Fracture Liaison Services: A Comprehensive Analysis of Implementation, Economic Impact, and Global Case Studies

2025-12-22 Research Reports 0

Abstract

Osteoporotic fragility fractures represent a critical global health challenge, inflicting substantial morbidity, mortality, and economic strain on healthcare systems and individuals alike. Fracture Liaison Services (FLS) have emerged as an indispensable, evidence-based strategy specifically designed for the secondary prevention of these debilitating fractures. This comprehensive report offers an exhaustive exploration of FLS, delving deeply into their foundational principles, diverse operational modalities, significant economic implications, persistent challenges encountered during implementation and scaling, and illuminating global success stories. By meticulously dissecting these multifaceted aspects, this report aims to furnish healthcare policymakers, clinical practitioners, researchers, and patient advocates with profound insights into the demonstrable efficacy, strategic considerations, and future trajectory of FLS in elevating the standard of osteoporosis care worldwide.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction: The Silent Epidemic of Osteoporotic Fractures and the Imperative for FLS

Osteoporosis, often termed the ‘silent disease,’ is characterized by compromised bone strength predisposing individuals to an increased risk of fracture. Globally, it affects hundreds of millions, with its prevalence escalating rapidly due to an aging population demographic. An osteoporotic fracture, typically defined as a fracture resulting from a fall from a standing height or less, is not merely an isolated traumatic event but rather a sentinel indicator of underlying skeletal fragility. These fractures, predominantly affecting the hip, spine (vertebral), wrist, and humerus, carry profound consequences, including chronic pain, loss of independence, diminished quality of life, and tragically, increased mortality, particularly following hip fractures.

The most alarming aspect of osteoporotic fractures is the ‘fragility fracture cascade’ or ‘fracture spiral.’ An individual who has sustained one fragility fracture faces a significantly heightened risk—often two to four times greater—of experiencing subsequent fractures compared to someone without a prior fracture. This insidious cycle perpetuates immense suffering and compounds the economic burden on healthcare systems. Despite this well-established risk, a staggering majority of patients (as high as 80% in some regions) who present with a fragility fracture are neither adequately investigated for osteoporosis nor initiated on appropriate bone protective therapy. This pervasive care gap, known as the ‘osteoporosis treatment gap,’ or ‘post-fracture care gap,’ represents a critical failing in current healthcare provision.

Fracture Liaison Services (FLS) were conceived as a systematic, proactive intervention to close this gap. Their fundamental objective is to identify, investigate, initiate treatment for, and monitor individuals who have experienced a fragility fracture, thereby breaking the cycle of recurrent fractures. FLS represent a paradigm shift from reactive treatment of fractures to proactive, preventative care for the underlying disease. This report will systematically unpack the intricacies of FLS, providing a detailed understanding of their structure, impact, and future potential.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. Operational Models and Best Practices for Implementing FLS

An effective Fracture Liaison Service is characterized by a structured, multidisciplinary approach that ensures comprehensive post-fracture care. While the specific configurations of FLS can vary based on local healthcare infrastructure, resource availability, and patient demographics, certain core components and best practices are universally recognized as essential for success.

2.1. Core Components of an FLS

An optimal FLS workflow typically incorporates a series of interconnected stages:

2.1.1. Systematic Identification and Notification

The initial and arguably most crucial step in an FLS is the accurate and systematic identification of patients who have sustained a fragility fracture. This often requires proactive screening across various points of care where fractures are managed. Potential identification triggers include:

  • Emergency Departments (EDs): Patients presenting with low-trauma fractures.
  • Orthopaedic Wards/Clinics: Patients admitted for fracture repair or attending follow-up appointments.
  • Radiology Departments: Reports indicating fragility fractures, especially vertebral fractures often missed clinically.
  • Primary Care Referrals: General practitioners identifying patients with new fractures or at high risk.

The FLS coordinator, often a dedicated nurse or allied health professional, is typically notified of potential fragility fracture patients. The aim is to capture a wide spectrum of fractures, moving beyond just hip fractures, to include clinically significant vertebral, wrist, humerus, and other non-hip, non-vertebral fractures, which also signify underlying osteoporosis and predict future fractures.

2.1.2. Comprehensive Risk Assessment and Diagnosis

Once identified, patients undergo a thorough assessment that extends beyond the immediate fracture management. This involves:

  • Confirmation of Fragility Fracture: Verification that the fracture was low-trauma.
  • Bone Mineral Density (BMD) Testing: Dual-energy X-ray absorptiometry (DXA) is the gold standard for measuring BMD and diagnosing osteoporosis. Access to DXA scanning within a reasonable timeframe is paramount.
  • Clinical Risk Factor Assessment: Evaluation of known risk factors for osteoporosis, such as age, sex, family history of hip fracture, prior fragility fractures, glucocorticoid use, smoking, alcohol consumption, rheumatoid arthritis, and other secondary causes of osteoporosis (e.g., hyperparathyroidism, malabsorption syndromes, chronic kidney disease, certain medications).
  • Fall Risk Assessment: Crucial for preventing future fractures, this involves assessing gait and balance, reviewing medications (especially those causing dizziness or sedation), evaluating visual impairment, assessing nutritional status (particularly vitamin D deficiency), and identifying environmental hazards.
  • Vertebral Fracture Assessment (VFA): For many, particularly older individuals, asymptomatic vertebral fractures are a significant risk factor for future fractures and often require specific imaging beyond standard spine X-rays or can be detected by lateral DXA scans.
  • Laboratory Investigations: Blood tests may be conducted to rule out secondary causes of osteoporosis (e.g., serum calcium, phosphate, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D, creatinine, thyroid stimulating hormone).

This comprehensive assessment allows for an accurate diagnosis of osteoporosis and identification of modifiable risk factors.

2.1.3. Treatment Initiation and Management Plan

Based on the assessment, an individualized treatment and management plan is formulated. This typically involves:

  • Pharmacological Interventions: Initiation of appropriate anti-osteoporosis medications (AOMs). These include oral or intravenous bisphosphonates, denosumab, teriparatide, abaloparatide, and romosozumab. The choice of medication depends on fracture severity, BMD T-scores, renal function, patient comorbidities, and individual preferences. Education on medication efficacy, administration, and potential side effects is critical.
  • Non-pharmacological Interventions:
    • Calcium and Vitamin D Supplementation: Ensuring adequate intake, often through supplements, is foundational.
    • Lifestyle Modifications: Counseling on smoking cessation, reduction of alcohol intake, and regular weight-bearing and muscle-strengthening exercise.
    • Fall Prevention Strategies: Referral to physiotherapy, occupational therapy, balance programs, medication review by a pharmacist, home safety assessments, and appropriate assistive devices.
  • Patient Education: Empowering patients with a thorough understanding of osteoporosis, their personal risk profile, the importance of adherence to treatment, and self-management strategies is fundamental to long-term success.

2.1.4. Follow-Up, Monitoring, and Long-Term Adherence

Ongoing management is vital to ensure treatment efficacy and sustained adherence. This involves:

  • Scheduled Follow-Up: Regular contact with the FLS team to monitor treatment adherence, assess side effects, and re-evaluate risk factors.
  • Treatment Persistence: Addressing barriers to adherence (e.g., misunderstanding, side effects, cost) and reinforcing the long-term nature of osteoporosis management.
  • Reassessment: Periodic reassessment of BMD, fracture risk, and treatment goals, typically every 1-3 years, to guide treatment adjustments or consider drug holidays if appropriate.
  • Communication with Primary Care: Clear communication and handover of care to the patient’s primary care physician for ongoing management, with the FLS acting as a specialized support service.

2.2. Operational Models of FLS

FLS models exhibit adaptability to diverse healthcare settings and resource landscapes. The core objective remains consistent: systematic identification and management. However, their structural and leadership configurations can vary significantly:

2.2.1. Orthogeriatric-Led Services

This model is typically found in acute care settings, often integrated within orthopaedic trauma units. Multidisciplinary teams, frequently led by geriatricians or orthogeriatricians, focus on the comprehensive medical management of older patients with fragility fractures, particularly hip fractures. These services bridge the acute surgical care with geriatric expertise, managing comorbidities, optimizing pre-operative and post-operative medical status, and initiating secondary fracture prevention. Studies consistently demonstrate that this integrated approach not only reduces subsequent fractures but also improves functional outcomes, reduces hospital length of stay, and decreases mortality rates in older patients (pubmed.ncbi.nlm.nih.gov/27632945/). The geriatrician’s expertise in polypharmacy, delirium, falls, and nutritional status is invaluable.

2.2.2. Nurse-Led Services

Nurse-led models are highly prevalent and have proven remarkably effective, especially in contexts where physician resources are limited or expensive. In these models, a dedicated FLS nurse or bone care coordinator is central to the service. This nurse is responsible for the systematic identification of patients, coordinating DXA scans and other diagnostic tests, educating patients, initiating treatment protocols (often in consultation with a medical lead), and overseeing follow-up and monitoring. Their role is pivotal in navigating patients through the care pathway and ensuring continuity. This model’s success stems from the nurse’s ability to build rapport with patients, provide detailed education, and efficiently coordinate care, demonstrating considerable success in various settings (pubmed.ncbi.nlm.nih.gov/29429033/).

2.2.3. Integrated Services

Integrated services represent a collaborative approach that deliberately involves multiple specialties to provide holistic care. This model might see orthopaedic surgeons, rheumatologists, endocrinologists, geriatricians, general practitioners, physiotherapists, occupational therapists, and dietitians working in concert. The FLS acts as a central hub, facilitating referrals and ensuring seamless communication between these specialists. Such integration is associated with improved patient outcomes, heightened patient satisfaction due to comprehensive care, and more efficient resource utilization (link.springer.com/article/10.1007/s00198-024-07181-7). It can be particularly effective in larger academic centers or health systems with diverse specialist capabilities.

2.2.4. Hybrid and Virtual FLS Models

Beyond these archetypes, hybrid models combine elements of the above, perhaps with a nurse coordinator liaising with an orthogeriatrician for complex cases or utilizing a centralized registry for identification across multiple sites. The advent of telemedicine has also paved the way for virtual FLS models, particularly for follow-up and patient education, enhancing accessibility for patients in remote areas or those with mobility challenges. These models leverage technology to deliver care remotely, maintaining key FLS functions while potentially reducing geographical barriers.

2.3. Best Practices for Implementation

Successful and sustainable FLS implementation relies on several key strategic pillars:

  • Strong Leadership and Advocacy (‘Bone Health Champion’): Identifying and empowering a dedicated individual or small team to champion the FLS program is critical. This ‘bone health champion’ (e.g., an enthusiastic surgeon, geriatrician, or nurse) drives the initiative, secures necessary resources, advocates for policy changes, and fosters collaboration among stakeholders. Their passion and persistence are often the driving force behind overcoming initial inertia and challenges (link.springer.com/article/10.1007/s00198-024-07181-7).

  • Robust Stakeholder Engagement: The success of an FLS hinges on securing active buy-in and collaboration from a broad spectrum of healthcare providers and administrators. This includes orthopaedic surgeons, emergency physicians, radiologists, geriatricians, endocrinologists, rheumatologists, primary care physicians, hospital executives, and even pharmacists and physical therapists. Regular communication, shared goals, and demonstrated benefits are essential to fostering this collaborative environment and overcoming departmental silos.

  • Standardized Protocols and Care Pathways: Clear, evidence-based protocols for patient identification, assessment, treatment initiation, and follow-up ensure consistency and quality of care. These protocols should be integrated into existing clinical workflows to minimize disruption and maximize efficiency. Development of specific care pathways, from fracture presentation to long-term follow-up, streamlines the patient journey.

  • Comprehensive Data Management and Evaluation Systems: Implementing robust data collection and analysis systems is non-negotiable for monitoring program effectiveness, ensuring quality control, and demonstrating value. Key metrics include the number of fragility fractures identified, percentage of patients undergoing DXA, rate of treatment initiation and adherence, and crucially, re-fracture rates. These data inform continuous quality improvement, facilitate reporting to stakeholders, and support advocacy efforts for sustained funding. Electronic health records (EHRs) can be leveraged for automated identification and tracking.

  • Proactive Patient Education and Engagement: Patients are active partners in their care. Providing accessible, clear, and consistent information about osteoporosis, the importance of medication adherence, lifestyle modifications, and fall prevention strategies significantly enhances engagement and improves long-term outcomes. Educational materials, support groups, and patient navigators can play a vital role.

  • Integration with Existing Healthcare Structures: Rather than operating as an isolated entity, successful FLS seamlessly integrate into existing hospital and community healthcare structures, leveraging established referral pathways and inter-departmental collaborations.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3. Economic Impact and Cost-Effectiveness of FLS

The economic rationale for implementing Fracture Liaison Services is compelling, rooted in the substantial financial burden imposed by osteoporotic fractures and the proven ability of FLS to mitigate these costs.

3.1. The Monumental Economic Burden of Osteoporotic Fractures

Osteoporotic fractures represent a significant and escalating economic drain on healthcare systems globally. In the United States alone, the annual costs associated with osteoporosis-related fractures are estimated to be approximately $20 billion, a figure projected to rise substantially as the population ages. The majority of these costs are borne by federal healthcare programs such as Medicare and Medicaid, highlighting the societal impact (pubmed.ncbi.nlm.nih.gov/24443384/).

These costs are multifaceted, encompassing:

  • Direct Medical Costs: These include acute hospitalization for fracture repair, surgical procedures, rehabilitation services (inpatient and outpatient), emergency department visits, physician fees, diagnostic imaging, and long-term care in nursing homes. Hip fractures, in particular, are the most costly, often requiring extensive hospital stays, complex surgery, and prolonged rehabilitation. Vertebral fractures, while sometimes managed non-surgically, can lead to chronic pain, loss of height, spinal deformity, and subsequent medical complications, incurring significant costs over time.
  • Indirect Costs: Beyond direct medical expenditures, osteoporotic fractures impose substantial indirect costs. These include lost productivity due to disability, premature mortality, decreased quality of life for patients and their caregivers, and the often-overlooked burden on family members who provide informal care. The psychological toll, including anxiety, depression, and fear of falling, also has an indirect economic impact.
  • Societal Costs: The cumulative effect of these direct and indirect costs translates into a significant societal burden, diverting resources that could otherwise be allocated to other public health initiatives. The economic impact extends beyond healthcare budgets, affecting social services and welfare programs.

3.2. The Demonstrated Cost-Effectiveness of FLS

Numerous health economic evaluations from diverse international settings have consistently demonstrated that implementing FLS is a highly cost-effective, and often cost-saving, intervention. The economic benefits accrue primarily from the reduction in subsequent fractures, which prevents the cascade of associated high-cost medical events.

3.2.1. Reduction in Subsequent Fractures and Associated Healthcare Utilization

FLS programs have proven remarkably effective in significantly reducing the incidence of subsequent fragility fractures. Meta-analyses and systematic reviews consistently report reductions in refracture rates ranging from 20% to over 50%, depending on the fracture type and FLS model. This translates directly into decreased demand for acute care services, including fewer hospital admissions, fewer surgical procedures, and a reduced need for expensive post-acute rehabilitation and institutional care (pubmed.ncbi.nlm.nih.gov/29460102/). By preventing subsequent fractures, FLS mitigate the need for these high-cost interventions, generating substantial savings for healthcare systems.

3.2.2. Improvement in Quality-Adjusted Life Years (QALYs)

Health economic evaluations often utilize Quality-Adjusted Life Years (QALYs) as a measure of health outcomes, combining both the quantity and quality of life. A QALY represents one year of perfect health. Studies on FLS have consistently reported favorable cost-per-QALY gained ratios, indicating that FLS deliver substantial health benefits relative to their costs (pubmed.ncbi.nlm.nih.gov/36662166/). This means that for a relatively modest investment, FLS can significantly improve the length and quality of life for patients, making them an attractive proposition from a societal perspective. The prevention of painful, debilitating fractures allows individuals to maintain independence, mobility, and overall well-being for longer, contributing positively to their QALYs.

3.2.3. Return on Investment (ROI) and Long-Term Savings

While FLS programs require initial investment for staffing, training, infrastructure, and medication, economic models and real-world data consistently show a positive return on investment (ROI) over a relatively short period. The prevention of high-cost refractures quickly offsets the initial program costs. For example, economic projections have indicated that in a country like the United Kingdom, widespread FLS implementation could avert thousands of fractures and lead to substantial cost savings over a five-year period, demonstrating their financial viability and sustainability (capturethefracture.org/index.php/news/new-economic-model-finds-fracture-liaison-services-are-highly-effective-20230208-1017). The economic benefits are often realized not just within the hospital budget but across the wider health and social care system, encompassing primary care, community services, and long-term care facilities.

3.3. Budget Impact and Sustainability

Understanding the budget impact of FLS is crucial for policymakers. While the initial setup costs might seem daunting, these are typically dwarfed by the long-term savings generated. A robust business case for FLS often emphasizes:

  • Avoided Costs: Highlighting the costs of future fractures that are averted, including subsequent hospitalizations, surgeries, and rehabilitation.
  • Improved Efficiency: By standardizing care pathways and reducing unnecessary readmissions, FLS can optimize resource utilization within the healthcare system.
  • Enhanced Quality of Life: While harder to quantify purely financially, the social and human benefits of preventing disability and improving quality of life are powerful arguments for investment.

Sustainable funding models are essential for the long-term success and scalability of FLS. These can include dedicated government funding, integration into hospital budgets with performance-based incentives, or collaborative funding from multiple healthcare payers. Advocacy efforts often focus on demonstrating the tangible savings and health benefits to secure ongoing financial support.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Challenges in Establishing and Scaling FLS Programs

Despite the compelling evidence supporting the efficacy and cost-effectiveness of Fracture Liaison Services, their widespread establishment and sustainable scaling face a range of significant challenges. These hurdles often require strategic planning, strong leadership, and innovative solutions.

4.1. Resource Constraints

One of the most pervasive challenges is the scarcity of dedicated resources, encompassing financial, human, and infrastructural components (pmc.ncbi.nlm.nih.gov/articles/PMC4591627/).

4.1.1. Financial Resources

Initial funding for establishing an FLS can be a significant barrier. This includes costs for:

  • Staffing: Hiring and training dedicated FLS coordinators (nurses, allied health professionals), administrative support, and potentially medical oversight.
  • Diagnostic Equipment: Ensuring access to DXA machines and other necessary diagnostic tools.
  • IT Infrastructure: Implementing or adapting data management systems for patient tracking, outcome monitoring, and reporting.
  • Educational Materials: Development and dissemination of patient and professional educational resources.

Securing sustainable funding mechanisms beyond initial grants is critical. Many healthcare systems operate under tight budgetary constraints, and new initiatives, even those with clear long-term benefits, can struggle to compete for funding against immediate acute care needs.

4.1.2. Human Capital

Shortages of trained personnel pose a substantial challenge. There is often a lack of healthcare professionals specifically trained in osteoporosis management and FLS coordination. This includes:

  • Specialized Nurses/Coordinators: Recruiting and retaining skilled nurses or allied health professionals with expertise in bone health, patient education, and care coordination.
  • Medical Specialists: Ensuring adequate access to endocrinologists, rheumatologists, or geriatricians for complex cases or oversight.
  • Administrative Support: Essential for managing patient data, scheduling appointments, and liaising with various departments.

Training existing staff, creating new roles, and fostering a culture of interdisciplinary collaboration are necessary to address these human resource gaps.

4.1.3. Infrastructure and Access

Adequate infrastructure, particularly access to diagnostic services, is crucial. This includes:

  • DXA Scanners: Ensuring sufficient availability and accessibility of DXA scanning facilities within a reasonable geographical proximity and waiting time.
  • Referral Pathways: Establishing clear, efficient, and well-understood referral pathways between the FLS and various medical departments (orthopaedics, primary care, radiology) and allied health services (physiotherapy, occupational therapy).
  • Technology: Integrating FLS processes with existing electronic health record (EHR) systems to facilitate identification, data collection, and communication can be challenging due to system incompatibilities or lack of interoperability.

4.2. Stakeholder Engagement and Inter-departmental Collaboration

Achieving consistent buy-in and active participation from all relevant stakeholders is paramount but often difficult to secure (pmc.ncbi.nlm.nih.gov/articles/PMC4591627/).

  • Orthopaedic Surgeons: While many orthopaedic surgeons recognize the importance of bone health, their primary focus is often on fracture repair. Integrating FLS into busy orthopaedic workflows requires clear communication of benefits and minimal additional burden on their time.
  • Emergency Department Physicians: Identifying fragility fractures in the fast-paced ED environment and initiating referral can be overlooked.
  • Primary Care Physicians (PCPs): PCPs play a vital role in long-term management, but may have varying levels of familiarity with osteoporosis guidelines or be overwhelmed by numerous other health priorities.
  • Hospital Administrators and Executives: Demonstrating the economic return on investment and alignment with institutional quality metrics is essential to secure administrative support and budget allocation.
  • Other Specialists: Engaging rheumatologists, endocrinologists, and geriatricians to provide expert consultation and manage complex cases is important.

Overcoming resistance to change, fostering a shared vision, and demonstrating the value of FLS to each stakeholder group requires sustained effort, clear communication, and the involvement of local ‘champions.’

4.3. Data Management, Evaluation, and Quality Assurance

Implementing robust data collection, analysis, and feedback systems is fundamental for monitoring program effectiveness, ensuring quality control, and facilitating continuous improvement. Challenges include:

  • Data Collection: Ensuring consistent and accurate capture of key metrics (e.g., patient demographics, fracture type, DXA results, treatment initiation, adherence, re-fracture rates) across different departments and IT systems.
  • System Integration: Lack of interoperability between various electronic health record systems can create data silos and hinder comprehensive patient tracking. Manual data entry is prone to errors and is resource-intensive.
  • Reporting and Feedback: Developing efficient systems for reporting performance data to stakeholders, identifying areas for improvement, and demonstrating value to funders and administrators.
  • Benchmarking: The ability to benchmark performance against national or international FLS standards (e.g., Capture the Fracture standards) requires standardized data elements and reporting mechanisms (link.springer.com/article/10.1007/s00198-024-07181-7).

4.4. Policy, Reimbursement, and Funding Issues

Inadequate policy support and fragmented reimbursement structures can severely impede the implementation and sustainable scaling of FLS (pmc.ncbi.nlm.nih.gov/articles/PMC4591627/).

  • Lack of National Directives: In many countries, FLS are not mandated or consistently funded at a national level, leading to a patchwork of services rather than comprehensive coverage.
  • Reimbursement for FLS Activities: Many FLS activities, such as patient education, care coordination, and comprehensive risk assessment, are not consistently reimbursed by health insurance or public health systems. This makes it difficult to justify the dedicated staffing and resources required.
  • Fee-for-Service vs. Value-Based Care: Traditional fee-for-service models often do not incentivize preventative care or care coordination. Transitioning to value-based care models, which reward improved patient outcomes and cost savings, could better support FLS, but this transition is often slow and complex.
  • Medication Access and Affordability: Even when osteoporosis is diagnosed, patient access to and affordability of appropriate anti-osteoporosis medications can be a barrier, particularly in systems with high patient co-pays or restrictive formularies.

Advocacy for policy changes, development of specific FLS reimbursement codes, and inclusion of FLS as a standard of care in national guidelines are essential to overcome these systemic barriers.

4.5. Patient Adherence and Engagement

Even with a well-functioning FLS, ensuring sustained patient adherence to long-term medication and lifestyle changes remains a significant challenge. Factors influencing adherence include:

  • Lack of Understanding: Patients may not fully grasp the chronicity of osteoporosis or the importance of long-term treatment.
  • Side Effects: Perceived or actual side effects of medications can lead to discontinuation.
  • Cost of Medications: Financial barriers can impact adherence.
  • Asymptomatic Nature of Osteoporosis: The lack of immediate symptoms can make it difficult for patients to perceive the benefit of daily medication.
  • Polypharmacy: Older patients often take multiple medications, increasing the complexity of their regimen and the risk of non-adherence.

Effective patient education, shared decision-making, and ongoing support from the FLS team are crucial to improving adherence and persistence with treatment.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Case Studies of Successful FLS Initiatives Globally

The theoretical benefits and economic arguments for FLS are powerfully reinforced by numerous real-world success stories from across the globe. These case studies highlight diverse approaches to FLS implementation, demonstrating their adaptability and profound impact.

5.1. Healthy Bones Program, Kaiser Permanente, USA

Kaiser Permanente, one of the largest integrated healthcare systems in the United States, implemented its ‘Healthy Bones Program’ across its Southern California region. This initiative stands out as a prime example of how a systematic, population-based approach to FLS can yield exceptional results within a managed care environment.

Program Design: The Healthy Bones Program leveraged Kaiser Permanente’s extensive electronic health record (EHR) system to proactively identify patients aged 50 and older who had sustained a fracture. Dedicated nurse bone health coordinators played a central role, contacting patients, arranging DXA scans, conducting comprehensive risk assessments, and initiating appropriate anti-osteoporosis therapy based on standardized protocols developed by a multidisciplinary team of endocrinologists, orthopaedic surgeons, and primary care physicians. The integrated nature of Kaiser Permanente allowed for seamless coordination between acute care, primary care, and specialty services.

Outcomes and Impact: The program achieved an impressive 37.2% reduction in hip fractures across the region, a remarkable feat given the rising incidence of fractures in an aging population. This reduction translated into significant economic savings, estimated at over $30 million in a single fiscal year due to averted hospitalizations, surgeries, and rehabilitation costs associated with hip fractures (ghlf.org/wp-content/uploads/2024/09/BHOF-PFS-comment-and-attachments-9.9.24.pdf). The success of Kaiser Permanente’s model underscores the power of systematic identification, standardized protocols, robust data utilization, and the efficiency inherent in an integrated healthcare delivery system.

5.2. Geisinger Health System, USA

Geisinger Health System, another prominent integrated healthcare provider in the US, implemented its own FLS with a strong emphasis on population health management and value-based care principles. Geisinger serves a largely rural population, adding a layer of complexity to healthcare delivery.

Program Design: Geisinger’s FLS focused on a proactive approach to identifying fracture patients and ensuring they received guideline-concordant osteoporosis care. The program utilized sophisticated data analytics within their EHR to flag patients at risk and track their progression through the FLS pathway. Nurse practitioners and physician assistants were instrumental in providing patient education, initiating treatment, and conducting follow-up. A key element was embedding bone health discussions and treatment initiation into the routine follow-up care for fracture patients, making it a seamless part of their recovery process.

Outcomes and Impact: Over a five-year period, Geisinger’s FLS implementation led to substantial cost savings estimated at $7.8 million. These savings were directly attributable to a reduction in subsequent fractures and the associated healthcare utilization costs. The Geisinger experience provides a compelling demonstration of the financial viability and effectiveness of FLS, even in diverse geographic settings, when anchored by strong organizational commitment and data-driven interventions (ghlf.org/wp-content/uploads/2024/09/BHOF-PFS-comment-and-attachments-9.9.24.pdf). It highlights how FLS can align with broader organizational goals of improving population health outcomes while simultaneously controlling costs.

5.3. Capture the Fracture (CTF) Initiative, International Osteoporosis Foundation (IOF)

The International Osteoporosis Foundation’s (IOF) ‘Capture the Fracture’ (CTF) initiative represents a monumental global effort to standardize and promote FLS implementation worldwide. Recognizing the global care gap, CTF provides a comprehensive framework, resources, and recognition program for FLS.

Program Design: CTF developed a Best Practice Framework (BPF) that outlines 13 quality standards for FLS, encompassing everything from patient identification and assessment to treatment initiation and long-term monitoring. Healthcare institutions seeking to establish or improve an FLS can utilize this framework as a roadmap. The initiative provides tools, guidance, and mentorship, and offers an accreditation program where FLS can be recognized at different levels (bronze, silver, gold) based on their adherence to the BPF standards. This creates a powerful incentive for quality improvement and provides a benchmark for excellence.

Outcomes and Impact: Since its inception, the CTF initiative has been instrumental in supporting the establishment and improvement of over 500 FLS in more than 47 countries across six continents (capturethefracture.org/healthcare-system). This extensive network facilitates knowledge sharing, promotes best practices, and fosters a global community dedicated to secondary fracture prevention. By providing a common standard and a supportive network, CTF has significantly accelerated the global adoption and refinement of FLS, making a tangible impact on reducing the burden of osteoporotic fractures internationally. The initiative emphasizes that even with varying resources, a commitment to systematic post-fracture care can lead to significant improvements.

5.4. Scottish Hip Fracture Audit and FLS Development, UK

Scotland stands out as a leading example of national FLS development and integration within a publicly funded healthcare system (NHS Scotland).

Program Design: Leveraging a robust national hip fracture audit, Scotland systematically identified the post-fracture care gap. This led to a concerted national effort to implement FLS across all health boards. The Scottish FLS models are primarily nurse-led, with dedicated FLS nurses working closely with orthopaedic, geriatric, and primary care teams. Strong emphasis was placed on standardized care pathways, training for FLS coordinators, and integration with national clinical guidelines. The national audit provided a crucial feedback loop, allowing for continuous monitoring of performance and identification of areas for improvement.

Outcomes and Impact: Scotland’s sustained commitment to FLS, supported by national policy and a robust audit system, has resulted in significant improvements in post-fracture care. Data from the Scottish Hip Fracture Audit demonstrated a substantial increase in the proportion of hip fracture patients receiving osteoporosis diagnosis and treatment. This systematic approach has contributed to reductions in re-fracture rates and improved patient outcomes across the country, serving as a powerful model for other nations seeking to implement FLS on a national scale within a universal healthcare system (medixeed.com/wp-content/uploads/2025/02/NOFSA-Masterclass-6-Fracture-liaison-services-%E2%80%93-Building-stronger-pathways-for-quality-osteoporosis-care.pdf). This demonstrates that with strong political will and national coordination, FLS can be successfully implemented comprehensively.

These case studies collectively underscore the profound potential of FLS to transform osteoporosis care. They illustrate that while operational models may vary, the core principles of systematic identification, comprehensive assessment, timely treatment, and sustained follow-up are universally effective in mitigating the devastating impact of recurrent fragility fractures.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Conclusion and Future Directions

Fracture Liaison Services represent a foundational and indispensable strategy for the secondary prevention of osteoporotic fragility fractures. This report has meticulously detailed their critical role in addressing the global burden of osteoporosis by systematically identifying, assessing, treating, and monitoring individuals who have already experienced a sentinel fracture. The evidence unequivocally demonstrates that FLS are not only clinically effective in reducing subsequent fracture rates but are also highly cost-effective, generating significant healthcare savings and improving the quality-adjusted life years for affected individuals. The compelling economic arguments, coupled with the profound human benefits of reducing pain, disability, and mortality, position FLS as a cornerstone of modern osteoporosis management.

Despite the clear benefits, the widespread establishment and sustainable scaling of FLS programs continue to face formidable challenges. These include chronic resource constraints—financial, human, and infrastructural—that impede implementation. Overcoming issues of stakeholder engagement, particularly ensuring consistent buy-in from orthopaedic surgeons, emergency physicians, and primary care providers, requires sustained advocacy and clear demonstration of value. Furthermore, the complexities of data management, evaluation, and ensuring interoperability across disparate healthcare IT systems remain critical hurdles for effective monitoring and continuous quality improvement. Perhaps most significantly, inadequate policy support and fragmented reimbursement structures often create systemic barriers, hindering the integration of FLS into routine care and undermining their long-term sustainability.

However, the global landscape of FLS is also replete with inspiring success stories, from the integrated health systems of Kaiser Permanente and Geisinger in the USA, demonstrating substantial economic returns and fracture reductions, to the International Osteoporosis Foundation’s ‘Capture the Fracture’ initiative, which has fostered a global network of over 500 FLS programs. National efforts, such as those in Scotland, illustrate how robust audit and policy commitments can drive widespread FLS adoption and positive outcomes within national healthcare systems.

Looking ahead, several key areas demand continued focus and innovation:

  • Policy and Advocacy: Sustained efforts are needed to influence policymakers at national and regional levels to mandate FLS implementation as a standard of care and to develop supportive reimbursement models that recognize the value of preventative care coordination.
  • Technological Integration: Further leveraging electronic health records, artificial intelligence, and telemedicine can enhance patient identification, streamline data collection, improve patient engagement, and extend the reach of FLS, particularly in rural or underserved areas.
  • Research and Innovation: Ongoing research is essential to refine FLS models, identify optimal staffing structures, explore the effectiveness of new anti-osteoporosis therapies within FLS pathways, and understand long-term patient adherence strategies. This also includes investigating hybrid models that integrate FLS more deeply with primary care and community services.
  • Global Collaboration and Equity: Expanding the reach of FLS to low- and middle-income countries, adapting models to suit diverse resource settings, and fostering international knowledge exchange through initiatives like ‘Capture the Fracture’ are crucial to addressing global health inequities in osteoporosis care.
  • Patient Empowerment: Continued emphasis on patient education, shared decision-making, and self-management support will be vital in improving treatment adherence and long-term outcomes.

In conclusion, Fracture Liaison Services represent a beacon of hope in the management of osteoporotic fractures. Their successful expansion and enduring impact hinge on a collective commitment from healthcare systems, policymakers, clinicians, and patients. By working collaboratively, we can ensure that a fragility fracture is no longer a precursor to subsequent, avoidable suffering, but rather a critical opportunity for intervention, ultimately reducing the immense burden of osteoporosis on individuals and healthcare systems globally.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

References

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