FFN Clinical ToolkitA generic fully referenced Fracture Liaison Service business plan template

Version: 1.0 Clean

Date: 13-10-2020

Note to business plan authors: Please note that the citations in this document have active EndNote links that have been created with the Thomson Reuters EndNote version X9 software. If you have this software, Reference Manager or other bibliographic software, you could export the Travelling Library into your software package. The output style has been set to Archives of Internal Medicine format.

ContentsExecutive summary...............................................................................................................................1

The need for a Fracture Liaison Service in [insert hospital name].........................................................2

The ageing population.......................................................................................................................2

Hip fractures impose a significant burden on patients and [insert hospital name]...........................3

An obvious opportunity for intervention: Half of hip fracture patients sustain prior fractures.........3

The impact of osteoporosis treatment on secondary fracture incidence..........................................4

Secondary fracture prevention: A global, regional, national and local care gap................................5

Current standards of secondary preventive care in [insert hospital name].......................................5

Fracture Liaison Services: A proven healthcare delivery solution..........................................................5

Definition of a high-performing Fracture Liaison Service..................................................................5

Examples of high-performing Fracture Liaison Services....................................................................5

Benchmarking performance: Clinical Standards for Fracture Liaison Services..................................6

Endorsement of the Fracture Liaison Service model of care.............................................................7

Implementation of a Fracture Liaison Service in [insert hospital name]...............................................8

Budgetary impact of a Fracture Liaison Service in [insert hospital name].............................................8

Summary.............................................................................................................................................10

References...........................................................................................................................................11

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Executive summaryFracture Liaison Services (FLS) improve quality and reduce costs through a reduction in emergency

admissions for hip and other fragility fractures.

The aim of the proposed FLS is to ensure that all patients aged [XX] years and over who

present to [insert hospital name] with a fragility fracture receive assessment and, where

warranted, pharmacological treatment for osteoporosis, and referral to local falls prevention

services to reduce their risk of subsequent fractures.

In 20XX, XXX patients presented with a hip fracture to [insert hospital name] incurring an

annual cost of $YYY,YYY to the healthcare system.

Half of hip fracture patients sustain a fragility fracture of the wrist, shoulder, humerus, hip or

other skeletal sites in the months or years prior to breaking their hip1-4.

Osteoporosis treatments have the potential to halve subsequent hip fracture incidence if

initiated after patients present to hospital with a fragility fracture5, 6.

The majority of individuals who sustain fragility fractures do not receive secondary

preventive care, comprised of osteoporosis assessment and, where warranted,

pharmacological treatment, and interventions to reduce the risk of falling7.

Published studies have demonstrated that the FLS model of care significantly reduces the

care gap in countries throughout the world8 and deliver cost-savings9.

The FLS model of care has been endorsed by governments10-18, healthcare professional

organisations19-24 and national osteoporosis societies25-28, and national alliances comprised of

these and other groups13, 29.

Implementation of the FLS model was advocated in the Global Call to Action on Fragility

Fractures which has been endorsed by 131 global, regional and national societies for

geriatric medicine, nursing, orthopaedics, osteoporosis, rehabilitation and rheumatology24.

The organization of the FLS model of care proposed in this business plan has been informed

by published studies of high-performing FLS and is adherent with widely endorsed

international30 and national31-34 Clinical Standards for FLS.

Note to authors: It is recommended that authors include a summary of the section of the

business plan titled Budgetary impact of a Fracture Liaison Service in [insert hospital name].

This business plan describes why a FLS is required at [insert hospital name], how the FLS will be

organized to deliver world class care, and what benefits the FLS will deliver in terms of improved

patient management, reduced secondary fracture incidence and reduced healthcare costs.

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The need for a Fracture Liaison Service in [insert hospital name]The ageing populationIn 2017, the United Nations World Population Prospects noted that the world population had

reached 7.6 billion people35. Globally, while currently there are twice as many children aged <15

years as adults aged ≥60 years, the age structure of the population is set to shift dramatically in the

coming decades. In [insert your country], the pace and extent of this shift can be illustrated by

consideration of the projected changes in old-age dependency ratios. The old-age dependency ratio

is the ratio of the population aged ≥65 years to the population aged 15–64 years, who are

considered to be of “working age.” These ratios are presented as the number of dependents per 100

persons of working age.

Note to business plan authors: Consider constructing a figure to illustrate the old-age dependency

ratios for your country. These can be obtained for the period 1950 to 2100 from the United Nations

document titled “World Population Prospects: Volume II: Demographic Profiles 2017 Revision.

ST/ESA/SER.A/400” by Department of Economic and Social Affairs, Population Division, ©2017 United

Nations available for download from:

https://population.un.org/wpp/Publications/Files/WPP2017_Volume-II-Demographic-Profiles.pdf

In the event that you create a figure based on this information, seek permission to do so from:

United Nations Department of Global Communications, 405 East 42nd Street, S-09FW001, New York,

NY 10017, USA. Email request to permissions@un.org

An example for Thailand is shown below.

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From World Population Prospects: Volume II: Demographic Profiles 2017 Revision. ST/ESA/SER.A/400, by Department of Economic and Social Affairs, Population Division, ©2017 United Nations. Reprinted with the permission of the United Nations.

Hip fractures impose a significant burden on patients and [insert hospital name]Hip fractures are often considered the most debilitating fragility fracture, for good reason:

Less than 50% of people who survive a hip fracture will walk unaided again36 and in many

cases they will never regain their former degree of mobility37.

A year after hip fracture, 60% of survivors require assistance with activities such as feeding,

dressing or toileting, and 80% need help with activities such as shopping or driving38 .

10-20% of people who sustain a hip fracture will be admitted to a care home in the year

after fracture39-41.

Note to business plan authors: It is suggested that authors include information on the annual

incidence of hip fracture in their country here, in addition to the number of individuals who present

to their hospital. Further, information on the costs that hip fractures impose on the healthcare

system could be included here.

An obvious opportunity for intervention: Half of hip fracture patients sustain prior fracturesWhile some younger individuals develop osteoporosis and sustain fragility fractures, the majority of

the disease burden is imposed upon people aged 50 years and over. Figure 1 overleaf provides an

illustration of the sequence of fractures that a person living with osteoporosis may experience after

their 50th birthday.

Individuals who have sustained a fragility fracture are at considerably increased risk of sustaining

subsequent fractures. Meta-analyses have established that a history of fracture at any skeletal site is

associated with approximately a doubling of future fracture risk42, 43. Further, subsequent fractures

appear to occur rapidly after an index fracture. In 2004, Swedish investigators examined the pattern

of fracture risk following a prior fracture at the spine, shoulder or hip 44. During five years of follow-

up, one third of all subsequent fractures occurred within the first year after fracture, and less than

9% of all subsequent fractures occurred in the fifth year. More recently, several studies have

demonstrated that secondary fracture risk is highest during the two years following an index

fracture, which has been characterised as the period of “imminent fracture risk”45-47.

From the obverse perspective, several studies have noted that up to half of hip fracture patients

sustained fractures at other skeletal sites during the months and years before breaking their hip.

This was first reported by US investigators in 19801, and has more recently been reported in studies

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from Australia2, Scotland3 and the USA4. In this regard, the Australian group coined the term “signal

fracture” to highlight the opportunity presented when individuals seek medical attention at a

hospital or community-based fracture clinic.

Figure 1. Fracture and morbidity for an individual with osteoporosis (adapted from The care of

patients with fragility fracture21)

The impact of osteoporosis treatment on secondary fracture incidenceNote to business plan authors: It would be appropriate to make reference to relevant

national/regional osteoporosis clinical guidelines at the beginning of this section. In these guidelines

- and many other guidelines published throughout the world - individuals who have sustained

fragility fractures are routinely identified as a priority group for osteoporosis assessment and

treatment, where warranted.

The 2016 International Osteoporosis Foundation (IOF) World Osteoporosis Day Report and an

associated narrative review article in Osteoporosis International provided commentary on the

evidence-base for osteoporosis treatments specifically in the context of secondary fracture

prevention. Authors might consider commenting upon these publications to describe the impact

osteoporosis treatments available in their countries have upon secondary fracture incidence. See:

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Gaps and solutions in bone health: A global framework for improvement. Harvey, NC and

McCloskey EV. Nyons: International Osteoporosis Foundation, 2016.5

Mind the (treatment) gap: a global perspective on current and future strategies for

prevention of fragility fractures. Harvey NC et al. Osteoporos Int. 2017 May;28(5):1507-

1529.6

Secondary fracture prevention: A global, regional, national and local care gapThe 2019 IOF Compendium of Osteoporosis documented a persistent and pervasive care gap in the

secondary prevention of fragility fractures throughout the world7.

Note to business plan authors: The authors may want to include relevant studies from their country.

Current standards of secondary preventive care in [insert hospital name]Note to business plan authors: The authors should include local data on the provision of secondary

preventive care for individuals who present to their hospital with a fragility fracture.

Fracture Liaison Services: A proven healthcare delivery solutionDefinition of a high-performing Fracture Liaison ServiceA Fracture Liaison Service (FLS, also known as a Secondary Fracture Prevention [SFP] Program in

some countries) is a system to ensure fracture risk assessment, and treatment where appropriate, is

delivered to all patients with fragility fractures. A FLS is usually comprised of a dedicated case

worker, often a clinical nurse specialist, who works to pre-agreed protocols to case-find and assess

fracture patients. While FLS are usually based in hospital, some primary care based FLS have been

developed48, 49. A FLS requires support from a medically qualified practitioner.

Examples of high-performing Fracture Liaison ServicesNote to business plan authors: The purpose of this section of the business plan is to clearly illustrate

how a high-performing FLS functions and what benefits it delivers. Consider referring to the Ganda

classification system50. Authors could provide a summary of FLS relevant to their country based on

this analysis or of FLS represented on the IOF Map of Best Practice described below 51. Authors could

also make reference to well-established and well documented FLS such as those described in the

publications below:

Australia: Royal Newcastle Centre and John Hunter Hospital

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A team approach: implementing a model of care for preventing osteoporosis related fractures. Giles

M et al. Osteoporosis International 2011 Aug;22(8):2321-232852.

The Costs of Confronting Osteoporosis: Cost Study of an Australian Fracture Liaison Service. Major G

et al. Journal of Bone and Mineral Research Plus. 2018 Apr 18;3(1):56-639.

Canada: St. Michael’s Hospital, Toronto

Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an

orthopaedic environment. Bogoch ER et al. Journal of Bone and Joint Surgery (Am) 2006

Jan;88(1):25-3453.

Fracture Prevention in the Orthopaedic Environment: Outcomes of a Coordinator-Based Fracture

Liaison Service. Bogoch ER et al. Journal of Bone and Joint Surgery (Am) 2017 May 17;99(10):820-

83154.

UK: Glasgow University Hospitals, Scotland

The fracture liaison service: success of a program for the evaluation and management of patients

with osteoporotic fracture. McLellan AR et al. Osteoporosis International. 2003;14(12):1028-103455.

Fracture liaison services for the evaluation and management of patients with osteoporotic fracture:

a cost-effectiveness evaluation based on data collected over 8 years of service provision. McLellan

AR et al. Osteoporosis International 2011 Jul;22(7):2083-209856.

USA: Kaiser Permanente Healthy Bones Program

Osteoporosis disease management: the role of the orthopaedic surgeon. Dell RM et al. Journal of

Bone and Joint Surgery (Am) 2008 Nov;90 Suppl 4:188-9457.

Osteoporosis disease management: What every orthopaedic surgeon should know. Dell RM et al.

Journal of Bone and Joint Surgery (Am) 2009 Nov;91 Suppl 6:79-8658.

Benchmarking performance: Clinical Standards for Fracture Liaison ServicesNote to business plan authors: Internationally endorsed Clinical Standards for FLS have been

published by IOF as a component of the IOF Capture the Fracture® Program. Details of the Capture

the Fracture® Program and the associated Best Practice Framework follow. National Clinical

Standards for FLS have also been published in Canada, Japan, New Zealand and the UK. Summaries

of these documents is also provided for the authors’ reference.

In 2012, the International Osteoporosis Foundation (IOF) launched the Capture the Fracture®

Program with publication of the 2012 World Osteoporosis Day thematic report59. Since 2012,

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Capture the Fracture® has developed into one of IOF’s leading initiatives. The key components of

Capture the Fracture® are:

Website: The Capture the Fracture® website - www.capture-the-fracture.org - provides a

comprehensive suite of resources to support healthcare professionals and administrators to

establish a new FLS or improve an existing FLS.

Webinars: An ongoing series of webinars provide an opportunity to learn from experts

across the globe who have established high-performing FLS and contributed to development

of guidelines and policy on secondary fracture prevention. As of July 2017, webinars have

been conducted in Chinese, Dutch, English, French, Italian, Japanese, Polish, Portuguese,

Spanish and Thai.

Best Practice Framework: The Best Practice Framework (BPF), which is currently available in

nine major languages, sets an international benchmark for FLS by defining essential and

aspirational elements of service delivery. The BPF serves as the measurement tool for IOF to

award Capture the Fracture® Best Practice Recognition status. The 13 globally-endorsed

standards of the BPF were published in Osteoporosis International in 201330.

Patient-level key performance indicator set: Developed in collaboration with the FFN

Special Interest Group on Secondary Fragility Fracture Prevention and the National

Osteoporosis Foundation (USA), the Capture the Fracture® Working Group adapted existing

metrics from the UK-based FLS Database60 to develop a patient-level Key Performance

Indicator (KPI) set for FLS61.

National Clinical Standards for FLS have also been published by national osteoporosis societies in

Canada31, Japan32, New Zealand62 and UK34. These standards are based upon the 5IQ framework (i.e.

standards relating to identification, investigation, information, initiation, integration and quality).

Note to business plan authors: As described in the FFN Clinical Toolkit, the IOF Capture the Fracture ®

Partnership launched in 2020 is developing a comprehensive suite of new resources to support

development and improvement of FLS worldwide. Read more at:

https://www.capturethefracture.org/capture-fracture-partnership.

Endorsement of the Fracture Liaison Service model of careNote to business plan authors: The FLS model of care has been widely endorsed and advocated for in

many countries throughout the world. The authors may consider that highlighting this widespread

endorsement to the intended recipients of their business plan may provide helpful perspective for

the administrators who will evaluate the business plan.

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The FLS model of care has been endorsed and advocated for by governments, healthcare

professional organisations and national osteoporosis societies, and national alliances comprised of

these and other groups. Examples from several countries include:

Australia: New South Wales Agency for Clinical Innovation10, Department of Health in

Western Australia11 and the SOS Fracture Alliance29.

Canada: Ontario Osteoporosis Strategy12 and Osteoporosis Canada25.

New Zealand: Live Stronger for Longer initiative13 and Osteoporosis New Zealand26.

Singapore: The Osteoporosis Patient Targeted and Integrated Management for Active Living

(OPTIMAL) program14.

UK: Department of Health15, 16, Public Health England17 and the Royal Osteoporosis Society27.

USA: The American Society for Bone and Mineral Research19, National Osteoporosis

Foundation63 and the Fragility Fracture Alliance64.

Further, the Global Call to Action on Fragility Fractures (CtA) has been endorsed by 131 global,

regional and national societies for geriatric medicine, nursing, orthopaedics, osteoporosis,

rehabilitation and rheumatology24.

Note to business plan authors: See the publication for the 81 organisations who endorsed the CtA

prior to publication and contact the FFN for information on the 50 organisations who have endorsed

the CtA since publication (Email: CtA@ff-network.org).

Implementation of a Fracture Liaison Service in [insert hospital name]This business plan makes the case for commissioning of a Fracture Liaison Service (FLS) in [insert

name of hospital], structured according to the internationally recognized Clinical Standards for FLS

described previously, to reduce the incidence of hip fracture amongst our older people.

Aim: The aim of the proposed FLS is to ensure that all patients aged [XX] years and over who present

to [insert hospital name] with fragility fractures receive assessment and, where warranted,

pharmacological treatment for osteoporosis, and referral to local falls prevention services to reduce

their risk of subsequent fractures.

Current provision: Note to business plan authors: Summarise the local data on the provision of

secondary preventive care for individuals who present to their hospital with a fragility fracture.

FLS Service model: Note to business plan authors: Include a detailed description of how the FLS will

be organized and what interventions will be offered to fracture patients. A patient pathway map

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through the FLS provides administrators with a clear overview of how the FLS will function. Further,

quantification of the proportion of all fragility fracture patients who will undergo investigations,

receive osteoporosis treatment and be referred into falls prevention programs provides an

opportunity to illustrate how the FLS will significantly improve quality of care as compared to

baseline levels.

Budgetary impact of a Fracture Liaison Service in [insert hospital name]Note to business plan authors: Successful business plans describe very clearly the costs and benefits

of the intended new service. Business plan authors could consider cost-effectiveness publications

from the following FLS to inform their modelling.

Australia: The Costs of Confronting Osteoporosis: Cost Study of an Australian Fracture

Liaison Service. Major G et al. Journal of Bone and Mineral Research Plus. 2018 Apr

18;3(1):56-639.

Canada: Cost-effectiveness of a fracture liaison service--a real-world evaluation after 6 years

of service provision. Hoch JS et al. Osteoporosis International 2016 Jan;27(1):231-24065.

Japan: Economic evaluation of osteoporosis liaison service for secondary fracture prevention

in postmenopausal osteoporosis patients with previous hip fracture in Japan. Moriwaki K

and Noto S. Osteoporosis International 2017 Feb;28(2):621-63266.

UK: Fracture liaison services for the evaluation and management of patients with

osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years

of service provision. McLellan AR et al. Osteoporosis International 2011 Jul;22(7):2083-

209856.

USA: The potential economic benefits of improved postfracture care: a cost-effectiveness

analysis of a fracture liaison service in the US health-care system. Solomon DH et al. Journal

of Bone and Mineral Research. 2014 Jul;29(7):1667-167467.

Note to business plan authors: This section of the business plan should highlight the personnel and

facilities that are required to implement a FLS, and their costs, which includes:

A FLS Coordinator who is usually a nurse practitioner (NP), a registered nurse (RN) or a

trainee physician.

A senior Specialist Physician to serve as medical lead for the FLS.

Administrative support to facilitate communication between the FLS and the patient, and in

healthcare systems with established primary care, the patient’s Primary Care Provider (PCP).

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Development of existing IT systems or establishment of a bespoke FLS database to underpin

communication with patients and healthcare professionals.

Access to axial dual energy X-Ray absorptiometry (DXA) scanning.

Access to laboratory testing.

Establishment of referral mechanisms to local falls prevention clinics.

Appropriate office space for FLS clinics to be held.

This section of the business plan will be highly country and site specific. Local service configurations

will significantly influence how the FLS is funded. Revenue modelling will be determined by the ratio

of cost vs. reimbursement for specific elements of service provision.

SummaryHip fractures exert a substantial toll on our local older people and the healthcare budgets. Half of hip

fracture patients give us considerable advance notice that one day they will present to the local

orthopaedic unit.

Implementation of a FLS in [insert name of local healthcare economy] will close the secondary

fracture prevention gap in our area. The FLS will improve the quality of care we give and reduce

costs associated with preventable fragility fractures. This business plan recommends commissioning

of this program as a matter of urgency.

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References1. Gallagher JC, Melton LJ, Riggs BL, Bergstrath E. Epidemiology of fractures of the proximal

femur in Rochester, Minnesota. Clin Orthop Relat Res. Jul-Aug 1980(150):163-171.2. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eisman J. Osteoporotic fracture: missed

opportunity for intervention. Osteoporos Int. Sep 2003;14(9):780-784.3. McLellan A, Reid D, Forbes K, et al. Effectiveness of Strategies for the Secondary Prevention

of Osteoporotic Fractures in Scotland (CEPS 99/03): NHS Quality Improvement Scotland; 2004.

4. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res. Aug 2007;461:226-230.

5. Harvey NC, McCloskey EV. Gaps and solutions in bone health: A global framework for improvement. Nyon.: International Osteoporosis Foundation; 2016.

6. Harvey NC, McCloskey EV, Mitchell PJ, et al. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int. May 2017;28(5):1507-1529.

7. Cooper C, Ferrari S. IOF Compendium of Osteoporosis. Nyons: International Osteoporosis Foundation; 2019.

8. Mitchell PJ, Cooper C, Fujita M, et al. Quality Improvement Initiatives in Fragility Fracture Care and Prevention. Curr Osteoporos Rep. Dec 2019;17(6):510-520.

9. Major G, Ling R, Searles A, et al. The Costs of Confronting Osteoporosis: Cost Study of an Australian Fracture Liaison Service. JBMR Plus. Jan 2019;3(1):56-63.

10. New South Wales Agency for Clinical Innovation. Osteoporosis Refracture Prevention. https://www.aci.health.nsw.gov.au/resources/musculoskeletal/osteoporotic_refracture/orp. Accessed 15 July 2020.

11. Government of Western Australia. Osteoporosis Model of Care. In: Department of Health Musculoskeletal Diabetes & Endocrine Falls Prevention and Aged Care Health Networks (WA), ed. Perth; 2011.

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19. Eisman JA, Bogoch ER, Dell R, et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. Oct 2012;27(10):2039-2046.

20. Mitchell PJ, Ganda K, Seibel MJ. Australian and New Zealand Bone and Mineral Society Position Paper on Secondary Fracture Prevention Programs. Sydney 2015.

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21. British Orthopaedic Association, British Geriatrics Society. The care of patients with fragility fracture 2007.

22. International Osteoporosis Foundation. Capture the Fracture® Programme website. https://www.capturethefracture.org/. Accessed 12 July 2020.

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32. Arai H, Ikeda S, Okuro M, et al. Clinical Standards for Fracture Liaison Services (FLS) in Japan. Tokyo: Japan Osteoporosis Society and FFN Japan; 2019.

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34. Gallacher SJ, Alexander S, Beswetherick N, et al. Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services. Camerton: Royal Osteoporosis Society; 2019.

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39. Autier P, Haentjens P, Bentin J, et al. Costs induced by hip fractures: a prospective controlled study in Belgium. Belgian Hip Fracture Study Group. Osteoporos Int. 2000;11(5):373-380.

40. Cree M, Soskolne CL, Belseck E, et al. Mortality and institutionalization following hip fracture. J Am Geriatr Soc. Mar 2000;48(3):283-288.

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42. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. Aug 2004;35(2):375-382.

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43. Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, 3rd, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. Apr 2000;15(4):721-739.

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47. Toth E, Banefelt J, Akesson K, Spangeus A, Ortsater G, Libanati C. History of Previous Fracture and Imminent Fracture Risk in Swedish Women Aged 55 to 90 Years Presenting With a Fragility Fracture. J Bone Miner Res. May 2020;35(5):861-868.

48. Brankin E, Mitchell C, Munro R, Lanarkshire Osteoporosis S. Closing the osteoporosis management gap in primary care: a secondary prevention of fracture programme. Curr Med Res Opin. Apr 2005;21(4):475-482.

49. Chan T, de Lusignan S, Cooper A, Elliott M. Improving Osteoporosis Management in Primary Care: An Audit of the Impact of a Community Based Fracture Liaison Nurse. PLoS One. 2015;10(8):e0132146.

50. Ganda K, Puech M, Chen JS, et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. Feb 2013;24(2):393-406.

51. International Osteoporosis Foundation. IOF Capture the Fracture®: Map of Best Practice https://capturethefracture.org/map-of-best-practice. Accessed 21 February 2019.

52. Giles M, Van Der Kallen J, Parker V, et al. A team approach: implementing a model of care for preventing osteoporosis related fractures. Osteoporos Int. Aug 2011;22(8):2321-2328.

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