Author: Arvin Alvea

Osteoporosis Canada (OC) is pleased to announce the updated version of “Key performance indicators (KPIs) for Canadian FLSs (v2.0)”. Version 2 of the OC FLS KPIs brings in new learnings from OC’s first national audit released in September 2018.

The FLS KPIs provide:

• A way to measure the performance of the FLS at the level of the system
• A useful tool to facilitate on-going continuous quality improvement through Plan-Do-Study-Act (PDSA) methodology to address any identified care gaps
• The ability for FLSs to compare their performance with that of other FLSs from across Canada

Canadian FLSs will be using KPI (Version 2.0) when participating in the next national FLS audit later in 2019.

The OC KPIs are a critical tool for the measurement and monitoring of the FLS’s effectiveness and will allow Canadian FLSs the opportunity to reach their full potential. Osteoporosis Canada’s goal is to ensure that no fragility fracture patient is “left behind” and that every Canadian has access to appropriate post-fracture care.

To view the complete English KPI document, please click here.

To view the complete French KPI document, please click here. 

The results from Osteoporosis Canada’s first national FLS audit demonstrate the positive impact of Canadian FLSs on the lives of fragility fracture patients. The promising results, released in September 2018, are included in the “Report from Canada’s first national FLS audit” which provides an overview of the audit for the cohort of patients enrolled in Canadian FLSs between April 1 and September 30, 2017.

The huge post-fracture care gap has been well documented in many Canadian jurisdictions.  Without FLS, less than 25% of fragility fracture patients will be diagnosed and/or treated for their underlying osteoporosis.

By significantly improving osteoporosis care, FLSs help prevent future fractures, reduce patient suffering and increase their independence. With less than 50 FLSs in Canada, many more FLSs are needed to provide appropriate care to fracture patients.

To read the full report, please click here

Osteoporosis Canada hosted 60 delegates from all 10 provinces at FLS Forum 2017 on February 25^th and 26^th in Toronto. Current evidence on models to close the post-fracture care gap was presented and delegates gained an understanding of the tools they need to implement effective FLS in their own jurisdictions.

Flourishing FLSs, and the up-and-comers had the opportunity to collaborate to generate ideas to break down barriers to implementation, and build a strong support network to advance the implementation of effective FLSs nationwide. Speakers included Peace Arch Hospital physician Dr. Sonia Singh and Director of Clinical Operations Teresa O’Callaghan, who shared their inspirational success story of securing permanent funding for the hospital’s FLS, and Paul Mitchell, who has spent the last 16 years working on programs to improve fragility fracture care and prevention throughout the world.

The National FLS Team will continue to work with all of the provinces to keep the momentum on FLS implementation across the country.

Closing the post-fracture care gap for the patients at Peace Arch Hospital (White Rock, British Columbia) has been a long-time dream for Dr. Sonia Singh. As a family physician who worked for 25 years in the Emergency Department, she has seen many repeat fractures which could and should have been prevented in the first place.

Inspired by Osteoporosis Canada’s FOCUS (Fractures = Osteoporosis Care for Us) Forum in November 2011, she organized a first meeting of stakeholders from the Fraser Health Authority interested in implementing a Fracture Liaison Service (FLS) in March 2012.

FLS in Canada still remains a relatively foreign entity. So despite the overwhelming evidence demonstrating that FLSs are both clinically effective and cost-effective, it is usually not an easy task to find funding for a province’s first FLS prototype. The Peace Arch FLS team persevered in their efforts and were rewarded: a grant was received from the Peace Arch Hospital Foundation and the FLS prototype opened its doors in February 2015.

The Peace Arch FLS is a 3i FLS model delivering appropriate osteoporosis care to the fragility fracture patients seen within the hospital’s orthopaedic outpatient clinics. Within the first year, the FLS had already shown huge improvements in patient care: the rate of osteoporosis treatment and /or referral to an osteoporosis specialist for specific complex indications in high risk patients went from 22% pre-FLS to 76% post FLS, a truly remarkable accomplishment in such a short time span and could not have been achieved without the committed support of the local orthopedic surgeons.

Having demonstrated the FLS’s immense value for fragility fracture patients, it became imperative to identify a sustainable source of funding. Working together for this common goal, the BC Ministry of Health Nurse Practitioner Program, Fraser Health Authority, White Rock/South Surrey Division of Family Practice and the Peace Arch Hospital administration provided for the FLS’s sustainability. The FLS is now a permanent and integral service at Peace Arch Hospital.

Congratulations to Dr. Singh and her FLS team for their on-going efforts and success! Osteoporosis Canada is grateful to the Peace Arch Hospital Foundation who had the foresight to see the immense value of the proposed FLS model. And kudos to the healthcare administrators for recognizing and supporting such an effective program!

It truly takes a village to raise an FLS.

The Osteoporosis Exemplary Care Program (OECP) at St. Michael’s

Hospital in Toronto, Ontario has been a leader in the FLS movement in Canada and worldwide. OECP was founded in 2002 by Dr. Earl Bogoch, orthopaedic surgeon at St. Michael’s Hospital in Toronto, and was the first FLS in Canada.

Under Dr. Bogoch’s leadership, the OECP/FLS at St. Michael’s is dedicated to closing the post-fracture care gap.  The FLS manages 350 to 450 fracture patients annually.

The key features of identification, investigation and initiation of treatment, commonly referred to as the “3 i’s of FLS”, are an integral part of the OECP.  The OECP coordinator proactively identifies patients who present to the hospital’s inpatient ward and outpatient fracture clinics with a fragility fracture. The coordinator then investigates, through bone mineral density (BMD) testing and assessing risk factors, to determine the patient’s future fracture risk and provides education on nutrition and fracture risk reduction strategies.  Where appropriate, the FLS coordinator refers the patient to an osteoporosis specialist or back to their primary care provider (PCP) to ensure appropriate treatment is initiated.

The OECP has demonstrated success at capturing patients at risk for future fractures and initiating testing and treatment to help prevent them.¹ The OECP also undergoes iterative modifications and improvements based on program performance outcomes and qualitative study results.

As reported at the American Society of Bone and Mineral Research Annual Meeting in Atlanta in September 2016, data from December 2010 to November 2013 revealed that 94% of high risk, treatment naïve fragility fracture patients were assessed by a specialist or a primary care physician; 70% were prescribed/recommended pharmacotherapy in addition to calcium and vitamin D.² These findings are significant for this patient population where typically less than 20% ever receive osteoporosis treatment without an FLS.^3-5

A cost-effectiveness analysis⁶ of the OECP, conducted after implementation of the program, demonstrated a high probability of cost-effectiveness of this intervention from the hospital cost perspective.Other economic evaluations done in Canada also demonstrate cost effectiveness of fracture prevention programs.^6-8

St. Michael’s OECP has also informed much of the work behind the Ontario Osteoporosis Strategy FLS.

The OECP is featured on Osteoporosis Canada’s online FLS Registry. Each of the FLSs showcased on the Registry has demonstrated a commitment to the principles of identification, investigation and initiation of treatment which will ensure fracture patients receive the care they need to help prevent future fractures. View the FLS Registry now at https://fls.osteoporosis.ca/fls-tools-and-resources/fls-registry-map

1. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006;88(1):25-34.
2. Bogoch E, Elliot-Gibson V, Beaton D, Josse R, Sale J, Norris E. 2016 Fracture Risk Specific Treatment Initiation Rates in an Orthopaedic Fracture Liaison Service. J Bone Miner Res 30 (Suppl 1). Available at http://www.asbmr.org/Itinerary/PresentationDetail.aspx?id=b616afc3-069c-4a24-8979-5f12b2e8389f Accessed September 8, 2016.
3. Papaioannou A, Giangregorio L, Kvern B, Boulos P, Ioannidis G, Adachi JD. The osteoporosis care gap in Canada. BMC Musculoskelet Disord. Apr 6 2004;5:11.
4. Papaioannou A, Kennedy CC, Ioannidis G, et al. The osteoporosis care gap in men with fragility fractures: the Canadian Multicentre Osteoporosis Study. Osteoporos Int. Apr 2008;19(4):581-587.
5. Bessette L, Ste-Marie LG, Jean S, et al. The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporos Int. Jan 2008;19(1):79-86.
6. Sander B, Elliot-Gibson V, Beaton DE, Bogoch ER, Maetzel A. A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs. J Bone Joint Surg Am. Jun 2008;90(6):1197-1205.
7. Yong JH, Masucci L, Hoch JS, Sujic R, Beaton D. Cost-effectiveness of a fracture liaison service-a real-world evaluation after 6 years of service provision. Osteoporos Int. 2016 Jan;27(1):231-40.
8. Majumdar SR, Lier DA, Beaupre LA, Hanley DA, Maksymowych WP, Juby AG, Bell NR, MorrishDW. Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Arch Intern Med. 2009 Jan;169(1):25-31.

A Fracture Liaison Service (FLS) is a specific model of care where a coordinator pro-actively identifies fracture patients, on a system-wide basis, and determines their fracture risk with the express purpose of facilitating effective osteoporosis treatment for high risk patients. FLS is, by far, the most effective secondary fracture prevention method to ensure fracture patients receive the osteoporosis care they need to prevent additional fractures.

The FLS Registry Map was launched to profile hospitals that have implemented FLSs meeting all of the 8 Essential Elements of Fracture Liaison Services.

Each of the FLSs showcased on the Registry map has demonstrated a commitment to the principles of identification, investigation and initiation of treatment which will ensure fracture patients will receive the care they need to help prevent future fractures.

Click here to view the Canadian FLS Registry Map

The Registry:

• Acknowledges those Canadian hospitals that have implemented effective 2i or 3i models of FLS care
• Allows a bird’s eye view of the breadth and location of FLS across the country

Are you an FLS who has not yet completed a submission to the Registry Committee?

We encourage you to open this link to further review the Essential Elements needed for an FLS to be successful and the application process for inclusion in the FLS Registry. Submissions will be reviewed on a regular basis by the FLS Registry Committee.

Osteoporosis Canada (OC) is excited to announce the upcoming launch of the OC FLS Registry. The OC FLS Registry will be an online map profiling FLS programs across Canada, which meet OC’s Essential Elements of Fracture Liaison Services. The Registry will allow insight into the breadth and location of FLS across the country. It will serve as a vital tool to assist with OC’s efforts to foster the implementation of effective FLS across Canada.

Submissions to the OC FLS Registry:

OC is now accepting submissions for the upcoming launch of the Registry. FLS programs across Canada are invited to submit their program for profile in the Registry. Submissions are open to all FLS programs currently in operation, from those who have newly opened to established programs. Submission forms can be found here.

Submissions received on a rolling basis and the Registry will be updated regularly throughout the year.

For more information, read our FAQ and/or email Katie Cvitkovitch, Manager of FLS with Osteoporosis Canada at kcvitkovitch@osteoporosis.ca

About FLS:

A Fracture Liaison Service (FLS) is a specific system-based model of care for secondary fracture prevention where a dedicated coordinator:

Osteoporosis Canada’s Quality Standards for Fracture Liaison Services in Canada were developed to support implementation of effective FLS. They provide clear guidance for healthcare professionals and administrators on what an effective FLS will deliver, and assurance that the FLS can be set up for success at the time of implementation.

To date, the Quality Standards have been endorsed both nationally and internationally by:

Download a copy of the Quality Standards for Fracture Liaison Services in Canada here.