Clinical FeaturesRheumatology

Updates in Ireland’s Fracture Liaison Service

The aim of a Fracture Liaison Service (FLS) is to identify people at risk of fracture, investigate when required, and initiate appropriate bone strengthening medication as indicated. A fracture resulting from a simple fall is known as a “fragility fracture”, and usually indicates the presence of osteoporosis. Fractures as a result of osteoporosis are one of the leading healthcare costs across Europe and numbers are rising steeply. A recent Europewide scientific report on fragility fractures predicts that Ireland will see an increase in cases of ~ 58%, the highest of all EU countries because of ageing demographics (Scope 2021, Kanis). These fragility fractures cause great distress and disability for over 30,000 people annually in Ireland, and can impact survival. Despite highly effective treatments being available to manage osteoporosis and thus reduce the risk of fracture, only a minority receive these.

FLS provides a system for assessing people aged 50 years and over who sustain a fragility fracture, to diagnose osteoporosis and identify those most at risk of future falls and more serious fractures such as those of the hip or spine.

FLS uses a consultant led multidisciplinary team approach and is an integrated service between acute and primary care settings. If properly resourced, it has the potential to reduce the number of people with acute, debilitating fractures admitted to the hospital setting. This aligns closely with both Sláintecare and Healthy Ireland principles. Ireland is only the second country globally to develop a national FLS database, with the aim of improving care for these people who sustain a first non-hip fragility fracture.

Up to 50% of people who sustain a major fracture (e.g. a hip fracture) would have had a previous nonhip “warning fracture”. Most of these people do not get screened, or treated at that point, for osteoporosis. An assessment of their risk of falling, which might help prevent future fractures, is also seldom carried out at the time of their initial fracture.

Many recent publications in the scientific literature have outlined the benefits that FLS provide, both in reducing the person’s risk of recurrent fractures, and for society as a whole in reducing the costs associated with caring for people who lose their ability to live independently as a result of these fractures.

FLS has been adopted globally as real-world data has demonstrated that this model of care has proven benefits in reducing future fracture numbers when investment is made in a high-quality service. Currently, Europe spends an estimated (¤37 billion on managing fragility fractures (¤400 million in Ireland), of which just ¤2 billion is spent on prevention.

The National Fracture Liaison Service (FLS) Steering Group welcomes the funding of eight advanced nurse practitioner (ANP) posts by the HSE during 2022. These nurses will play a critical role in patient care by proactively identifying and managing the care of patients presenting with fractures. They will ensure screening for, and treatment of osteoporosis and falls risk, with patient education to enable selfmanagement of their bone health. The FLS ANP’s also monitor treated patients for the year ahead to ensure tolerability and adherence with prescribed medication given the very low treatment rates postfracture presently.

While these ANP posts are welcomed, it is imperative that national implementation with full resourcing occurs in the next two years. This will enable each FLS to address rising fracture numbers, create value for the health service and deliver significant benefits to patients who would otherwise go on to sustain additional fragility fractures.

The Irish Fracture Liaison Service Database (FLS – DB) was established in 2020 by the National Fracture Liaison Services steering committee under the governance of the National Clinical Programme for Trauma and Orthopaedic Surgery. The FLS – DB is aligned with the International Osteoporosis Foundation’s “Capture the Fracture” initiative which aims to improve access for people to comprehensive Fracture Liaison Services globally.

In October 2022 the first Irish FLS – DB Report was published. This report analysed the secondary preventative management of fragility fractures received by over 2,000 patients (~ 26% of the expected number) during 2021 in eight out of the sixteen hospitals in Ireland which currently manage patients presenting with fractures. The low proportion of patients identified and treated demonstrates the gaps in service provision within Ireland in adequately managing these patients, in line with international best practice standards.

Mr Paddy Kenny, Joint National Clinical Lead for the National Clinical Programme for Trauma and Orthopaedic Surgery said “The development of a Fracture Liaison Services Database is a key enabler in implementing recommendation 15 of the 2018 HSE report – “A Trauma System for Ireland”. Having Irish data will facilitate policy makers to plan service delivery more effectively and efficiently into the future. I commend the national clinical leads in promoting the work that this group has completed to date and welcome last year’s appointment of eight advanced nurse practitioners for fracture liaison services nationally.”

Prof Frances Dockery, joint clinical lead for the Fracture Liaison Service Database said: “This report provides a benchmark for future service developments in Ireland. The current lack of investment in a national Fracture Liaison Service needs to be addressed as a matter of urgency so that all 16 hospitals that manage patients with fractures in Ireland can establish a sustainable FLS, which will contribute data to the National FLS Database to monitor the standards of care their patients receive”.

Mr Aaron Glynn, joint clinical lead for the Fracture Liaison Service Database, noted that “Fracture Liaison Services should be considered essential ‘secondary prevention’ services, and as such is an enabler in improving patient health and wellbeing.”

The second report of the FLS – Database will be published in October 2023. To find out more about this initative please contact

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