Strategies for more effective fracture secondary prevention in the United Kingdom

Occurrence of a fracture doubles the incidence of secondary fractures. Guidelines from around the world recommend that patients with fractures should be assessed for osteoporosis to determine their need for fracture secondary prevention, as this can halve their risk of further fractures. In practice, assessment for osteoporosis after fractures is seldom provided. Since 1999 our Fracture Liaison Service (FLS) has provided routine, systematic post-fracture assessment to all women and men age 50+ who present with a new low trauma fracture to our orthopaedic and trauma departments. The FLS is effected by a dedicated Nurse Specialist who a) identifies all patients presenting with a new fracture (whether managed as inpatients or as outpatients), b) offers them all post-fracture assessment for osteoporosis & fracture risk, c) provides this assessment at a one-stop clinic including DXA & d) recommends treatment (where required) according to protocol and communicates this to the patients’ GPs.

This study reports the outcomes and incidence of secondary fractures and mortality during the first 8years of the FLS. 7505 women, age (mean(SD)) 73.3(12)yr & 2180 men, age 68.8(11.7)yr, with 11096 consecutive new low-trauma fracture presentations were processed. All were offered post-fracture assessment; 79% underwent assessment but 21% were too unwell or refused. Of those assessed, 39% were treated with bisphosphonate (& calcium/vitD), 30% with calcium/vitD, 4% with other treatments & 28% received no treatment. Of the 9685 patients processed, 11% sustained ≥1 further fracture: of these, 21% occurred within 6months(mo.) of the index fracture, and 35% & 58% occurred within 12 & 24mo. 20% of patients died during the 8years’ follow-up.

A systems-based approach, such as our FLS, can, however, achieve post-fracture assessment for fracture secondary prevention in ~79% of patients with new fractures. No service model has yet been shown to deliver higher rates of post-fracture assessment than are achieved by the FLS.