Section 9: Models of care for fracture prevention


  1. Multidisciplinary, coordinator-based FLS are recommended to systematically identify men and women with fragility fractures, facilitating timely assessment of fracture and falls risk, and where appropriate, tests to exclude secondary causes of osteoporosis, radiological investigation including BMD testing, and initiation of pharmacological and non-pharmacological interventions to reduce risk of falls and fractures (Strong recommendation).
  2. FLSs should include embedded local audit systems supported by a clinical fracture database to enable monitoring of care provided to fracture patients [e.g., Royal College of Physicians FLS-Database]; (Strong recommendation).
  3. FLSs should employ a range of case finding strategies to identify all inpatients and outpatients with fragility fractures (Strong recommendation).
  4. Diagnostic imaging services should routinely evaluate the spine in all imaging of postmenopausal women, and men age ≥50 years, in which the spine is visualised, and report vertebral fractures using standardised methods (Strong recommendation).
  5. Patients recommended drug treatment for osteoporosis should be offered tailored information about osteoporosis and its treatments and further medication reviews to support adherence and to discuss alternative treatments if unacceptable adverse events arise or adherence is difficult (Strong recommendation).
  6. Primary care clinicians should always have in mind the possibility of vertebral fracture in postmenopausal women and men age ≥50 years who present with acute onset back pain, especially thoracic pain, if they have risk factors for osteoporosis ( see Section 3) (Strong recommendation).

FLS models of care

  1. Collaboration between primary care clinicians, secondary care physicians, orthopaedic surgeons, radiologists, and pharmacists and between the medical and non-medical disciplines concerned, should underpin secondary fracture prevention programmes.
  2. Fracture Liaison Service (FLS) programmes reduce re-fracture rates and improve survival 292, 293(Evidence levels Ia and IIb). The Department of Health and NHS RightCare both state that FLS should be provided for all patients sustaining a fragility fracture 294, 295, which aligns with the International Osteoporosis Foundation’s global Capture the Fracture® programme 296 and the Royal Osteoporosis Society (ROS) FLS Clinical Standards 297.
  3. FLS should provide fully coordinated, intensive models of care for secondary fracture prevention. FLS models which provide identification, assessment and treatment initiation, or a treatment recommendation to primary care, are more clinically effective and cost-effective in improving patient outcomes than approaches that provide identification and/or patient alerts, and/or patient education only 298; (Evidence Level Ia). The required approach is a FLS in which identification, assessment and osteoporosis treatment are all conducted within an integrated electronic health care network, overseen by a coordinator and utilizing a dedicated database measuring performance 296, 298-300; (Evidence Level Ia).
  4. FLS which initiate pharmacological treatment, rather than making a treatment recommendation for primary care initiation, have higher rates of treatment initiation 299; (Evidence Level Ia). FLS should also initiate appropriate non-pharmacological interventions and communicate ongoing care effectively with primary care practitioners 297. FLS should provide a coordinated programme with an integrated approach for falls and fracture prevention; all individuals with a fracture should be fully assessed for falls risk and appropriate interventions to reduce falls should be undertaken301. As risk of re-fracture is highest immediately after a fragility fracture, secondary fracture prevention assessment and intervention should be initiated as soon as possible, and no later than 16 weeks post fracture, as recommended by the Royal Osteoporosis Society 51,297.

FLS patient identification

  1. FLSs need to employ a range of case finding strategies, to identify both inpatients and outpatients with fragility fractures, and people with vertebral fractures who are often undiagnosed. Reasons for non-identification of vertebral fractures include the absence of a fall as a trigger for investigation, absence of symptoms, or attribution of symptoms to other causes. Furthermore, in patients who do have spinal imaging, use of ambiguous non-standardised terminology in imaging reports, and failure to routinely evaluate the vertebrae captured in imaging of other body systems can both contribute to non-identification of vertebral fractures. The Royal Osteoporosis Society recommend that radiology services should establish local processes to ensure that the spine is routinely evaluated for the presence of vertebral fracture in all available imaging and that reports identifying vertebral fractures should be standardised, using the words ‘vertebral fracture’, are actionable, and indicate future management 302; (Evidence Level IV).
  2. Primary care plays an important role in case finding for osteoporotic fractures, particularly vertebral fractures as acute onset back pain, especially thoracic pain, is a common presenting complaint. Targeted use of spinal imaging can help increase case identification, appropriate symptom management, and prompt secondary fracture prevention.

Providing patient information and adherence support

  1. Patients identified by any clinical service, to be in need of further intervention, should be offered an explanation of osteoporosis, the causes, consequences and how it can be managed with pharmacological and non-pharmacological interventions. When discussing pharmacological treatment, explanation should be offered for why drug treatment is recommended, the aims and benefits, common and/or severe side effects, the practicalities of taking the medicine and for how long it should be taken 303; (Evidence Level IV). The use of decision aids in osteoporosis to support communication of medicine risk-benefit has been shown to improve shared decision making, reduce decisional conflict and improve accuracy of patient perceived fracture risk 304; (Evidence Level Ib). Information should be tailored to the needs of the patient to make it accessible and understandable, including provision of written information 305.
  2. To promote treatment adherence, healthcare professionals should elicit and address any beliefs and concerns associated with reduced adherence and establish realistic treatment expectations with the patient 303, 305. No one type of intervention has been demonstrated to enhance medicines adherence in osteoporosis care, but multi-component models with active patient engagement have the most positive effects 306, 307; (Evidence Level Ia). FLS models with a greater number of patient interactions have demonstrated greater clinical effectiveness 300; (Evidence Level Ia). The NOGG supports the Royal Osteoporosis Society recommendation to follow-up within 16 weeks and 52 weeks post fracture, to review use of medications that increase the risk of falls and/or fracture, to ensure co-prescription of calcium and vitamin D with bone protective interventions where indicated, to review adverse effects and monitor adherence to therapy 297.