Supporting Fracture Liaison Services in England and Wales: A role for pharmacists?
Authors: Janjua S S , Boardman H F , Sami A , Tanna N K , Toh L S , Javaid M K 
Published: November 2023

Abstract

Introduction
Fracture Liaison Service (FLS) deliver secondary fracture prevention to adults aged 50 years and over. Performance is measured against ten benchmarks [B1-10]: cases identified [B1], spine fractures [B2], assessment within 90 days [B3], dual x-ray absorptiometry (DXA) within 90 days [B4], falls risk assessment [B5], bone treatment recommended [B6], strength and balance by 16 weeks [B7], 16-week follow-up [B8], treatment by first follow-up [B9] and 1-year drug adherence check [B10]. Each indicator has standards for meeting &gt;80% of target (green), 50-79% (amber) and &lt;50% (red). For Spine fractures [B2], &gt;20% identified denotes green, amber for 11-19% and red for &lt;10%. For bone treatment recommended [B6], green denotes &gt;50% and red &lt;50%. Audit data is uploaded to the Fracture Liaison Service Database (FLS-DB).1

Aim
To establish whether FLSs meet performance targets and identify how pharmacists could support the service.

Methods
This work was done as part of a PhD project at the University of Nottingham looking at how pharmacists could improve osteoporosis medication adherence. Therefore, an existing service which encounters people with osteoporosis (FLS) was investigated to see if it required support. Approval reference: 017-2021.
National averages for benchmarks were analysed to see if targets were being met over a 5-year period (2016-2020).1 The Royal Osteoporosis Society (ROS) Clinical Standards for FLSs2 were reviewed to identify areas where pharmacists could support the service. Findings were reviewed by two authors of the Clinical Standards for FLSs.

Results
Less than half (49%) of FLSs’ in England and Wales submitted data consistently between 2016-2020. Of those who submitted, only recommendations to initiate bone treatment [B6] met the required target (&gt;50% of patients) in 2018 (53%), 2019 (52.4%) and 2020 (52.9%). However, B9: Treatment by 1st follow-up targets were not met.
Possibly due to the lack of data for pharmacy support, the ROS Clinical Standards for FLSs do not mention pharmacists. Staffing data shows no pharmacists employed at FLSs. However, the research team identified eleven areas where implementation of referral pathways between community pharmacy (CP) and FLSs could support patient management. These were related to identification of people aged over 50 years with a fragility fracture (1.1), investigations of fragility fracture risk within 12 weeks of a fracture diagnosis (2.1, 2.2), provision of information to patients and healthcare professionals (3.1, 3.2, 3.3, 3.4), interventions such as drug treatment initiation, reviews, referrals to falls prevention services (4.1, 4.2, 4.3) and integration of the wider healthcare system to ensure long term management of osteoporosis (5.1). Multi-disciplinary working and incorporating primary and secondary fracture prevention and medicines review outcomes,3 would help inform transfer of care on this pathway.

Discussion/Conclusion
FLSs’ needs support to ensure benchmark targets are met especially related to anti-osteoporosis medication initiation and adherence. Due to their expertise, pharmacists could support the FLS, particularly with treatment initiation and adherence related monitoring. Implementation of a two-way referral pathway between FLSs’ and community pharmacy could help improve patient outcomes. Limitation: There is missing data as not all FLSs upload to the FLS-DB.

References
1. Royal College of Physicians. Fracture Liaison Service Database, https://www.fffap.org.uk/fls/flsweb.nsf/
2. Royal Osteoporosis Society. Effective Secondary Prevention of Fragility Fractures: Clinical Standards for Fracture Liaison Services, August 2019. https://theros.org.uk/media/1eubz33w/ros-clinical-standards-for-fracture-liaison-services-august-2019.pdf
3. Tanna, N., Tatla, T., Winn, T., Chita, S., Ramdoo, K., Batten, C. and Pitkin, J. (2016) Clinical Medication Review and Falls in Older People—What Is the Evidence Base? Pharm. Pharmacol., 7, 89-96. http://dx.doi.org/10.4236/pp.2016.72012