Effectiveness of an integrated hospital-community care pathway for fragility fractures' secondary prevention: the PROMOTER-II study

Summary : As the global population ages, osteoporosis and fragility fractures (FF) are emerging health concerns worldwide. This study assesses the effectiveness of an integrated hospital-community pathway in improving prescription and adherence to anti-fracture treatment. Additionally, it analyzes the re-fracture rate and mortality at a 24-month follow-up from an index FF. Purpose: Evaluate the effectiveness of an integrated healthcare pathway (IHCP) on appropriateness and adherence to anti-fracture treatment (AFT) in adults aged ≥ 50 years, hospitalized due to fragility fracture (FF). Re-fractures and mortality rates were explored as secondary outcomes. Methods: Subjects aged 50 years and more, resident in the province of Pavia, Italy, were enrolled at the time of hospital admission due to major FF, in the period 2016–2018 and 2019–2020 before and after the implementation of the IHCP, respectively. Data were extracted from the administrative database of the Health Protection Agency of Pavia, starting from the index event and until 24 months. Data analyses were conducted for the primary and secondary outcomes. Univariate and multivariate Cox regression models were fitted. Results: Among 9186 participants (74.7% women), aged 78 years, 12.7% initiated an AFT, and half of them (6.3%) within 6 months after the index FF. Comparing pre- and post- IHCP implementation phases, the appropriateness of AFT initiation increased in subjects with index humerus/wrist FF, oral AFT prescription decreased, while subcutaneous or intravenous treatments increased (p < 0.001). Total adherence to AFT slightly increased. The re-fracture rate was 5.2 per 100 person/year, with age, IHCP implementation, and hip FF associated with a higher likelihood of refracture. The mortality rate was 13.4 per 100 person/year, with age, male gender, IHCP, and hip fracture as independent risk factors. Appropriate AFT significantly reduced mortality compared to no treatment (HR 0.55), with one-year adherence showing the strongest benefit (HR 0.18). Adherent patients had threefold lower mortality than non-adherent ones. Hip and vertebral fractures had an increased death risk (p < 0.001) compared to wrist and/or humerus. AFT results in an effect modifier of the association between the site of FF and mortality risk (p = 0.003). Conclusion: The implementation of an IHCP, based on a FLS integrated model, shows a tendency to improve FF management, especially among younger patients with humerus or wrist FF. We confirmed a lower mortality among subjects received appropriate AFT.