Dr Alun Cooper discusses how fracture liaison services, funded through practice-based commissioning, can be used to improve osteoporosis care and treatment compliance

Osteoporosis is a chronic condition, with fracture as the acute event. Of patients over the age of 50 years, 1 in 2 women and 1 in 5 men will suffer a fragility fracture.1 Patients with hip fractures occupy 1 in 5 orthopaedic beds2 and all fractures in patients 60 years or older account for more than 2 million bed days in England per year.3 This is more than for heart disease, diabetes, or chronic obstructive pulmonary disease (COPD). Approximately one-third of those individuals suffering a hip fracture will die within a year and about half of those who survive can no longer live independently after the injury has been sustained.4 Total costs for social and hospital care are in excess of £1.8 billion per year.5 Of patients suffering a vertebral fracture, 40% will have constant pain and experience difficulties with daily living,6 and 80% of older people in a survey of women aged ?75 years said that they would rather die than suffer the reduced quality of life that can follow a hip fracture.7

Current state of care

Despite the personal, financial, and social costs resulting from fragility fractures, care is suboptimal. The Scottish Hip Fracture Audit8 says that ‘the significant prevalence of recent falls and previous fragility fractures with low levels of drug treatment for osteoporosis suggests many of these fractures may have been preventable’.

The Audit documented 30% of patients as having fallen at least once in the previous 6 months, and 28% had a history of a previous fragility fracture, of whom only 12% were on the secondary prevention treatment of a bisphosphonate and calcium/vitamin D as recommended by NICE Technology Appraisal 87.9 At 42 days post-admission (median length of hospital stay was 24 days), 52% of patients were prescribed some form of bone health medication, 21% of prescriptions being for a bisphosphonate/calcium/vitamin D combination. According to the Audit, 55% of patients admitted from home had returned to be cared for in their own home and 33% had returned to independent living. Only 42% of patients, who were discharged directly home from acute orthopaedic care, reported that they were being prescribed bone health medication at 6 weeks post-admission.8 The National Strategy for Scotland suggests that Community Health Partnerships should be used to improve management of long-term diseases.10

In England, reduction of emergency admissions by 5% by 2008 is a national priority that should be achieved by provision of improved primary care services for people with long-term conditions.11 Care for these patients also features prominently in standards set out for the NHS in Wales.12

National evaluation of care standards

The first national evaluation of care standards in primary care for older people at risk of falls and osteoporotic fractures, using the QRESEARCH database, was funded by The Information Centre.13 The report acknowledges that quality of data in these clinical areas is variable and generally poor, but on the basis of a pilot survey it felt it was possible to collect useful data. Overall, 14.8% of women in the UK over 65 years of age were recorded as having a fragility fracture13 compared to 21.1% in a study (and subsequent questionnaire) from Scotland alone.14 If the prevalence of fractures is estimated incorrectly as being low, then treatment rates will be less than those reported.

Investigations and pharmacology

NICE Technology Appraisal 87 recommends that postmenopausal women aged 75 years and over, who have suffered a fragility fracture, should be considered for treatment with bisphosphonates for secondary prevention of osteoporosis.9 In the QRESEARCH study, 25% of females aged 75 years or over with a history of fragility fracture had evidence of treatment. The prevalence rate was between 40% and 66% of that expected.13 In the younger age group, aged 65–74 years old, NICE recommends that women should receive treatment if osteoporosis is confirmed by dual-energy X-ray absorptiometry (DXA).9 In the QRESEARCH database, only 9.8% of females aged 65–74 years had evidence of a DXA scan. One-third of practices showed no patients in this group being referred for DXA. Of 65–74 year olds with a prior fragility fracture who also had a diagnosis of osteoporosis, 73% received treatment.13

NICE also recommends that calcium and vitamin D are coprescribed with the bisphosphonates unless the patient’s calcium intake is adequate or they are vitamin D replete.9 Coprescription was recorded in 54% of cases.13 Although guidelines demonstrate the need for reliable secondary fracture prevention, bone densitometry is conducted in less than 15% of patients, and bisphosphonate treatment is initiated in only 1–13% of patients.15 It is anticipated that the recently launched National Hip Fracture Database will improve the management of patients who attend hospital with fragility fractures.16

Reasons for low implementation rates

There are many potential reasons why the numbers of patients being investigated and treated for secondary fracture prevention are so low. Miscommunication between secondary and primary care is often a factor, with the orthopaedic surgeon often believing that osteoporosis will be dealt with in primary care. It is also a matter of concern that treatments for bisphosphonates may interfere with normal bone healing, although there is no evidence to support this as yet17 and, indeed, studies in rats showed stronger callus formation.18

Fracture liaison services

The fracture event is a unique opportunity for the initiation of osteoporotic assessment and treatment. Many hospitals have therefore established a fracture liaison service (FLS), with demonstrable benefits.19

The function of the FLS is to identify and treat patients presenting with fracture to hospitals and then offer them appropriate information on osteoporosis and treatment. It also provides advice to GPs on management of osteoporosis and treatment options. An example of such a service is that set up in Glasgow.20 It accepts direct referrals from orthopaedics and fracture clinic staff and provides a direct access densitometry service for GPs. It is estimated that currently 30% of UK hospitals have an FLS21 and this type of service has been endorsed nationally4 and internationally as a model of best practice for secondary fracture prevention.

How to expand the service

The recent revision to the GMS contract has not changed the clinical domains of the Quality Outcomes Framework.22 This represents a missed opportunity to implement structured, systematic care. However, those involved in commissioning services still have an opportunity to focus on osteoporotic care. Practice-based commissioning (PBC) gives local clinicians greater control over resources, so that the service can respond better to local needs. The commissioning budget should be used to identify patient needs, design a service that responds to those needs, and allocate resources depending on local priorities. The benefits can be seen in a greater variety of services, potentially from a greater number of providers. These services should be closer to home and more convenient for patients. Practice-based commissioning should also increase efficiency, for example by reducing unnecessary hospital stays. Decision-making should be closer to communities and there should be greater involvement in commissioning from front-line doctors and nurses.

A broader based FLS

A more broadly based FLS, located in primary care, can be covered by PBC and will provide an opportunity to improve practice and reduce the variations seen across practices. As with any new service it will be dependent on the enthusiasm of its champions, who could be from primary or secondary medical care and/or from PCT or NHS acute trust management. In order to facilitate communication, two multidisciplinary groups would ideally be established. The first would be a local group to identify local needs and develop local protocols using best practice (Box 1), the second should involve all stakeholders relating to the PCT. This would enable the sharing of common practice problems and joint goals. The outcomes from these groups need to be communicated to all involved in the care of elderly patients—GPs, nursing homes, and pharmacists.

Box 1: Suggested members of a local Fracture Liaison Service group

Primary care representative—perhaps GPwSI Secondary care:
    • rheumatologist
    • orthogeriatrician
    • co-opted members, for example radiologist, orthopaedic surgeon for specific issues

PCT/Trust management

Physiotherapist/occupational therapist

Pharmacists—trust and community

Representative from ambulance service

Patient representative, perhaps from voluntary service such as the National Osteoporosis Society

Role of the FLS nurse

An essential component of this FLS is a nurse to integrate and coordinate primary and secondary care. The role is not dissimilar to that of the diabetes, COPD, or heart failure nurse. Based in primary care, in addition to being involved with the person who has recently suffered a fracture (incident fracture), he/she would need to establish a validated register of patients who have previously suffered a fragility fracture (prevalent fracture). Furthermore a register of those at high risk but who, as yet, have not had a fracture (primary prevention), for example, those with a family history of hip fracture, those who have used oral steroids, or who have rheumatoid arthritis, needs to be compiled. This could be set up using the recently produced World Health Organisation Fracture Risk Assessment Tool (FRAX™), which is available at www.shef.ac.uk/FRAX. Using clinical risk factors, the FRAX can be used to calculate the absolute risk of a patient experiencing a hip fracture or any osteoporotic fracture over the next 10 years. The FLS nurse could then: refer susceptible people for a DXA scan; investigate for secondary causes of osteoporosis, if appropriate; and provide a report and management plan for the GP. The FLS nurse would also need to liaise with falls clinics and nursing homes.

As with any asymptomatic chronic condition, compliance in medicine taking is poor,23 side-effects are increased, and the benefits of therapy are reduced if the medication is not taken in the correct way. The central role of primary care in promoting compliance has been recognised24 and an FLS nurse is ideally placed to do this and offer lifestyle advice.

In addition to improving compliance in taking bone remodelling agents, an FLS, perhaps involving medicines usage reviews by pharmacists, would be ideally placed to ensure coprescribing of calcium and vitamin D. For those patients unable to take oral treatments, a community-based intravenous administration service could be established to contain costs and provide a more local service for patients. Benchmarks for quality of care need to be established against which the service can be audited.


The importance of the role of primary care in following up patients who present in secondary care has been emphasised.25 Reducing osteoporotic fractures is a manageable goal for primary care, and PBC, using a primary care-based FLS, can provide the mechanism to ensure that this happens.

  • NICE recommends that women aged 75 years and over with a fracture should take bisphosphonates, but only 25% are treated accordingly
  • Bisphosphonates are now available generically and at low cost
  • NICE recommends women aged 65–74 years with an osteoporotic fragility fracture receive bisphosphonates as treatment options after confirmation by DXA scan, but only approximately 10% have been scanned
  • Untreated osteoporosis is a major risk factor for admission with fractured neck of femur, which accounts for a large number of admissions and bed days and costs to the NHS
  • There is a great opportunity with PBC to design a community-based service to ensure those experiencing fractures are assessed and treated appropriately
  • Script costs:a
      • alendronic acid for osteoporosis, £1.03 for weekly dose
      • calcium and vitamin D, £4.06 a month
  • Tariff prices:b fracture neck of femur with hip replacement £7815, without replacement £5052
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