The Fracture Liaison Service at Queen Elizabeth Hospital: A 3-year review
The 3-year review of Fracture Liaison Service (FLS) at Queen Elizabeth Hospital (QEH) depicted its effectiveness in preventing secondary Fragility Hip Fracture (FHF), demonstrating a clinically feasible service model. The caregiver education session included in the FLS improved the quality and efficiency of care provided by caregivers. The service rendered by Fracture Liaison Nurse (FLN) has resulted in better awareness on the secondary fracture prevention and overall patient satisfaction. In addition, the effective function-based rehabilitation programs offered by FLS did yield positive clinical outcomes for the FHF patients.
FHF is an untoward event in elderly adults due to its frequent link towards disability, high peri-operative risk, institutionalization, and mortality. The co-care of hip fracture by orthopedic surgeons and the geriatricians/rehabilitation group has been the focus of service development recently.1 The goals of such service are to reduce time to surgery, encourage post-operative early mobilization, and minimize peri-operative complications and mortality.1
In Hong Kong, there are 15 hospitals which provide emergency orthopedic services for almost all hip fracture patients (98%).1 Due to the aging population, the annual number of elderly patients undergoing hip fracture surgery has increased significantly by 24.5% from 3,678 in 2000 to 4,579 in 2011 and is projected to increase by 3-fold by 2040.2 Approximately 30% patients under the age of 80 years were unable to walk independently 1 year after hip fracture and became homebound, whereas 20-40% patients were admitted to an elderly care home. Mortality at 1 year after hip fracture was as high as 27% in males and 15% in females, which are markedly higher than the 1.6% mortality rate in a Hong Kong age-matched population.2 However, based on the record of osteoporosis medicines initiation from 2009 to 2012, only 9-15% of fracture patients who are eligible for treatment of osteoporosis in Hong Kong received bone medication within 1 year after their hip fracture.3 To prevent osteoporotic hip fracture, there is a need to allocate more resources to implement the best practices framework to those high-risk post hip fracture patients before they go on to break another bone, especially when the incidence rate of re-fracture was approximately 8% in the Hong Kong population (Figure 1).3,4
FLS is a coordinator-based, sustainable rehabilitation service in the secondary fracture prevention for patients with fragility fractures.2 The objective of FLS is to proactively identify all patients with osteoporosis or presenting with fractures to receive risk assessment and appropriate treatment in the clinical setting.5 In previous individual approaches, patient and provider education has failed to increase diagnosis or treatment of osteoporosis. Other interventions were also unable to improve rates of secondary prevention for fractures.5 FLS is a systematic approach with high quality care that can potentially lower the chance of secondar y fracture through early patient identification, prompt treatment with good compliance, fall prevention education, and sustained rehabilitation.2 By reducing the incidence of future fractures, improving the overall quality of care for osteoporosis patients, and reducing potential healthcare expenditures due to future fractures, various models of FLS have been implemented and proven to be cost effective in many countries.2,5
FLS from the Department of Orthopaedics and Traumatology (O&T) at QEH was pioneered in 2017.6 The aim of this comprehensive program is to prevent secondary fractures among FHF patients.6 A multidisciplinary team (MDT) including FLNs ensures a smooth journey during hospitalization and rehabilitation for FHF patients.6 An essential element of this FLS program is to have a FLS coordinator to facilitate the identification of patients with fragility fracture and to investigate patients’ risk factors, including bone mass density scanning where appropriate. This coordinated approach across multiple specialty departments provides support to patient referral towards the appropriate service for the right inventions. In addition to providing relevant information for patient outcome tracking, the FLS also ensures sufficient MDT-patient interaction as well as primary and follow-up care.7 Fundamentally, the MDT members can also provide education to patients as well as caregivers on bone health, nutrition, exercise, and home safety.6 Additionally, individualized assessments for patients are conducted to identify their potential needs for care. In order to help patients maintain their independent living, advices based on their Activities of Daily Living (ADL) will also be offered by the MDT.6
The “3 I” protocol (Identification, Investigation, and Initiation) for osteoporosis screening and care is applied to the system.6 In the initial Identification stage, the FLS coordinator will coordinate with MDT members to identify patients who are with or are at high risk of fragility fracture. In the subsequent Investigation stage, the coordinator will work with specialists to identify patient risk through demographic profile, features of current fracture episode, medical history, bone mass density scanning, etc. In the Initiation stage, the coordinator team will work with a wider specialists team to discuss treatment options appropriate for the patients and coordinate follow-up appointments with the patient with intention to support and manage their conditions to reduce the risks of future fractures.7
In this research spotlight, the 3-year effectiveness and outcome of FLS at QEH were assessed.
In order to assess the outcome and performance of FLS after the third year of introduction, all the new FHF admissions into the Department of O&T and the patients attending day ward follow-up between 2017-2019 at QEH were reviewed retrospectively.6 The assessment included treatment retention rate, drug compliance rate and secondary fracture rate.6
Results and discussion
From 2017 to 2019, almost 100% (2,060/2,066) admitted FHF patients were screened on bone health medication with FLN education since the launch of FLS service in late 2017. In this period, FLS has provided bone health assessment and education to these 2,060 admitted FHF patients. The mean age of the FHF patients is 84 years with male to female ratio of 1:2.4. 75% FHF patients underwent operations, with 58% having fracture fixations and 42% having replacement operations.6
Of the 2,060 FHF patients, 567 eligible patients have initiated and continued anti-osteoporosis management since 2017.6 A treatment initiation rate of 84% (476/567) in anti-osteoporosis treatment was observed for both 2018 and 2019.6 The drug compliance rate was 92% in 2018 and 93% in 2019, respectively. The follow-up rate at the day ward was >92% in 2019.6 The rate of secondary fracture consistently reduced from 4.67% in 2017 to 2.82% in 2019 (Figure 2A).6 Majority of the patients enrolled in the outpatient clinic completed second year of zoledronic acid dose (Figure 2B).6
The lead author of the study Dr. Tiu, Kwok-Leung from the Department of O&T at QEH, stated that the data represents a comprehensive review of the current FHF care provided by FLS at QEH. Dr. Tiu mentioned, “FHF causes a huge social and economic burden to the family and the society in Hong Kong,” and highlighted that the success of FLS is mainly due to the standardized and streamlined treatment plan.
Even though, the acute surgical treatment complies with the international standards, a standardized orthogeriatric co-management approach can further improve the acute care. By recognizing FHF as a chronic disease model, poor functional recovery, low prescription rate of bone health medications, and low attendance rate for follow-up were identified as problems in the subsequent management.
With an aging population and increasing longevity, the FHF rate is expected to increase continuously. A comprehensive multidisciplinary chronic disease management model that includes FLS programs should be implemented to improve patient outcomes, prevent secondary fractures, and reduce the economic burden in Hong Kong. Dr. Tiu also emphasized the importance of communication between multidisciplinary team members, “We need to check the capacity of the whole group.” As the coordinator, FLN plays a very important role in this part and can help enhance the communication between various health-care parties involved so that the patient and caregiver can easily follow a clearly defined care pathway. FLN can also help patients improve the adherence rate to the medication regimens by stressing the importance and benefits of good treatment compliance. The implementation of FLS is imminent that can assist the health care professionals to continuously monitor and improve the standard of care as well as prevent secondary fractures for the FHF patients. Dr. Tiu concluded, “With an increasing population of hip fracture patients, Fracture Liaison Service with a protocol-driven standardized management approach is practical and cost-effective to improve the care for patients with FHF.”