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H. Hagino, T. Wada (2019)Osteoporosis liaison service in Japan
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Summary Our FLS team aimed to ensure that patients admitted to the orthopedic department were promptly initiated for medication and identify and initiate medication for patients admitted to other departments. Our innovative FLS system along with admission screening and osteoporosis education have proven effective in identifying patients with osteoporosis and initiating medication. Purpose The fracture liaison service (FLS) plays a crucial role in the secondary prevention of fragility fractures by involv- ing various medical professionals. Our FLS team had two goals for preventing primary and secondary fractures: ensuring that patients admitted to the orthopedic department were promptly initiated on medication and identifying and initiating medication for patients admitted to other departments. Methods From April 2020 to March 2023, we analyzed the number of dual-energy X-ray absorptiometry (DEXA) scans per- formed, the DEXA rate among patients with proximal femoral fractures, and the rate of medication initiation each year. Our hospital implemented the FLS system in April 2022. It is a unique system utilizing admission screening form and osteoporosis educational appointments conducted by rehabilitation staff to initiate medication for orthopedic and non-orthopedic patients. Results The average monthly number of DEXA scans increased significantly, with 47.7 in 2020, 57.0 in 2021, and 90.8 in 2022. The DEXA rate among proximal femoral fracture patients increased from 23.3% in 2020 to 88.1% in 2021 and 100% in 2022. The rate of treatment initiation also increased remarkably, from 21.7% in 2020, to 68.7% in 2021, reaching 97.8% in 2022. We performed 504 interventions, resulting in 251 patients diagnosed with osteoporosis, of whom 134 (56 from non-orthopedic departments) successfully started medication. Conclusions Our innovative FLS system, incorporating an admission screening form and osteoporosis educational appoint- ments, proved effective in identifying patients with osteoporosis and facilitating medication initiation, which will prevent both primary and secondary fractures. Keywords Fracture liaison service · Osteoporosis · Screening form · Patient education · Patient identification · Medication initiation Introduction Population aging is a global problem, with aging rates over 65 years old reaching 29.8% in Japan, 22.2% in Germany, 21.3% in France, 18.9% in the United Kingdom, and 16.7% * Shunsuke Kikuchi in the United States in 2021 . In Yaita City, the location of firstname.lastname@example.org our hospital, the population aging rate is 33.9%, exceeding Department of Orthopedic Surgery, International University the national average . of Health and Welfare, Shioya Hospital, Yaita City, Tochigi, Healthy life expectancy, the number of disease- and dis- Japan ability-free years an individual can expect to live, is a key Department of Orthopedic Surgery, School of Medicine, measure used by the World Health Organization (WHO) to International University of Health and Welfare, Narita City, assess the health and well-being of a nation. The average life Chiba, Japan Vol.:(0123456789) 1 3 117 Page 2 of 9 Archives of Osteoporosis (2023) 18:117 expectancy for Japanese individuals was 81.0 years for men Osteoporosis manager certification is granted to those with and 87.1 years for women in 2016. However, the difference national qualifications such as nurses, radiology techni- between average life expectancy and healthy life expectancy cians, clinical laboratory technicians, physical therapists, was 8.9 years for men and 12.3 years for women . This occupational therapists, pharmacists, and dietitians, who disparity indicates a decline in the quality of life, increased have attended specific lectures and passed an examination burden on families, and increased social security costs, and obtained certification. In total, 3928 people had been including medical expenses and long-term care benefits. A certified as osteoporosis manager until April 2023, and of concerted effort to extend healthy life expectancy is needed these, 48% were nurses; 19%, physical therapists; 16%, to bring it closer to average life expectancy. pharmacists; 6%, radiology technicians; 3%, dietitians; 2%, According to a survey of support and nursing care occupational therapists; and 6%, others. Recognizing the requirements in Japan, musculoskeletal problems account importance of secondary fracture prevention, particularly for one-fifth of cases, with 12.5% attributed to fractures and in patients with fragility fractures, the Japanese Osteoporo- falls and 10.8% to joint diseases . Osteoporotic fractures sis Society and Fragility Fracture Network–Japan (FFN-J) can result in immobilization, chronic back pain, and long- published the Japanese version of the FLS clinical standards term care dependency. in 2019  outlining the minimum indicators for second- Osteoporosis is described by WHO as a condition typified ary fracture prevention. There are five stages: identification, by reduced bone mass, abnormal bone tissue microstructure, investigation, initiation, integration, and information. increased bone fragility, and elevated fracture risk. In 2022, the medical service reimbursement introduced In 1994, WHO published a report focusing on fracture a new evaluation criterion for patients with hip fractures risk assessment in postmenopausal osteoporosis screening undergoing osteoporosis evaluation and treatment, aligned . The report outlined diagnostic criteria based on meas- with guidelines such as those from the FLS and OLS. This urements of bone mineral density (BMD) and acknowledged reflects the growing recognition and adoption of FLS and osteoporosis affected over 75 million individuals across the OLS in Japan. USA, Europe, and Japan. Our FLS team established two primary goals. The first Although the Japanese population is approximately was ensuring that patients admitted to the orthopedic depart- 125 million and is unchanged, the number of osteoporosis ment, especially those with proximal femoral fractures, patients in Japan continues to rise annually and is estimated undergo comprehensive evaluation and receive appropriate to have reached 12.8 million individuals in 2015 (3 and 9.8 medication. The second goal entailed identifying individu- million men and women, respectively) . Consequently, als with osteoporosis admitted to all departments, and ini- fracture prevention through osteoporosis intervention has tiating outpatient medication and care following discharge. become a pressing concern. Underscoring the importance of The FLS team devised a novel system to screen all hospital secondary fracture prevention, DM Black et al. demonstrated admissions using a distinctive admission screening form that after a vertebral fracture, the likelihood of subsequent (Fig. 1) and scheduling osteoporosis educational appoint- vertebral fractures increases by a factor of 4.7, and the prob- ments with rehabilitation staff. ability of hip fractures by 2.6 . Our aim is to diminish the number of fracture cases The fracture liaison service (FLS), initially established in within the community by identifying osteoporosis patients the United Kingdom in the late 1990s, has expanded world- and enhancing treatment initiation rates. This study aimed wide . FLS provides secondary prevention for fragility to demonstrate the impact of our FLS team’s interventions fractures by involving various medical professionals. By sys- on the frequency of DEXA scanning, treatment initiation tematically and proactively identifying patients who have rates, and the identification of osteoporosis patients among sustained fragility fractures and assessing their risk of future all hospitalized individuals. fragility fractures, FLS offers guidance and therapies to miti- gate the risks. Evidence indicates that this service increases BMD testing, facilitates the initiation of appropriate medica- Methods tion, and reduces the incidence of fragility fractures. In Japan, the Osteoporosis Liaison Service (OLS) is an FLS intervention initiative to prevent fragility fractures associated with osteo- porosis . OLS is a unique Japanese system developed by Our hospital’s FLS began operating in April 2022. The the Japan Osteoporosis Society that targets wide range of patients with osteoporosis and older people, and is intended FLS team comprises a physician, outpatient and acute ward nurses, recovery ward staff, regional cooperation staff, a to prevent primary fractures via cooperation of physicians and medical staff of various professions, led by the osteopo- pharmacist, a radiologist, physical therapists, occupational therapists, nutritionists, medical affairs personnel, and care rosis manager certified by the Japan Osteoporosis Society. 1 3 Archives of Osteoporosis (2023) 18:117 Page 3 of 9 117 Fig. 1 Admission screening ID ID䠖䠖 form for osteoporosis. If one of the answers is yes, a request for Na Name me䠖䠖 Ns Ns䠖䠖 team intervention is issued 1. 1. Th The ca e cau us se e of of ad admi missi ssion on is is a a pr prox oxim imal al fe femo mora ral l fr fra ac ct tu ur re e or or ve vert rteb ebra ral l fra fract ctur ure e YE YESN SNO O 2. 2. Hi Hist stor ory y of of a a pr proxi oxima mal l fe femo mora ral l fra frac ct tu ur re e or or ve vert rteb ebra ral l fra frac ct tu ur re e YE YESN SNO O 3. 3. Ov Over er 40 40 ye year ars s ol old d wi with th ot othe her r fr frac actu ture res s YE YESN SNO O 4. 4. Use Use of of assi assist stiv ive e de devi vice ces s fo for r wa walk lkin ing g YE YESN SNO O 5. 5. Al Alb b < < 3. 3.5 5 g/ g/dL dL YE YESN SNO O managers, all providing comprehensive support. The proce- Non-orthopedic patients dures followed at each stage are outlined below. Diagnosis occurs during hospitalization Stage 1: Identification Provision of printed instructions emphasizing the importance of osteoporosis treatment upon discharge • All hospitalized patients are screened using a designated Osteoporosis educational appointment scheduled on form (Fig. 1) the same day as the outpatient visit following dis- charge, during which an osteoporosis manager pro- vides a detailed explanation of treatment importance • Admission cause: proximal femoral fracture or ver- Referral to an orthopedic specialist to initiate medi- tebral fracture cation • History of proximal femoral fracture or vertebral fracture Stage 4: Integration • Age over 40 with other fractures • • Use of assistive devices for walking (indicating fall Yearly appointments for DEXA scans risk) Facilitation of continued medication through regional Albumin level < 3.5 g/dl (indicating malnutrition) cooperation with nearby clinics Telephone follow-up with patients who have not been For fresh lumbar spine compression fractures, MRI is seen finally performed for making a diagnosis. Regarding old lumbar spine compression fractures, the decision is based Stage 5: Information on the patient’s own or family’s report. In accordance with previous studies, the reference value for malnutrition was set Regular FLS team workshops at 3.5 g/dL albumin . If any criteria apply, the patient Attendance at sponsored lectures by pharmaceutical com- is at high risk of fracture, and an intervention request is panies forwarded to the FLS team. Seminars for all employees Stage 2: Investigation The intervention process for inpatients is depicted in Fig. 2. All patients complete the admission screening • DEXA measurement of BMD form. FLS intervention is requested for patients identi- Blood test to evaluate bone metabolism markers fied as having a high risk of fracture. The patients have • Fall risk assessment conducted by rehabilitation staff a BMD test, and if osteoporosis is confirmed, blood tests are conducted to assess bone metabolism markers. In addi- Stage 3: Initiation tion to general items such as electrolytes, renal, and liver functions, bone metabolism markers such as P1NP, bone- • Orthopedic patients specific alkaline phosphatase (BAP), and TRACP-5b were Initiation of medication during hospitalization tested. Orthopedic patients begin medication immediately, 1 3 117 Page 4 of 9 Archives of Osteoporosis (2023) 18:117 Fig. 2 FLS intervention flow while non-orthopedic patients are diagnosed and provided Data analysis with printed instructions highlighting the importance of osteoporosis treatment upon discharge. Non-orthopedic Capture the proximal femoral fractures patients attend an osteoporosis educational appointment on the same day as their outpatient visit following dis- We summarized the total number of DEXA examinations, charge. A certified osteoporosis manager from the reha- the DEXA examination rate for patients with proximal bilitation staff, discussed inpatient DEXA results, general femoral fractures, and the medication initiation rate for knowledge of osteoporosis, fracture risk, the necessity of each year between April 2020 and March 2023. This meas- osteoporosis treatment, and exercise therapy. If the patient ured our FLS team’s first objective of providing reliable consents, an outpatient orthopedic appointment is sched- intervention for proximal femoral fractures. uled. This process ensures intervention for orthopedic and non-orthopedic patients with osteoporosis. Patients in the non-orthopedic group vary widely, including cardiology Eec ff t of admission screening form and osteoporosis patients with heart failure and atrial fibrillation, patients educational appointment on identifying on glycemic control admitted to the Division of Diabe- osteoporosis patients and facilitating medication tes and Metabolism, patients with stroke admitted to the initiation Division of Neurosurgery, and patients with metabolic encephalopathies admitted to the Division of Neurology We summarized the total number of FLS team interven- and likewise. The drugs available in our hospital included tions, bone density tests, diagnosed osteoporosis, and bisphosphonates, teriparatide, denosumab, romosozumab, treatment initiated between April 2022 and March 2023. raloxifene, and vitamin D. 1 3 Archives of Osteoporosis (2023) 18:117 Page 5 of 9 117 This measured the second objective of our FLS team, Eec ff t of admission screening form and osteoporosis i.e., identifying patients with osteoporosis admitted to all educational appointment on identifying departments and initiating outpatient medication and care osteoporosis patients and facilitating medication following discharge. initiation Regarding FLS team interventions, detailed results Results are presented in Fig. 5 and Table 1. The results of the responses to the admission screening form are shown in Capture the proximal femoral fractures Table 2. In total, 109 patients answered yes to the ques- tion: The cause of admission is a proximal femoral frac- The results of this study are presented using fiscal years: ture or a vertebral fracture. Forty-three patients answered April 2020 to March 2021, April 2021 to March 2022, and yes to the question: History of proximal femoral fracture April 2022 to March 2023 are referred to as years 2020, or a vertebral fracture. Forty-three patients answered 2021, and 2022, respectively. yes to the question: Over 40 years old with other frac- The average monthly number of DEXA examinations tures. Three hundred nineteen patients answered yes to increased significantly, from 47.7 in 2020, to 57.0 in 2021, the question: Use of assistive devices for walking, and and 90.8 in 2022 (Fig. 3). The DEXA examination rate for 208 patients answered yes to the question: Alb < 3.5 g/ patients with proximal femoral fractures increased from dL. Regarding the number of patients answering yes to 23.3% in 2020 to 88.1% in 2021 and 100% in 2022. Simi- multiple questions, two questions were 163; three ques- larly, the rate of treatment initiation rose remarkably from tions were 23; four questions were 3; and five questions 21.7 to 68.7%, and 97.8% in 2020, 2021, and 2022, respec- were 0. tively (Fig. 4). All patients were started on bisphosphonates There were 504 intervention orders, with 131 (26.0%) and vitamin D. for orthopedic and 373 (74.0%) for non-orthopedic patients. DEXA examinations were performed on 346 (68.6%) patients (123 orthopedic and 223 non-orthope- dic), excluding 108 (21.4%) patients with poor general condition and 50 (9.9%) patients with short-term hos- pitalization (e.g., examination hospitalization, minor surgery, chemotherapy). Of the 346 patients who under- went DEXA, 251 (72.5%) (101 orthopedic and 150 non- orthopedic) were diagnosed with osteoporosis, while 95 (27.5%) patients had normal bone density. The details of 251 patients diagnosed with osteoporosis are shown in Table 3. No statistically significant differences were found in age and bone density. Of the 251 osteoporosis patients, 134 (53.3%) (78 ortho- pedic and 56 non-orthopedic patients) began medication. Details of the initiated anti-osteoporosis drugs are shown Fig. 3 Number of DEXA scans (monthly average) Fig. 4 Intervention rates for patients with proximal femoral fractures 1 3 117 Page 6 of 9 Archives of Osteoporosis (2023) 18:117 Fig. 5 Participant selection flow chart Table 1 Details of the participants (orthopedics and non-orthopedics) vitamin D, 5 taking denosumab, 4 taking romosozumab, 3 taking teriparatide, 3 taking vitamin D, and 1 taking Orthopedics Non-orthopedics All raloxifene. Of the 78 patients who did not receive treat- Intervention order 131 (26.0%) 373 (74.0%) 504 ment, 27 (34.6%) patients experienced challenges with DEXA 123 (35.5%) 223 (64.5%) 346 medication administration (e.g., renal dysfunction, severe Diagnosis of osteoporosis 101 (40.2%) 150 (59.8%) 251 heart failure, electrolyte abnormalities, difficulties taking Start medication 78 (58.2%) 56 (41.8%) 134 medication), 8 (10.3%) patients were transferred to other hospitals, and 43 (55.1%) patients were lost to follow-up. Nineteen patients with osteoporosis in the non-orthopedic in Table 4. A total of 39 (15.5%) patients had already been group were seen for the osteoporosis educational appoint- ment, 13 (68.4%) of whom were seen by an orthopedic introduced to anti-osteoporosis drugs, which included: 15 patients taking bisphosphonates (BP), 8 taking BP + specialist eventually leading to treatment. Table 2 Results of admission Screening questions Number of participants screening form answering yes 1. The cause of admission is a proximal femoral fracture or vertebral fracture 109 2. History of a proximal femoral fracture or vertebral fracture 43 3. Over 40 years old with other fractures 43 4. Use of assistive devices for walking 319 5. Alb <3.5 g/dL 208 Multiple yes 2 questions 163 3 questions 23 4 questions 3 5 questions 0 1 3 Archives of Osteoporosis (2023) 18:117 Page 7 of 9 117 Table 3 Details of the patients All Orthopedics Non-orthopedics p diagnosed with osteoporosis (orthopedics and non- Age 83.3 ± 8.8 82.9 ± 9.8 83.6 ± 8.1 0.58 orthopedics) Male 61 14 47 Female 190 87 103 BMD T-score of lumbar spine −1.95 ± 1.66 −2.07 ± 1.43 −1.87 ± 1.81 0.39 BMD T-score of femoral neck −3.06 ± 0.86 −3.17 ± 0.91 −2.99 ± 0.82 0.13 Table 4 Details of the initiated anti-osteoporosis drugs (orthopedics teaching, the examination and treatment initiation rates and non-orthopedics) significantly improved. With the support of the FLS team, we incorporated DEXA into the clinical pathway, achiev- Orthopedics Non-orthopedics ing a 100% testing rate in 2022. The treatment initiation Bisphosphonates + vita- 55 (70.5%) 6 (10.7%) rate reached 97.8%, with only one patient refusing medica- min D tion. The first FLS team objective was achieved. Bisphosphonates 3 (3.8%) 23 (41.1%) The second objective was to identify and initiate treat- Teriparatide 10 (12.8%) 6 (10.7%) ment for osteoporosis patients admitted to other depart- Denosumab 2 (2.6%) 10 (17.9%) ments. In 1 year, the FLS team initiated medication for 56 Romosozumab 3 (3.8%) 7 (12.5%) non-orthopedic osteoporosis patients who would have previ- Raloxifene 1 (1.3%) 0 (0%) ously been overlooked. Unlike conventional Japanese FLS Vitamin D 4 (5.1%) 4 (7.1%) teams that solely focus on patients with proximal femoral Total 78 56 and vertebral fractures, our FLS team was innovative in identifying osteoporosis patients among all admissions . Nevertheless, there were challenges regarding patients admitted in other departments. The first challenge was Discussion determining which patients should undergo DEXA for BMD testing. We developed a simple admission screening form Increases in examination and treatment initiation rates aiming to keep the screening as straightforward as possi- have already been reported with FLS intervention, and its ble. Secondly, if the DEXA test revealed osteoporosis, the impact on fracture prevention has also been documented next challenge was deciding when to initiate medication. [12–16]. The number needed to treat (NNT), a statistical Orthopedic surgeons could not intervene aggressively in measure of treatment efficiency, is 20 for fracture preven- another department due to the patient’s overall health condi- tion with FLS intervention , in contrast to 119 for the tion. Moreover, communication problems with doctors from prevention of coronary artery disease using hyperlipidemia other departments arose. It was also important to explain medication, and 255 for myocardial infarction . Sev- the diagnosis to the patient’s family members, who play a eral studies have demonstrated the cost-effectiveness of crucial role. FLS [19–22] confirming it as a highly efficient interven- We decided to perform only the examination and diagno- tion for fracture prevention. sis, with intervention after discharge. Initially, orthopedic Our hospital operates on approximately 60 proximal outpatient appointments were scheduled simultaneously femoral fracture cases annually. FLS intervention has with the other appointments, but patients were often con- facilitated reliable testing and intervention for proximal fused by the mixed instructions or refused to comply. We femoral fractures. The level of interest in osteoporosis var- devised a strategy to provide osteoporosis education from a ies among orthopedic surgeons. Our team has two expe- certified osteoporosis manager during the outpatient wait- rienced doctors in leadership positions and two younger ing time. Many patients had already received rehabilitation doctors. The younger doctors tend to prioritize surgical intervention during their hospital stay. They readily accepted procedures over the prevention of secondary fractures. In guidance from already familiar rehabilitation staff and seam- 2020, doctors with a limited interest in prevention were lessly transitioned to the orthopedic outpatient department. involved in teaching, resulting in an examination rate of Many patients were satisfied with the detailed explanations only 23.3% and a treatment initiation rate of 21.7%. Even obtained from osteoporosis managers. When patients visit considering the data from previous references, it is reason- the outpatient department, there is typically a waiting time able to assume that the examination and treatment initia- for blood tests and other procedures, which can be stressful tion rates were around 20% [23, 24]. In 2021, after one and unproductive. This system effectively uses that time. of the authors of the present paper (SK) was assigned to While simple and easy to implement, this system is novel 1 3 117 Page 8 of 9 Archives of Osteoporosis (2023) 18:117 and unique in Japan. It has enabled the identification and References intervention of non-orthopedic patients with osteoporosis. 1. United Nations Population Division. UN population division web- Many patients were satisfied with the detailed explanations site. https:// popul ation. un. org/. Accessed 1 June 2023 provided by the osteoporosis managers. Interestingly, about 2. Yaita city J (2023) Population by age (each age) and gender (Basic 68.4% of the patients who came to the osteoporosis educa- resident register). https://ww w.ci ty.y aita.t ochigi. j p/upl oade d/at tac tional appointment saw an orthopedic specialist; however, hment/ 16301. pdf. Accessed 1 Jun 2023 3. Special subcommittee of the local system research committee we need to raise this value. 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Report of a WHO study group. 843:1–129 https:// apps. who. int/ ple as possible and conducting meetings during work hours. iris/ handle/ 10665/ 39142. Accessed 1 Jun 2023 Additionally, our hospital has six certie fi d osteoporosis man - 6. Osteoporosis CftPaTo. Osteoporosis Prevention and Treatment agers (three nurses, and one pharmacist, physical therapist, Guidelines 2015 Edition. http://w ww.j osteo.c om/j a/g uidel ine/d oc/ and occupational therapist) who actively engage in patient 15_1. pdf. Accessed 1 June 2023 7. Black DM, Arden NK, Palermo L, Pearson J, Cummings SR education. The staff are motivated to educate patients. (1999) Prevalent vertebral deformities predict hip fractures and Our FLS team has only been operational for approxi- new vertebral deformities but not wrist fractures. Study of osteo- mately 1 year, and therefore cannot yet assess fracture pre- porotic fractures research group. J Bone Miner Res 14:821–828. vention rates. Nonetheless, we aim to maintain our high https:// doi. org/ 10. 1359/ jbmr. 1999. 14.5. 821 8. Gallacher SJ (2005) Setting up an osteoporosis fracture liaison examination and treatment initiation rates, and sustain a high service: background and potential outcomes. Best Pract Res Clin treatment continuation rate, which will ultimately contribute Rheumatol 19:1081–1094. https://doi. or g/10. 1016/j. ber h.2005. 07. to long-term fracture prevention in the community. In conclusion, our innovative FLS system, with admis- 9. Hagino H, Wada T (2019) Osteoporosis liaison service in Japan. Osteoporos Sarcopenia 5:65–68. https:// doi. org/ 10. 1016/j. afos. sion screening and osteoporosis educational appointments, 2019. 09. 003 has proven effective in identifying osteoporosis patients and 10. Clinical standards for fracture liaison services in Japan. http:// initiating medication. Further research on long-term FLS www . jos teo. com/ ja/ news/ doc/ 200518_ 3. pdf. 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Gonzalez-Quevedo D, Perez-Del-Rio V, Moriel-Garceso D, datasets were generated or analyzed during the current study. Fernandez-Arroyabe N, Garcia-Melendez G, Montanez-Ruiz M, Bravo-Bardaji M, Garcia-de-Quevedo D, Tamimi I (2022) Declarations A 2-year follow-up of a novel fracture liaison service: can we reduce the mortality in elderly hip fracture patients? A prospec- Conflict of interest None. tive cohort study. Osteoporos Int 33:1695–1702. https:// doi. org/ 10. 1007/ s00198- 022- 06298-x Open Access This article is licensed under a Creative Commons Attri- 14. Lems WF, van den Bergh JP, Geusens P (2022) The fracture liai- bution 4.0 International License, which permits use, sharing, adapta- son service, a step forward not only in fracture reduction, but also tion, distribution and reproduction in any medium or format, as long in mortality reduction. 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J Am Geriatr Soc 69:3435–3444. https://doi. or g/10. 1111/ jgs. 17381 Publisher’s Note Springer Nature remains neutral with regard to 21. Saunders H, Sujic R, Bogoch ER, Jain R, Jinah A, Elliot-Gibson jurisdictional claims in published maps and institutional affiliations. V, Mendlowitz AB, Linton D, Inrig T, Isaranuwatchai W, Sale JE (2021) Cost-utility analysis of the Ontario fracture screening and prevention program. J Bone Joint Surg Am 103:1175–1183 1 3
Archives of Osteoporosis – Springer Journals
Published: Sep 13, 2023
Keywords: Fracture liaison service; Osteoporosis; Screening form; Patient education; Patient identification; Medication initiation
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