Fracture liaison services: improving outcomes for patients with osteoporosis

Figures & data

Table 1 Summary of evidence presented on fracture risk reduction in FLSs

Author (years)	Study design	Study participation	FLS type	Comparison	Outcome
Lih et al^Citation33 (2011)	Prospective controlled intervention study	Age >45 years + minimal trauma fracture (non-vertebral)	A	Primary care follow-up	Reduced re-fracture rate in FLS: HR 5.63, 95% CI 2.73–11.6, P<0.01 for re-fracture in GP group
Van der Kallen et al^Citation34 (2014)	Prospective –questionnaires	Age >50 years + minimal trauma fracture	A	Patients not attending follow-up clinic	Reduced re-fracture rate: 5.1% vs 16.4%, P<0.001
Dell et al^Citation38 (2008)	Prospective cohort study using service data of 11 medical centres	Age >60 (all), or age >50 + fragility fracture/DXA scan/on osteoporosis treatment	A	Against previous performance	Reduced re-fracture rate: average 37.2% (range 23.1%–60.7%)
Greene and Dell^Citation28 (2010)	Prospective cohort study using service data	Age >60 (all), or age >50 + fragility fracture/DXA scan/on osteoporosis treatment	A	Against previous performance	38.1% reduction in hip fractures compared to expected figures
Nakayama et al^Citation40 (2016)	Historical cohort study	Age >50 years + minimal trauma fracture	A	Hospital without FLS	Reduced re-fracture rate: HR 0.67, 95% CI 0.47–0.95, P=0.025
Huntjens et al^Citation41 (2014)	Retrospective cohort study	Age >50 years + non-vertebral fracture	A	Hospital without FLS	Reduced re-fracture rate, in time-dependent fashion. After 1 year: HR 0.84, 95% CI 0.64–1.10. After 2 years: HR 0.44, 95% CI 0.25–0.79
Astrand et al^Citation42 (2012)	Retrospective –questionnaires	Age 50–75 years + wrist/proximal humerus/vertebral/hip fracture	B	Historic cohort (same hospital)	Reduced re-fracture rate: HR 0.58, 95% CI 0.40–0.87
Solomon et al^Citation43 (2007)	Randomized controlled trial	Age >65 years, prior fracture or glucocorticoid usage	C/D	4 arms: C, D, modified C, usual care	No difference between the groups in terms of re-fracture

Notes: FLS type [37] A – Service which identifies, investigates and initates treatment; Type B – Service which identifies and investigates but refers patients back to their primary care physician to initiate treatment; Type C – Service which identifies patients at risk and informs their primary care physician to undertake the appropriate assessment and treatment; Type D – Service which identifies at risk patients and only inform and educate the at-risk patient.

Abbreviations: CI, confidence interval; DXA, dual energy X-ray absorptiometry; FLS, fracture liaison service; GP, general practitioner; HR, hazard ratio.

Table 2 Summary of evidence presented on bone health assessment initiated by FLSs

Author (years)	Study design	Study participation	FLS type	Comparison	Outcome
Murray et al^Citation45 (2005)	Retrospective comparison study – patient questionnaire	Age >50 years + proximal humerus/first intracapsular hip fracture	A	Different hospital with no FLS	Improved DXA scanning: humeral fractures: 85% vs 6%; hip fractures: 20% vs 9.7%
Majumdar et al^Citation23 (2007)	Randomized controlled trial	Age >50 years + hip fracture	A	Same hospital, usual care (included education)	Improved BMD testing: 80% vs 29%, adjusted OR 11.6, 95% CI 5.8–23.5, P<0.001
Majumdar et al^Citation46 (2008)	Randomized controlled trial	Age >50 years + wrist fracture	C (included GP reminders)	Same hospital, usual care (education)	Improved BMD testing: 52% vs 18%, RR 2.8, 95% CI 1.9–4.2, P<0.001
van Helden et al^Citation25 (2007)	Retrospective comparison study	Females >50 years + new fracture	A – Nurse case-finds in ED	5 other hospitals, usual care	Improved DXA scanning: 71% vs 4%, RR 11, 95% CI 3.6–35.1
Ruggiero et al^Citation47 (2015)	Prospective	Age >65 years + proximal femoral fracture	A	Historic cohort (same hospital)	Improved DXA scanning: 47.62% vs 14.53%, P<0.0001
Cosman et al^Citation31 (2016)	Prospective – patient questionnaires	Age >50 years + rehabilitation following hip fracture	A	Historic cohort (same hospital)	Improved DXA scanning: 65% vs 35%
Dell et al^Citation38 (2008)	Usage data since service implementation (11 medical centers)	All patients classed as high risk.	A	Against previous performance	DXA scanning: 247% over first 4 years, 263% over first 6 years
Greene and Dell^Citation28 (2010)		Age >60 years; or age >50 years + previous fragility fracture/have had a previous DXA scan/on osteoporosis treatment
Axelsson et al^Citation55 (2016)	Retrospective	Age >50 years + fracture of hip/vertebra/pelvis/shoulder/wrist	B	Historic cohort (same hospital)	Improved DXA scanning following FLS: 39.6% vs 7.6%
Hawker et al^Citation48 (2003)	Matched cohort study. Followed up by telephone after 3 months	Age >40 years + fracture of wrist/hip/ankle/vertebra/humerus	C	Same clinics, usual care	DXA scanning more likely following contact with service: OR 5.22, P<0.0001
Solomon et al^Citation43 (2007)	Randomized controlled trial	Age >65 years + prior fracture/glucocorticoid usage	C/D	4 arms: C, D, modified C, usual care	No difference between the groups in terms of numbers of DXA scans performed
Bliuc et al^Citation49 (2006)	Randomized study	Minimal trauma fractures	D with the offer of free DXA	D without DXA offer	Improved DXA scanning when offered free alongside education: 38% vs 7%, P=0.001
Kuo et al^Citation32 (2007)	Retrospective comparison study	Minimal trauma fractures	B	D	Improved DXA scanning following type B service: 83% vs 26%
Wallace et al^Citation50 (2011)	Two-center retrospective comparison	Females >75 years + neck of femur fracture	B	Usual care	Improved documentation of osteoporosis risk factors with FLS: 83% vs 7%

Notes: FLS type [37] A – Service which identifies, investigates and initates treatment; Type B – Service which identifies and investigates but refers patients back to their primary care physician to initiate treatment; Type C – Service which identifies patients at risk and informs their primary care physician to undertake the appropriate assessment and treatment; Type D – Service which identifies at risk patients and only inform and educate the at-risk patient.

Abbreviations: BMD, bone mineral density; CI, confidence interval; DXA, dual energy X-ray absorptiometry; ED, emergency department; FLS, fracture liaison service; GP, general practitioner (primary care physician); OR, odds ratio; RR, relative risk.

Table 3 Summary of evidence presented on treatment initiation by FLSs

Author (years)	Study design	Study participation	FLS type	Comparison	Outcome
Majumdar et al^Citation23 (2007)	Randomized controlled trial	Age >50 years + hip fracture	A	Same hospital, usual care (included education)	Increased prescription of bisphosphonates: 51% vs 22%, adjusted OR 4.7, 95% CI 2.4–8.9, P>0.01
Majumdar et al^Citation46 (2008)	Randomized controlled trial	Age >50 years + wrist fracture	C (included GP reminders)	Same hospital, usual care (education)	Increased prescription of bisphosphonates: 22% vs 7%, adjusted RR 2.6, 95% CI 1.3–5.1, P=0.008
Van der Kallen et al^Citation34 (2014)	Prospective–questionnaires	Age >50 years + minimal trauma fracture	A	Patients not attending follow-up clinic	Increased treatment rate: 81.3% vs 54.1%, P<0.01
Murray et al^Citation45 (2005)	Retrospective comparison study – patient questionnaires	Age >50 years + proximal humerus/first intracapsular hip fracture	A	Different hospital with no FLS	Increased treatment rate: 85% vs 20% – hip fractures, 50% vs 37% – humeral fractures
Ruggiero et al^Citation47 (2015)	Prospective	Age >65 years + proximal femoral fracture	A	Historic cohort (same hospital)	Increased initiation of treatment: 48.51% vs 17.16% (P<0.01)
Axelsson et al^Citation55 (2016)	Retrospective	Age >50 years + fracture of hip/vertebra/pelvis/shoulder/wrist	B	Historic cohort (same hospital)	Increased treatment rate: 31.8% vs 12.6%
Wallace et al^Citation50 (2011)	Two-center retrospective comparison	Females >75 years + neck of femur fracture	B	Usual care	Increased treatment rate: 90.5% vs 60.9%, P<0.01
Solomon et al^Citation43 (2007)	Randomized controlled trial	Age >65 years + prior fracture/glucocorticoid usage	C/D	4 arms: C, D, modified C, usual care	No difference between the groups in terms of treatment

Notes: FLS type [37] A – Service which identifies, investigates and initates treatment; Type B – Service which identifies and investigates but refers patients back to their primary care physician to initiate treatment; Type C – Service which identifies patients at risk and informs their primary care physician to undertake the appropriate assessment and treatment; Type D – Service which identifies at risk patients and only inform and educate the at-risk patient.

Abbreviations: CI, confidence interval; FLS, fracture liaison service; GP, general practitioner (primary care physician); OR, odds ratio; RR, relative risk.

Table 4 Official publication from professional organizations and stakeholders on fragility fracture management and FLSs

Organization	Years	Report/campaign	Summary
The National Institute for Health and Care Excellence (NICE)	2012	Clinical Guideline 146: osteoporosis: assessing the risk of fragility fracture^Citation75	Describes recommended methods of assessment of risk of fragility fractures.
Department of Health	2009	Falls and fractures: effective interventions in health and social care^Citation64	Describes key targets in treatment and prevention of falls and fractures. “Objective 2” describes the role of FLSs in acute and primary care.
	2009	Fracture prevention services: an economic evaluation^Citation63	Reports findings of an economic model that equates to possible national savings of £8.5 million over 5 years, as a result of secondary fracture prevention.
British Orthopaedic Association (BOA)	2007	The Care of Patients with Fragility Fracture (“The Blue Book”), in collaboration with the British Geriatrics Society^Citation76	Outlines the problems associated with osteoporosis and fragility fractures, focusing on treatment of hip fractures and collaboration with inpatient geriatric care. Section 2.2 discusses the proposed role of FLS.
	2014	British Orthopaedic Association Standards for Trauma (BOAST) 9: Fracture Liaison Services^Citation77	Advocates implementation of FLS, suggests inclusion criteria and outlines 11 standards expected of FLSs.
International Osteoporosis Foundation (IOF)	2012	Capture the Fracture^Citation7	Defines the problem of osteoporosis and fragility fractures and reports early results from pioneering FLSs worldwide.
	2013	Best Practice Framework^Citation65	Provides standards and framework for regulation and objective assessment of FLSs.
	2014	International Fracture Liaison Service Toolkit^Citation78	Outlines the evidence justifying the need for FLS, how to implement and plan an FLS and guidance about wider implementation on a national level.
	2014	“Love Your Bones” Campaign^Citation79	Patient-orientated e-newsletter and campaign aimed at increasing awareness and uptake of available services.
National Osteoporosis Society (NOS)	2015	Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services^Citation66	Describes the need for FLS and the 5IQ model to achieve fracture prevention (identify, investigate, inform, intervene, integrate, quality).
	2015	Fracture Liaison Service Implementation Toolkit^Citation80	Online toolkit designed to help with setting up an FLS.
	2015	“Stop At One” Campaign^Citation81	Public-facing website aimed at improving awareness and increasing uptake of investigations and treatment.
Royal College of Physicians (RCP)	2013	Falls and Fragility Fracture Audit Programme (FFFAP)^Citation82	National clinical audit to assess the care received by patients with fragility fractures and inpatient falls, comprising National Hip Fracture Database, Fracture Liaison Service Database and National Audit of Inpatient Falls.
	2015	Fracture Liaison Service Database (FLS-DB)^Citation67	National audit to evaluate assessment and treatment of osteoporosis and falls. Composed of 2 components: facilities audit to determine what structures and policies are in place and a patient audit for existing FLSs to determine patient outcomes. The first report is expected in Spring 2017.
American Orthopaedic Association (AOA)	2009	Own the Bone^Citation83	Web-based publicly accessible program that allows entry of anonymized data into a registry and provides 10 specific prevention measures.
The American Society for Bone and Mineral Research (ASBMR)	2012	Making the First Fracture the Last Fracture: ASBMR Task Force Report on Secondary Fracture Prevention^Citation84	Publication in the Journal of Bone and Mineral Research, outlining the need for secondary prevention of fragility fractures and implementation of FLS.
National Bone Health Alliance (NHBA) (USA)	2013	Fracture Prevention Central (FPC)^Citation85	Online toolkit to help with setting up and running an FLS.
European Union Geriatric Medicine Society (EUGMS)	2016	A comprehensive fracture prevention strategy in older adults: EUGMS statement^Citation86	Position paper by the Interest Group on Falls and Fracture Prevention of the EUGMS, outlining existing evidence and advocating the need for a comprehensive and multidisciplinary fracture prevention strategy.

Abbreviation: FLS, fracture liaison service.

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