Bleeding Patients More: 'Setting Up a Successful Fracture Liaison Service'

 After emerging on the scene in the early 2000s, fracture liaison services (FLS) have solidified their place for preventing secondary fractures.

Ultimately, the goal of an FLS is to reduce subsequent fractures, secondary care admissions, home care admissions, and boost overall health for patients who have already experienced at least one fracture, said Andrea Singer, MD, of MedStar Georgetown University Hospital in Washington, D.C., speaking at a session at the 2025 American Association of Clinical Endocrinologyopens in a new tab or window (AACE) annual meeting.

"FLS is a way of improving our abysmal current approach [to managing patients with fractures]," added fellow panelist Neil Binkley, MD, of the University of Wisconsin in Madison.

While access to an FLS is somewhat limited across the U.S., the 2020 AACE osteoporosis clinical guidelinesopens in a new tab or window recommend that patients who experienced fragility fractures be referred to an FLS whenever available. Currently 1,171 FLS from 61 countries belong to the International Osteoporosis Foundation's "Capture the Fractureopens in a new tab or window" global program established in 2012 to provide resources, training, and tools for these programs.

What Is an FLS?

In short, FLS are "a focused, strategic, and persistent approach to disease management for patients who have had that prevalent or first fracture," said Singer.

Running an FLS takes the balanced coordination of a multidisciplinary team of healthcare providers to manage short-term and long-term care for these patients.

At the heart of every FLS is a care coordinator. This is typically a nurse practitioner or physician assistant, although it doesn't have to be, said Singer. "[This is] somebody who is going to work the system and really coordinate care, and also generally a bone health champion."

Under the direction of an FLS coordinator, teams also employ primary care providers, medical specialists, physical therapists, pharmacists, nutritionists, orthopedics, surgeons, radiologists, and more.

"There have been a number of studies that show that the more comprehensive the FLS program, the better the outcomes," Singer pointed out.

One such report was a 74-study meta-analysisopens in a new tab or window that found patients in FLS programs had higher rates of bone mineral density (BMD) testing (48% vs 23.5%), osteoporosis treatment initiation (38% vs 17.2%), and adherence (57% vs 34.1%) than those receiving usual care. They also had a 5% lower risk for refracture and 3% lower risk of mortality over a maximum 72 months of follow-up.

Finding Fracture Patients

The first step of any FLS program is patient identification."If we can't find these patients, we can't do anything for them," said Singer.

"The idea is that in a systematic way, patients are identified wherever they come into the system," she said. "They are then channeled through the program so that they have an evaluation, they get a diagnosis, and -- in a perfect world -- they also get treated. Sometimes they make it to us after the second [fracture], but the idea is they're the low-hanging fruit and we should be able to recognize these patients and channel them to an organized program."

Ann Kearns, MD, PhD, of Hennepin Healthcare in Minneapolis, said that when she set up an FLS at the Mayo Clinic in the early 2000s, she first aligned herself with the orthopedic teams and focused on patients who were hospitalized primarily with hip fracture. "[These patients] were the lowest hanging fruit," she said.

To find patients, you could perform a baseline audit of patients at your institution, Kearns suggested, but added that this requires you work with your institution to set up an electronic system.

"Having a champion in the orthopedic team [is helpful] because they're often seeing the patients first," she added. "They do trickle in through other avenues -- primary care, the emergency room, a spine center, neurology, neurosurgery -- there's a lot of ways that fractures can trickle into the system, so you [need] to have a wider, sweeping [approach] if you really want to capture all of them."

Overcoming FLS Barriers

Setting up an FLS doesn't come without unique hurdles, however. "It's a difficult sell sometimes, because it requires resources," said Kearns.

"You're largely talking about a population that doesn't generate a lot of revenue. Although cost-avoidance is always the strategy, it's not as attractive to administrators as revenue-stream improvement. Everyone can agree it's the right thing, but it's hard to do, because you're going to need people. And people cost money."

One recent cost-analysisopens in a new tab or window that looked at 200 FLS patients found the program cost exceeded any savings from reducing secondary fractures. Medication was the main factor, making up 89% of FLS costs. Over a 2-year period, overall cost per patient enrolled in an FLS was $1,189.

But Kearns also advised against self-implemented barriers, like requiring an unnecessary amount of testing before scheduling patients.

This was echoed by speaker Kristyn Hare, MMS, PA-C, of the University of Wisconsin in Madison, who described her experience setting up an FLS in the orthopedics division of her institution. "We did initially require that the patients have a BMD assessment before they saw us, but then we got a very long wait-time, so patients were just falling off the schedule because they forgot why the BMD was needed by 6 to 9 months later."

"Really, you want to capture these patients in that teachable moment," she continued. "They currently have a fracture and a debility that is preventing them from doing some things they enjoy in their life. So, if you frame it as you want to prevent the next fracture so this doesn't happen to them repeatedly, they're really a captive audience."

Disclosures

Singer reported relationships with Amgen, Astellas, Agnovos, Radius, UCB, and Pfizer.

Binkley reported research support paid to institution from Radius and GE Healthcare.

Kearns reported no disclosures.

Hare reported no disclosures.

https://www.medpagetoday.com/spotlight/aace-osteoporosis/115924