Just as the link between untreated hypertension & myocardial infarction is undeniable, so is the knowledge that osteoporosis leads to fractures.
In a similar effort, the Division of Rheumatology at Loma Linda University Health (LLUH), California, spearheaded a project to create an FLS in partnership with the Departments of Endocrinology, Orthopedic Surgery, and Geriatrics. An LLUH needs-assessment study showed that up to 90% of patients admitted to the hospital for a fracture in this medically underserved region of the Inland Empire of Southern California were not being initiated on treatment for osteoporosis subsequent to discharge. Notably, at least 40% of patients had come in for a second fracture.6
Fracture Liaison Services are essential to increase the detection and treatment rate of osteoporosis. They streamline the connection between the inpatient and outpatient settings, as well as provide intervention at a critical point in the care of osteoporotic patients. Based on LLUH’s experience, it is crucial to create an easy manner for orthopedic surgery and hospitalist services to consult the FLS through an order set when admitting a patient for a fragility fracture.
During the inpatient encounter, the FLS can coordinate and schedule an outpatient follow-up appointment in the osteoporosis clinic with an endocrinologist or a rheumatologist. In addition, the patient is given an appointment for an outpatient DXA scan, and their vitamin D level is measured—satisfying Medicare hospital requirements to provide post-fracture care.
In addition, the FLS has enhanced postgraduate education. Residents rotate on the Fracture Liaison Service while on their endocrinology and rheumatology rotations and are provided workshops on DXA interpretation. Multidisciplinary monthly meetings on various topics related to osteoporosis management and secondary causes of osteoporosis enhance the rotation and serve to keep rheumatologists, endocrinologists and geriatricians apprised of the latest advances in osteoporosis care.
FLS programs can also be run by other specialties. The Southern California Kaiser Permanente Healthy Bones Program is one of the more established Fracture Liaison Services in the country. The Healthy Bones program was developed by orthopedist Richard O’Dell, MD, in 2011.7 Between 2002 and 2007, DXA scans increased 263%, the number of patients receiving anti-osteoporosis treatment increased 153%, and the overall hip fracture rate was reduced by 38.1%.8
Kaiser Permanente is a closed health system with its own insurance product, an advantageous position to be in when effecting change. The Healthy Bones Program, in part, can attribute some level of success to ease of transitions across healthcare systems owing to its all in-network group of providers, as well as uniform insurance packages where DXA scans are known to be covered.
GHS and LLUH, on the other hand, are open health systems where primary care providers may be located out of network and myriad insurance plans are in play, some of which may not cover DXA scans, or access to a covered DXA facility may not be within driving distance of a patient. Due to dwindling reimbursement, access to DXA scans nationwide is a well-recognized problem.