The Journal of Bone and Joint Surgery (American). 2008;90:1197-1205.
doi:10.2106/JBJS.G.00980
© 2008 The Journal of Bone and Joint Surgery, Inc.
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A Coordinator Program in Post-Fracture Osteoporosis Management Improves Outcomes and Saves Costs

Beate Sander, MEcDev1, Victoria Elliot-Gibson, MSc2, Dorcas E. Beaton, PhD2, Earl R. Bogoch, MD3 and Andreas Maetzel, MD, PhD4

1 Division of Clinical Decision-Making and Health Care Research, University Health Network, 200 Elizabeth Street, EN 13-239, Toronto, ON M5G 2C4, Canada
2 Li Ka Shing Knowledge Institute, Mobility Program Clinical Research Unit, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
3 Li Ka Shing Knowledge Institute, St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail address: bogoche{at}smh.toronto.on.ca
4 Amgen (Europe), Alpenquai 30, Lucerne 6002, Switzerland

Investigation performed at University Health Network and St. Michael's Hospital, Toronto, Ontario, Canada

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from an unrestricted research grant from Merck Frosst Canada, and a CIHR New Investigators Award. In addition, one of the authors became a salaried employee (with a salary in excess of $10,000), and continues to be an employee, of Amgen (Europe) GmbH in November 2004. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Background: The orthopaedic unit at a university teaching hospital hired an osteoporosis coordinator to identify patients with a fragility fracture and to coordinate their education, assessment, referral, and treatment of underlying osteoporosis. We report the results of an analysis of the cost-effectiveness of the use of a coordinator (in comparison with the use of no coordinator) in avoiding future costs of subsequent hip fracture.

Methods: A one-year decision-analysis model was developed. The health outcome was subsequent hip fracture; only direct hospital costs were considered. With use of patient-level data from a previously described coordinator program and data from the literature, the expected annual incidence of subsequent hip fracture was calculated, on the basis of the type of index fracture (wrist, hip, humerus, other), attribution to osteoporosis, age, and gender. The rate of patient referral, the initiation of osteoporosis treatment, and adherence to therapy were modeled to modify the expected incidence of future hip fracture in the presence of a coordinator (with use of data from the program) and in the absence of a coordinator (with use of data from the literature). Sensitivity analysis modeling techniques were used to assess variable uncertainty and to evaluate coordinator cost-effectiveness.

Results: Deterministic cost-effectiveness analysis showed that a tertiary care center that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from thirty-four to thirty-one in the first year, with a net hospital cost savings of C$48,950 (Canadian dollars in year-2004 values), with use of conservative assumptions. Probabilistic sensitivity analysis indicated a 90% probability that hiring a coordinator costs less than C$25,000 per hip fracture avoided. Hiring a coordinator is a cost-saving measure even when the coordinator manages as few as 350 patients annually. Greater savings are anticipated after the first year and when additional costs such as rehabilitation and dependency costs are considered.

Conclusions: Employment of an osteoporosis coordinator to manage outpatients and inpatients who have fragility fractures is predicted to reduce the incidence of future hip fractures and to save money (a dominant strategy). A probabilistic sensitivity analysis showed a high probability of cost-effectiveness of this intervention from the hospital cost perspective.

Level of Evidence: Economic and decision analysis, Level I. See Instructions to Authors for a complete description of levels of evidence.


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