Data published in The Journal of Bone Mineral Research support the cost-effectiveness of a high-intensity fracture liaison service (FLS) model of osteoporosis care following upper extremity fragility fracture.

Investigators abstracted data from the Comparing Strategies Targeting Osteoporosis to Prevent Fractures after an Upper Extremity Fracture trial. According to study protocol, patients over 50 years of age who had experienced an upper extremity fracture (n=361) were randomly assigned to receive either an “active control” or a “case manager” intervention model. The case manager intervention was a high-intensity FLS model, in which a case manager actively identified patients, investigated bone density, and initiated treatment as appropriate. In the active control model, patients instead experienced a low-intensity FLS program, in which they were encouraged to seek screening or prevention management from their family physician.

Related Articles

Patients were followed for 24 months, with bone mineral density testing and initiation of bisphosphonate treatment occurring at 6 months post-fracture. A Markov decision analytic model was used to assess the cost-effectiveness of both intervention models compared with usual care. The usual care group was simulated and assumed to be identical to the study cohort in terms of clinical and demographic factors. The health effect of each intervention was measured in quality-adjusted life years (QALYs), as well as fracture reduction rates. Cost was assessed using several factors, including intervention cost, cost of subsequent fractures, and cost of osteoporosis treatments. All cost estimates were calculated in Canadian dollars.

The mean age of enrolled patients was 63 years, and 89% were women. The case manager intervention group experienced an increased rate of bone mineral density testing from 75% to 87% and achieved a 48% rate of bisphosphonate treatment. The rate of bisphosphonate treatment in this group was significantly greater than the 28% achieved by the active control intervention group (P <.0001). Each intervention group was superior to the estimated 12% rate of treatment achieved with the usual care group. The per-patient costs of the case manager and active control interventions were $66 and $18, respectively.

However, the case manager intervention avoided 9 additional fractures per 1000 patients compared with the active control group. This value increased to 18 fewer fractures per 1000 patients compared with usual care. The case manager intervention also gained 7 and 14 QALYs per 1000 patients when compared with the active control and usual care groups, respectively. According to cost analyses, the case manager group saved $333 per patient in relation to active control and $564 with respect to usual care. The active control group saved $231 per patient while gaining 7 QALYs and causing 9 fewer fractures per 1000 patients compared with usual care.

Although both intervention models were more cost effective than usual care, the case manager intervention dominated active control. Additionally, the case manager intervention more effectively improved quality of life, treatment uptake, and subsequent fracture rates in older adults after upper extremity fracture.  


Majumdar SR, Lier DA, McAlister FA, Johnson JA, Rowe BH, Beaupre LA. Cost-effectiveness of osteoporosis interventions to improve quality of care after upper extremity fracture: results from a randomized trial (C-STOP Trial) [published online February 19, 2019]. J Bone Miner Res. doi:10.1002/jbmr.3699