The development of regional fracture liaison services

Andrew Gray

Fracture Liaison Services (FLS) medically and physically optimise patients thus reducing the risk of secondary fracture after fragility related fractures. Any FLS model involves a committed team of individuals from a range of allied specialties who focus on managing osteoporosis and preventing further falls and fractures in at risk patients.

DEXA or FRAX assessments are the commonly used tools that diagnose osteoporosis and identify the likelihood of recurrent falls and fractures respectively. FLSs are important because they identify the treatment gap that often occurs after osteoporotic fractures where there is frequently a lack of investigation and treatment intervention post injury. This results in a higher (and unnecessary) risk of sustaining further fractures with the associated exacerbation of pain, dysfunction and loss of independence.

Any FLS needs to be efficient and cost effective within our financially restricted NHS. The challenge of justifying the funding to key stakeholders is constant. Ideally, the treatment pathway is streamlined and smooth from acute fracture management through to a secondary fracture prevention plan. The Fragility Fracture Network (FFN) in its 2018 global ‘call to action’ [1] describes this pathway in terms of the ‘four pillars’, (Figure 1). As orthopaedic surgeons we lead and are mostly involved in ‘Pillar 1’ based around acute fracture management, ensuring gold standard surgical care in terms of timing and type that best enables immediate mobilisation. This is concurrent with early orthogeriatric assessment that is essential in minimising the morbidity and early mortality after major osteoporotic fracture. Hip fractures have been central to this in recent years – however they form only 20% of all fragility fractures and therefore these standards of care need to be more universally applied.

Figure 1: The ‘four pillars' of Fragility Fracture Care.

Effective rehabilitation after injury is central to ‘Pillar 2’ with secondary fracture prevention the mainstay of ‘Pillar 3’ whilst the key aspects of ‘Pillar 4’ are the management of local and national policies that can influence and improve the fragility fracture pathway.

When setting up an FLS or improving an existing one there is much to consider in terms of standardising and streamlining the service. The original FLS model designed in Glasgow [2] was simple and did not over complicate, (Figure 2). It is worth revisiting 25 years after its initiation in 1999. Fractures were referred to the FLS via set routes either through the fracture clinic or the emergency department.

Figure 2: Simple fracture liason services (FLS) model.

In-patients with more severe osteoporotic fractures that required hospital admission were also recruited. The patients were then assessed and treated with categories of treatment that involved treatment of osteoporosis and education and falls prevention. Importantly this treatment plan was then communicated effectively back to primary care to implement the recommendations made.

Important aspects to consider with this model were: a. In the first 18 months, 4,600 fragility fracture patients were assessed. b. 20% of that patient cohort were started on osteoporosis treatment without BMD testing. c. 75% had bBMD testing of which 80% were found to need treatment – a high pick-up rate with good specificity and sensitivity.

1. It was a doctor light service primarily delivered by clinical nurse specialists who worked with pre-agreed, standardised and evidence-based protocols. They identified, recruited, and assessed the patients.

2. Although orthopaedic surgeons were encouraged to engage, the ‘FLS champions’ tended to be the consultant endocrinologists with a proven interest in treating osteoporosis.

3. Critical to success was the establishment of multidisciplinary stakeholder groups representing all hospital specialities, local primary carers, and the regional health authority groups, i.e., the people who controlled finance and had influence.

4. Audit and data capture was complete.

   a. In the first 18 months, 4,600 fragility fracture patients were assessed.

   b. 20% of that patient cohort were started on osteoporosis treatment without BMD testing.

   c. 75% had bBMD testing of which 80% were found to need treatment – a high pick-up rate with good specificity and sensitivity.

5. During the first 10 years, 50,000 consecutive patients were assessed by this FLS. During that time hip fractures were reduced by 7% versus an increase of 17% in other parts of the UK where local health authorities had not implemented an FLS – an improvement in Glasgow, a city that contains some affluent areas but also some of the poorest and deprived areas in the country.

6. A far higher proportion of wrist and hip fractures were assessed and treated when compared to other areas of the country that did not have a similar service.

7. Cost-effectiveness was demonstrated – for each 1,000 patients managed by the FLS, 18 fractures (11 hip fractures) were prevented with a significant cost saving to the local health authority.

This simple model was successful because there was a defined team and people who knew their specific roles. There was also an accessible and defined population that could be recruited. The FLS goals and objectives were SMART: Specific, Measurable, Achievable, Realistic and Time dependent.

In developing a regional FLS the product needs to be an improvement upon what already exists. It should identify a high proportion of patients who have sustained a fragility fracture and assess them in a cost effective and time efficient manner using DEXA and FRAX only as needed. Effective multi-modality treatment can then be initiated. Importantly it should have the tools and capability to follow-up and monitor patients.

With any clinical service there are key steps to success in terms of setting up and evolving the service. Firstly, you need to know the important steps in your pathway and be able to monitor their relative impact because any pathway is only as strong as its weakest link. For example, an FLS may be strong at identifying and recruiting patients but if the processes are not in place to investigate and treat patients effectively then the system fails.

Harness and use data. Data trumps opinion but do not get swamped by it. Data should be validated but only the relevant, worthwhile information that will influence improvement and change should be presented to the service group.

Welcome change. Processes should evolve and not remain static. Just because something is working doesn’t mean to say that it cannot be improved upon. Discuss at an early stage with the people who may be affected by a process change and get their input early to keep them on board. Workshops can provide insight into how processes work in practice and allow people to express an opinion. Consider new possibilities, don’t let legacy processes stifle new ideas.

Test, test, and test again. Test before you implement a change to make sure anything introduced operates effectively in practice. Use a sample population to test and realise that change isn’t always smooth.

Automate. Are there opportunities to do this at key steps – the obvious one with regards to an FLS is patient recruitment. Virtual fracture clinics, emergency department screening, fracture clinics, at risk patient groups available on GP databases, better screening and pick up of vertebral fractures. Automation standardises, reduces pressure on the work force, and saves time and money.

Join forces. Establish a multidisciplinary strategy group from the outset. Agree to assessment and management protocols with all stakeholders. Ensure clear and consistent communication between all the multidisciplinary team.

Summary

1. A streamlined FLS service can help to identify osteoporosis patients at risk of fracture and provide them with the necessary care and treatment to manage their osteoporosis and future falls risk.

2. Effective monitoring and data collection to look at outcome allows the service to improve and evolve.

3. In approaching key players in terms of funding and supporting your regional FLS should emphasise the importance of avoiding health inequality in terms of ability to access a gold standard FLS after fragility fracture.

References

1. Dreinhofer 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):1393-7.

2. McClennan AR, Gallagher 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):1028-34.

Andrew Gray is a consultant with a specialist interest in orthopaedic trauma at James Cook University Hospital. He is an active member of the Fragility Fracture Network and is committed to fragility fracture care and its education, to such an extent that he sustained his first, last year, demonstrating that in terms of secondary fracture prevention, he is a falls risk (on skis and whilst multitasking). Over the past four years, he has co-chaired the Fracture Liaison Service Academy Network (FAN) which is committed to making fracture liaison services more effective.