Nature has provided us with an opportunity to systematically identify almost half of individuals who will break there hip in the future... through identifying those who experience a fragility fracture today. This is why implementation of FLS is crucial.
The pyramid below illustrates the populations that can be targeted for fracture risk assessment from the perspective of ease of case-finding. Patients presenting to hospital Emergency Departments or community-based fracture clinics with new fragility fractures are the most readily identifiable group – their fracture is bringing them to clinical attention.
The next tranche of the pyramid – patients with prior fracture – refers to those patients that have suffered a fragility fracture in the past. In the absence of a system being in place at the time that the prior fractured occurred, assessment for osteoporosis will probably not have been done. These prior fracture patients could be identified for fracture risk assessment if hospital or community-based fracture clinics maintain electronic patient records. Alternatively, in countries with established primary care infrastructure, the patient’s general practitioner could also hold information on prior fracture history.
In order to implement an effective systems-based approach to secondary prevention for individuals presenting to urgent care services with new fragility fractures, the scope of such a service must be clearly defined from the outset. The graph on the right provides a context to consider which groups of fracture patients should be targeted. Some of the established FLS models began by targeting just hip fracture patients. The scope was subsequently expanded to include all patients admitted to hospital and, finally, all patients managed in the outpatient fracture clinic setting. Other services aimed for total patient capture from the outset.
In localities which currently lack a systematic approach to case-finding individuals with new fragility fractures, it is likely that patients who have fractured in the past have not received osteoporosis assessment or treatment. Case-finding of prior fragility fracture patients could be conducted electronically where electronic patient management systems have fracture data coded in a reliable fashion. If such electronic searches are not possible, questionnaires targeted to older adults provide a means to conduct retrospective case-finding. A publication from the UK highlights a successful illustration of this approach: