The Impact of COVID-19 Pandemic on Canadian FLSs and Innovative Measures Taken to Improve Patient Outcomes

The Covid-19 pandemic has had a major impact on healthcare services and FLSs have not been immune.  Many FLSs across the country have been temporarily suspended as their staff was redeployed to pandemic efforts.  Of those FLSs which remained operational, the FLS coordinators had to quickly adapt to the marked reduction (or total lack thereof) of other osteoporosis services such as BMD testing.

With dedication and innovation, FLS coordinators across Canada have faced this new challenge head on and have helped minimize the negative impacts of the pandemic on their fragility fracture patients. Shannon Falsetti is the FLS coordinator at the Misericordia Community Hospital in Edmonton, Alberta.  She indicates: “When our site was closed due to an outbreak, I was able to seamlessly work from home and complete virtual follow ups. Our IT department made sure I had appropriate access while still maintaining privacy and documentation policies”. 

Lack of access to BMD testing was of course a major consequence of the pandemic across this country.  FLS coordinators worked with Diagnostic Imaging services to facilitate rescheduling of many BMD tests that had to be cancelled.   

Ensuring that high risk patients are initiated and/or continued on the urgently needed osteoporosis treatment is always a priority for FLS coordinators.  For many patients on parenteral osteoporosis treatment, this posed some new and unexpected challenges as many of them were fearful of leaving their homes.  FLS coordinators helped find solutions for them which included coordinating a switch to an oral therapeutic option, arranging for local pharmacists to administer their injection or, in certain cases, helping patients learn how to self-inject using virtual communication tools.  

In these times of uncertainty, some patients needed reassurances and coordinators were able to explore fears and feelings with their patients and family. They also took this time to review the importance of fracture risk, share information regarding local public health recommendations and to determine some safety strategies to minimize the risk of Covid-19 exposure (e.g. home collections for lab work, home care or pharmacy delivery).

The goal for every FLS program is to identify fragility fracture patients, investigate the patient’s risk of future fractures, and initiate prescription therapy for those at high risk. With many FLSs now resuming this important work, fragility fracture patients who have access to an FLS are truly lucky to have such dedicated healthcare professionals providing them with the care they need to help them prevent future fractures.

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.

Breaking the cycle of recurrent fractures: 2019 Implementation Science Team Project Grant Recipient

After rigorous peer review, the Michael Smith Foundation for Health Research (MSFHR) recently awarded the Fraser Health Authority team in British Columbia (BC), a three-year project team grant worth $500,000. The project, titled “Breaking the cycle of recurrent fracture: Scaling up a secondary fracture prevention program in Fraser Health to inform spread across British Columbia”, is co-led by Dr. Sonia Singh (Fraser Health clinician-researcher,) Larry Funnell (Patient partner researcher) and Dr. Tania Bubela (Simon Fraser University, Dean of Health Sciences). This project may well be the tipping point for Fracture Liaison Service (FLS) implementation in BC. This project will explore how the FLS model implemented at the Peace Arch Hospital (White Rock) in Fraser Health can be successfully adapted and scaled-up to other hospital sites within the health authority.

This leading-edge project aligns with the mandate of Osteoporosis Canada in supporting nation-wide implementation of effective secondary fracture prevention. One key expected outcome is to inform an FLS implementation strategy that can be used to spread the FLS model across BC, thereby improving patients’ quality of life after low-trauma fractures and decreasing health care costs related to recurrent fractures. The research findings from this project may result in dramatically improved access to appropriate osteoporosis care for fracture patients in BC and will impact future program planning of secondary fracture prevention across Canada.

Key Performance Indicators (KPIs)

Osteoporosis Canada (OC) is pleased to announce the updated version of “Key performance indicators (KPIs) for Canadian FLSs (v2.0)”. Version 2 of the OC FLS KPIs brings in new learnings from OC’s first national audit released in September 2018.

The FLS KPIs provide:

  • A way to measure the performance of the FLS at the level of the system
  • A useful tool to facilitate on-going continuous quality improvement through Plan-Do-Study-Act (PDSA) methodology to address any identified care gaps
  • The ability for FLSs to compare their performance with that of other FLSs from across Canada

Canadian FLSs will be using KPI (Version 2.0) when participating in the next national FLS audit later in 2019.

The OC KPIs are a critical tool for the measurement and monitoring of the FLS’s effectiveness and will allow Canadian FLSs the opportunity to reach their full potential. Osteoporosis Canada’s goal is to ensure that no fragility fracture patient is “left behind” and that every Canadian has access to appropriate post-fracture care.

To view the complete English KPI document, please click here.

To view the complete French KPI document, please click here.  

Congratulations to Fraser Health’s Fracture Liaison Service team!

A development grant to improve osteoporosis care for fragility fracture patients has been awarded to British Columbia’s Fraser Health Authority. Funding for “Breaking The Cycle Of Recurrent Fracture: Scaling Up A Fracture Prevention Program In British Columbia” was awarded by the Michel Smith Foundation for Health Research.
Osteoporosis Canada congratulates the project co-leads, Dr. Sonia Singh (FLS Medical Lead, Peace Arch Hospital, Fraser Health), Larry Funnell (patient partner), Tania Bubela (Dean of Health Sciences, Simon Fraser University), and Teresa O’Callaghan (executive sponsor, Executive Director Peace Arch Hospital, Fraser Health) and all their team members.
This project will explore how the Fracture Liaison Service (FLS) model implemented at one hospital in BC (Peace Arch Hospital, White Rock) can be successfully adapted and scaled-up to other hospital sites to break the cycle of recurrent fractures.
The evidenced-based FLS model has been recognized and adopted worldwide as the most effective model for preventing recurrent osteoporosis-related fractures in a cost-effective manner. FLS involves a dedicated coordinator who “captures” the patient at the point of orthopedic care for low-trauma fracture and seamlessly integrates secondary fracture prevention into the overall fracture experience. FLS coordinators link up with community family physicians to ensure on-going care and follow-through of the initiated interventions to prevent further fractures.
The Michael Smith Foundation development grant was one of 10 projects chosen in a provincial competition for Implementation Science Research. The Fraser Health team now goes on to the next stage of the competition which is to develop a full grant proposal to roll out Fracture Liaison Service (FLS) at multiple sites in Fraser Health and evaluate implementation over three years. Five projects will be funded in June 2019.
Given the great need for more FLSs, Osteoporosis Canada wishes the team every success with the next round of the competition and increasing uptake of FLS in British Columbia.

Osteoporosis Canada’s first national FLS audit

The results from Osteoporosis Canada’s first national FLS audit demonstrate the positive impact of Canadian FLSs on the lives of fragility fracture patients. The promising results, released in September 2018, are included in the “Report from Canada’s first national FLS audit” which provides an overview of the audit for the cohort of patients enrolled in Canadian FLSs between April 1 and September 30, 2017.

The huge post-fracture care gap has been well documented in many Canadian jurisdictions.  Without FLS, less than 25% of fragility fracture patients will be diagnosed and/or treated for their underlying osteoporosis.

By significantly improving osteoporosis care, FLSs help prevent future fractures, reduce patient suffering and increase their independence. With less than 50 FLSs in Canada, many more FLSs are needed to provide appropriate care to fracture patients.

To read the full report, please click here.

Osteoporosis Canada hosts the FLS Forum 2017

FLS Registry Launches Online Map

A Fracture Liaison Service (FLS) is a specific model of care where a coordinator pro-actively identifies fracture patients, on a system-wide basis, and determines their fracture risk with the express purpose of facilitating effective osteoporosis treatment for high risk patients. FLS is, by far, the most effective secondary fracture prevention method to ensure fracture patients receive the osteoporosis care they need to prevent additional fractures.

The FLS Registry Map was launched to profile hospitals that have implemented FLSs meeting all of the 8 Essential Elements of Fracture Liaison Services.

Each of the FLSs showcased on the Registry map has demonstrated a commitment to the principles of identification, investigation and initiation of treatment which will ensure fracture patients will receive the care they need to help prevent future fractures.

The Registry:

  • Acknowledges those Canadian hospitals that have implemented effective 2i or 3i models of FLS care
  • Allows a bird’s eye view of the breadth and location of FLS across the country

Are you an FLS who has not yet completed a submission to the Registry Committee?

We encourage you to open this link to further review the Essential Elements needed for an FLS to be successful and the application process for inclusion in the FLS Registry. Submissions will be reviewed on a regular basis by the FLS Registry Committee.