Fig. 12.1
An example of a UK hospital-based Fracture Liaison Service
However, despite the proven efficacy of FLS, there remains a chronic insufficiency in the number of established FLS present in countries across the world [12]. In Europe, 19 of 27 countries estimated presence of FLS in less than ten per cent of their institutions [17]. In the Asia Pacific region, nine out of sixteen countries report that 0 % of their hospitals have an FLS [18]. In the remaining seven countries (which include including China, Japan and Australia) the percent of hospitals with an FLS varied between 1 and 25 %. Only Singapore reported widespread establishment of FLS in their hospitals (>50 %) [19]. Importantly, where FLS models are in place, there is a significant variability in service design making it difficult to measure service performance and assess potential for patient benefit [14]. Working from the strategy that setting a standard in health care and measuring services against these standards is a powerful tool to improve patient management, the International Osteoporosis Foundation (IOF) Capture the Fracture® (CTF) programme has developed criteria and standards for secondary fracture prevention. The CTF programme provides standards and assesses FLS against these standards in order to collect homogenous data points and provide consistent measurement of performance worldwide. A study in 2013 showed that the single framework and criteria set are able to benchmark services across the various different health care systems in the world [15].
12.3 How to Implement an FLS
Implementation of an FLS can be seen through four interlinked stages: Establishing secondary fracture prevention as a policy priority; a successful financial proposal; FLS implementation; and FLS improvement and sustainability (Fig. 12.2).
Fig. 12.2
Stages to implement an FLS
The key steps for a successful financial proposal are to determine the medium and long-term benefits of the service for both health and social care systems savings. The benefits require the expected annual number of fragility fractures for the site to be calculated. The numbers who would then be identified, investigated, initiated on therapy and adherent to therapy are then used to estimate the number of fragility fractures avoided. The usual fracture groups are hip fractures, other inpatient fragility fracture patients, patients managed in the trauma outpatient setting and finally vertebral fractures. Such a calculator has been developed in the UK for the National Health Service by the UK National Osteoporosis Society. With the expected number of patients an FLS would see annually and the type model of service delivery for identification, investigation, initiation and monitoring, the resources needed to run the FLS can be derived and also inform the costs of the FLS. The service model for the FLS should be informed by the IOF CTF Best Practice Framework (see below). Following this framework helps ensure the chosen service model works for the patients seen by the FLS. The FLS is likely to require resources for specialist practitioners, administrators, information technology, provision of estates, densitometry, blood investigations and training.
To progress from the initial intention to setup an FLS locally to a competitive business proposal requires in itself careful project management (see table below).
Plan |
Establish a multi-disciplinary FLS project team which will likely include the following individuals in your hospital or health system: |
Lead Clinician for Osteoporosis |
Orthopaedic surgeon with interest in hip fracture surgery |
Geriatrician |
Radiology or nuclear medicine specialists |
Relevant specialist nurses, physiotherapists and Allied Health Care Professionals |
Representative of hospital or health system pharmacy group |
Representative of local primary care physicians |
Representative from hospital or health system administration responsible for new services |
Conduct a baseline audit to establish care gaps for fragility fracture sufferers: |
Number of women and men aged ≥50 years presenting with a fragility fracture |
Proportion of women and men aged ≥50 years receiving post-fracture osteoporosis care in accordance with relevant clinical guidelines (BMD testing and osteoporosis medications) |
Review any data from previous local audits of fragility fracture care |
Design prototype FLS service model to eliminate the management gap: |
Write specific and time-dependent aims and objectives |
Identify how to capture fragility fracture patients |
Write case-finding protocols for the appropriate setting, e.g. inpatient ward, fracture clinic, diagnostic imaging, etc. |
Ensure all members of multi-disciplinary FLS project team endorse the prototype FLS model |
Ensure management protocols are approved by appropriate local and national organisations before FLS clinics are initiated |
Discuss all documentation and communication mechanisms with relevant stakeholders |
Engage hospital or health systems management to fund pilot phase |
Do |
Implement prototype service model |
Collect audit data throughout pilot phase |
Study |
Analyse improvement in provision of care from audit |
Refine prototype service model to improve performance further |
Act |
Implement changes and monitor performance improvement |
Repeat PDSA cycle through continuous ongoing audit and review |
Implementation of an FLS requires careful management. The aim is to optimise the secondary fracture prevention from identification to monitoring in one patient group (e.g. patients presenting to the outpatients or hip fracture patients) and then, when running successfully, extend to other patient groups. Effective project management is key to the success of this phase, and this is a different skill set than skills required to achieve a competitive financial case for funding an FLS. Consideration needs to be given to recruitment and training of staff, as there is often a general paucity of FLS experienced practitioners. There are several national programmes accross the world providing educational courses on secondary fracture prevention and FLS implementation [20]. Additional work may be required to develop clinical pathways where patients will be identified, including arranging DXA scanning, taking blood samples to exclude secondary causes of osteoporosis and increase the scope of FLS based on fractures types starting with hip fracture then incorporating other fracture types (non-hip patients, then outpatients and finally vertebral patients), as illustrated in Fig. 12.3. Once the initial FLS is running, there are several ways to expand it:
Fig. 12.3
Steps to implement an FLS
- (i)
Implement an FLS Centre of Excellence with subsequent expansion to other localities
Have a centre of reference then use it as a model for other centres within the same region/country. The FLS coordinator should act as a country champion and should promote international standards to run an effective FLS.
- (ii)
Gradually increase the intensity of the FLS model from Type B (2i) model to Type A (3i)
In 2013, a systematic review on post-fracture models of care provided a useful framework for classification [13]. FLS models were classified according to their level of identification, investigation and initiation (called the 3i’s) of fragility fracture patients and were summarized in four types from A-D. Type A models deliver the 3 i’s; Type B models deliver the 2 i’s (identification and investigation); Type C models deliver 1 i (identification); Type D models are the lowest level when no proactive case-finding occurs. The more intensive the models of post-fracture care are, then the more effective they become. A Type B model can be easily expanded to a Type A model within the same infrastructure. The Ganda systematic review reported that FLS significantly reduces repeat fracture rates [13].
- (iii)
Enhance the intervention based on patient identification from regional/provincial healthcare administrative databases or other electronic medical record systems
Find cases of vertebral fractures through diagnostic imaging. Vertebral fractures are associated with a 2–5 fold increase in future fracture risk reducing quality of life and increased morbidity and mortality [21–23]. They are the least diagnosed fractures in terms of osteoporosis assessment and treatment [24–26]. A significant number of individuals undergo diagnostic imaging in hospitals for conditions other than osteoporosis. This presents an opportunity for case-finding of vertebral fractures [27].
- (iv)
Implement a region wide Type A (3i) model of FLS
This is the fastest way to expand: from the outset to maximise health gains in the shortest time-frame possible
- (a)
Sustaining an FLS.
Sustaining an FLS requires regular reviews of the number of patients identified, time to assessment, treatment rates for bone and falls interventions, time to monitoring assessments for bone and falls events and interventions, participant satisfaction and experience questions and participation in national and/or international peer review and/or audit programmes.
- (a)
12.4 Capture the Fracture® Programme
12.4.1 Description
To support and promote the use of effective models of care across the globe, the IOF launched the CTF programme at the IOF European Congress on Osteoporosis and Osteoarthritis in Bordeaux, France in March 2012. This expert-led and evidence-based programme aims to reduce secondary fractures by facilitating the implementation of FLS on a global level. A primary resource developed by CTF is the Best Practice Framework (BPF), which sets standards for FLS, serves as a benchmark for existing FLS and serves as a guidance tool for developing an effective FLS [15]. In an effort to engage the global medical community, CTF offers a Best Practice Recognition programme where FLS can submit their service to IOF for evaluation against the BPF standards in order to receive a gold, silver or bronze star in recognition of achievements. The FLS is then included in the showcase of best practice and plotted on the CTF Map of Best Practice that displays participating FLS and their respective achievement level (Fig. 12.4). To influence change, the map can be used as a visual representation of FLS available worldwide, their achievements, as well as the areas for opportunity and development in secondary fracture prevention.
Fig. 12.4
CTF Map of Best Practice
12.4.2 Best Practice Framework (BPF)
The BPF has been developed by a steering committee and shaped by input from leaders of established FLS throughout the world. It has developed internationally endorsed standards for best practice, will facilitate change at the national level to ensure FLS models are effective and work for their local population as well increase awareness of the challenges and opportunities presented by secondary fracture prevention to key stakeholders. The BPF sets an international benchmark for FLS, which defines essential and aspirational elements of service delivery and serves as the measurement tool for IOF to award ‘Capture the Fracture® Best Practice Recognition’ in celebration of successful FLS worldwide. The 13 globally-endorsed standards of the BPF are detailed below [15]:
12.4.2.1 Standard 1: Patient Identification
Fracture patients within the scope of the institution (inpatient and/or outpatient facility or health-care system) are identified to enable delivery of secondary fracture prevention. The intention of this standard is to ascertain the route by which fracture patients are identified. The standard recognises that some institutions will manage just inpatients, some will manage just outpatients and others will manage both in- and outpatients.
12.4.2.2 Standard 2: Patient Evaluation
Identified fracture patients within the scope of the institution are assessed for future fracture risk. The intention of this standard is to determine what proportion of all patients presenting to the institution or system with a fracture are evaluated for future fracture risk. As for the other standards, it is clear that some institutions will just manage inpatients, some will manage just outpatients and others will manage both in and outpatients. The standard recognises circumstances when the best practice is to bypass fracture evaluation and go straight to treatment protocols (e.g. for patients who are over 80 years old).
12.4.2.3 Standard 3: Post-fracture Assessment Timing
The post-fracture assessment for secondary fracture prevention is conducted in a timely fashion after fracture presentation. Timing of when subsequent fracture risk assessment is done is crucial. The assessment can performed by any qualified provider but must be tracked by the FLS coordinator and must contain appropriate post fracture assessment elements such as bone density testing, risk assessment or other assessment procedures relevant to the patient. This is to ensure a formal fracture risk assessment has been done.
12.4.2.4 Standard 4: Vertebral Fracture
The institution has a system whereby patients with previously unrecognised vertebral fractures are identified and undergo secondary fracture prevention evaluation. The majority of vertebral fractures are unrecognised or undetected. The aim of this standard is to encourage the establishment of systems to identify vertebral fractures amongst patients presenting and/or admitted to the institution for any condition. Knowledge of vertebral fracture status in addition to bone mineral density (BMD) has been shown to significantly improve fracture risk prediction for secondary fractures.
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