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A fracture liaison service for patients with osteoporotic fractures

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Mayrine Fraser, BSc, RGN.

Osteoporosis Nurse Specialist

Osteoporosis is characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. The disease presents clinically as fractures that occur at any site in the skeleton and typically occur with minimal trauma (World Health Organization, 1994).

Osteoporosis is characterised by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. The disease presents clinically as fractures that occur at any site in the skeleton and typically occur with minimal trauma (World Health Organization, 1994).

Osteoporosis is a major and growing public health concern that results each year in at least 50 000 hip fractures, and similar numbers of vertebral and distal forearm fractures. The annual direct and indirect costs of managing the disease are an estimated £1 billion (Dolan and Torgerson, 1998). This figure is likely to rise as the proportion of elderly people in the population increases.

To address the growing burden of morbidity and mortality associated with osteoporotic fractures successfully, people at highest risk - those with osteoporosis who have already sustained a fracture - need to be targeted (Cummings et al, 1995; Ross et al, 1991; 1993; van Staa et al, 2002).

Before 1999, patients with new fractures who were admitted to the orthopaedic unit or seen at the fracture clinics at the Western Infirmary, Glasgow, were given little or no information about osteoporosis, and no formal osteoporosis or falls risk assessment took place. If patients expressed concern about the disease following their fracture, they were advised to see their GP, who could refer them back to the hospital for assessment of osteoporosis via the Direct Access DXA Service (DADS), which had been introduced in 1998.

DXA is dual energy X-ray absorptiometry. It is a low-dose non-invasive X-ray technique for measuring the calcium content of bone (bone mineral density, BMD). It is performed most usefully at the hip and spine and is used to diagnose osteoporosis, predict fracture risk and target treatment to those who will benefit. DADS is offered at this hospital to GPs who can refer patients if they fulfil at least one of five key referral criteria, including history of previous fracture and being over 50.

Audit was undertaken to identify what proportion of those who had attended the hospital with fractures of hip and wrist within the past 12 months were offered osteoporosis assessment and treatment via DADS; only 3-12% of these patients had been referred for assessment.

The DADS service offered 'open access' to primary care for osteoporosis assessment in patients with recent fractures. But it was not adequately addressing the needs of patients who were presenting with new fractures.

As a result of this audit the providers of the osteoporosis services met with representatives of the orthopaedic services and GPs to consider how fracture patients could be identified and undergo osteoporosis assessment more consistently. The concept of the fracture liaison service (FLS) was developed with the aim of finding fracture cases in women and men over 50 years, specifically those with 'low-trauma fracture'. This is defined as fractures sustained in falls from less than head height and not sustained in road traffic accidents, who present to the orthopaedic department and accident and emergency (A&E) services.

Key factors to consider were:

- How many patients aged 50 years or over attend the hospital because of a new fracture each year?

- What is the pathway of care of fracture patients within the hospital?

- What would be the stage in that pathway to meet and assess these patients?

- Who could help identify these patients?

This hospital lacked a reliable database of patients attending with a fracture. It was estimated that there were 1200 fracture cases (in women and men of 50 years or over) per year for our hospital catchment population of 250 000. The actual number was later shown to be around 1300 a year.

Development of the fracture liaison service
NHS and pharmaceutical company funding was raised for one year initially to develop a pilot FLS. A G-grade osteoporosis nurse specialist (ONS) was assigned to provide the service. This nurse was to act as the link person between the existing bone metabolism services and the orthopaedic fracture services, under the auspices of the consultant endocrinologist in charge of the hospital's bone metabolism clinical and DXA services. The skills expected of the ONS are outlined in Box 1.

The ONS had previously worked as a trauma ward sister in the orthopaedic department, but had limited knowledge of osteoporosis. The nurse's first month of employment was therefore devoted to an intensive education programme. This training continued through supervision of DXA-scan reporting. The nurse also sat in during the consultant's bone clinics. Protocols were devised to support the service and enable the nurse to work independently, and core documentation was developed to support this (Box 2).

In addition, patient education literature was obtained; this included Are You at Risk? and Osteoporosis, published by the National Osteoporosis Society (NOS, 2002; 2003). Additional educational material, including a leaflet on fall prevention, was developed by the ONS.

To ensure maximum impact, a wide range of secondary care staff were involved in decisions about the development of this innovative service. The orthopaedic surgeons were involved from the outset in discussions. They were fully engaged with the aims of the service and allowed the ONS free access to their fracture patients.

Other key staff involved in preparatory discussions included the orthopaedic unit nurse manager, trauma ward and fracture clinic nurses, A&E medical and nursing staff, the DXA unit radiographer, orthopaedic secretaries and both ward and fracture clinic receptionists. Medical records staff agreed to provide hospital case records to support the one-stop clinic (see below).

Implementing the service
Stage 1. Identifying the fracture patients - Following discussion with the orthopaedic surgeons, it was agreed that the ONS's daily attendance at the 8am pre-ward round meeting, which lasts about 30 minutes, would be the best way to identify patients admitted to the trauma unit with fractures in the preceding 24 hours.

These patients are visited and assessed by the specialist nurse in the trauma ward either that day, or later if they are to undergo surgery. Outpatients with fractures are identified daily, during their attendance at a dedicated new fracture clinic at 1.30pm. This clinic lasts from 30 to 60 minutes.

The nurse spends a short time with these patients, discussing osteoporosis, highlighting the importance of assessment and explaining what the process involves.

Patients who attend outside contracted hours of work such as at weekends, are identified from fracture clinic letters typed by the orthopaedic secretaries for all new fracture attendances. The specialist nurse writes them a letter inviting them to attend the DXA clinic for assessment.

Stage 2. Assessing osteoporosis risk - The radiographer who performs DXA sets aside two sessions exclusively for the FLS's one-stop clinic. Twenty-two patients a week are allocated to these sessions. A clerical assistant sends outpatient appointments, along with a patient self-history questionnaire, which patients are asked to complete and bring to the consultation with the OSN.

The time between the patient's fracture and an appointment at the one-stop clinic is scheduled to be about six weeks, allowing enough time for them to recover from much of their fracture-related disability. An assessment is then conducted at the one-stop clinic (Box 3).

Central to the FLS is the use of the Glasgow Integrated System for the Management of Osteoporosis (GISMO), an ACCESS database, which was developed to support the service, and into which all service activity is logged.

After assessment is carried out at the clinic, all information is entered into the database; GISMO generates a patient-specific letter, which is signed by both the ONS and consultant endocrinologist.

The FLS letter is then sent to the GP and copied to the orthopaedic surgeon. This letter includes:

- The DXA scan results

- A summary of prevalent osteoporosis and fracture risk factors

- Treatment recommendation (in which drug name, dose and regimen are explicitly stated)

- Lifestyle recommendations.

GISMO was developed not only as the means of communicating with primary care but also for prospective audit of the FLS.

The service provided
In the first two years, 2587 patients over the age of 50 with fractures were identified by the ONS (Figure 1); 81% of fractures were in women. Wrist fractures were the most common, followed by fractures at hip, humerus and ankle.

Forty-eight per cent of fracture patients were seen as inpatients, with the remainder seen as outpatients at the fracture clinic. The ONS met personally with 71% of patients in the ward or at the fracture clinic, and the rest were contacted by letter, with an invitation to attend for assessment of osteoporosis risk.

Assessment for osteoporosis and treatment, where appropriate, was achieved in about 80% of patients. Of 2587 fracture patients, 55% were given appointments for DXA and further assessment of osteoporosis risk.

The prevalence of osteoporosis in women with fractures, defined on the basis of the lower of DXA measurements at spine or hip, ranged from 30% in those with ankle fractures to over 70% in those with hip fractures. The corresponding figures in men were 10% and 80% respectively (Figure 2).

About 19% of all fracture cases declined to be assessed or failed to attend for DXA assessment. However, as a result of assessment by the FLS, about 25% of all patients are treated with a bisphosphonate with calcium and vitamin D, and about 30% with calcium and vitamin D alone. Not all patients require treatment; 13% are advised not to take any treatment for bone strengthening after assessment because their BMD was above a level where treatment has been shown to be effective in reducing future fracture risk.

Feedback about the perceptions of the FLS by patients who had been assessed and by GPs was sought within the first year of the service:

- Eighty-four per cent of patients thought it had been either a 'very worthwhile' or 'quite worthwhile' experience

- Eighty-three per cent stated they were more aware of the nature of osteoporosis

- Fifty-two per cent had a greater awareness of how to reduce their risk of falling

- Twenty per cent reported that they had stopped or reduced smoking and some had lowered their alcohol intake following their assessment by the FLS

- Seventy-four per cent of GPs perceived the FLS to be a 'very good' or 'excellent' service.

Treatment recommendations from the FLS require the participation of the patients' GPs to implement and prescribe the treatment. The ultimate success of the FLS is dependent upon whether the patients receive the recommended treatment. To assess this, questionnaires were sent out to 300 patients who had been diagnosed with osteoporosis after their fracture by the liaison service and for whom treatment had been recommended, approximately eight months after their assessment. The patients were asked to record their current medication. No reference was made in the questionnaire to what treatment had been recommended by the FLS to the patients' GP. Of the 69% who returned their forms, 88% of those patients whose GPs had been recommended to prescribe a bisphosphonate said they were taking the specific bisphosphonate that had been recommended. Only 4% of those who responded stated they were not on any therapy. GPs typically do follow the treatment plans recommended by the FLS.

In order to provide patients who have been diagnosed as having osteoporosis following their assessment by the FLS with further support, meetings have been arranged to address their educational needs. Topics covered at these meetings included a review of the aims of treatment and treatment options including the need for calcium and vitamin D, the importance of exercise (and how to access local exercise classes), how to reduce risk of falling and the role of the National Osteoporosis Society. There is also an open 'questions-and-answers' session in which patients can raise any other osteoporosis-related issues of concern. Between 100 and 150 attend, sometimes bringing carers with them. Of those who do attend, 84% have found the meeting to be either a 'very' or 'extremely' worthwhile experience. As a result they felt they were more aware about osteoporosis (84%) and 70% said it would improve their commitment to their treatment.

The recommended approach to tackling osteoporosis is to identify cases from 'high-risk' groups of patients (so called, 'case finding') rather than perform population screening (Royal College of Physicians, 1999). Identification of low BMD by axial DXA is crucial because it is a key determinant of fracture risk; targeting low BMD with certain drug therapies has been shown to reduce fracture risk at clinically important sites by as much as 50%.

Patients over 50 who present with fractures are a group at 'high risk' of fracture (Cummings et al, 1995; Ross et al, 1991; 1993; van Staa et al, 2002); furthermore, dependent on the site of fracture, up to 80% of women and men with fractures have osteoporosis. Fracture risk is compounded by the fact that fracture predisposes to further fracture, independent of BMD. Use of axial DXA to measure BMD permits treatment to be targeted to those whose fracture risk can be reduced with antiresorptive therapy (Black et al, 1996; Chesnut et al, 2000; Cummings et al, 1998; Ettinger et al, 1999; Pols et al, 1999).

Conversely, at least in those over 80 years, targeting antiresorptive treatment at patients whose fracture risk is based primarily on risk factors for falling, but in whom BMD is not known to be reduced to a level where antiresorptive treatment can help, has not been shown to reduce fracture risk (McClung et al, 2001). However, these patients, who are typically deficient in vitamin D because they are housebound, may benefit from prescription of vitamin D with calcium (see below) (Chapuy et al, 1994), as well as from assessment to achieve falls' risk reduction.

The FLS achieves 'case finding' of all fracture patients over 50 years, who are at high risk of fracture and offers them assessment of osteoporosis by DXA (where appropriate), in order to target treatment effectively. The aim is to target treatment to achieve the optimal benefit in fracture risk reduction. While all fracture cases are offered assessment by the FLS, about 80% accept this invitation and undergo assessment and/or treatment. This compares to osteoporosis assessment rates of 3 to 10% before the development of the FLS. The role and input of the FLS does not end with the provision of assessment of osteoporosis and, where necessary, the recommendation of treatment. Through provision of a further opportunity to engage patients in an education programme that has been tailored to their needs, the FLS has defined a novel role in supporting the ongoing management of patients that may facilitate their longer term adherence to treatment.

Responsibility for providing a FLS does not necessarily lie with any particular medical or surgical specialty, but with those who have the enthusiasm and willingness to act as 'lead clinicians' in providing local osteoporosis services. The lead clinician could be an orthopaedic surgeon, but traditionally service priorities dictate that others tend to take the lead. The challenge is how to take assessment for osteoporosis to fracture cases in an orthopaedic or A&E setting. Our FLS is based on the principle that the expertise of osteoporosis assessment and treatment, led by an endocrinologist, is delivered by a dedicated specialist nurse. The FLS bridges interdepartmental boundaries, through our development of the role of the osteoporosis nurse specialist. Our orthopaedic surgeons permit total access of the FLS to their patients; our model does not require any alteration in the orthopaedic surgeons' clinical practice or time. Central to the success of the service is the GISMO, a database that was written specifically for the service to record clinically relevant information relating to osteoporosis, fracture and treatment, to generate reports for GPs on each patient who has been assessed and to allow audit of the process.

Demonstration, through audit, of the radical improvement in delivery of treatment for the secondary prevention of osteoporotic fractures in our patients with fractures resulted in permanent funding of this service by the NHS after a pilot phase. Demographic changes, with increasing numbers of elderly people in the population, will lead to greater numbers of fractures. With appropriate patient selection and targeting of treatment, the incidence of fractures can be reduced. Therefore in forthcoming years the FLS is expected to reduce the rate of increase in incident fractures.

The FLS is a novel model of care that provides liaison between the bone metabolism and orthopaedic services, and delivers osteoporosis assessment and treatment to patients over 50 years with fractures. It has proved to be an effective model for the secondary prevention of fractures, with treatment being targeted at those at the highest risk. The FLS has transformed the delivery of treatment for the secondary prevention of osteoporotic fractures in fracture patients, an achievement that is reflected in the very positive feedback from patients who have been assessed, and from their GPs.

Black, D.M., Cummings, S.R., Karpf, D.B. et al. (1996)Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 348: 9041, 1535-1541.

Chapuy, M.C., Arlot, M.E., Delmas, P.D., Meunier, P.J. (1994)Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. British Medical Journal 308: 6936, 1081-1082.

Chesnut, C.H., III, Silverman, S., Andriano, K. et al. (2000)A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. PROOF Study Group. American Journal of Medicine 109: 4, 267-276.

Cummings, S.R., Black, D.M., Thompson, D.E. et al. (1998)Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. Journal of the American Medical Association 280: 24, 2077-2082.

Cummings, S.R., Nevitt, M.C., Browner, W.S. et al. (1995)Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. New England Journal of Medicine 332: 12, 767-773.

Dolan, P., Torgerson, D.J. (1998)The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporosis International 8: 6, 611-617.

Ettinger, B., Black, D.M., Mitlak, B.H. et al. (1999)Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. Journal of the American Medical Association 282: 7, 637-645.

McClung, M.R., Geusens, P., Miller, P.D. et al. (2001)Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. New England Journal of Medicine 344: 5, 333-340.

National Osteoporosis Society. (2002)Are You at Risk? Bath: NOS.

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Pols, H.A., Felsenberg, D., Hanley, D.A. et al. (1999)Multinational, placebo-controlled, randomized trial of the effects of alendronate on bone density and fracture risk in postmenopausal women with low bone mass: results of the FOSIT study. Foxamax International Trial Study Group. Osteoporosis International 9: 5, 461-468.

Ross, P.D., Davis, J.W., Epstein, R.S., Wasnich, R.D. (1991)Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Annals of Internal Medicine 114: 11, 919-923.

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van Staa, T.P., Leufkens, H.G., Cooper, C. (2002)Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporosis International 13: 624-629.

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