Clinical FeaturesRheumatology

Establishing a Fracture Liaison Service: Supporting the Case

Written by Kenny Franks, Project Manager, Fracture Liaison Service, Royal College of Surgeons in Ireland with Mr Aaron Glynn and Dr Frances Dockery, Clinical Leads, Fracture Liaison Service Database


Fragility fractures are fractures sustained after a simple fall in people aged 50 years and over. Osteoporosis is the most common underlying condition. Fragility fractures have a significant impact on Irish people and our healthcare system. Approximately 200,000 people in Ireland have osteoporosis with over 32,000 new osteoporosis-related fractures occurring annually. Not only has this a colossal impact on the health of those who suffer, but broken bones caused by osteoporosis cost the healthcare system more than ¤460 million per annum.

SCOPE report

Osteoporosis is a disease which affects mostly older adults and fragility fractures often result in pain and long-term disability, as well as substantial costs to the healthcare system.

The International Osteoporosis Foundation (IOF) report ‘Osteoporosis in Europe; A Compendium of Country-Specific Reports (2022)’ documents the epidemiology and economic burden of osteoporosis in 29 European countries. Their ‘Scope 21 Score Card for Osteoporosis in Europe’, estimates that in the Irish population of those aged 50 years or more, approximately 77% of women and 22% of men are affected by osteoporosis.

Some key additional figures from the SCOPE report

  • Hip and spine fractures in older adults are a major cause of morbidity and mortality with the report estimating that in Ireland, amongst those over 50 years, 115 of every 100,000 deaths are related to osteoporotic fractures.
  • As the Irish population ages, it is expected that by 2034, the number of people aged above 50 years in Ireland is likely to increase by 38%.
  • With this ageing demographic it is expected that the number of fractures in Ireland will rise by around 58% in this time period.

The economic cost of new and previous fragility fractures was estimated at ¤460 million in 2019, equivalent to ¤95.7 for every individual in Ireland, and an increase of 73% compared to 2010. Given the strain fragility fractures currently put on patients and on the healthcare system it is imperative that health authorities and healthcare professionals take action to address this expected increase.

In order to do this, we need the systems in place to provide systematic fracture prevention strategies for those at highest fracture risk, namely, those who have already sustained a fragility fracture and prevent their risk of further fractures.

At present, just 10 Irish hospitals operate fracture liaison services, and none of them span anything close to the expected coverage of fragility fractures numbers arriving to their Emergency and Radiology departments.

Addressing the findings within the new research, Mr Aaron Glynn, Orthopaedic Surgeon and joint clinical lead for the Fracture Liaison Service Database said, “Despite the high cost of osteoporotic fractures, the new report exposes a large and worrying treatment gap. Approximately 150,000 women aged over 50 are estimated to be at high risk of fracture and should be considered for osteoporosis treatment, but only 68% receive treatment according to the European scorecard estimate. Without treatment for osteoporosis, people at high-risk remain unprotected against potentially debilitating and life-threatening fractures which is going to grow enormously due to the ageing population.”

President of the IOF, Professor Cyrus Cooper, is calling for greater prioritisation of osteoporosis and it’s associated challenges. Speaking about the research findings he said, “This important report has exposed the need for greater efforts to prioritise osteoporosis and musculoskeletal disease prevention in Europe. We must take urgent action to reduce the burden and costs of osteoporotic fractures on our healthcare systems. In doing so, we will help ensure that older adults are able to enjoy mobile, independent lives as they age, free of debilitating fragility fractures.

The National Fracture Liaison Service Steering committee

The National Fracture Liaison Service Steering committee was established in 2018 to develop and implement a national programme to improve patient outcomes after a fragility fracture through compliance with national and international standards.

The Steering committee is tasked with implementing Recommendation 15 of “A Trauma System for Ireland: Report of the Trauma Steering Group (2018)” which states; “The HSE should develop a comprehensive Fracture Liaison Service to provide high quality, evidence-based care to those who suffer a fragility fracture with a focus on achieving the best outcomes for recovery, rehabilitation and secondary prevention of further fracture.”

FLS Audit Report

New research recently published from the The Royal College of Surgeons in Ireland (RCSI) further highlights the need for the establishment of a Fracture Liaison Service (FLS) in Irish hospitals.

The new research, “Fracture liaison services in Ireland – how do we compare to international standards?” calls for more widespread use of FLS in Irish hospitals.

A FLS service assesses people over the age of 50 who have sustained a fragility fracture to determine their risk of further fractures.

They have an estimation of fracture risk, falls risks and if necessary, they are then referred for a diagnostic scan (known as a DXA), then recommendations of appropriate treatment. The patient and their GP are fully informed of the treatment recommendations.

This process, when in situ, has been proven to prevent further fractures at a population level. The fracture liaison service originated in Scotland, with the world’s first FLS opening in Glasgow approximately 20 years ago.

In 2019 Scotland became the second country in the world, after New Zealand, with 100% FLS provision across all health boards.

This new national survey, the first to be completed in Ireland, indicates that the implementation, and resourcing, of a national FLS would bring fracture prevention services in Irish hospitals in line with international standards, improve outcomes and quality of life for patients as well as offer substantial cost savings to the health service which is much needed.

European data suggests that by 2030 there will be a 25% increase in the numbers presenting with these fractures. Should the numbers increase by the predicted 25% by 2030 in Ireland, this will be the highest of all EU countries.

The research also found that no trauma site in Ireland is identifying all patients sustaining fractures. 50% of all sites reported that it took patients up to four months after their fracture for their first prescription for osteoporosis medication.

Speaking about the new research Mr Paddy Kenny, Joint National Clinical Lead for the National Clinical Programme for Trauma and Orthopaedic Surgery (NCPTOS), said “The publication and findings of this new survey of FLS in Ireland demonstrates the need for the implementation of FLS nationally as a matter of urgency. FLS has been proven internationally to be effective clinically and economically for the management of secondary fracture prevention. This service will result in reduced hospital admissions. The Trauma & Orthopaedic programme fully supports the establishment of the FLS Database which will be publishing its preliminary report and recommendations later this year.”

The research findings underline the urgent need for a policy to support the national implementation of FLS across Irish trauma hospitals. Such a service would provide the best method of identifying, treating and monitoring these patients and are proven to reduce fracture numbers, improve treatment for patients and substantially reduce the cost burden to the health service.

Sixteen public hospitals were invited to participate in the survey with a 100% response rate. Ten sites (62.5%) reported the existence of FLS and these sites managed 3,444 non-hip fractures during 2019, representing 19% of the expected non-hip fragility fracture numbers occurring annually in Ireland.

Six of the ten sites surveyed reported their services being established more than a decade but due to inadequate resourcing, they were failing to meet several of the thirteen standards as outlined in the International Best Practice Framework – “Capture the Fracture”.

Dr Frances Dockery joint clinical lead for the Fracture Liaison Service Database suggests that all the information, evidence and clinical feedback points to the need for a national policy for FLS. Dr Dockery said: “We urgently need a policy to support the national implementation of FLS across all Irish trauma hospitals. Fracture Liaison Services (FLS) provide the best method of identifying, treating and monitoring these patients and are proven to reduce fracture numbers, improve treatment for patients and substantially reduce the cost burden to the health service.”

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