BOAST - Fracture Liaison Services

Background and justification

Fracture Liaison Services (FLS) provide secondary prevention for fragility fractures (defined as a fracture following a fall from standing height or less). These services systematically and proactively identify patients in secondary and/or primary care who have suffered a fragility fracture and assess the patient’s risk of future fragility fracture in a timely fashion. FLS then provide advice and/or therapy to reduce that risk. There is now good evidence that these services are cost-effective and can result in a reduction in the incidence of fragility fractures in the local population.

Inclusions

All patients aged 50 years or older with a fragility fracture that present to an Emergency Department or fracture clinic or have a fragility fracture, such as pelvic or vertebral compression, that is identified in primary care.

Standards for Practice

1. A Fracture Liaison Service should be available to all hospitals that provide definitive fracture care, either as an inpatient or an outpatient e.g. fracture clinic,acute spinal clinic.
2. Fracture Liaison Services should be led by a consultant physician or general practitioner with appropriate training and expertise in osteoporosis management.
3. Fracture Liaison Services should have systems in place that identify all patients 50 years old and over presenting with a fragility fracture, including vertebral fractures. There must be clear entry criteria into the pathway and this should include patients presenting to, and managed within, primary care.
4. All patients presenting with a fragility fracture must be provided with written information giving advice on the nature of fragility fractures, bone health, lifestyle, nutrition and bone protection treatment.
5. Patients must be offered a multifactorial bone health assessment within 3 months of the incident fracture.
6. Fracture Liaison Services must have a system to identify patients at risk of falls and ability to either assess and recommend treatment(s) or refer rapidly to an appropriate service.
7. Fracture Liaison Services must have timely access to DEXA scanning. Patients who need DEXA should be offered a date for scan within 12 weeks of their fracture.
8. Fracture Liaison Services should have a linked metabolic bone service that allows patients timely access to expert medical advice when required.
9. Fracture Liaison Services should maintain good communication with the patients and their General Practioner who must be informed of all test results and theraputic recommendations.
10. Fracture Liaison Services should have a system in place to review patient compliance with treatment.
11. Fracture Liaison Services should undertake routine audit and submit data to the National FLS-Database once this is established.

Evidence Base

NICE Clinical Guidance CG146. Osteoporosis: assessing the risk of fragility fracture 
https://www.nice.org.uk/guidance/CG146

NICE Technology Appraisal TA161. Secondary prevention of osteoporotic fragility fractures.
https://www.nice.org.uk/Guidance/TA161

NICE Quality Standard QS16. Quality standard for hip fracture
http://www.nice.org.uk/guidance/QS16