2.8 Fracture liaison service and improving treatment rates for osteoporosis
To access the References, please follow the URL link
1 What is a fracture liaison service?
The fracture liaison service (FLS) was developed in response to a pervasive and persistent postfracture care gap evident among fragility fracture patients (FFPs) throughout the world [1]. The majority of people aged 50 years and older who present with a fragility fracture do not receive the osteoporosis assessment and management as advocated in clinical guidelines [2–7]. Furthermore, interventions intended to identify and mitigate risk factors for falls are often not a standard component of postfracture care. The secondary fracture prevention care gap and the role that FLS can play to reduce it have been highlighted by international and national campaigns, including:
International Osteoporosis Foundation′s (IOF) Capture the Fracture Campaign [1, 7, 8]
Osteoporosis Canada′s Make the FIRST break the LAST with Fracture Liaison Services [9]
Osteoporosis New Zealand′s Bone Care 2020 [10]
Falls and Fractures Alliance in England [11]
The rationale for prioritizing secondary fracture prevention stems from epidemiological observations that about half of all hip fracture patients break another bone before they fracture their hip [15–18]. Among postmenopausal women, estimates suggest that one-sixth will have suffered a fragility fracture at any relevant skeletal site (ie, generally excluding fractures of the skull, fingers, and toes) [5]. Taken together, among women aged 50 years and older, these data suggest that half of all future cases of hip fracture will emanate from the one-sixth of the population who have suffered a prior fragility fracture. Older men account for 30% of the world′s hip fractures. Information on the prevalence of prior fracture history is not broadly available. However, several studies suggest that 30–59% of men who have suffered a hip fracture had previously broken another bone [15, 16, 18]. The IOF [8, 19], the Endocrine Society [20], and other organizations [6, 9, 21, 22] endorse secondary fracture prevention as a requirement for men too.
A broad array of pharmacological interventions has been demonstrated to reduce future fracture risk for individuals who have suffered a fragility fracture [23]. Given that these treatments have been available for 20 years, why are they not routinely being targeted to individuals at high risk of suffering further fractures? This question has been considered by investigators from several countries [2, 3]. A study that evaluated the practice of orthopedic surgeons and general practitioners (GPs) in the UK provided an insight into why this apparent breakdown in chronic disease management is occurring [24]. Surgeons and GPs were asked about their routine clinical practice when confronted with three clinical scenarios:
A 55-year-old woman with a low-trauma Colles wrist fracture
A 60-year-old women with a vertebral wedge fracture
A 70-year-old woman with a low-trauma femoral neck fracture
Both groups agreed in principle that FFPs should be investigated for osteoporosis, ie, 81% of surgeons and 96% of GPs. However, as indicated in Fig 2.8-1 , in most scenarios both surgeons and GPs would not take direct responsibility to do so themselves. This study mirrors the findings of systematic reviews that considered barriers to secondary fracture prevention in clinical practice. There is a tendency for orthopedic surgeons and primary care providers to rely upon one another to implement secondary fracture prevention, resulting in its omission for the majority of FFPs. The fracture liaison service was developed to overcome the lack of clarity regarding clinical ownership of secondary prevention efforts, and to eliminate the care gap.
The fracture liaison service is a program designed to ensure that all FFPs above a specific age receive secondary preventive care. This program includes both osteoporosis assessment and treatment, and where appropriate, an intervention to reduce the risk of falls. A critical component of an FLS is personnel dedicated to identifying, investigating, and initiating secondary preventive care for fracture patients. While this FLS coordinator is often a nurse practitioner or registered nurse, some FLS have employed physicians in training or allied healthcare professionals to fulfil this role. An FLS will adhere to protocols of care agreed with all relevant local hospital specialists, primary care providers, and health system administrators.
The scope of an FLS may vary, depending on the case mix of fracture patients presenting to the particular hospital or health system. The FLS may manage all FFPs, just those admitted as inpatients to a hospital, or just those managed in the outpatient setting. The operational structure of an FLS will be influenced by local orthopedic service configurations, particularly the presence or absence of orthopedic-geriatric comanagement services for FFPs also known as geriatric fracture centers or orthogeriatrics services [25, 26].
The place of an FLS in a systematic approach to hip fracture care and prevention is illustrated in Fig 2.8-2 , which describes the approach being taken in New Zealand [10]. This approach was based on previous experience from the UK [27], which has also been adopted in Australia [28], Canada [9], and the United States [14], and internationally by IOF [1]. The FLS can be configured to provide secondary preventive care for all FFPs. In institutions with established orthopedic-geriatric comanagement services, which usually manage osteoporosis and fall risks for hip fracture patients, the FLS can serve the nonhip FFPs, which usually represents 80–85% of the fragility fracture case load [25, 26].
The process of planning for an FLS, considerations during implementation, and results achieved from well-established, high-performing FLS will be discussed in the next topics of this chapter.
2 Planning
All successful FLS programs have required an individual to champion the case for FLS implementation within their institution or health system. This person is often formally or informally designated as the “lead clinician for osteoporosis” in his/her place of work. In the hospital setting, the FLS champion may be an endocrinologist, rheumatologist, geriatrician, or orthopedic surgeon. Some FLS programs have been established in primary care, where the FLS champion is a GP (ie, a family physician) with a special interest in osteoporosis or musculoskeletal disease [29]. A selection of useful resources to support champions embarking upon their FLS development efforts is available in topic 5 of this chapter. The key steps in planning for an FLS that a physician champion should consider are illustrated in Fig 2.8-3 .
2.1 Stakeholders
The care of FFPs involves a broad group of health professionals and administrative staff. The champion′s first task is to identify which individuals should become members of a multidisciplinary stakeholder group that will guide and enable development of the FLS. This group is likely to include:
The FLS champion
Orthopedic surgeons with an interest in hip or fragility fracture surgery
Geriatricians, orthogeriatricians, hospitalists, or internists working in orthopedic-geriatric comanagement services
A radiologist and/or nuclear medicine specialist
Relevant specialist nurses, physiotherapists, and other allied healthcare professionals
Information technology (IT) professionals responsible for development and/or installation of an FLS database
Hospital and primary care pharmacy or medicines management representatives
Hospital administration and/or business planning group representatives
Local primary care-based service commissioning group representatives
Local primary care practice representatives
Local public health authority representatives
2.2 Needs assessment
Numerous published audits of secondary fracture prevention have reported, in the absence of a systematic approach, that most FFPs do not receive guideline-based care [7]. To illustrate that a need exists for development of a new FLS, an audit is likely necessary to quantify the local care gap. Analysis of the following key performance indicators over a 1–3-month period would provide an adequate overview of postfracture care at baseline:
How many women and men aged 50 years and older presented to the hospital or health system with a fragility fracture, which resulted from a fall from standing height or less, and who were managed either as inpatients or outpatients?
Of these, what percentage received an osteoporosis assessment? This question needs to be answered for two groups, ie, those that were assessed with bone mineral density (BMD) measurement by axial dual-energy x-ray absorptiometry (DEXA) scan and those assessed without a DEXA scan.
What percentage received an assessment of fall risk factors, either delivered by an appropriately skilled clinician within an FLS or by referral to a local falls service, or equivalent, operating independently of an FLS?
Of these, what percentage received lifestyle advice relating to osteoporosis, including diet and activity? What percentage received specific medication for osteoporosis, and what percentage received advice and/or intervention to mitigate fall risk for identified risk factors?
The processes for identification, investigation, and initiation of secondary preventive care need to be designed by the stakeholder group. It can be more efficient to establish a subgroup to define draft processes, documentation, and communication mechanisms that can be reviewed and amended by the entire stakeholder group membership. Key considerations will include:
Defining the initial scope of the FLS, eg, inpatients and/or outpatients, patients aged 50 years and older or 65 years and older
Determining how existing IT systems can aid identification of fracture patients, and facilitate ordering of investigations and communication with local primary care providers
Considering the impact of FLS on capacity of local bone densitometry services
Related posts:
2.2 Overcoming barriers to implementation of a care model
2.4 Elements of an orthogeriatric comanaged program
2.3 Clinical practice guidelines
2.9 Use of registry data to improve care
2.5 Adapting facilities to fragility fracture patients
2.6 Orthogeriatric team—principles, roles, and responsibilities
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
