This document summarizes a cost-effectiveness model of Fracture Liaison Services (FLS) care in the Netherlands. The model found that FLS care would be highly cost-effective, with a cost of €9,076 per quality-adjusted life year gained. Total 5-year costs with FLS would be only 1.7% higher than current costs but would prevent fractures and improve health outcomes. The model can help decision-makers prioritize secondary fracture prevention and allow local payers and FLS to predict costs and benefits of implementation.

1. Cost-effectiveness of FLS care in the Netherlands
• M Kassim Javaid – Associate Professor, Metabolic Bone Disease
• Rafael Pinedo Villanueva – Associate Professor, Health Economics
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal
Sciences (NDORMS), University of Oxford
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Prof. Kassim Javaid

2. Disclosures
In the last three years,
Dr Javaid has received honoraria, unrestricted research grants, travel and/or
subsistence expenses from:
• Amgen, Kyowa Kirin, UCB, Besin Healthcare, Sanofi
Dr Pinedo Villanueva has received honoraria, unrestricted research grants, travel
and/or subsistence expenses from:
• Amgen, Kyowa Kirin, UCB, Mereo,
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Prof. Kassim Javaid

3. Intro / Background
• Rationale for FLS
• Barriers to implementation
• Why we need models
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Prof. Kassim Javaid

4. It’s a warning
sign for
osteoporosis
and further
fractures
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Prof. Kassim Javaid

5. Black Lancet 1996; Freemantle N, Osteoporos Int 2013
Do anti-osteoporosis treatments work?
• Over 20 years ago:
• Alendronate (n=1022) vs placebo (n=1005)
Hormonal therapies, Bisphosphonates, SERMs, Strontium, RANKL inhibitors,
PTH analogues, Anti-sclerostin
40% reduction in hip
70% reduction in spine
20% reduction in other sites
5
0
4
3
2
1
0
6 12 18 24 30 36
Time frombaseline (months)
Proportion
of
women
with
fracture
(%)
C
linical vertebral fracture
Placebo
Alendronate
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Prof. Kassim Javaid

6. The challenge getting the patients on treatment
= FLS local implementation
+
Alendronate
Risedronate
Ibandronate
Raloxifene
Strontium
Zoledronate
Denosumab
Teriparatide
Abaloparatide
Romosozumab
Lower fracture risk
=
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Prof. Kassim Javaid

7. Concept
of FLS
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Prof. Kassim Javaid

8. Getting an FLS
started & Sustainable
TOP DOWN
BOTTOM UP
An adequately resourced
local FLS
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Prof. Kassim Javaid

9. Fracture liaison services – Recognition
Recognition on the Capture the fracture map
A way to benchmark and improve services
How many non-Starred FLSs ?
We need universal coverage.
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Prof. Kassim Javaid

10. FLS model needs to overcome barriers to start/ sustain
Effective
anti-osteoporosis
management
for 5 years
System level barriers
Clinical level barriers
Patient level barriers
1Drew BMC Muscul Dis 2015; 2Wennberg Soc Sci Med 1982; 3Rossini OI 2006
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Prof. Kassim Javaid

11. TOP DOWN- Getting DECISION makers to prioritse FLS
Competing priorities
Post- COVID 19 rebuild
Elective backlog
Workforce limitations
Use of technology- do more with less
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Prof. Kassim Javaid

12. Comparison with other long term conditions
Dementia /
Anti-cholinesterase
Medication
Cause of long-term care / institutionalisation (%)1
Reduction
in
healthcare
use
Comparing Institutional Care and expected benefit from secondary prevention
0
0.1
0.2
0.3
0% 5% 10% 15% 20%
Stroke / Blood pressure2
Fractures / Osteoporosis drugs4
Heart disease/ Cholesterol5
Parkinson / Rasagline7
Lung disease/ Inhalers6
Frailty/ Exercise3
1Japanese Ministry of Health, Welfare & Labour 2019; 2Lakhan 2009; 3Garcia 2020, 4Tsuda 2020, 5Koskinas 2018; 6Sliwka 2019, 7Hattori 2019
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Prof. Kassim Javaid

13. TOP DOWN
Competing priorities
Post- COVID 19 rebuild
Telemed
Elective backlog
reduce emergency/ bed days/ operations/
clinic
Workforce limitations
Clear training and support
Use of technology- do more with less
FLS manager – semi-automated pathways
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Prof. Kassim Javaid

14. Why do we
need a
Calculator?
Anti-osteoporosis medications are
approved as cost –effective already
Benefit Calculator
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Prof. Kassim Javaid

15. Zinnige Zorg report
• 22,000 extra patients being treated
• 1,500 fracture prevented per year
• saving €13.5 million per year
€20 million additional per year
(€10.4 million hospital, €9.4 million medications/ GP)
> how were these data calculated?
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Prof. Kassim Javaid

16. National
Calculator?
National/ Regional: Expected costs and
benefits from implementation for
decision makers
Local level: FLS size and expected
performance from FLSs
Benefit Calculator: using national data/ expert consensus
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Prof. Kassim Javaid

17. Terminology
• Cost-effectiveness ≠ cost saving
• Cost-effectiveness:
• FLSs
vs
• Current practice
Δ
Cost
(€)
Δ Effect (QALY)
Current
practice
FLS?
Extra costs
Extra benefit
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Prof. Kassim Javaid

18. Terminology
• Cost-effectiveness ≠ cost saving
• Cost-effectiveness:
• FLSs
vs
• Current practice
Δ
Cost
(€)
Δ Effect (QALY)
FLS?
Extra costs
Extra benefit
Current
practice
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Prof. Kassim Javaid

19. Terminology
• Cost-effectiveness ≠ cost saving
• Cost-effectiveness:
• FLSs
vs
• Current practice
• In Netherlands, a €50,000 -
€80,000 per QALY is generally
used
Δ
Cost
(€)
Δ Effect (QALY)
FLS?
Current
practice
FLS?
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Prof. Kassim Javaid

20. Terminology
• QALY = quality-adjusted life year
6 months 1 year
0.5
1.0
Health
utility
estimate
1 QALY
0
Time (Years)
Quality of
life scale
(0-1)
0
1
Health profile with
intervention
Health profile without
intervention
Quality
adjusted
life years
gained
Time to first event
Life expectancy
1
2
3
4
1
2
3
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Prof. Kassim Javaid

21. FLS Benefit and Budget Impact Calculator
Now + 5 years
Current
practice
FLS
Current
practice
• Re-fractures
• QALYs
• Admissions
• Operations
• Bed days
• Care home
• Costs averted
• Costs PFC
Benefit and
Budget Impact
Calculator
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Prof. Kassim Javaid

22. Pathway
Sentinel
fracture
A&E
Trauma
clinic
Discharge
Inpatient
admission
Hip Spine Other
Temporary
rehabilitation
Relative’s
home
Carer-
supported
home
Independent
home
Surgery
Non-surgical
treatment
Dead
Long-term
institutional
care
Re-fracture
Hip Spine Other
Fracture free
Identification
Assessment
Treatment
Monitoring
FLS
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Prof. Kassim Javaid

23. Key features of the model
• Individual-level simulation
• Account for imminent fracture risk
• 5-year time horizon
• Six cohorts
• Men / Women
• Sentinel fracture site: Hip / Spine / Other
Figure 1
Figure 2
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Prof. Kassim Javaid

24. Inputs
From Dutch literature
• Population characteristics
• Adherence to medication
• Mortality rates
• Hospital length of stay
• Health care costs
• Medication costs
• Social care costs
• Discharge destination
From international literature
• Re-fracture rates
(site- and sex-specific, from Denmark)
• Treatment efficacy
• Time to treatment effect
• Adherence to medication
From clinical experts
• Pharmacologic practice
• Case identification
• Adherence to medication
• Monitoring rates
• Hospital care
• FLS operation: staff time, examinations
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Prof. Kassim Javaid

25. Health benefits
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Prof. Kassim Javaid

26. Resource use
Fewer fractures ! Healthcare resources freed
Fewer fractures ! Social care resources freed
Fracture prevention " Assessment " Examinations
Fracture prevention " Ident + Assess + Treat + Monitor "
Staff
32 full-time Administrators
5 full-time Doctors
136 full-time Nurses
FLS
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Prof. Kassim Javaid

27. Costs
Savings (€) in healthcare costs
Savings (€) in social care costs
Investment (€) in fracture prevention
Net investment (€)
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Prof. Kassim Javaid

28. Cost-effectiveness and costs over time
• Total 5-year costs with FLSs = only 1.7% higher than costs now
• €9,076 per QALY gained
(A range of reference
between €50,000 and
€80,000 per QALY1 is
generally used in the
Netherlands)
1 V.T.Reckers-Droog et al (2018)
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Prof. Kassim Javaid

29. Results in context
• FLSs internationally: consistently cost-effective
• Other interventions in the Netherlands
• SLIMMER Diabetes 2 prevention: €13k-€18k /QALY 1
• FLSs in the Netherlands
• Highly cost-effective ! Value for money
• Excellent results
• For patients
• For health care system capacity and efficiency
1 Duijzer et al, 2019
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Prof. Kassim Javaid

30. Utilization of the tool
• Regional / National Decision makers
• National data & transparent model
• Prioritise secondary fracture prevention compared to other long term conditions
• Local Payers
• Predicted costs for implementation of FLS
• Staged implementation– hips/ inpatients/ outpatients / vertebral fractures
• Expected performance to be reached by FLS for expected benefits.
• FLSs
• Service model
• Patient pathway targets for service improvement
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Prof. Kassim Javaid

31. Next steps
• Test model > publication
• Localise use
• Hospital level expected staffing
• Expected benefits Copyright
Prof. Kassim Javaid

32. Summary
• NL needs universal FLS coverage
• Benefit and Budget impact model
• Utilization and next steps
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Prof. Kassim Javaid