Frequently Asked Questions
What is a Fracture Liaison Service (FLS)?
A Fracture Liaison Service (FLS) is a specific model of care where a dedicated coordinator (usually a nurse) proactively identifies fracture patients on a system-wide basis (this is best done in the orthopaedic services where fracture patients are seen acutely), and determines whether they are at high risk to suffer new fractures. If deemed to be at high risk of future fractures, then the FLS will facilitate the initiation of effective osteoporosis treatment for those patients, which will significantly reduce their risk of suffering new fractures. FLS is the only intervention that has been proven to have a meaningful impact on the post-fracture care gap (i.e., improving the rate of osteoporosis treatment at least two-fold after a fracture). For more information, see FLS info sheet 6.1. For more technical information on FLS, see Essential Elements.
What is the osteoporosis care gap and why is it important?
After a fracture, a person’s risk for another fracture approximately doubles and will most likely occur within the next two years (see FLS info sheet 2.0). In individuals over the age of 65, the most common second/next fracture is a broken hip. New fractures can be reduced with effective osteoporosis management.
However, the recently released Osteoporosis and related fractures in Canada: Report from the Canadian Chronic Disease Surveillance System 2020 (Public Health Agency of Canada, 2020) indicates that “less than 20% who fracture receive an osteoporosis diagnosis, bone mineral density test, or an osteoporosis medication prescription within the following year.” The osteoporosis care gap refers to the remaining 80% of patients who should receive an assessment/diagnosis of osteoporosis with appropriate management/treatment, which can significantly reduce the risk of the next fracture. For more information on the care gap, see FLS info sheet 3.0.
Why are FLSs needed?
The scientific evidence supporting FLS is very robust. After more than 25 years of research in this field, it has been well documented that only FLS can have a meaningful impact on the post-fracture care gap, i.e., increasing the rate of appropriate osteoporosis treatment at least two-fold. FLS has outperformed all other post-fracture interventions in terms of significantly improved patient outcomes and reduction in healthcare costs. For more information, see FLS info sheet 5.0 and FLS info sheet 9.0.
How is an FLS different from what is happening now in our hospitals and communities?
Without an FLS, only 20% of patients who present with an acute fragility fracture are leaving the hospital or orthopaedic outpatient clinic with a plan to investigate and manage any underlying bone fragility/osteoporosis. Why is this so? Because everyone who treats these patients already has a job: the orthopaedic surgeons, the Emergency Department doctors, the primary care providers (family physicians, etc.). Everyone is focused on managing the acute fracture and no one is specifically assigned the responsibility to help prevent the patient’s next fracture. FLS will do that by making sure a dedicated FLS coordinator takes on that job. For more information, see FLS info sheet 7.0.
Why focus on preventing the second fracture? Wouldn’t it be more appropriate to be focusing on preventing the first fracture?
Preventing first fractures seems like it should be intuitive. But “primary fracture prevention” involves lifelong optimization of bone health and minimizing risk factors. It also needs to target the entire population, hence it is a huge and very expensive undertaking. Focusing on those who have already had an osteoporotic fracture allows for the prompt identification of those who are the most at risk for an imminent next fracture so that they can be prescribed osteoporosis treatment, thereby reducing the risk of that next fracture by as much as 50%. Focusing on “secondary fracture prevention” also is a much more manageable and affordable solution as it targets only a very small proportion of the total population (e.g., only those who have suffered a recent fracture). For more information, see FLS info sheet 10.0.
How can a community-based osteoporosis program impact the care gap?
A community-based osteoporosis program, like a local Osteoporosis Clinic, can be a very effective solution for those patients who are referred to it. The problem is that, without an FLS in place, only a very small proportion of fracture patients are ever referred to an osteoporosis program or to an osteoporosis specialist in the first place. Because community-based osteoporosis programs/clinics end up seeing so very few of the total fracture patients, they are not able to make a meaningful dent in the post-fracture care gap.
What department does FLS fall under…is it a surgical program, an outpatient program, or a community program?
By reducing the number of future fractures, FLS has a beneficial impact right across the healthcare system, thus favorably impacting many acute (e.g., emergency, surgery, orthopaedic services) and community health resources (e.g., Home Care, Long Term Care, rehab services).
However, there isn’t a single common home for FLS within the Canadian healthcare system. In various regions of Canada, FLS falls under very different departments, the most common being orthopaedic services, primary health care, geriatrics, or osteoporosis specialty programs. Most new FLSs will need to find their own “home” within their local healthcare system in order to obtain sustainable funding. This is not always an easy task.
How will FLS benefit seniors?
By preventing recurrent and debilitating fractures of the hips, spine, humerus, pelvis, and wrists, FLS programs can help seniors remain more mobile and active, thereby preserving independence. Keeping seniors in their own homes and out of assisted living is a goal of any FLS. Ironically, keeping seniors in their homes may increase Home Care but should decrease hospitalizations and nursing home care for seniors and therefore lower this burden on the healthcare system. For related information, see FLS info sheet 14.0.
Why hasn’t FLS been implemented in every orthopaedic hospital in Canada?
It is a sad fact that only a small minority of Canadians who suffer a fracture currently have access to an FLS. Implementing a new FLS program requires an up-front investment as a dedicated FLS coordinator, typically a nurse, will need to be hired. Finding funding for any new healthcare program is always challenging. It is hoped that this world-renowned, evidence-based program will become more common in Canada in the near future. For further information, see FLS info sheet 12.0 and FLS info sheet 15.1.
Can the implementation of an FLS save on healthcare costs?
There is an initial investment with the hiring of an FLS coordinator, but cost-effectiveness studies done in Canada and internationally have shown that after only 2-4 years of operation, most FLSs will become a cost-saving endeavor simply because they prevent expensive fractures. For more information, see FLS info sheet 13.0.
How are FLSs funded?
To offer ongoing FLS with a dedicated FLS coordinator requires a sustainable source of government funding (see FLS info sheet 12.0). In Canada, as FLS is such a rare entity, it has often proven quite difficult to convince healthcare administrators and governments to invest in FLS. There are so many other competing healthcare priorities.
Many passionate FLS teams have used other external funding sources (e.g., from a temporary research grant or a temporary philanthropic grant) to finance the implementation of their first FLS. Once implemented, they collect the FLS patients’ data which will invariably demonstrate how effective their new FLS is. They use that data to try to convince healthcare administrators to step up and take over the ongoing FLS costs. This strategy has been effective for many, although not all, FLS teams in Canada. It is unfortunate that FLS stakeholders have to go to such great lengths to ensure that fracture patients in their region have access to an effective FLS.
This seems like an expensive model of care to address fracture prevention. Aren’t there other models that are cheaper that could do the same thing?
Unfortunately not: research conducted over the past 25 years has included many simpler models, such as alert systems and education to both patients and primary care providers. All such models have consistently shown very little impact on the post-fracture care gap. FLS is the only model that consistently achieves a meaningful improvement in the level of osteoporosis treatment, typically at least doubling appropriate care post-fracture. FLS has also been shown to decrease the rate of repeat fractures and to reduce mortality (see FLS info sheet 9.0). Additionally, by preventing expensive hip fractures (which cost an average of over $60,000 per hip fracture to the healthcare system), FLSs end up saving the healthcare system money, even after accounting for the additional salary cost for the FLS coordinator and any additional osteoporosis medications that are prescribed. For further information, see FLS info sheet 4.0.
Our site has just added an alert letter that goes out to the primary care provider after an Emergency Department visit: can this be a reasonable substitute for an FLS? It would be a lot less expensive than hiring a dedicated FLS coordinator.
Alert systems are considered “1i” post-fracture care models. Numerous studies, in Canada and internationally, have consistently demonstrated that 1i models make only a small impact on the post-fracture care gap (e.g., increases the rate of osteoporosis treatment from 13 to 17%). Alert systems cannot come close to matching the very meaningful improvement seen with an FLS (at least doubling the rate of appropriate osteoporosis treatment). For further information, see FLS info sheet 4.0.
Why can’t we just educate primary care providers and patients about the importance of getting treatment to prevent recurrent fractures? Wouldn’t that be easier and cheaper?
Numerous studies looking at educational interventions targeting fracture patients have consistently shown no impact at all on the post-fracture care gap. The fact is that there are many barriers to effective osteoporosis care in this patient group and education alone cannot fix those barriers. FLS is the only proven way to meaningfully improve appropriate osteoporosis care for fragility fracture patients. However, patient education is a very important component of any FLS. But patient education alone, without FLS, will not fix the post-fracture care gap. For further information, see FLS info sheet 4.0.
Who will be a part of the FLS team and how will the primary care provider (PCP) be involved?
Once an FLS is implemented, the FLS “team” will typically be multidisciplinary. Central to this team is the dedicated FLS coordinator (see FLS info sheet 7.0). Also needed will be support from one or more physicians as well as some clerical assistance. The FLS coordinator will connect with the PCP (family physician or nurse practitioner) regarding the outcome of investigations, fracture risk assessment, and osteoporosis treatment. At the end of the FLS’s follow-up period (typically one year for most Canadian FLSs), the FLS coordinator will ensure a smooth transition of care back to the patient’s PCP for longer-term osteoporosis management and follow-up.
How can I refer my osteoporosis patients to the FLS?
FLS is not a referral program or clinic for patients with osteoporosis. Patients do not get referred to an FLS; they are automatically picked up and seen by the FLS coordinator when they present to the hospital or outpatient orthopaedic clinic with a new fracture.
In rare cases, an FLS may accept a referral for a fracture patient who was inadvertently ‘missed’ (e.g., who accessed the hospital’s/clinic’s orthopaedic services during the FLS coordinator’s absence from work).
While it is the goal of Osteoporosis Canada to support the creation of FLSs so they are available for all fracture patients in Canada, at present that is not the case. The majority of Canadians who fracture still do not have access to an FLS. A map and complete listing of Canadian FLSs is available here.
Can someone with a family history of fractures get referred to an FLS?
No, only patients who are receiving care for a new fracture in a hospital or orthopaedic clinic will be seen by the FLS coordinator. The FLS coordinator identifies patients with a fracture suspicious for osteoporosis. FLS is typically embedded within the orthopedic care that the fracture patients receive when in the hospital or orthopaedic clinic. A person with a family history of fracture needs to reach out to their primary care provider (family physician or nurse practitioner) to see what their risk of a fracture may be and if there is any need for osteoporosis investigation and/or treatment at this time.
My patient is falling frequently, can I refer them to the FLS to address their falls?
FLS is not a fall prevention clinic. Primary care providers can explore referral options for local fall prevention programs or seniors’ clinics that may be appropriate for their patients. Having said that, many FLSs work in close partnership with local falls prevention programs. They will commonly refer patients who are at increased risk for falls.