Fracture Liaison Service and Its Role in Secondary Fracture Prevention in Malaysia: A Scoping Review

@#Introduction: Fragility fractures, which occur after a lowtrauma injury, increases with advancing age. Such fracture doubles the life-time risk of sustaining another fracture. This risk is highest in the immediate 18 months after the index fracture. However, most patients do not receive the appropriate risk assessment and intervention to reduce this risk. A coordinated model of care termed Fracture Liaison Service (FLS) has been reported to address this treatment gap. Materials and methods: This scoping review aims to explore the potential role and delivery of FLS services in Malaysia. Scientific and non-scientific sources relevant to FLS were identified from electronic bibliographic databases, specialist journals and relevant websites. Findings were categorised into themes and presented narratively. Results: FLS services remain concentrated in the Klang Valley. Even within FLS services, many do not have extensive coverage to risk assess all fracture patients. These services are multidisciplinary in nature where there are links between different departments, such as orthopaedics, osteoporosis expertise, bone densitometry, rehabilitation, falls services and primary care. FLS was able to increase the number of people undergoing fracture risk assessment and treatment. The importance of FLS was highlighted by local experts and stakeholders. Its implementation and delivery are supported by a number of national guidelines. Conclusion: FLS is central to our national efforts to reduce the impending fragility fracture crisis in the coming years. Continued effort is needed to increase coverage within FLS services and across the country. Training, awareness of the problem, research, and policy change will support this endeavour.

Research on the application of Internet + technical liaison service model in elderly osteoporotic hip fractures patients after surgery / 中国实用护理杂志

Objective:To explore the effect of Internet + technical liaison service mode on the postoperative continuing nursing of elderly patients with osteoporotic hip fractures.Methods:A total of 92 elderly patients with osteoporotic hip fractures who were admitted into in Orthopaedics Department of the First Affiliated Hospital of Soochow University from July 2018 to December 2019 were selected, and randomly divided into intervention group and control group by random number table method, with 46 cases in each group. The control group was given routine follow-up outside hospital, while the intervention group was given the continuing nursing led by the orthopedic specialist nurses based on the Internet + Technology home orthopedic care platform. All patients were followed up to 6 months after operation, and the differences of Harris Hip Score (Harris), Numeric Rating Scales (NRS), Barthel Index, Short Form 36-item Health Survey (SF-36) between the two groups were compared.Results:The Harris scores were 49.74 ± 4.28, 76.59 ± 4.33 and 90.78 ± 2.61 in the intervention group, and 46.17 ± 3.85, 74.26 ± 4.24 and 88.65 ± 2.17 in the control group in 1, 3 and 6 months after operation, respectively. The differences were statistically significant ( t=-4.20, -2.60, -4.26, all P<0.05). The NRS scores in the intervention group were 1.33 ± 0.47, 0.83 ± 0.38 and 0.76±0.43 in 1, 3 and 6 months after operation respectively, while the NRS scores in the control group were 1.61 ± 0.54, 0.96 ± 0.42 and 0.84 ± 0.38, respectively. The difference in pain scores between the two groups was statistically significant only at 1 month after operation ( t=2.68, P<0.05). The Barthel Index in the intervention group were 61.74 ± 8.90, 93.80 ± 5.29 and 98.26 ± 2.83 in 1, 3 and 6 months after operation respectively, while those of the control group were 60.33 ± 5.81, 91.09 ± 7.52 and 97.83 ± 3.10, respectively. The difference in Barthel Index between the two groups was statistically significant only in 3 months after operation ( t=-2.00, P<0.05). The scores of SF-36 in the intervention group were 93.73 ± 3.89, 100.26 ± 3.77 and 107.50 ± 3.56 at 1, 3 and 6 months after operation respectively, while those of the control group were 92.67±3.42, 97.71±2.67 and 103.68±2.83, respectively. The difference in SF-36 scores between the two groups was statistically significant only at 3 and 6 months after operation ( t=-3.74, -5.71, P<0.05). Conclusions:The continuing nursing based on multi-disciplinary team cooperation in hospital + Internet + Technology home orthopaedic nursing platform led by orthopaedic specialist nurses can improve joint function, relieve pain and improve quality of life of elderly patients with osteoporotic hip fractures after operation.

Effect of moderate exercise therapy and fracture liaison service on osteoporotic hip fracture / 中国实用护理杂志

Objective:To explore the clinical effect of moderate exercise therapy and fracture liaison service in osteoporotic hip fracture.Methods:From June 2018 to June 2020, 120 patients with osteoporotic hip fracture admitted to Nanjing Hospital Affiliated to Nanjing Medical University were selected. The patients were divided into study group and control group by random number table method, 60 cases in each group. The control group was treated with routine nursing and moderate exercise therapy, and the control group was treated with fracture liaison service, clinical observation and comparison of treatment compliance, bone mineral density (BMD), Numerical Rating Scale (NRS) score and nursing satisfaction before and after intervention.Results:The BMD and NRS scores in the study group were (0.90±0.25) g/cm 2, (1.0±0.3) points, higher than those in the control group (0.80±0.18) g/cm 2, (1.0±0.25) points. The difference was statistically significant ( t values were 2.514, 2.547, P<0.05). The total compliance rate and nursing satisfaction of the study group were 93.30% (56/60) and 95.00% (57/60) respectively, which were significantly higher than 80.00% (48/60) and 83.33% (50/60) of the control group. The difference was statistically significant ( χ 2 values were 4.615, 4.227, P<0.05). Conclusion:Moderate exercise therapy and fracture contact service intervention can effectively improve bone mineral density and total compliance rate, relieve pain and improve nursing satisfaction.

Servicio de enlace para pacientes con fracturas por osteoporosis / Osteoporotic fracture liaison service

Los pacientes con fracturas por fragilidad presentan elevadas tasas de morbimortalidad, lo que implica además un alto costo para el erario público. Luego de una fractura por osteoporosis, la mayoría de los pacientes no recibe una adecuada evaluación y tratamiento. Para suplir este vacío de atención médica se crearon distintas políticas; la mejor de ellas son los Servicios de Enlace de Pacientes con Fracturas (Fracture Liaison Service, en inglés). Estos programas tienen una vigencia internacional de más de diez años y son patrocinados por organismos internacionales. La finalidad de estos servicios es la prevención secundaria de fracturas. La modalidad de trabajo tiene como objetivo facilitar y asegurar la rápida identificación, el diagnóstico y la terapéutica de esta población en diferentes contextos asistenciales. La experiencia internacional demuestra que estos servicios son exitosos pues logran incrementar el inicio y la adherencia al tratamiento, disminuir las tasas de mortalidad, de morbilidad y de nuevas fracturas, y son costo-efectivos. En nuestro medio, el inicio de los Servicios de Enlace es reciente. El propósito de esta actualización es realizar una revisión de los fundamentos, características, modalidad operativa y los logros obtenidos por dichos programas. Las fracturas por fragilidad ósea constituyen un problema importante para la salud pública. Esta presentación tiene como objetivo alertar y motivar a la comunidad médica a intervenir de manera sistemática y dinámica para mejorar el cuidado habitual en esta población de pacientes. (AU)

Fragility fractures are associated with increased morbidity and mortality rates and higher costs. After a fracture, most patients do not receive adequate assessment and treatment. To fill this gap in medical care, different policies have been created; the best of them being the Fracture Liaison Services. These programs have been in place for over ten years worldwide and are sponsored by international organisms and societies. The purpose of the Fracture Liaison Services is secondary fracture prevention. Their goal is to ensure the rapid identification, diagnosis and treatment of this population in different clinical contexts. They increase treatment adherence and decrease mortality and morbidity rates and the incidence of new fractures. International experience shows that these services are successful and costeffective. (AU)

Application of fracture liaison service model in patients with osteoporotic vertebral compression fractures / 中华创伤杂志

Objective@#To investigate the effects of fracture liaison service (FLS) model on the medication compliance of patients, quality of life, pain and re-fracture rate in patients with osteoporotic vertebral compression fracture (OVCF).@*Methods@#A prospective case control study was conducted to analyze the clinical data of 117 OVCF patients admitted to Department of Pain of Guizhou Provincial People's Hospital from January 2017 to September 2017. According to the random table method, patients were divided into control group (58 patients) and intervention group (59 patients). Routine nursing was adopted in the control group, and fracture liaison service mode was adopted in the intervention group on the basis of the control group until 3 months after discharge. Morisky scale was used to compare the medication compliance of patients on admission, at discharge, 1 month, and 3 months after discharge, and SF-36 was used to evaluate the quality of life. The SF-36 scale contained eight dimensions including physiological function, physiological performance, physical pain, overall health, vitality, social function, emotional function and mental health. Visual analogue scale (VAS) was used to evaluate the pain of patients. The re fracture rates of the two groups were compared.@*Results@#There were no significant differences between the two groups concerning gender, age, history of diabetes, history of hormone use, number of vertebral fractures, fracture site and cause of injury (P>0.05). In the intervention group, the medication compliance scores of patients in the first and third months after discharge were (5.5±2.0)points and (6.3±1.8)points, which were higher than those in the control group [(3.5±2.2)points and (3.3±1.8)points] (P<0.05). Within each group, there were significant differences among the medication compliance scores at the different time points of evaluation (on admission, at discharge, 1 month, and 3 months after discharge). The scores of the eight dimensions of the SF-36 scale in the intervention group were higher than those in the control group at 1st and 3rd months after discharge (P<0.05). Within each group, there were significant differences among the SF-36 scores at the different time points of evaluation. The pain scores of the intervention group at discharge and 1st and 3rd months after discharge were ( 3.1±1.7)points, (1.8±1.3)points, (1.4±1.3)points, all lower than those in the control group [(5.2±1.7)points, (3.6±1.6)points, (2.7±1.8)points] (P<0.05). Within each group, there were significant differences among the pain scores at the different time points of evaluation. At 1st and 3rd months after discharge, the re-fracture rates of the intervention group were both 2%, and the those of the control group were 3% and 9%, respectively, showing no significant difference between the two groups (P>0.05).@*Conclusion@#The FLS model can effectively alleviate the pain of OVCF patients, improve the medication compliance and quality of life of patients after discharge, but it cannot reduce the short-term re fracture rate after discharge.

Application of fracture liaison service model in patients with osteoporotic vertebral compression fractures / 中华创伤杂志

Objective To investigate the effects of fracture liaison service(FLS)model on the medication compliance of patients,quality of life,pain and re-fracture rate in patients with osteoporotic vertebral compression fracture(OVCF).Methods A prospective case control study was conducted to analyze the clinical data of 117 OVCF patients admitted to Department of Pain of Guizhou Provincial People's Hospital from January 2017 to September 2017.According to the random table method,patients were divided into control group(58 patients)and intervention group(59 patients).Routine nursing was adopted in the control group,and fracture liaison service mode was adopted in the intervention group on the basis of the control group until 3 months after discharge.Morisky scale was used to compare the medication compliance of patients on admission,at discharge,1 month,and 3 months after discharge,and SF-36 was used to evaluate the quality of life.The SF-36 scale contained eight dimensions including physiological function,physiological performance,physical pain,overall health,varsity,social function,emotional function and mental health.Visual analogue scale(VAS)was used to evaluate the pain of patients.The re fracture rates of the two groups were compared.Results There were no significant differences between the two groups concerning gender,age,history of diabetes,history of hormone use,number of vertebral fractures,fracture site and cause of injury(P＞0.05).In the intervention group,the medication compliance scores of patients in the first and third months after discharge were(5.5±2.0)points and(6.3±1.8)points,which were higher than those in the control group [(3.5 ±2.2)points and(3.3± 1.8)points](P＜0.05).Within each group,there were significant differences among the medication compliance scores at the different time points of evaluation(on admission,at discharge,1 month,and 3 months after discharge).The scores of the eight dimensions of the SF-36 scale in the intervention group were higher than those in the control group at 1 st and 3rd months after discharge(P＜0.05).Within each group,there were significant differences among the SF-36 scores at the different time points of evaluation.The pain scores of the intervention group at discharge and 1st and 3rd months after discharge were(3.1±1.7)points,(1.8±1.3)points,(1.4±1.3)points,all lower than those in the control group [(5.2±1.7)points,(3.6±1.6)points,(2.7±1.8)points](P＜0.05).Within each group,there were significant differences among the pain scores at the different time points of evaluation.At 1 st and 3rd months after discharge,the re-fracture rates of the intervention group were both 2％,and the those of the control group were 3％and 9％,respectively,showing no significant difference between the two groups(P＞0.05).Conclusion The FI.S model can effectively alleviate the pain of OVCF patients,improve the medication compliance and quality of life of patients after discharge,but it cannot reduce the short-term re fracture rate after discharge.

Osteoporosis liaison service in Japan

A fracture liaison service (FLS) is a secondary fracture prevention program that is led by a coordinator. A program called the osteoporosis liaison service (OLS), which includes FLS, was first implemented in Japan and has become popular for solving problems related to osteoporosis treatment. OLS and FLS have the same purpose, namely preventing fragility fractures, but while FLS focuses mainly on secondary fracture prevention in fracture patients, OLS addresses this issue as well as primary fracture prevention at clinics and in communities.

ROLE OF GP IN OSTEOPOROSIS MANAGEMENT

fractures will affect one-third of women andone-fifth of men 50 years old and older worldwide.1 Toprevent the inevitable rise in hip fracture occurrences,early patient identification is of paramount importance.Patients with timely osteoporosis diagnosis andappropriate management can remain fracture free.Fracture Liaison Services (FLSs) arecare-coordinator-based secondary fracture preventionprogrammes that systematically identify fragilityfracture patients, then assess, investigate and treatthem for underlying osteoporosis as appropriate.2 Theyare promoted by the International OsteoporosisFoundation (IOF) as a cost-effective strategy forreducing the osteoporosis care gap, the refracture rate,and mortality.3,4 Identifying patients with high fracturerisk using the WHO fracture risk assessment tool(FRAX), and discussing the treatment thresholds basedon patient’s ideas, concerns, expectations and caregoals, using a shared decision-making approach, is apatient-centric and cost-effective way to manageosteoporosis and prevent fractures.

The development of Taiwan Fracture Liaison Service network

Osteoporosis and its associated fragility fractures are becoming a severe burden in the healthcare system globally. In the Asian-Pacific (AP) region, the rapidly increasing in aging population is the main reason accounting for the burden. Moreover, the paucity of quality care for osteoporosis continues to be an ongoing challenge. The Fracture Liaison Service (FLS) is a program promoted by International Osteoporosis Foundation (IOF) with a goal to improve quality of postfracture care and prevention of secondary fractures. In this review article, we would like to introduce the Taiwan FLS network. The first 2 programs were initiated in 2014 at the National Taiwan University Hospital and its affiliated Bei-Hu branch. Since then, the Taiwan FLS program has continued to grow exponentially. Through FLS workshops promoted by the Taiwanese Osteoporosis Association (TOA), program mentors have been able to share their valuable knowledge and clinical experience in order to promote establishments of additional programs. With 22 FLS sites including 11 successfully accredited on the best practice map, Taiwan remains as one of the highest FLS coverage countries in the AP region, and was also granted the IOF Best Secondary Fracture Prevention Promotion award in 2017. Despite challenges faced by the TOA, we strive to promote more FLS sites in Taiwan with a main goal of ameliorating further health burden in managing osteoporotic patients.