Fracture liaison services

Fracture Liaison Services deliver innovative, preventive care that will improve quality and reduce costs through a reduction in unscheduled emergency admissions.

• Why do we need Fracture Liaison Services:

  Osteoporosis care of patients presenting with fragility fractures has been described as “… a Bermuda Triangle comprised of orthopaedic surgeons, primary care physicians and osteoporosis experts, into which the fracture patient disappears.” An audit undertaken amongst UK GPs and orthopaedic surgeons reveals why this happens in the absence of a systematic approach. The majority of orthopaedic surgeons would discharge a patient with a fragility fracture without initiating investigation; the majority of GPs would only trigger an assessment if prompted to do so by the orthopaedic surgeon. Thus a ‘Catch 22’ situation prevails where neither those responsible for fixing the fracture nor those responsible for long-term care initiate assessment. Clearly, many opportunities to prevent further fractures are being missed

• What is a Fracture Liaison Service:

  A Fracture Liaison Service (FLS) is a system to ensure fracture risk assessment, and treatment where appropriate, is delivered to all patients with fragility fractures. An FLS is usually comprised of a dedicated case worker, often a clinical nurse specialist, who works to pre-agreed protocols to case-find and assess fracture patients. An FLS can be based in primary or secondary care and requires support from a medically qualified practitioner, be they a GP with specialist interest or a hospital doctor with expertise in fragility fracture prevention. The structure of a hospital-based FLS is indicated in the diagram below which was adapted from the BOA-BGS Blue Book on the care of patients with fragility fracture

Click on image to enlarge

* Older patients, where appropriate, are identified and referred for falls assessment

• FLS is clinically effective:The hospital-based Fracture Liaison Service model was first developed in the Glasgow University teaching hospitals in 1999. The FLS began operating in November 1999 in West Glasgow and in November 2000 in South Glasgow. During the first 18 months of operation:
  • More than 4,600 patients with fractures of the hip, wrist, upper arm, ankle, foot, hand and other sites were seen by osteoporosis specialist nurses
  • Nearly three-quarters were considered for BMD testing and treatment was recommended for approximately 20% of patients without the need for BMD testing
  • 82% of patients tested were found to be osteopenic or osteoporotic at the hip or spine

  During the first decade of this century well over 50,000 consecutive fracture patients have been assessed by the Glasgow FLS. During this period hip fracture rates in Glasgow have reduced by 7.3% versus almost a 17% increase in England, where even now only 37% of localities operate an FLS. A Scottish national audit compared case ascertainment for hip and wrist fractures in Glasgow versus 5 other centres operating less systematic models of care. Ninety-seven percent of hip fracture and 95% of wrist fracture patients were assessed by the Glasgow FLS versus less than 30% for any other service configuration.

• FLS is cost-effective: In May 2011, a formal cost-effectiveness analysis of the Glasgow FLS was published. This study concluded that 18 fractures were prevented, including 11 hip fractures and £21,000 was saved per 1,000 patients managed by the FLS versus ‘usual care’ in the UK. Given that 300,000 patients present to UK hospitals with fragility fractures every year, this equates to potential savings of £6.3 million per year if FLS was universally available. Economic analyses from the Department of Health and Kaiser Permanente in the United States reported similar findings. Indeed, modelling of the Toronto FLS equivalent model concluded that cost-savings would be achieved within the first year of operation
• National bodies endorse FLS:Professional organisations, patients’ societies and policy makers have all called for universal access to FLS in the UK:
  • Professional organisations: The BOA-BGS Blue Book on care of the patient with fragility fracture is endorsed by all professional organisations involved in fragility fracture care. The Blue Book states:
    “Establishment of an integrated Fracture Liaison Service in every UK hospital, which operates in close collaboration with local general practice, offers the optimal system of healthcare delivery to implement NICE guidance consistently for all patients presenting with fragility fractures.”
    The 2010 Royal College of Physicians national audit of falls and bone health stated:
    “We recommend that all localities commission a Fracture Liaison Service following the best-evidenced models either for acute-based services (e.g. Glasgow) or primary care-based services (West Sussex).”
  • Patients’ societies: The National Osteoporosis Society published Manifestos for each of the UK countries outlining 5 policy priorities, the first of which was:
    “We want a Fracture Liaison Service linked to every hospital that receives fragility fractures in the UK, to ensure that every fragility fracture patient gets the treatment and care they need.”
  • Policy makers: The Department of Health in England’s Prevention Package for Older People stated:
    “(Fragility fracture patients) constitute just 16% of the local population but it is from these clearly identifiable groups that 50% of hip fractures occur. Targeting these groups in primary care and through Fracture Liaison case-finding Services based in hospital provides ready access to those at greatest risk of hip fractures.”
• International bodies endorse FLS: In May 2011, the Fracture Working Group of the International Osteoporosis Foundation (IOF) published an IOF Position Paper on post-fracture co-ordinator-based models of care. This paper highlights Fracture Liaison Services as a model of care that has been proven to clinically and cost-effectively close the secondary fracture prevention gap. The paper concludes:
  “Whether at the level of a local general hospital or a national healthcare system, successful transformation of care relies upon consensus being achieved amongst all players in the multi-disciplinary team that care for fracture patients. As many millions of patients present to hospitals worldwide with fragility fractures every year, the opportunity to improve outcomes is too good to miss.”
• Access to FLS in the UK: The Royal College of Physicians national audit of falls and bone health has reported on access to Fracture Liaison Services since 2005. In Q4-2005, 27% of localities in England, Wales and Northern Ireland had established an FLS. By Q4-2008 this has increased to 29%, despite two consecutive NICE Technology Appraisals on secondary fracture prevention having been published by this time. In May 2011, the Royal College of Physicians national audit reported that still only 37% of localities had established an FLS. Given that the audit had been conducted a year after publication of the Department of Health Prevention Package recommendations on FLS, the RCP national audit group concluded:

“This is perhaps the key finding of this Audit: Only 35% of localities (based on acute hospitals) have a fracture liaison nurse and, by extension, a Fracture Liaison Service (FLS). FLS (is) the best evidenced model for secondary fracture prevention, with potential for cost savings. Establishment of a FLS is the foundation of Objective 2 of the DH Prevention package – the identification and treatment of patients presenting with a first fragility fracture. There has been little increase in the number of sites reporting a fracture liaison nurse since 2008. There is also doubt as to the adequacy of some FLSs, as the number of hours provided to fracture liaison is very low in many sites.”

Policy makers, professional organisations and patient societies all endorse Fracture Liaison Services and call for universal access for all localities in the United Kingdom

The Breaking Point Report provided a snapshot of the current situation for women with osteoporosis in the UK.

Breaking Point described the practical steps that must be taken by healthcare professionals, policy makers and commissioners, as well as the public to prevent avoidable suffering and cost of osteoporotic fractures.