Fracture Liaison Service (FLS) in Nova Scotia: A Primary Health Care program improving osteoporosis care for patients presenting with fragility fractures

A province-wide post fracture care gap has previously been documented in Nova Scotia: in 2010, only 23% of hip fracture patients received osteoporosis medication within 6 months of their fracture.1

With the assistance of the Dartmouth General Hospital (DGH) Foundation and a philanthropic grant from Sun Life Financial, the first Nova Scotia (NS) FLS was implemented at the DGH in February of 2013.  The DGH FLS proved its effectiveness at the end of its first year with 79% of the hip fracture patients and 81% of the total high risk patients receiving a first line osteoporosis medication within 6 months of fracture (excluding patients lost to follow-up).2  

With proof of concept established, the DGH FLS model became the prototype for future NS FLSs.  Embracing clinically-effective and value-based innovations, the Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority (NSHA) proceeded to staged expansion of FLS within the province, with implementation of new FLSs at the Valley Regional Hospital in Kentville in 2016 and at the Cape Breton Regional Hospital in Sydney in 2017.  Currently, three of the province’s five orthopaedic centres operate an FLS for fragility fracture patients presenting to inpatient and outpatient orthopaedic services.

The NSHA FLS program is administered by Primary Health Care.  A critical priority of the NS FLS is to integrate the patient’s osteoporosis care with their primary care provider (PCP). As these patients’ fracture risk is high and imminent, the goal is to facilitate urgent initiation of osteoporosis treatment for those who need it.  Communication with the patient’s PCP is initiated at the FLS nurse’s very first interaction with the fracture patient.  The FLS nurse coordinates all of the required investigations.  A comprehensive report including the results of all investigations, the patient’s fracture risk by FRAX and recommendations specific to the patient’s fracture risk as per OC’s clinical practice guidelines is provided to the PCP.   As all of the required information is conveniently in the PCP’s hands, initiation of the urgently needed treatment is expedited.  Additionally, the FLS nurse will follow the patient for one year, to help monitor adherence to osteoporosis treatment and to respond to their frequent questions and concerns. 

As with all effective FLSs, the NS FLSs ensure they optimize patient outcomes with a continuous quality improvement process in place.  They participated in Osteoporosis Canada’s first national FLS audit for the 6-month cohort of patients enrolled April 1-September 30, 2017.3 During that timeframe, 347 NS patients were enrolled in the FLSs.  In NSHA FLSs, 42.7% of the patients with fragility fracture were identified (first i) compared to national average of 57%.  Fracture risk was completed (second i) in 92.5% (national average 89%).  Treatment initiation (third i) in high risk patients was 52.4% (national average 49%). 

Participation in that national FLS audit was most informative for the NS FLSs.   The first i was noted to be Nova Scotia’s biggest area for improvement.  Upon further exploration, one of the NSHA FLS exclusion criteria, patients without a primary care provider (PCP), was identified as the main barrier:  patients without PCP were 15.1%, 11.4% and 6.8% respectively in Dartmouth, Kentville and Sydney.  As a result of this audit, NSHA’s FLS Care Directive has now been updated to include those patients without PCP. NS FLSs will be participating in OC’s second national FLS audit and are hoping to see improved results. All of the FLSs in Nova Scotia are committed to continuous quality improvement to ensure that they are meeting the needs of fragility fracture patients.


  1. Nova Scotia: Department of Health and Wellness. Acute and Chronic Disease Target Setting Project – Summary Report; 2012.
  2. Thériault D, Purcell C. A Fracture Liaison Service specifically designed to address local government concerns can be effective. Journal of Bone and Mineral Research, 2014;(Suppl. 1).
  3. Theriault D, Purcell C, Griffin G, Pimentel B. NSHA Fracture Liaison Services (FLS): improving osteoporosis care for patients with fragility fractures.  Primary Healthcare Research Day 2019, Halifax.