EVALUATION OF A HYBRID DIGITAL AND IN-PERSON OUTPATIENT FRACTURE LIAISON SERVICE FOR NON-HIP FRAGILITY FRACTURES

Osteoporosis affects over 2.3 million Canadians (1). Employing an osteoporosis nurse coordinator can improve diagnosis and management from 48% to 96% (2). A 3i model of care, which appropriately identifies fragility fractures, organizes investigations, and initiates a bone health care plan has been shown to be cost-effective for hip fracture care (3), yet there is a paucity of 3i fracture liaison programs (FLSs) for non-hip fragility fractures. An opportunity exists to incorporate digital health solutions into the design of outpatient FLSs, in order to increase efficiency and access. This study aimed to quantify recruitment rates, future fracture risk, first line therapy initiation, and patient satisfaction with a 3i outpatient FLS approved by Osteoporosis Canada. This is a prospective cohort study of adult patients (18 years or older) presenting to a Level 1 trauma centre outpatient fracture clinic with a non-hip and non-vertebral, low-energy fracture (i.e., fall from standing height). Once enrolled in the outpatient FLS, the nurse coordinator completed an in-person comprehensive health history and evaluated future fracture risk using the FRAX assessment tool. Based on risk stratification and our established bone health care pathway, the appropriate investigations were completed (i.e., bloodwork, bone mineral density testing). These results and individualized care plans were reviewed with the program orthopaedic surgeon and endocrinologist via teleconference. Personalized care plans and follow-ups were then completed by the research nurse in-person or virtually, based on each patient's preference. Patient satisfaction was evaluated via a survey. Descriptive statistics were used for analysis and all patients had a minimum of six months follow-up. A total of 185 consecutive patients were recruited between October 2020 and May 2022. The majority were female (88.1%), with an average age of 65.9 (± 9.8) years. The most common presenting fracture type was a distal radius fracture, followed by proximal humerus fractures (Figure 1). In total, 33.3% of patients were classified as high-risk, based on a FRAX assessment of a 10-year major osteoporotic fracture probability of 20% or more, while 49.4% were classified as high-risk, based on a FRAX assessment of a 10-year hip fracture probability of 3% or more. Based on Osteoporosis Canada guidelines, osteoporosis therapy was initiated for 47% of patients at high-risk for subsequent fracture. Additionally, 6.5% of patients presented already on pre-injury pharmacotherapy had an alteration in their prescriptions to help optimize their bone health. Alendronate was the most commonly prescribed pharmacotherapy (60%). A total of 98% of participants felt the program should “probably” or “definitely” be continued and 95% rated the program as “good” or “excellent.” Nearly half of the patients presenting to a fracture clinic with a fragility fracture are high-risk for subsequent fracture and meet criteria for an informed discussion about osteoporosis pharmacotherapy initiation for reducing fracture risk. This hybrid model of in-person and virtual care provides increased accessibility to a 3i outpatient FLS for non-hip and non-vertebral body fracture patients. Patient satisfaction was very high and investigation into cost-savings with a hybrid model is warranted. For any figures or tables, please contact the authors directly.

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