Impact of multidimensional assessment on anti-fracture treatment decisions in patients with fragility hip fractures within a Fracture Liaison Service

Abstract

Background

Osteoporosis is a chronic condition characterized by increased fracture risk. Fragility fractures, especially hip fractures, represent a significant health and economic burden due to population aging. Despite the efficacy of approved treatments in lowering fracture recurrence, post-fracture treatment rates remain suboptimal. To address these issues, various post-fracture care programs, including Fracture Liaison Services (FLS), have been implemented worldwide. While FLS models effectively reduce refracture risk and maintain cost-effectiveness, it is unclear if these benefits apply equally to all patients, especially those with higher comorbidities and reduced functional capacity, who may face worse prognoses. This study aimed to identify the primary factors influencing anti-fracture therapy decisions in older patients with fragility fractures, using a multidimensional geriatric assessment approach integrated into our FLS program.

Methods

A retrospective analysis was conducted on patients aged 65 and above with hip fractures admitted to Azienda Ospedale-Università Padova. Patients were categorized based on anti-fracture treatment (bisphosphonates, Denosumab, anabolic agents) or calcium/vitamin D supplements only. Clinical data, including the Multidimensional Prognostic Index (MPI) and its components, were collected. Statistical comparisons between treated and untreated groups were made, and a CHAID decision tree was used to explore decision-influencing factors.

Results

The study included 493 patients (average age 84.7 years, 71.8% female). Patients receiving anti-fracture treatment were notably younger, with only 11.2% classified as MPI class 3 (severe prognosis) compared to 60.8% of untreated patients (p < 0.001). Among treated patients (n = 427), 75.3% received bisphosphonates, 7.3% Denosumab, and 2.2% anabolic agents. The CHAID decision tree highlighted MPI class as the primary determinant of treatment, with functional autonomy (Instrumental Activity of Daily Living or IADL) and cognitive status as subsequent factors, leading to an overall prediction accuracy of 70%.

Conclusion

The integration of the MPI into multidisciplinary taking care of old patients with hip fractures may provide a structured approach for individualizing treatment decisions, considering aspects such as prognosis, functional autonomy, and cognitive status. Further studies are needed to validate the long-term outcomes of this approach.