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Meta-Analysis
. 2021 Aug;32(8):1517-1530.
doi: 10.1007/s00198-021-05911-9. Epub 2021 Apr 7.

The impact of fracture liaison services on subsequent fractures and mortality: a systematic literature review and meta-analysis

N Li  1 , M Hiligsmann  2 , A Boonen  3 , M M van Oostwaard  4   5 , R T A L de Bot  2   6 , C E Wyers  4   5 , S P G Bours  3 , J P van den Bergh  4   5   7
Affiliations
Meta-Analysis

The impact of fracture liaison services on subsequent fractures and mortality: a systematic literature review and meta-analysis

N Li et al. Osteoporos Int. 2021 Aug.

Abstract

This systematic review and meta-analysis suggests that fracture liaison service (FLS) is associated with a significantly lower probability of subsequent fractures and mortality although the latter was only found in studies comparing outcomes before and after the introduction of an FLS.

Introduction: To systematically review and evaluate the impact of fracture liaison services (FLSs) on subsequent fractures and mortality using meta-analysis.

Methods: A literature search was performed within PubMed and Embase to identify original articles published between January 1, 2010, and April 30, 2020, reporting the effect of FLSs on subsequent fractures and/or mortality. Only studies comparing FLS to no-FLS were included. A meta-analysis using random-effects models was conducted. The quality of studies was appraised after combining and modifying criteria of existing quality assessment tools.

Results: The search retrieved 955 published studies, of which 16 studies fulfilled the inclusion criteria. Twelve studies compared outcomes before (pre-FLS) and after (post-FLS) FLS implementation, two studies compared outcomes between hospitals with and without FLS, and two other studies performed both comparisons. In total, 18 comparisons of FLS and no-FLS care were reported. Follow-up time varied from 6 months to 4 years. Sixteen comparisons reported on subsequent fractures and 12 on mortality. The quality assessment revealed methodological issues in several criteria. Excluding studies with very high selection bias, the meta-analysis of nine comparisons (in eight papers) revealed that the FLS care was associated with a significantly lower probability of subsequent fractures (odds ratio: 0.70, 95% CI: 0.52-0.93, P=0.01). In studies with a follow-up > 2 years, a significantly lower probability of subsequent fractures was captured for FLS care (odds ratio: 0.57, 95% CI: 0.34-0.94, P=0.03), while in studies ≤ 2 years, there was no difference in the odds of subsequent fractures. No significant difference in the odds of mortality was observed (odds ratio: 0.73, 95% CI: 0.49-1.09, P=0.12) in the meta-analysis of eight comparisons (in seven papers). However, a significantly lower probability of mortality was identified in the six pre-post FLS comparisons (odds ratio: 0.65, 95% CI: 0.44-0.95, P=0.03), but not in studies comparing hospitals with and without FLS. No difference was observed in mortality stratified by follow-up time.

Conclusion: This systematic review and meta-analysis suggests that FLS care is associated with a significantly lower probability of subsequent fractures and mortality although the latter was only found in studies comparing outcomes before and after the introduction of an FLS. The quality assessment revealed that some important methodological issues were unmet in the currently available studies. Recommendations to guide researchers to design high-quality studies for evaluation of FLS outcomes in the future were provided.

Keywords: Fracture liaison service; Meta-analysis; Mortality; Subsequent fracture.

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Conflict of interest statement

Mickaël Hiligsmann has received research grants through institution from Amgen, Radius Health, and Theramex; Joop P. van den Bergh has received research funding from Amgen, Eli Lilly, and UCB; Annelies Boonen, Robin de Bot, Sandrine P.G. Bours, Caroline E. Wyers, and Marsha M. van Oostwaard declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
PRISMA flowchart of the study selection process
Fig. 2
Fig. 2
FLS versus no-FLS for subsequent fracture: overall and subgroup analysis by study design. CI, confidence interval; IV, inverse variance; FLS, fracture liaison service. Asterisk indicates comparison between hospitals with and without FLS
Fig. 3
Fig. 3
FLS versus no-FLS for subsequent fracture: subgroup analysis by follow-up duration. CI, confidence interval; IV, inverse variance; FLS, fracture liaison service. Asterisk indicates comparison between hospitals with and without FLS
Fig. 4
Fig. 4
FLS versus no-FLS for mortality: overall and subgroup analysis by study design. CI, confidence interval; IV, inverse variance; FLS, fracture liaison service. Asterisk indicates comparison between hospitals with and without FLS
Fig. 5
Fig. 5
FLS versus no-FLS for mortality: subgroup analysis by follow-up duration. CI, confidence interval; IV, inverse variance; FLS, fracture liaison service. Asterisk indicates comparison between hospitals with and without FL
See this image and copyright information in PMC

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