Improvements needed in the standard of care
Improved outcomes







According to the World Health Organisation, osteoporosis is characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. The disease presents clinically as fractures that occur at any site in the skeleton and typically occur with minimal trauma.

Fragility fractures are indicators of osteoporosis, and as such all patients with low-trauma fractures should be considered for further investigation for osteoporosis and, if confirmed, started on osteoporosis medication.1

In 2010, the Royal College of Physicians (RCP) audited the quality of the clinical care delivered to patients who had fallen and fractured a bone and had been seen in a hospital emergency department (A&E). Only 32% of patients with a non-hip fracture received an adequate fracture risk assessment and just 28% were established on anti-osteoporosis medications within 12 weeks.2

As a result the Department of Health incentivised primary care services to initiate these treatments for relevant patients, but by the end of the first year of this scheme, fewer than one in five patients were receiving the treatments.

It was agreed that good clinical practice for these patients would require a systematic approach that encompasses case finding, assessment, initiation and monitoring of treatment—a fracture liaison service (FLS).

Fracture liaison services are coordinator-based models of secondary fracture prevention services, designed to identify patients at increased risk for secondary fractures and to ensure the patients initiate appropriate treatment via improved care coordination and communication.3

The aim is to:

  • Close the care gap for fracture patients, 80% of whom are currently never offered screening and/or treatment for osteoporosis
  • Enhance communication between healthcare providers by providing a care pathway for the treatment of fragility fracture patients.4

In 2013, the International Osteoporosis Foundation (IOF) initiated the promotion of FLS programmes worldwide. This was based on the findings of the Fracture Working Group of the Committee of Scientific Advisors of the IOF. It published a position paper on coordinator-based systems for secondary prevention in fragility fracture patients and consolidated knowledge of the development, effectiveness and common factors that underpin successful clinical systems designed to close the secondary fracture prevention care gap.5

However, literature suggests that there are varied outcomes from the models of care that are in place to take responsibility for this investigative and treatment process.4

A recent study found that implementation of FLS across the UK and globally is increasing although by no means is there universal coverage. There is also growing awareness that FLS is becoming a ‘standard of care’ and not an optional extra. To ensure maximum benefit to patients and payers alike, it is important that the model of FLS delivery addresses appropriate clinical quality standards and metrics, but according to the study there is more work to do in terms of identification of vertebral fractures.6

Authors concluded that the most powerful lesson learned from developing FLS is the value of effective partnership working between charitable organisations, healthcare professionals and government bodies. This collaborative working has allowed rapid development and implementation of FLS, addressing the varying agendas and needs of patients, healthcare providers, commissioners and health and social care planners.6


Improvements needed in the standard of care

A new report from the RCP this year also found that improvements are still required in the standard of care for patients with fragility fractures.2

The audit is the first annual review into identification, assessment, treatment and monitoring of patients over 50 years who have experienced a fragility fracture—fractures occurring as a result of normal activities, such as a fall from standing height or less. The review measured services against guidance and standards set by the National Osteoporosis Society and NICE.

The key finding was that there was a marked variability in access to and the quality of care provided by these services, depending on where patients lived.

Less than a quarter of FLS were able to assess over 95% of patients within 90 days, and 28% of FLS saw less than half of patients in the same time frame. Only 41% of patients who were prescribed anti-osteoporosis medication were monitored by 12-16 weeks post fracture.

More positively, the report found 40% of patients were now receiving a falls assessment across all FLS, compared to the previous figure of 32% from 2010.

Authors of the report said more work is needed to improve monitoring, and called on clinical commissioning groups without an FLS to “actively” work with local NHS staff to develop, fund and implement a service.

Other findings were:

  • Overall, 67% of patients were assessed by an FLS within 90 days of their fracture.
  • In total, 43% of patients were assessed with a DXA scan within 90 days of their fracture.
  • Monitoring remains an issue. Although there has been an improvement, only 41% of patients who were prescribed anti-osteoporosis medication had monitoring contact documented within the audit.

Recommendations from the audit are that all FLSs should submit data to the FLS database. NHS foundation trusts are required to participate in National Clinical Audit and Patient Outcomes Programme (NCAPOP) audits that are relevant to the services that they provide as part of their NHS contract. Those services that are not currently participating should implement an urgent action plan to address this.


Improved outcomes

The lack of variability is a concern given results of a meta-analysis published this month that found that FLS programmes improved outcomes of osteoporosis-related fractures and reductions in re-fracture incidence and mortality.2

Adults with osteoporosis who received care from a FLS programme were also more likely to undergo bone mineral density (BMD) testing and initiate and adhere to osteoporosis treatment versus adults receiving usual care, according to study findings.3

The study analysed data from 16 randomised controlled trials and 58 observational studies conducted in adults with osteoporosis aged at least 50 years between January 2000 and February 2017.

Studies assessed patients with osteoporosis-related fractures in a hospital, clinic, community or home-based setting, managed using either a FLS programme or usual care. Researchers assessed measurement of BMD at any site, treatment initiation, adherence to treatment, the incidence of refracture and rates of all-cause mortality.

Key findings were:

  • In the 37 studies that reported on BMD testing, researchers found that unweighted average rates of BMD testing were 48% in the FLS arms and 23.5% in the usual care arms, with follow-up periods ranging from 3 to 26 months.
  • In a meta-analysis, patients who participated in FLS interventions were more likely to undergo BMD testing versus controls (absolute risk increase, 0.24; 95% CI, 0.18-0.29), with results persisting in separate analyses of randomised controlled trials and observational studies.
  • In 46 studies reporting on osteoporosis treatment initiation rates, FLS interventions were associated with a 20% higher absolute risk increase in treatment initiation rates versus control arms (95% CI, 0.16-0.25).
  • In 25 studies assessing adherence to osteoporosis treatment, researchers found that FLS interventions were associated with a 22% higher absolute risk increase in adherence to medication (95% CI, 0.13-0.31), with follow-up ranges of three to 48 months across studies.
  • In 11 studies evaluating rates of refracture, FLS interventions were associated with a 5% reduction in absolute risk for refracture versus usual care (95% CI, –0.08 to –0.03; number needed to treat = 20), with follow-up ranges of six to 72 months.
  • Mortality among patients in a FLS intervention was reduced by 3% compared with usual care (95% CI –0.05 to –0.01).



The implementation of fracture liaison services is important to improve outcomes of osteoporosis-related fractures and to reduce the disease burden of osteoporosis.


Alison Bloomer, Managing editor, GM

Conflict of interest: none declared.



1. Walters S, Khan T, Ong Tand, Sahota O. Fracture liaison services: improving outcomes for patients with osteoporosis Clin Interv Aging 2017; 12: 117–27


3. Wuab CH, Tuc ST, Chang YF, et al. Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: A systematic literature review and meta-analysis. Bone 2018; 111: 92-10


5. Marsh D, Akesson K, Beaton DE, et al; IOF CSA Fracture Working Group. Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int. 2011; 22(7): 2051–65

6. Shipmana K, Doyle A, Ardenb H, et al. Development of fracture liaison services: What have we learned? Injury 2017; 48(7): S4–S9