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Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework



A hip fracture liaison service that was implemented in 2 hospitals in Alberta, Canada, co-managed by a nurse and physician, was effective for improving initiation of osteoporosis medication following hip fracture.


To examine implementation of an in-patient hip fracture liaison service (H-FLS) to improve osteoporosis medication use after hip fracture using the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance).


Using population-based administrative data from 7 quarters before and up to 7 quarters after H-FLS implementation, we examined new starts, continued use, and overall use (new starts + continued use) of osteoporosis medication after hip fracture. A total of 1427 patients 50 years and older that underwent hip fracture surgery at 1 of 2 tertiary hospitals in a Canadian province and survived to 12 months post-fracture were included. We also compared treatment initiation rates by sex and hospital.


Of the 1427 patients, 1002 (70.2%) were female (mean age = 79.3 ± 11.9 years) and 425 (29.8%) were male (mean age = 73.8 ± 13.8 years). Based on pre-fracture residence within the health zone, 1101 (69%) were considered eligible (Reach). New starts of osteoporosis medication increased from 24.7% pre- to 43.9% post-implementation of the H-FLS (p < 0.001) (effectiveness). The proportion of patients prescribed osteoporosis medication prior to a hip fracture remained consistent (15.1% pre-; 14.7% post-implementation; p = 0.88) with a resultant improvement in overall medication use from 39.8% pre- to 58.6% post-implementation (p < 0.001). Both sites significantly improved medication initiation (site 1: 27.9% pre- to 40.3% post-implementation; site 2: 19.6% pre- to 50.0% post-implementation; p < 0.001 for both) (adoption). Medication initiation in females improved from 26.0% pre- to 43.4% post-implementation while initiation in males improved from 21.7% pre- to 45.1% post-implementation (p < 0.001[females]; p = 0.001[males]) (implementation). Post-implementation, elevated initiation rates were retained over the 7 quarters (p = 0.81) (maintenance).


An H-FLS based in two tertiary hospital sites significantly improved use of osteoporosis medications after hip fracture in both males and females.

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  1. 1.

    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778

    CAS  Article  Google Scholar 

  2. 2.

    Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35:293–305

    CAS  Article  Google Scholar 

  3. 3.

    Hodsman AB, Leslie WD, Tsang JF, Gamble GD (2008) 10-year probability of recurrent fractures following wrist and other osteoporotic fractures in a large clinical cohort: an analysis from the Manitoba Bone Density Program. Arch Intern Med 168:2261–2267

    Article  Google Scholar 

  4. 4.

    Johnson NA, Stirling ERB, Divall P, Thompson JR, Ullah AS, Dias JJ (2017) Risk of hip fracture following a wrist fracture meta-analysis. Injury 48:399–405

    Article  Google Scholar 

  5. 5.

    Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 22:465–475

    Article  Google Scholar 

  6. 6.

    Cauley JA, Smagula SF, Hovey KM, Wactawski-Wende J, Andrews CA, Crandall CJ, LeBoff MS, Li W, Coday M, Sattari M, Tindle HA (2017) Optimism, cynical hostility, falls, and fractures: the Women's Health Initiative Observational Study (WHI-OS). J Bone Miner Res 32:221–229

    Article  Google Scholar 

  7. 7.

    Chen JS, Hogan C, Lyubomirsky G, Sambrook PN (2009) Management of osteoporosis in primary care in Australia. Osteoporos Int 20:491–496

    CAS  Article  Google Scholar 

  8. 8.

    Mendis AS, Ganda K, Seibel MJ (2017) Barriers to secondary fracture prevention in primary care. Osteoporos Int 28:2913–2919

    CAS  Article  Google Scholar 

  9. 9.

    van den Berg P, Schweitzer DH, van Haard PMM, van den Bergh JP, Geusens PP (2015) Meeting international standards of secondary fracture prevention: a survey on Fracture Liaison Services in the Netherlands. Osteoporos Int 26:2257–2263

    Article  Google Scholar 

  10. 10.

    Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, Eisman JA, March L, Seibel MJ (2013) Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24:393–406

    CAS  Article  Google Scholar 

  11. 11.

    Wu CH, Tu ST, Chang YF, Chan DC, Chien JT, Lin CH, Singh S, Dasari M, Chen JF, Tsai KS (2018) Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: a systematic literature review and meta-analysis. Bone 111:92–100

    Article  Google Scholar 

  12. 12.

    Wu CH, Kao IJ, Hung WC, Lin SC, Liu HC, Hsieh MH, Bagga S, Achra M, Cheng TT, Yang RS (2018) Economic impact and cost-effectiveness of fracture liaison services: a systematic review of the literature. Osteoporos Int 29:1227–1242

    Article  Google Scholar 

  13. 13.

    Wu CH, Chen CH, Chen PH, Yang JJ, Chang PC, Huang TC, Bagga S, Sharma Y, Lin RM, Chan DC (2018) Identifying characteristics of an effective fracture liaison service: systematic literature review. Osteoporos Int 29:1023–1047

    Article  Google Scholar 

  14. 14.

    Hull L, Goulding L, Khadjesari Z, Davis R, Healey A, Bakolis I, Sevdalis N (2019) Designing high-quality implementation research: development, application, feasibility and preliminary evaluation of the implementation science research development (ImpRes) tool and guide. Implement Sci 14:80

    Article  Google Scholar 

  15. 15.

    Glasgow RE, Vogt TM, Boles SM (1999) Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health 89:1322–1327

    CAS  Article  Google Scholar 

  16. 16.

    Majumdar SR, Beaupre LA, Harley CH, Hanley DA, Lier DA, Juby AG, Maksymowych WP, Cinats JG, Bell NR, Morrish DW (2007) Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med 167:2110–2115

    Article  Google Scholar 

  17. 17.

    Morrish DW, Beaupre LA, Bell NR, Cinats JG, Hanley DA, Harley CH, Juby AG, Lier DA, Maksymowych WP, Majumdar SR (2009) Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial. Arthritis Rheum 61:209–215

    Article  Google Scholar 

  18. 18.

    Gardner MJ, Brophy RH, Demetrakopoulos D, Koob J, Hong R, Rana A, Lin JT, Lane JM (2005) Interventions to improve osteoporosis treatment following hip fracture. A prospective, randomized trial. J Bone Joint Surg Am 87:3–7

    Article  Google Scholar 

  19. 19.

    Jones G, Warr S, Francis E, Greenaway T (2005) The effect of a fracture protocol on hospital prescriptions after minimal trauma fractured neck of the femur: a retrospective audit. Osteoporos Int 16:1277–1280

    Article  Google Scholar 

  20. 20.

    Murray AW, McQuillan C, Kennon B, Gallacher SJ (2005) Osteoporosis risk assessment and treatment intervention after hip or shoulder fracture. A comparison of two centres in the United Kingdom. Injury 36:1080–1084

    CAS  Article  Google Scholar 

  21. 21.

    Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM (2006) Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 20:172–178

    CAS  Article  Google Scholar 

  22. 22.

    Hofflich HL, Oh DK, Choe CH, Clay B, Tibble C, Kulasa KM, Shah PK, Fink E, Girard PJ, Schwartz AK, Maynard GA (2014) Using a triggered endocrinology service consultation to improve the evaluation, management, and follow-up of osteoporosis in hip-fracture patients. Jt Comm J Qual Patient Saf 40:228–234

    PubMed  Google Scholar 

  23. 23.

    Davis JC, Guy P, Ashe MC, Liu-Ambrose T, Khan K (2007) HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. J Gerontol A Biol Sci Med Sci 62:888–891

    Article  Google Scholar 

  24. 24.

    Miki RA, Oetgen ME, Kirk J, Insogna KL, Lindskog DM (2008) Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial. J Bone Joint Surg Am 90:2346–2353

    Article  Google Scholar 

  25. 25.

    Ruggiero C, Zampi E, Rinonapoli G, Baroni M, Serra R, Zengarini E, Baglioni G, Duranti G, Ercolani S, Conti F, Caraffa A, Mecocci P, Brandi ML (2015) Fracture prevention service to bridge the osteoporosis care gap. Clin Interv Aging 10:1035–1042

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Majumdar SR, Lier DA, Beaupre LA, Hanley DA, Maksymowych WP, Juby AG, Bell NR, Morrish DW (2009) Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Arch Intern Med 169:25–31

    Article  Google Scholar 

  27. 27.

    Diem SJ, Peters KW, Gourlay ML, Schousboe JT, Taylor BC, Orwoll ES, Cauley JA, Langsetmo L, Crandall CJ, Ensrud KE (2017) Screening for osteoporosis in older men: operating characteristics of proposed strategies for selecting men for BMD Testing. J Gen Intern Med 32:1235–1241

    Article  Google Scholar 

  28. 28.

    Farford B, Balog J, Jackson KD, Montero D (2015) Osteoporosis: what about men? J Fam Pract 64:542–552

    PubMed  Google Scholar 

  29. 29.

    National Osteoporosis Foundation Guidelines (2010). Available at Accessed 18-10-2017

  30. 30.

    Osteoporosis Canada Guidelines (2017) Available at Accessed 15-11-2017

  31. 31.

    International Osteoporosis Foundation. International Osteoporosis Foundation Capture the Fracture: best practices framework for fracture liaison service. Available at Accessed 06-12-2018

  32. 32.

    Boudreau DM, Yu O, Balasubramanian A, Wirtz H, Grauer A, Crittenden DB, Scholes D (2017) A survey of women's awareness of and reasons for lack of postfracture osteoporotic care. J Am Geriatr Soc 65:1829–1835

    Article  Google Scholar 

  33. 33.

    Danila MI, Outman RC, Rahn EJ, Mudano AS, Redden DT, Li P, Allison JJ, Anderson FA, Wyman A, Greenspan SL, LaCroix AZ, Nieves JW, Silverman SL, Siris ES, Watts NB, Miller MJ, Curtis JR, Warriner AH, Wright NC, Saag KG (2018) Evaluation of a multimodal, direct-to-patient educational intervention targeting barriers to osteoporosis care: a randomized clinical trial. J Bone Miner Res 33:763–772

    CAS  Article  Google Scholar 

  34. 34.

    Ganda K, Schaffer A, Pearson S, Seibel MJ (2014) Compliance and persistence to oral bisphosphonate therapy following initiation within a secondary fracture prevention program: a randomised controlled trial of specialist vs. non-specialist management. Osteoporos Int 25:1345–1355

    CAS  Article  Google Scholar 

  35. 35.

    Wozniak LA, Johnson JA, McAlister FA, Beaupre LA, Bellerose D, Rowe BH, Majumdar SR (2017) Understanding fragility fracture patients' decision-making process regarding bisphosphonate treatment. Osteoporos Int 28:219–229

    CAS  Article  Google Scholar 

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This study was supported by an Alberta Innovates Partnerships for Research and Innovation in the Health System grant (RES0024l76), a Covenant Health Research Grant (RES0030391), as well as substantial in-kind contributions from the Alberta Health Service’s Bone and Joint Health Strategic Clinical Network and the Alberta Bone and Joint Health Institute to initiate and evaluate the clinical program.

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Corresponding author

Correspondence to L. A. Beaupre.

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Conflict of interest

LA Beaupre receives salary support as the David Magee Chair in Musculoskeletal Research in the Faculty of Rehabilitation Medicine at the University of Alberta.

SR Majumdar held the Endowed Research Chair in Patient Health Management supported by the Faculties of Medicine and Dentistry and Pharmacy and Pharmaceutical Sciences at the University of Alberta during the term of this study.

C Smith owns personal shares of Amgen Inc., manufacturer of medications used by the Fracture Liaison Service.

F Moradi, H Khong, L Evens, H Hanson, A Juby, and P Kivi declare that they have no conflicts of interest.

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Beaupre, L.A., Moradi, F., Khong, H. et al. Implementation of an in-patient hip fracture liaison services to improve initiation of osteoporosis medication use within 1-year of hip fracture: a population-based time series analysis using the RE-AIM framework. Arch Osteoporos 15, 83 (2020).

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  • Hip fracture
  • Osteoporosis
  • Fracture liaison service
  • Medication