Barriers to the identification of fragility fractures for secondary fracture prevention in an orthopaedic clinic-based fracture liaison service: a prospective cohort study

Abstract

Background: The goal of this study was to determine the identification and participation rates of fragility fracture patients in a Fracture Liaison Service (FLS). We also identified factors affecting performance in patient identification. Methods: Surgeons, staff, and FLS nurses of an outpatient orthopaedic clinic from a hospital (Montreal, Canada) identified patients 50 yr of age or older with a fragility fracture eligible to join an FLS from January 2014 to March 2015. The list of orthopaedic referrals for the same period was retrieved and compared to our list of patients in the FLS to determine the participation rate. An in-house questionnaire was dispensed to volunteer staff to identify gaps in fragility fracture identification. Results: We identified 1011 patients with fractures from the orthopaedic referral list. Two hundred forty-nine patients (24.6%) were not identified because of nonreferral by surgeons or staff. Of the 762 remaining patients, 288 were excluded for high-energy trauma (n = 126), fracture of the face, skull, foot, or hand (n = 87), and other reasons (n = 75). Out of 474 patients with fragility fracture, 295 (62.2%) joined the FLS (178 refusals (37.6%). FLS managers only accessed 46.9% (474/1011) of eligible patients. The highest difficulty reported by the staff was about the time allocated to patient identification considering their workload. Conclusions: Major barriers to diagnosis and treatment of underlying osteoporosis in fragility fractures are nonreferral from orthopaedic surgeons or staff, and patient refusal. Challenges reside in implementing an institutional policy for optimal screening, better surgeon, staff, and patient education combined with improved systematic clinical management programs.