Fracture Liaison Services

A Game-Changer in Osteoporosis and Fracture Prevention 

On behalf of Endocrine Society’s Bone and Mineral Special Interest Group Steering Committee, Vafa Tabatabaie, MD, and Muriel Babey, MD, discuss the importance of fracture liaison services, how they can contribute to an improved quality of life for the patients as well as cost savings for the facility, and why the time to start one is now.

Osteoporotic fractures pose a significant threat to the health and independence of older adults worldwide. Despite advances in medical care, only about 20% of individuals who suffer an initial fragility fracture receive appropriate evaluation and treatment aimed at identification and treatment of osteoporosis and therefore remain at high risk for subsequent fractures.

To close the gap between acute fracture management and long-term treatment of osteoporosis, multiple professional organizations have recommended establishing Fracture Liaison Service (FLS), a proactive and cost-effective approach that has been shown to transform secondary fracture prevention, save costs and improve patient outcomes. 

What Is a Fracture Liaison Service? 

FLS is a patient-centered, coordinated care model designed to identify, assess, and manage patients who have experienced a fragility fracture. FLS programs have gained global recognition as the most effective strategy for preventing future fractures among patients with osteoporosis. The FLS team is typically led by a “champion” physician and includes other healthcare professionals such as nurse practitioners and patient coordinators; the program ensures that patients receive comprehensive and timely evaluation and care tailored to their needs, including patient education on diet and lifestyle improvement, fall prevention, and medication. The FLS model seeks to identify patients who have already suffered a fracture and connect them to appropriate care, rather than waiting for patients to find their way to the right provider. 

Despite abundant evidence in the literature about proven benefits of FLS including reducing the risk of future fractures and associated mortality, enhanced patient education and adherence to treatment, improved health and quality of life, increased healthcare efficiency, and impressive cost saving, the FLS model remains underutilized in many parts of the world. As Napoli, Ebeling and Kiel noted in their recent opinion piece in the New England Journal of Medicine [Napoli N., Ebeling, P.R., Kiel D.P. “Coordinating Multidisciplinary Care — Improving Outcomes after Fragility Fractures.” N Engl J Med 392;2], lack of reimbursement for FLS-related services in the U.S. creates a financial barrier that renders administrators and healthcare leaders unwilling to absorb the initial costs of establishing such service, such as hiring patient coordinators.

“There is no one-size-fits-all when it comes to FLS. Each institution has limitations and strengths; it is important for champions to start somewhere, stay pragmatic and flexible and modify their protocols as they go with the goal of capturing the patients at highest risk for recurrent fracture. FLS is a never-ending QI project.” — Vafa Tabatabaie, MD, is professor of medicine and orthopedics; interim chief, Division of Endocrinology; and director of Fracture Liaison Services at Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y.

It is also possible that FLS champions face uncertainty when trying to decide where to start and which FLS model to adopt. RESTORE (REducing future fractureS and improving ouTcOmes of fRagility fracturE) is a pragmatic randomized clinical trial which proposes to compare two approaches to secondary fracture prevention: enhanced usual care where patients and their primary care providers are provided with bone health educational materials, and augmented FLS, where patients are referred to a local bone health specialist.

The primary outcome is cumulative incidence of new fragility fractures occurring within two years after randomization. The centralized FLS model employed in the RESTORE study provides an alternative framework for future FLS programs and if found to be superior to usual care, will impact quality of fragility fracture care and U.S. healthcare policy, which may result in the Centers for Medicare and Medicaid Services (CMS) beginning to reimburse comprehensive post-fracture care in the U.S. While we await the results of RESTORE to identify which type of FLS practice is more effective and while advocacy efforts for recognizing FLS reimbursement models are ongoing, we turn to Endocrine Society members and beyond to share their experience of establishing successful FLS programs. 

HiROC: FLS at Geisinger

Based in Danville, Pa., Geisinger Health System’s FLS branded High Risk Osteoporosis Clinic (HiROC) uses an in-house consultation model. The initial model was designed so that all patients older than 50 years of age who are admitted with a hip fracture have an inpatient consult by rheumatology to initiate evaluation for osteoporosis and arrange for outpatient follow up.

Thomas Olenginski, MD, rheumatologist and HiROC FLS physician champion notes that over the years, trauma surgeons, hospitalists and emergency room providers started consulting rheumatology for other types of fracture as well. Despite challenges in providing optimal care for this vulnerable population, Geisinger’s FLS team has consistently initiated treatment in about 75% of eligible patients, and more than 50% of patients seen in hospital choose to follow up in clinic post-discharge.

Having documented a roughly 15%, six-month post-fracture mortality rate in all patients, and importantly, 20% in men, Olenginski and his team strive to provide timely post-fracture care and hope their work inspires others to champion the cause of secondary fracture prevention through integrated FLS care.

Serving The Bronx: FLS at Montefiore Einstein

Vafa Tabatabaie, MD, director of FLS at Montefiore Einstein in The Bronx, N.Y., and a member of Endocrine Society’s Bone and Mineral Special Interest Group, established a multidisciplinary FLS program at her institution in 2014. “A few months before graduating endocrine fellowship, I received a consult request from our orthopedic service to see a woman who was admitted with bilateral femoral neck fractures after falling while bowling,” she recalls. “I immediately thought, how come this is the first time I am receiving such a consult request despite knowing many cases of fragility fracture are treated in our institution every day?”

As populations age worldwide, the burden of osteoporotic fractures is expected to increase, including an expected doubling of incidence of hip fractures in the next few decades. While we must strive to detect osteoporosis and prevent fractures before they happen, secondary prevention of fragility fractures is guaranteed to deliver an immediate impact in enhancing health and wellbeing of patients worldwide. – Muriel Babey, MD, assistant professor, adjunct, Division of Endocrinology, Metabolism, and Diabetes, University of California – San Francisco, San Francisco, Calif.

Montefiore Einstein FLS was formed in 2014 as a collaborative effort between orthopedic surgery, geriatrics and endocrinology. Their current protocol involves several arms, including initiation of alendronate at discharge by a consultant geriatrician who co-manages patients admitted with hip fracture. “There is no one-size-fits-all when it comes to FLS,” Tabatabaie says. “Each institution has limitations and strengths; it is important for champions to start somewhere, stay pragmatic and flexible and modify their protocols as they go with the goal of capturing the patients at highest risk for recurrent fracture. FLS is a never-ending QI project.” 

The Future of Fracture Liaison Services 

As populations age worldwide, the burden of osteoporotic fractures is expected to increase, including an expected doubling of incidence of hip fractures in the next few decades. While we must strive to detect osteoporosis and prevent fractures before they happen, secondary prevention of fragility fractures is guaranteed to deliver an immediate impact in enhancing health and wellbeing of patients worldwide.

For individuals who have experienced a fragility fracture, enrolling in an FLS program could be a life-changing step toward stronger bones and a healthier future. As awareness grows, more hospitals and healthcare systems recognize the value of this innovative approach. With continued support from policymakers and healthcare providers, Fracture Liaison Services have the potential to revolutionize osteoporosis care and significantly improve patient outcomes worldwide.

The time to start your FLS is NOW!

Muriel Babey, MD, is assistant professor, adjunct, in the Division of Endocrinology, Metabolism, and Diabetes, at the University of California – San Francisco, San Francisco, Calif.

Vafa Tabatabaie, MD, is professor of medicine and orthopedics; interim chief, Division of Endocrinology; and director of Fracture Liaison Services at Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, N.Y.