treatment, our osteoporosis clinical pathway includes an interactive educational program led by a multidisciplinary team (nurse, dietitian, physiotherapist, occupational therapist, and physician) approximately 8 to 12 weeks after fracture. Nutrition, physical activity, fall prevention, and available osteoporosis treatments are discussed, as well as the results of the DXA examination. One of the major aims is to increase patients’ knowledge and confidence about what they can do to help themselves (eg, taking medication, calcium and vitamin D supplements, and lifestyle changes) and to develop an ongoing partnership between health professionals, the patient, and the patient’s family.

An integrated-care delivery model for postfracture care was reported in Ontario, Canada. The initial component of this model focuses on improving emergency department/fracture clinic communication to patients and their family physician. A multicomponent educational intervention focused on osteoporosis screening and management was associated with a significant increase in the overall rate of adherence to osteoporosis management guidelines in high-risk older patients.31

Is a Fracture Liaison Service cost-effective?

In a first nonrandomized controlled trial in 102 Canadian patients older than 50 years with a wrist fracture, a multifaceted intervention consisting in faxed physician reminders about osteoporosis treatment guidelines led to a 30% absolute increase in osteoporosis treatment within 6 months as compared with usual care.32 This intervention strategy was cost-effective, saving Can$13 per patient and gaining 0.012 quality-adjusted life-year (QALYs) per patient.

Another cost-effective analysis in postfracture osteoporosis management in Canada has shown that hiring a coordinator costs less than Can$25 000 to avoid one hip fracture and that it is cost-saving when the coordinator manages as few as 350 patients annually.33

Another cost-benefit analysis of fracture liaison services was performed based on data collected by the West Glasgow Fracture Liaison Service. Based on a hypothetical cohort of 1000 fragility fracture patients, it was estimated that 686 of 740 patients requiring treatment would receive treatment by the fracture liaison service compared with 193 in usual care. Despite additional costs for assessments and drugs, £21 000 could be saved since 18 fractures (including 11 hip fractures) would be prevented.29

In an Australian prospective controlled fracture prevention study, a Markov model was developed that integrated fractures probabilities and resources utilization data obtained directly from their 4-year Minimal Trauma Fracture Liaison Service (MTFL), which significantly reduces the risk of refracture by 80%.34 This model accounted for hip, forearm, and humerus fractures. Over the 10-year simulation period and as compared with a parallel control group treated by standard care, the MTFL improved QALYs by 0.089 years and led to increased costs of 1486 Australian dollars (AUD) per patient. Overall, the incremental cost-effectiveness ratio versus standard care was AUD 17 291 per QALY gained.

In a randomized trial of 220 patients with hip fracture, it was demonstrated that a hospital-based case manager can increase the rate of appropriate osteoporosis treatment to 51% compared with 22% for usual care. A Markov decision-analytic model showed that the intervention cost Can$56 per patient and that for every 100 patients it could prevent approximately 4 hip fractures and 6 fractures in total. This intervention was also associated with a modest increase of 0.04 QALYs and a cost saving of Can$2576 per patient.35

In another randomized trial of 272 patients 50 years of age or older with wrist fracture, a multifaceted quality improvement intervention directed at patients and their primary care physicians tripled the rates (22% vs 7%) of osteoporosis treatment within 6 months of fracture compared with usual care. A cost effectiveness analysis of this intervention has also shown that for 100 included patients, approximately 1 hip fracture and 3 fractures in total could be avoided. Therefore, compared with usual care, a modest increase of 0.011 QALYs and a cost saving of Can$268 per patient were associated with the intervention strategy.36

In a 4-year prospective controlled study investigating the effect of a coordinated intervention program, the risk of new fractures was lower in the intervention group (4% vs 19%, P<0.01); moreover, the median time to refracture was prolonged to 26 months, while it was 16 months (P<0.01) in the control group.37 Therefore, the cumulative incidence of first refracture in the intervention and control groups was 0.5% vs 7.5% at 12 months and 1.5% vs 17% at 24 months. By linking electronic medical records of 620 000 fracture patients with guidelines for osteoporosis management through a network approach, the Kaiser Southern California Healthy Bones Program resulted in a significant increase in referrals for bone densitometry and prescriptions of antiosteoporotic therapies compared with historical data. In addition, the number of hip fractures had decreased by an average of 37%, which showed that this approach is highly cost-effective.29,33

Could you please explain how your fracture liaison service works?

A recent low-trauma fracture is the primary criterion to identify patients at increased risk of osteoporosis and of subsequent fracture to whom tailored additional investigations and preventive strategy of care are proposed by the orthopedic surgeon and/or primary care physician. In addition, an interactive educational program on the management of the disease is proposed to the patients and their families.2 After the acute care of the low-trauma fracture by the orthopedic team, patients are enrolled for medical management into this “osteoporosis pathway,” which includes three steps (Figure 1).2

Figure 1
Figure 1. Course of the osteoporosis clinical pathway.

Green arrows represent the patient’s track from the low-trauma fracture and red
arrows represent the constant interaction between the physician in charge of
the patient and the multidisciplinary team of the osteoporosis clinical pathway.
Abbreviations: DXA, dual-energy x-ray absorptiometry; OP, osteoporosis.
After reference 2: Chevalley et al. Osteoporos Int. 2002;13(6):450-455. © 2012,
International Osteoporosis Foundation and National Osteoporosis Foundation.

First, the coordinating nurse collects data on osteoporosis risk factors—including previous fractures—on the degree of patient awareness of osteoporosis, and on calcium and protein intake. Second, a bone density measurement and/or additional biochemical determinations to rule out secondary osteoporosis are proposed. The role of the managing nurse is to coordinate and monitor care in the orthopedic ward, to increase patient awareness and also to provide education on osteoporosis to the staff. Referral to a metabolic bone diseases specialist for patients with a complex medical history and/or other bone disease concerns about 8% of the patients enrolled in our osteoporosis pathway. Third, treatment proposals, with information on their costs and potential side effects, are forwarded to the orthopedic surgeon or the primary care physician, who decides upon the implementation of these proposals. These proposals are based on published clinical guidelines for postmenopausal osteoporosis.17 An educational program is proposed, which is open to family members as well. (Figure 1).2

1. Mauck KF, Cuddihy MT, Trousdale RT, et al. The decision to accept treatment for osteoporosis following hip fracture: exploring the woman’s perspective using a stage-of-change model. Osteoporos Int. 2002;13(7):560-564.
2. Chevalley T, Hoffmeyer P, Bonjour JP, Rizzoli R. An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporos Int. 2002;13(6):450-455.
3. Cuddihy MT, Gabriel SE, Crowson CS, et al. Osteoporosis intervention following distal forearm fractures: a missed opportunity? Arch Intern Med. 2002;162 (4):421-426.
4. Dreinhofer KE, Anderson M, Feron JM, et al. Multinational survey of osteoporotic fracture management. Osteoporos Int. 2005;16(suppl 2):S44-S53.
5. Casez P, Uebelhart B, Gaspoz JM, Ferrari S, Louis-Simonet M, Rizzoli R. Targeted education improves the very low recognition of vertebral fractures and osteoporosis management by general internists. Osteoporos Int. 2006;17(7):965- 970.
6. Reginster JY, Adami S, Lakatos P, et al. Efficacy and tolerability of once-monthly oral ibandronate in postmenopausal osteoporosis: 2 year results from the MOBILE study. Ann Rheum Dis. 2006;65(5):654-661.
7. Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med. 2007;356(18):1809-1822.
8. Meunier PJ, Roux C, Seeman E, et al. The effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. N Engl J Med. 2004;350(5):459-468.
9. Reginster JY, Seeman E, De Vernejoul MC, et al. Strontium ranelate reduces the risk of nonvertebral fractures in postmenopausal women with osteoporosis: Treatment of Peripheral Osteoporosis (TROPOS) study. J Clin Endocrinol Metab. 2005;90(5):2816-2822.
10. Delmas PD, Rizzoli R, Cooper C, Reginster JY. Treatment of patients with postmenopausal osteoporosis is worthwhile. The position of the International Osteoporosis Foundation. Osteoporos Int. 2005;16(1):1-5.
11. Schousboe JT, Ensrud KE, Nyman JA, Melton LJ, 3rd, Kane RL. Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women. J Am Geriatr Soc. 2005;53(10):1697-1704.
12. Seeman E, Eisman JA. 7: Treatment of osteoporosis: why, whom, when and how to treat. The single most important consideration is the individual’s ab solute risk of fracture. Med J Aust. 2004;180(6):298-303.
13. Compston J. Guidelines for the management of osteoporosis: the present and the future. Osteoporos Int. 2005;16(10):1173-1176.
14. Solomon DH, Morris C, Cheng H, et al. Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions. Mayo Clin Proc. 2005;80(2):194-202.
15. Kaptoge S, Armbrecht G, Felsenberg D, et al. Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study. Osteoporos Int. 2006;17(9): 1369-1381.
16. McClung MR. Do current management strategies and guidelines adequately address fracture risk? Bone. 2006;38(2 suppl 2):S13-S17.
17. Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013;24(1):23-57.
18. Fitt NS, Mitchell SL, Cranney A, Gulenchyn K, Huang M, Tugwell P. Influence of bone densitometry results on the treatment of osteoporosis. CMAJ. 2001;164 (6):777-781.
19. Pickney CS, Arnason JA. Correlation between patient recall of bone densitometry results and subsequent treatment adherence. Osteoporos Int. 2005;16 (9):1156-1160.
20. Casez P, Uebelhart B, Gaspoz JM, Ferrari S, Louis-Simonet M, Rizzoli R. Targeted education improves the very low recognition of vertebral fractures and osteoporosis management by general internists. Osteoporos Int. 2006;17(7): 965-970.
21. Warner BW, Kulick RM, Stoops MM, Mehta S, Stephan M, Kotagal UR. An evidenced- based clinical pathway for acute appendicitis decreases hospital duration and cost. J Pediatr Surg. 1998;33(9):1371-1375.
22. Dowsey MM, Kilgour ML, Santamaria NM, Choong PF. Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Med J Aust. 1999;170(2):59-62.
23. Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan BG. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA. 2000;283(6):749-755.
24. Bradshaw BG, Liu SS, Thirlby RC. Standardized perioperative care protocols and reduced length of stay after colon surgery. J Am Coll Cardiol. 1998;186(5): 501-506.
25. Murray AW, McQuillan C, Kennon B, Gallacher SJ. Osteoporosis risk assessment and treatment intervention after hip or shoulder fracture. A comparison of two centres in the United Kingdom. Injury. 2005;36(9):1080-1084.
26. Charalambous CP, Kumar S, Tryfonides M, Rajkumar P, Hirst P. Management of osteoporosis in an orthopaedic department: audit improves practice. Int J Clinl Pract. 2002;56(8):620-621.
27. Miki RA, Oetgen ME, Kirk J, Insogna KL, Lindskog DM. Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial. J Bone Joint Surg Am. 2008;90(11):2346-2353.
28. Ganda K, Puech M, Chen JS, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2013;24(2):393-406.
29. McLellan AR, Wolowacz SE, Zimovetz EA, et al. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int. 2011;22(7):2083-2098.
30. Clowes JA, Peel NF, Eastell R. The impact of monitoring on adherence and persistence with antiresorptive treatment for postmenopausal osteoporosis: a randomized controlled trial. J Clin Endocr Metab. 2004;89(3):1117-1123.
31. Simone MJ, Roberts DH, Irish JT, et al. An educational intervention for providers to promote bone health in high-risk older patients. J Am Geriatr Soc. 2011;59(2): 291-296.
32. Majumdar SR, Johnson JA, Lier DA, et al. Persistence, reproducibility, and costeffectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial. Osteoporos Int. 2007;18(3): 261-270.
33. Sander B, Elliot-Gibson V, Beaton DE, Bogoch ER, Maetzel A. A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs. J Bone Joint Surg Am. 2008;90(6):1197-1205.
34. Cooper MS, Palmer AJ, Seibel MJ. Cost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention study. Osteoporos Int. 2012;23(1):97-107.
35. Majumdar SR, Lier DA, Beaupre LA, et al. Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Arch Intern Med. 2009;169(1):25-31.
36. Majumdar SR, Lier DA, Rowe BH, et al. Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture. Osteoporos Int. 2011;22(6):1799-1808.
37. Lih A, Nandapalan H, Kim M, et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int. 2011;22(3):849-858.

Keywords: fracture liaison service; osteoporosis; patient management; secondary fracture prevention