Current Rheumatology Reports

, 16:455 | Cite as

Fracture Liaison Services: Promoting Enhanced Bone Health Care

  • Juliet AizerEmail author
  • Marcy B. Bolster
Osteoporosis and Metabolic Bone Disease (KG Saag, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Osteoporosis and Metabolic Bone Disease


The high prevalence of osteoporotic fractures and their major effect on morbidity and mortality emphasizes the critical need to optimize bone health care. Patients presenting with fragility fractures are at high risk of subsequent fracture, but treatment rates have remained low for these patients. Recently developed fracture liaison services have successfully increased osteoporosis treatment, with improved patient outcomes. We review factors contributing to the treatment gap in osteoporosis, the function of fracture liaison services in reducing this gap, and lessons learned from the literature on effective formats, key elements, and suggestions for managing challenges in implementation of a fracture liaison service.


Fracture liaison service FLS Osteoporosis management Osteoporosis treatment Secondary fracture prevention Fracture prevention Quality of care Bone health 


Compliance with Ethics Guidelines

Conflict of Interest

Juliet Aizer reports that she has no conflict of interest. Dr. Aizer received funding in part from the Rheumatology Research Foundation Clinician Scholar Educator Award. Marcy B. Bolster reports the receipt of a research grant from Eli Lilly, outside the submitted work.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    LeBlanc ES et al. Hip fracture and increased short-term but not long-term mortality in healthy older women. Arch Intern Med. 2011;171(20):1831–7.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Haentjens P et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380–90.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Brauer CA et al. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302(14):1573–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Boonen S et al. Functional outcome and quality of life following hip fracture in elderly women: a prospective controlled study. Osteoporos Int. 2004;15(2):87–94.PubMedCrossRefGoogle Scholar
  5. 5.
    Hall SE et al. Hip fracture outcomes: quality of life and functional status in older adults living in the community. Aust NZ J Med. 2000;30(3):327–32.CrossRefGoogle Scholar
  6. 6.
    Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359(9319):1761–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Lyles KW et al. Zoledronic Acid and Clinical Fractures and Mortality after Hip Fracture. N Engl J Med. 2007;357(18):1799–809.PubMedCrossRefGoogle Scholar
  8. 8.
    Beaupre LA et al. Oral bisphosphonates are associated with reduced mortality after hip fracture. Osteoporos Int. 2011;22(3):983–91.PubMedCrossRefGoogle Scholar
  9. 9.
    Sambrook PN et al. Oral bisphosphonates are associated with reduced mortality in frail older people: a prospective five-year study. Osteoporos Int. 2011;22(9):2551–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Bolland MJ et al. Effect of osteoporosis treatment on mortality: a meta-analysis. J Clin Endocrinol Metab. 2010;95(3):1174–81.PubMedCrossRefGoogle Scholar
  11. 11.
    Center JR et al. Osteoporosis medication and reduced mortality risk in elderly women and men. J Clin Endocrinol Metab. 2011;96(4):1006–14.PubMedCrossRefGoogle Scholar
  12. 12.
    Colon-Emeric CS et al. Potential mediators of the mortality reduction with zoledronic acid after hip fracture. J Bone Miner Res. 2010;25(1):91–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Wolfe F et al. Bisphosphonate use is associated with reduced risk of myocardial infarction in patients with rheumatoid arthritis. J Bone Miner Res. 2013;28(5):984–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Heyworth L et al. Comparison of interactive voice response, patient mailing, and mailed registry to encourage screening for osteoporosis: a randomized controlled trial. Osteoporos Int. 2014;25(5):1519–26.PubMedCrossRefGoogle Scholar
  15. 15.
    Aizer J et al. Predictors of bone density testing in patients with rheumatoid arthritis. Rheumatol Int. 2009;29(8):897–905.PubMedCrossRefGoogle Scholar
  16. 16.
    Center JR et al. RIsk of subsequent fracture after low-trauma fracture in men and women. JAMA. 2007;297(4):387–94.PubMedCrossRefGoogle Scholar
  17. 17.
    National Committee for Quality Assurance. HEDIS, 2003.Google Scholar
  18. 18.
    Medicare National Committee for Quality Assurance State of Health Care Quality 2008 Report. HEDIS, 2008.Google Scholar
  19. 19.
    Inderjeeth CA, Glennon D, Petta A. Study of osteoporosis awareness, investigation and treatment of patients discharged from a tertiary public teaching hospital. Intern Med J. 2006;36(9):547–51.PubMedCrossRefGoogle Scholar
  20. 20.
    Solomon DH et al. Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education. J Bone Miner Res. 2007;22(11):1808–15.PubMedCrossRefGoogle Scholar
  21. 21.••
    Eisman JA et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012;27(10):2039–46. A review of the rationale for an FLS, and this paper provides a framework and toolkit for systems based implementation of an FLS.PubMedCrossRefGoogle Scholar
  22. 22.
    McLellan AR et al. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int. 2003;14(12):1028–34.PubMedCrossRefGoogle Scholar
  23. 23.
    Wallace I et al. An evaluation of an enhanced fracture liaison service as the optimal model for secondary prevention of osteoporosis. JRSM Short Rep. 2011;2(2):8.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Chakravarthy J et al. Secondary prevention of fragility fractures by orthopaedic teams in the UK: a national survey. Int J Clin Pract. 2008;62(3):382–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Murray AW et al. Osteoporosis risk assessment and treatment intervention after hip or shoulder fracture. A comparison of two centres in the United Kingdom. Injury. 2005;36(9):1080–4.PubMedCrossRefGoogle Scholar
  26. 26.
    Majumdar SR et al. Cost-effectiveness of a multifaceted intervention to improve quality of osteoporosis care after wrist fracture. Osteoporos Int. 2011;22:1799–808.PubMedCrossRefGoogle Scholar
  27. 27.
    Boudou L et al. Management of osteoporosis in fracture liaison service associated with long-term adherence to treatment. Osteoporos Int. 2011;22(7):2099–106.PubMedCrossRefGoogle Scholar
  28. 28.
    Dell R. Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int. 2011;22(3):457–60.PubMedCrossRefGoogle Scholar
  29. 29.
    Lih A et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int. 2011;22(3):849–58.PubMedCrossRefGoogle Scholar
  30. 30.•
    Cooper MS, Palmer AJ, Seibel MJ. Cost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention study. Osteoporos Int. 2012;23(1):97–107. An investigation of the cost-effectiveness of an FLS, considering a variety of potential scenarios in a 10-year simulation.PubMedCrossRefGoogle Scholar
  31. 31.
    McLellan AR et al. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int. 2011;22(7):2083–98.PubMedCrossRefGoogle Scholar
  32. 32.
    Solomon DH et al. The potential economic benefits of improved postfracture care: a cost-effectiveness analysis of a fracture liaison service in the US healthcare system. J Bone Miner Res. 2014;29(7):1667–74.PubMedCrossRefGoogle Scholar
  33. 33.
    Coulson I. Co-ordinating an orthopaedic service. Nurs Stand. 1993;7(32):37–40.PubMedGoogle Scholar
  34. 34.
    Charalambous CP et al. Improving osteoporosis assessment in the fracture clinic. Ann R Coll Surg Engl. 2009;91(7):596–8.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Gardner MJ et al. Interventions to improve osteoporosis treatment following hip fracture. A prospective randomized trial. J Bone Joint Surg Am. 2005;87(1):3–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Austin SM, et al. Effect of physician reminders on preventative care: meta-analysis of randomzied clinical trials. Proc Annu Symp Comput Appl Med Care. 1994:121–124.Google Scholar
  37. 37.
    Lee RH et al. Osteoporosis screening and treatment among veterans with recent fracture after implementation of an electronic consult service. Calcif Tissue Int. 2014;94(6):659–64.PubMedCrossRefGoogle Scholar
  38. 38.•
    Eekman DA et al. Optimizing fracture prevention: the fracture liaison service, an observational study. Osteoporos Int. 2014;25(2):701–9. In addition to patient outcomes, this paper includes rich data on differences between patients who accepted invitations to attend an FLS.PubMedCrossRefGoogle Scholar
  39. 39.
    Huntjens KM et al. Implementation of osteoporosis guidelines: a survey of five large fracture liaison services in the Netherlands. Osteoporos Int. 2011;22(7):2129–35.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Inderjeeth CA et al. A multimodal intervention to improve fragility fracture management in patients presenting to emergency departments. MJA. 2010;193:149–53.PubMedGoogle Scholar
  41. 41.
    Premaor MO et al. Obesity and fractures in postmenopausal women. J Bone Miner Res. 2010;25(2):292–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Ong T et al. A United Kingdom perspective on the relationship between body mass index (BMI) and bone health: a cross sectional analysis of data from the Nottingham Fracture Liaison Service. Bone. 2014;59:207–10.PubMedCrossRefGoogle Scholar
  43. 43.••
    Curtis JR, Silverman SL. Commentary: the five Ws of a Fracture Liaison Service: why, who, what, where, and how? In osteoporosis, we reap what we sow. Curr Osteoporos Rep. 2013;11(4):365–8. This paper describes not only the basics of FLS but also solutions to some challenges encountered in FLS implementation.PubMedCrossRefGoogle Scholar
  44. 44.
    Osteoporosis-Associated Fracture Implementation Guide 2013. The Joint Commission.; accessed 7/11/14.
  45. 45.•
    Oates MK. Invited commentary: fracture follow-up program in an open healthcare system. Curr Osteoporos Rep. 2013;11(4):369–76. This paper relays an elaborate account of FLS implementation in a healthcare system, providing practical details useful for operationalizing an FLS.PubMedCrossRefGoogle Scholar
  46. 46.
    Mitchell PJ. Fracture Liaison Services: the UK experience. Osteoporos Int. 2011;22 Suppl 3:487–94.PubMedCrossRefGoogle Scholar
  47. 47.
    Bunta AD. It is time for everyone to own the bone. Osteoporos Int. 2011;22 Suppl 3:477–82.PubMedCrossRefGoogle Scholar
  48. 48.••
    Akesson K et al. Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013;24(8):2135–52. This paper describes the International Osteoporosis Foundation's “Capture the Fracture” campaign, intended to support world-wide FLS implementation.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Fraser M, McLellan AR. A fracture liaison service for patients with osteoporotic fractures. Prof Nurse (London, England). 2004;19(5):286–90.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Division of Rheumatology, Hospital for Special SurgeryWeill Cornell Medical CollegeNew YorkUSA
  2. 2.Division of RheumatologyHarvard Medical School, Massachusetts General HospitalBostonUSA

Personalised recommendations