Closing the Gap: Highlighting FLS for Osteoporosis Management

Divya Sistla, MD, FACP, a steering committee member of the Endocrine Society’s Early-Career Special Interest Group (SIG), discusses how the University of Pittsburgh Medical Center uses a multidisciplinary approach to successfully improve osteoporosis treatment via a fracture liaison service.

In the United States, approximately 2 million new cases of osteoporotic fractures are diagnosed annually. This surpasses the combined annual new cases of myocardial infarction, breast cancer, and prostate cancer. Currently, around 319 million individuals are at increased risk of fractures, and this is expected to double within the next few decades. This will result in higher hospital admission rates and economic burden with fracture related healthcare costs projected to exceed $95 billion by 2040.

Thanks to [FLS], awareness of osteoporosis has increased within our hospital, particularly among primary care providers and our internal medicine residents, who handle the majority of outpatient patient care and hopefully now will be even more proactive in identifying and treating this vulnerable patient population.

According to the International Osteoporosis Foundation, 80% of patients who have experienced at least one osteoporosis-related fracture are neither diagnosed nor treated for osteoporosis, highlighting a large gap in care which requires immediate attention.

Osteoporosis Care Gaps

Osteoporotic fractures are associated with increased mortality. Studies show a five- to eightfold increase in mortality risk within the first three months after a hip fracture, with risk being higher for men. There is an elevated risk of a second fragility fracture within the first year of the index fracture.

Despite this data, osteoporosis medication management is suboptimal worldwide. Primary care providers are essential in the early recognition of osteoporosis and associated fragility fractures and the initiation of evidence-based management. Despite their care, treatment rates stay suboptimal due to multifactorial barriers. Concerns about rare but serious adverse effects, such as osteonecrosis of the jaw and atypical femoral fractures, often deter initiation. Clinical inertia further contributes, as providers must balance the complexity of multiple comorbid conditions. Moreover, the asymptomatic nature of osteoporosis until a fracture occurs leads to underestimation of its significant morbidity and mortality, thereby diminishing the urgency of intervention.

Prior to the implementation of a fracture liaison service (FLS) at our institution, the percentage of women receiving osteoporosis treatment within 12 months of a post-fracture was only 8.2% in the first three months prior to 2023, which is close to the national average of 7.1%. At 12 months, only 13.8% of patients were on anti-osteoporosis medication, compared to the national average of 11.9%. A large multinational study involving 86,000 patients across different countries and healthcare systems found that only 11% of U.S. Medicare patients, 39% in Canada, and 25% in other countries filled a prescription for osteoporosis within three months of their first hip fracture.

Expert Recommendations: Fracture Liaison Service (FLS)

The American Society for Bone and Mineral Research recommends that women and men over the age of 65 who sustain a hip or spine fracture be managed through an FLS or a coordinated multidisciplinary team. This model ensures that patients are evaluated for underlying osteoporosis and receive prompt treatment to reduce the risk of subsequent fractures within one to two years.

First developed in the U.K. in the 1990s, the FLS has since become an evidence-based, systematic approach to secondary fracture prevention. It is now implemented worldwide, with major U.S. health systems — including Kaiser Permanente and Massachusetts General Hospital — adopting the model to improve post-fracture care and outcomes. There are several models of FLS — the most basic ones focus on patient education and recommendations to primary providers. However, the advanced FLS models provide comprehensive care that includes diagnosis and prompt treatment. For example, the FLS at Massachusetts General Hospital started incorporating inpatient administration of zoledronic acid, achieving improved treatment rates. Furthermore, studies have proven that inpatient intravenous zoledronic acid leads to significant improvements in bone mineral density compared with placebo, without adversely affecting fracture healing.

Our Experience and Success Story

Since July 2023 at University of Pittsburgh Medical Center (UPMC), we have been successfully operating an FLS under the leadership of our metabolic bone unit director, Diana Pinkhasova, MD. Our dedicated team of endocrinologists — including Karen Selk, DO; Lauren Willard, DO; Sann Mon, MD; Niveditha Manivannan, MD; and myself — works closely with orthopedic surgeons led by Dr. Gele Moloney and her team who identify patients with fragility fractures and places a consult to endocrinology. The multidisciplinary team also includes hospitalist medicine representative, Bhagat Kondaveeti, MD. Our clinical pharmacists and nursing staff also play vital roles in ensuring comprehensive patient care.

The goal of the FLS is to identify patients aged 50 and older with fragility fractures, conduct thorough evaluations, and provide education and treatment. Since July 2023, at our Geriatric Center of Excellence, we have evaluated over 800 such patients, and we have successfully administered in-house intravenous zoledronic acid to approximately 127 of them. Some reasons for delayed or non-treatment include severe vitamin D deficiency, advanced renal disease, or patient refusal. These patients were given follow-up plans with their primary care physicians or endocrinologists, depending on the severity of underlying osteoporosis, need for evaluation of secondary causes, and patient preferences.

This was a new workflow, and our team met several challenges initially. Concerns arose about intravenous zoledronic acid cost, impact on the length of stay, and the need for isolation precautions due to potential drug excretion in urine. Despite the initial barriers, we increased osteoporosis treatment within three months of fracture from 8.2% to 18.1% which is about a 120% increase. This was achieved in just two years’ time. We are now exploring expanding this program to other UPMC sites.

Osteoporotic fractures are associated with increased mortality. Studies show a five- to eightfold increase in mortality risk within the first three months after a hip fracture, with risk being higher for men. There is an elevated risk of a second fragility fracture within the first year of the index fracture.

Our experience proves how a multidisciplinary approach can effectively improve and close the care gap in osteoporosis treatment. We have found the most successful strategy is to evaluate and start treatment promptly following a fragility fracture.

Thanks to this service, awareness of osteoporosis has increased within our hospital, particularly among primary care providers and our internal medicine residents, who handle the majority of outpatient patient care and hopefully now will be even more proactive in identifying and treating this vulnerable patient population.

Sistla is a clinical assistant professor at University of Pittsburgh Medical Center. She practices general endocrinology and obesity medicine. Her clinical research focuses on adrenal pathology, osteoporosis and neuroendocrine. She is passionate about patient safety, quality improvement, and teaching. She is an Endocrine Society Early-Career SIG steering committee member.