Cost‐Effectiveness of Orthogeriatric and Fracture Liaison Service Models of Care for Hip Fracture Patients: A Population‐Based Study

Fracture liaison services are recommended as a model of best practice for organizing patient care and secondary fracture prevention for hip fracture patients, although variation exists in how such services are structured. There is considerable uncertainty as to which model is most cost‐effective and should therefore be mandated. This study evaluated the cost‐ effectiveness of orthogeriatric (OG)‐ and nurse‐led fracture liaison service (FLS) models of post‐hip fracture care compared with usual care. Analyses were conducted from a health care and personal social services payer perspective, using a Markov model to estimate the lifetime impact of the models of care. The base‐case population consisted of men and women aged 83 years with a hip fracture. The risk and costs of hip and non‐hip fractures were derived from large primary and hospital care data sets in the UK. Utilities were informed by a meta‐regression of 32 studies. In the base‐case analysis, the orthogeriatric‐led service was the most effective and cost‐effective model of care at a threshold of £30,000 per quality‐adjusted life years gained (QALY). For women aged 83 years, the OG‐led service was the most cost‐effective at £22,709/QALY. If only health care costs are considered, OG‐led service was cost‐effective at £12,860/QALY and £14,525/QALY for women and men aged 83 years, respectively. Irrespective of how patients were stratified in terms of their age, sex, and Charlson comorbidity score at index hip fracture, our results suggest that introducing an orthogeriatrician‐led or a nurse‐led FLS is cost‐effective when compared with usual care. Although considerable uncertainty remains concerning which of the models of care should be preferred, introducing an orthogeriatrician‐led service seems to be the most cost‐effective service to pursue. © 2016 American Society for Bone and Mineral Research.     

An economic evaluation: Simulation of the cost‐effectiveness and cost‐utility of universal prevention strategies against osteoporosis‐related fractures

A patient‐level Markov decision model was used to simulate a virtual cohort of 500,000 women 40 years old and over, in relation to osteoporosis‐related hip, clinical vertebral, and wrist bone fractures events. Sixteen different screening options of three main scenario groups were compared: (1) the status quo (no specific national prevention program); (2) a universal primary prevention program; and (3) a universal screening and treatment program based on the 10‐year absolute risk of fracture. The outcomes measured were total directs costs from the perspective of the public health care system, number of fractures, and quality‐adjusted life‐years (QALYs). Results show that an option consisting of a program promoting physical activity and treatment if a fracture occurs is the most cost‐effective (CE) (cost/fracture averted) alternative and also the only cost saving one, especially for women 40 to 64 years old. In women who are 65 years and over, bone mineral density (BMD)‐based screening and treatment based on the 10‐year absolute fracture risk calculated using a Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool is the best next alternative. In terms of cost‐utility (CU), results were similar. For women less than 65 years old, a program promoting physical activity emerged as cost‐saving but BMD‐based screening with pharmacological treatment also emerged as an interesting alternative. In conclusion, a program promoting physical activity is the most CE and CU option for women 40 to 64 years old. BMD screening and pharmacological treatment might be considered a reasonable alternative for women 65 years old and over because at a healthcare capacity of $50,000 Canadian dollars ($CAD) for each additional fracture averted or for one QALY gained its probabilities of cost‐effectiveness compared to the program promoting physical activity are 63% and 75%, respectively, which could be considered socially acceptable. Consideration of the indirect costs could change these findings. © 2013 American Society for Bone and Mineral Research     

Diagnostic Utility of Clinical Tests for SLAP Lesions: A Systematic Literature Review

Abstract

SLAP lesions are often complex injuries with varied defects and tissue involvement that are challenging to diagnose clinically. The literature notes the need for visualization under arthroscopy for adequate diagnostic accuracy. The goal of this article is to provide a current best-evidence synthesis with regard to physical examination tests used for the diagnosis of SLAP lesions. A literature search yielded 17 studies that investigated the diagnostic utility of clinical tests for SLAP lesions. These studies investigated 19 clinical tests. A narrative review and a systematic review of methodological quality using the QUADAS methodological quality assessment tool yielded 3 high-quality diagnostic utility studies. Current best evidence indicates that a negative finding for the passive compression test provides the therapist with the greatest evidence-based confidence that a SLAP lesion is absent. A positive finding on the anterior apprehension maneuver, the anterior slide test, the Jobe relocation test, the passive compression test, the Speed test, and the Yergason test or a combination of positive findings on the Jobe relocation test and the active compression test or the Jobe relocation test and the anterior apprehension maneuver provides the therapist with the research-based confidence required to rule in a SLAP lesion. For ruling in a SLAP lesion, the greatest diagnostic value should likely be placed on a positive finding on the passive compression test. Suggestions for future research are provided.