The development of regional fracture liaison services

Fracture Liaison Services (FLS) are healthcare programmes designed to identify and manage patients at risk of secondary fractures following an initial osteoporotic fracture. They aim to improve patient outcomes through systematic assessment, treatment initiation, and ongoing monitoring to prevent future fractures. Renowned consultant orthopaedic surgeon Mr Andrew Gray further discusses the development of regional fracture liaison services in the UK.

Fracture Liaison Services (FLS) medically and physically optimise patients, thereby reducing the risk of secondary fractures following fragility-related fractures. An FLS model involves a dedicated team of professionals from various allied specialities who concentrate on managing osteoporosis and preventing further falls and fractures in at-risk patients.

DEXA and FRAX assessments are commonly used methods for diagnosing osteoporosis and estimating the likelihood of recurrent falls and fractures, respectively. FLSs are crucial because they address the fracture gap that often occurs after a secondary fracture, where the patient was already at risk of osteoporosis but did not receive timely intervention. This gap increases the unnecessary risk of further fractures, exacerbating pain, dysfunction, and loss of independence.

An efficient and cost-effective FLS is essential within our financially constrained NHS. Justifying funding to key stakeholders can be challenging, especially within the fragmented and often non-cohesive approach to fracture management and secondary fracture prevention. The Fragility Fracture Network (FFN) proposes a solid "four pillars" strategy for the success of any FLS.

The four pillars are as follows:

1. Multidisciplinary acute care/ improved surgical care and mortality.
2. Rehabilitation.
3. Acute care/ falls and bone health.
4. Holistic care.

The first pillar, "Improved surgical care and mortality," focuses on enhanced anaesthetics and surgical care, resulting in better outcomes and standardised practices that improve mortality rates. This is complemented by early orthogeriatric assessment, a multidisciplinary team-based approach that improves intervention and surgery for those at high fracture risk. However, less than 20% of all fragility fractures are formally diagnosed, and patients are not consistently referred for bone mineral density scans. Therefore, care needs to be more universally adhered to.

Effective rehabilitation post-injury is central to Pillar 2, entitled “rehabilitation” which focuses on follow-up care for secondary fractures. Pillar 3, entitled "falls and bone health," builds upon Pillar 2 by enhancing outcomes and introducing new prevention strategies to stabilise patients with fragility fractures.

When establishing an FLS, a thorough understanding of the region and its service demands is crucial. This includes considerations of the catchment area, access to services, and population characteristics. This applies to both FLS completions for patients aged 18 and over within NHS Trust areas, where approximately 50% of fractures were successfully assessed. Fractures were referred to the FLS from two primary sources: either through the fracture clinic or the emergency department.

Patients with more severe osteoporotic fractures requiring hospitalisation were also included in the programme. These patients underwent assessment and received treatment, focusing on osteoporosis management and secondary pain prevention. Importantly, this treatment was meticulously tracked, monitored, and effectively integrated back into primary care to ensure the implementation of recommended strategies.

The service was led by doctors primarily based in secondary care. They implemented a standardised, evidence-based approach tailored to their area, focusing on identifying, reviewing, and reassessing patients. While orthopaedic surgeons were encouraged to participate in the FLS structure, final decisions typically rested with the consultant overseeing osteoporosis treatment.

Central to the service's success was the formation of a multidisciplinary hospital team comprising geriatricians, nurses, orthogeriatric specialists, and other relevant disciplines, with a strong emphasis on managing secondary hip fractures. Comprehensive audit and data capture were integral to operations.

During the initial 12 months, the service assessed 1,400 follow-up fracture patients, achieving a higher proportion of wrist and hip fracture assessments compared to other regions lacking similar services. Demonstrating cost-effectiveness, the FLS prevented 18 fractures per 1,000 patients managed, resulting in significant savings for the local health authority.

This streamlined model thrived due to clear role definitions and a committed steering committee. Objectives were SMART (specific, measurable, achievable, realistic, time-bound), ensuring effectiveness and accountability.

In developing a regional FLS, improvements over existing services were crucial. The initiative aimed for coordinated and efficient fragility fracture prevention, utilizing tools like DEXA and FRAX for assessing and clinically modifying secondary fracture risks. Integration with GPs facilitated continuous monitoring of patients.

Successful outcomes hinged on building strong relationships with key stakeholders aligned with NHS strategies. Understanding local demographics and osteoporosis prevalence guided effective service implementation and secondary prevention strategies.

Embracing change and continuous improvement were pivotal. Innovation based on best practices and stakeholder insights fostered adaptive processes and explored new possibilities. Rigorous testing of assumptions ensured practical effectiveness, while automation streamlined patient management and reduced workforce pressures.

Collaborative multidisciplinary strategies, supported by agreed assessment and management protocols, ensured cohesive care delivery across all stakeholders.

A well-established FLS service identifies at-risk osteoporosis patients, provides necessary care and prevention measures, and achieves effective outcomes through rigorous monitoring and auditing. Understanding regional fragility fracture risks is critical to optimising health gains.

If you would like to book a consultation with Dr Gray, do not hesitate to do so by visiting his Top Doctors profile today.

References:

Dreinhoefer KE, Mitchell PJ, Bégué T, et al. "A global call to action to improve the care of people with fragility fractures". Injury. 2018;49(8):1393-1397.

McLellan AR, Gallacher S, Fraser M, McQuillian C. "The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture." Osteoporosis Int. 2003;14(12):1028-1034.