Identifying characteristics of an effective fracture liaison service: systematic literature review

Abstract

Fracture liaison services (FLS) have been demonstrated to improve outcomes following osteoporotic fracture. The aim of this systematic literature review (SLR) was to determine the characteristics of an FLS that lead to improved patient outcomes. We conducted a SLR, including articles published between 2000 and February 2017, using global (Medline, EMBASE, PubMed and Cochrane Library) and local databases. Studies including patients aged ≥ 50 years with osteoporotic fractures enrolled in an FLS were assessed. Information extracted from each article included key person coordinating the FLS (physician, nurse or other healthcare professional), setting (hospital vs community), intensity (single vs multiple), duration (long vs short term), fracture type and gender. A meta-analysis of randomised controlled trials was conducted based on the key person coordinating the FLS. Out of 7236 articles, 57 were considered to be high quality and identified for further analysis. The SLR identified several components which contributed to FLS success, including multidisciplinary involvement, driven by a dedicated case manager, regular assessment and follow-up, multifaceted interventions and patient education. Meta-analytic data confirm the effectiveness of an FLS following an osteoporotic fracture: approximate 27% increase in the likelihood of BMD testing and up to 21% increase in the likelihood of treatment initiation compared with usual care. The balance of evidence indicates that the multifaceted FLS and dedicated coordination are important success factors that contribute to effective FLS interventions which reduce fracture-related morbidity and mortality.

Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition

“…(4)(5)(6)(7)(8)(9)(10)(11) FLS programs are cost-effective or cost-saving in several different practice settings, (8) and have been broadly and successfully adopted internationally. A substantial, growing body of literature demonstrates that the most effective organizational approach to secondary fracture prevention is a multidisciplinary case management approach that frequently takes the form of a fracture liaison service (FLS).…”

“…A substantial, growing body of literature demonstrates that the most effective organizational approach to secondary fracture prevention is a multidisciplinary case management approach that frequently takes the form of a fracture liaison service (FLS). (4)(5)(6)(7)(8)(9)(10)(11) FLS programs are cost-effective or cost-saving in several different practice settings, (8) and have been broadly and successfully adopted internationally. (12,13) Although there may be settings where FLS programs cannot be fully implemented, the coalition strongly recommends that institutions attempt to establish them.…”

Fragility Fracture Prevention—Implementing a Fracture Liaison Service in a High Volume Orthopedic Hospital

“…More BMD testing was performed in association with forearm factures, rather than with spinal or humerus fractures; and more pharmacological treatment was performed following forearm fractures rather than following spinal fractures. According to the same review, these data suggest the rate of BMD assessment after major bone fracture was lower than following minor bone fracture [34].…”

“…According to a systematic literature review of 53 high quality studies, the degree of patient compliance with FLS varies significantly with the type of program, depending on several factors, such as the presence and qualification of the coordinator, the type of healthcare system, the amount of financial resources invested, and the quality of education provided [34]. The fracture location may also influence the management of osteoporotic fractures, potentially reflecting clinician bias: BMD testing was performed significantly more in association with humerus fracture (85% of patients) than with hip fracture (21% of patients), improving as a consequence the prevention of the former.…”

“…Despite that, women are more likely to suffer from a fragility fracture in their lifetime (50% versus 20% for men) [25], correlations between sex and FLS initiation, intensity, and compliance are also controversial [34,35]. Contrary to the hypothesis of an inherent gender bias in the management of osteoporotic fractures [34], Ruggiero et al found a 1-year adherence to complete pharmacological treatment to be independent of age, sex, history of fracture, and ongoing drug treatment declared during anamnesis at admission [36].…”