Fracture Liaison Service Research Articles

Improving the quality of the fracture liaison service through the implementation of a structured health record

ObjectiveAccording to the best practice framework for secondary fracture prevention, all patients aged ≥50 years with a fracture should be assessed for osteoporosis within the fracture liaison service (FLS). The...

Effectiveness of fracture liaison services in osteoporosis.

In response to the gradual decline in the number of prescriptions for anti-osteoporosis medication (AOM) following fragility fractures, fracture liaison services (FLSs) have been set up around the world with the aim of filling this treatment gap. Several studies have already reported the benefits of such organizations, particularly in reducing fracture risk, mortality rates and healthcare costs, and literature on FLSs has increased at a steady pace over time. A narrative review was conducted on the latest available findings on the effectiveness of FLSs. Various approaches to implementing an effective FLS program are discussed. FLS programs have enhanced the management of osteoporosis-related fractures. However, several studies have highlighted that not all FLSs are necessarily effective in reducing subsequent fracture risk and mortality. Long-term AOM persistence and monitoring are another critical issue in FLS programs. A few studies have reported that FLSs are associated with an improvement in AOM persistence, regardless of the type of AOM. Practitioners in the FLS setting need to be aware of the impact of recency of fracture and fracture recurrence rates, and the need for timely interventions. The administration of zoledronic acid in an in-patient setting may improve AOM treatment rates in patients, who often encounter obstacles to outpatient follow-up. Introducing 'vertebral fracture identification services' in FLS programs is also an option. However, doing so leads to an increase in workload and this would need to be considered by any FLS that is considering introducing such a service. Evidence suggests that digital technologies can support (i) multidisciplinary teams in providing the best possible patient care based on current evidence, and (ii) patient self-management. However, as the methodological quality of many of the studies evaluating these technologies was poor, their validity of their results is limited. Further research should focus on the optimal implementation of post-fracture care using automated systems, and standardized reporting of patient's characteristics and outcome measures using key performance indicators.

Quality improvement initiative: implementing routine vertebral fracture assessments into an Australian Fracture Liaison Service

Osteoporosis is a global health concern and a major contributor to worldwide mortality rates. Vertebral fractures due to osteoporosis are common and often undetected. Since vertebral fractures are often missed,...

Closing the Treatment Gap: Implementing a Fracture Liaison Service in Public Healthcare A Case Study from Chile

Osteoporotic fractures, especially of the hip and spine, entail significant morbidity and mortality, with a 50% increased risk of hip fracture following a prior fracture. Globally - and in Chile, a low rate of post-fracture osteoporosis treatment persists. The International Osteoporosis Foundation's "Capture the Fracture" initiative advocates optimal practices, including Fracture Liaison Services (FLS); however, in Chile, there are only two FLS, both in the private healthcare system. This study aims to implement the first FLS in the public domain, specifically at the Dra. Eloísa Díaz Clinical Hospital, at Santiago. The methodology is based on the Logic Model, emphasizing the importance of human resources, especially a coordinating nurse. The findings identify the problem, necessary resources, key actions, and short, medium, and long-term goals. External factors such as the hospital environment and collaboration with existing programs are considered. A graphical representation of the Logic Model is presented, along with proposed evaluation indicators. Addressing fragility fractures as a public health issue is pertinent, and hospital authorities' acceptance of our project for implementation is highlighted. This initiative is anticipated to inspire other public health centers in Chile to implement similar services, contributing to closing the treatment gap and enhancing patients' quality of life.

Clinical and biological parameters associated with fracture recurrence according to fracture liaison service dataset.

The aim of this study was to describe the characteristics of patients taken in charge by a fracture liaison service and sustaining a recurrent osteoporotic fracture. This was a retrospective and monocentric study based on the dataset of patients included in the FLS of the Department of Rheumatology of the Amiens University Hospital. To be included in the study cohort, patients must have had at least two consecutive osteoporotic fractures between January 2009 and December 2019. Three hundred thirty-seven patients were included. The mean age at index fracture was 77.3 ± 12.5 years. Eighty-four percent of the patients were women. 89.3% of the patients had a Charlson comorbidity index between 1 and 4. Nearly half of the patients had cognitive disorders. Femoral neck was the most frequent site for both index and recurrent fractures. Thirty-seven percent of patients benefited from a consultation in Rheumatology after their index fracture. The main reasons for the lack of follow-up were cognitive disorders and patient rejection. Our study showed that recurrent fracture occurs rapidly after the index fracture and that rheumatological and therapeutic managements are not sufficient, mainly because of cognitive disorders or patients' refusal impairing the patients to benefit from specialized management.

Cost Analysis of a Fracture Liaison Service: A Randomized Controlled Trial for the Secondary Prevention After Fragility Fractures of the Hip

ObjectiveFracture liaison services (FLSs) have proven to be effective for secondary fracture prevention. In this study, we evaluated the essential factors in determining whether the FLS saves or loses more than it costs. MethodsA randomized controlled trial was performed in patients with hip fragility fractures using a hospital-based FLS program in parallel with a cost analysis. Data were generated from a cohort of patients using actual data for FLS effectiveness, individual costs of hip fracture treatment, and medication costs based on an accepted treatment algorithm. ResultsA total of 200 patients were randomized, and 180 were analyzed for costs. The FLS program had an overall cost despite the savings in reducing secondary fractures. Medication was 89% of the costs and was the main factor for the FLS costs exceeding the savings. Specifically, using the medication algorithm in this study, the overall cost per patient enrolled in the FLS was $1189 for a 2-year period. If intravenous zoledronic acid had been used, then the overall cost would have been $489. If only oral bisphosphonates had been used, then the FLS would have cost $159 per patient for a 2-year period. ConclusionThe present analysis shows that medication cost is the critical component in cost-effectiveness of an FLS program. The FLS program costs would be significantly lower if patients are prescribed less expensive drugs to treat osteoporosis. Additional work needs to be performed refining the medication algorithm considering medication costs but individualized to patient needs based on fracture risk.

Effects of Fracture Liaison Service on Outcomes of Patients with Hip Fracture in Rural Area of an Asian Country.

Fracture Liaison Services (FLS) has been proven effective in reducing subsequent fractures and related mortality. However, more research is needed on the impact of FLS on the 30-day readmission rate and its effectiveness in rural hospitals. This study aims to assess the impact of FLS on clinical outcomes including readmission rates, subsequent fractures, and fracture-related mortality in rural areas of an Asain country. In a rural hospital in Taiwan, we conducted a two-year prospective cohort study on elderly individuals with fragility hip fractures. The study compared the clinical outcomes between the control group and the FLS-cohort group. Logistic regression analysis was used to identify factors contributing to 1-year mortality after injury. 556 patients were enrolled. (304 in the control group and 252 in the FLS group) The mean age was 79.8years. The findings revealed that the introduction of FLS did not result in significant differences in mortality, readmission, complication, subsequent fractures, or secondary hip fractures. However, there were notable improvements in the length of hospital stay and the proportion of patients receiving surgery within 48h following the implementation of FLS. Subgroup analysis showed that FLS patients who received anti-osteoporotic treatment had lower mortality and 30-day readmission rates. Factors associated with higher 1-year mortality included male, high ASA level, and delayed surgery. This study provides the real-life evidence of the effect of intensive FLS model in a rural hospital in an Asian country. While FLS did not show significant differences in certain clinical outcomes, it led to shorter hospital stays and increased timely surgeries. FLS patients receiving anti-osteoporotic treatment had better mortality and readmission rates. Further research is necessary to gain a comprehensive understanding of the impact of FLS care in rural areas of Asia.

Secondary fracture prevention with osteoporosis medication after a fragility fracture in Sweden remains low despite new guidelines

SummaryThis national register study investigated osteoporosis medication prescriptions for secondary fracture prevention among older Swedish adults. Although prescription proportions are increasing for both men and women, they remain low, especially among individuals aged 90 and older. Improved Fracture Liaison Services could increase the prescription proportions and should be bolstered.PurposeDespite clear guidelines for secondary fracture prevention among older adults, it seems undertreatment persists. We aimed to describe secondary fracture prevention with medical osteoporosis treatment in the older Swedish population. Specifically, how prescription has changed over time and if these patterns differ in sociodemographic subgroups.MethodsBetween 2007 and 2020, osteoporosis medication use was studied among all Swedish residents aged 70 and older who had a fragility fracture in the previous 5 years. Previous fragility fractures were defined as fractures of the humerus, wrist, hip, or vertebrae. Osteoporosis medication was defined as any prescription of bone-enhancing medications (including bisphosphonates and denosumab).ResultsOsteoporosis medication increased over the study period, especially among men. Prescription among individuals 90 + was consistently two- to threefold lower compared to 70–79- and 80–89-year-olds. In 2018–2020, 8–17% of women and 5–9% of men, depending on age, received osteoporosis medication. At the beginning of the study period, women with higher education were more likely to be prescribed osteoporosis medication, though this difference decreased over time. Prescription of vitamin D and/or calcium as the only treatment was more common than osteoporosis medications throughout the study period.ConclusionDespite increasing prescription proportions, medical treatment for secondary fracture prevention remains low. In addition, it is more common to be prescribed vitamin D or calcium than osteoporosis medication after a fragility fracture, contrary to current guidelines. These results indicate that there is room for improvement for Fracture Liaison Services in Sweden.

Development, implementation and evaluation of a multinational FLS mentorship programme in Latin America

SummaryRealising the benefits of systematic secondary fracture prevention requires supporting local sites to get started and becoming effective. We here describe the development, implementation and impact of a regional fracture liaison service (FLS) mentorship programme in Latin America that led to 64 FLS getting started and coverage of 17,205 patients.IntroductionDespite treatments and service models to deliver effective secondary fracture prevention, most patients are left untreated after a fragility fracture. To improve the capability to get FLS started and more effective, we describe the development, implementation and evaluation of an international programme to develop national communities of FLS mentors as part of the Capture the Fracture Partnership in Latin America.MethodsThe IOF regional team and the University of Oxford developed the curriculum and associated resources for training mentors in setting up FLS, service improvement and mentorship. Mentors were selected during a preparatory meeting, trained using live online sessions followed by regular mentor-led post-training meetings. The programme was evaluated using a pre-training needs assessment and post-training evaluation based on Moore’s outcomes.ResultsThe mentorship programme was initiated in Mexico, Brazil, Colombia and Argentina. The mentors were multidisciplinary, including orthopaedic surgery, rehabilitation, rheumatology, endocrinology, geriatrics, gynaecology and internal medicine. There was 100% participation in training sessions and reported satisfaction with the training. Since the initiation of the training programme, 22 FLS have been set up in Mexico, 30 in Brazil, 3 in Colombia and 9 in Argentina, in comparison with two in Chile and none in any other LATAM countries that were not involved in the mentorship programme. This equates to approximately 17,025 additional patients identified from 2019 to 2021 after initiation of mentorship. The mentors have engaged with 58 FLS for service development. Post-training activities include two published national best practice guidelines and other country-specific resources for FLS in the local language.ConclusionDespite the COVID pandemic, the mentorship pillar of the Capture the Fracture Partnership has developed a community of FLS mentors with measurable improvement in national FLS provision. The programme is a potentially scalable platform to develop communities of mentors in other countries.

The Capture the Fracture® Partnership: an overview of a global initiative to increase the secondary fracture prevention care for patient benefit

SummaryThe Capture the Fracture® Partnership (CTF-P) is a unique collaboration between the International Osteoporosis Foundation, academic units and industry partners to enhance the implementation of effective, efficient fracture liaison services (FLSs) with a good patient experience. CTF-P has generated valuable resources for the specific countries as well as the broader FLS community to improve the initiation, effectiveness and sustainability of FLS in a wide range of healthcare settings.

Fracture Liaison Service and Its Role in Secondary Fracture Prevention in Malaysia: A Scoping Review.

Fragility fractures, which occur after a low-trauma injury, increases with advancing age. Such fracture doubles the life-time risk of sustaining another fracture. This risk is highest in the immediate 18 months after the index fracture. However, most patients do not receive the appropriate risk assessment and intervention to reduce this risk. A coordinated model of care termed Fracture Liaison Service (FLS) has been reported to address this treatment gap. This scoping review aims to explore the potential role and delivery of FLS services in Malaysia. Scientific and non-scientific sources relevant to FLS were identified from electronic bibliographic databases, specialist journals and relevant websites. Findings were categorised into themes and presented narratively. FLS services remain concentrated in the Klang Valley. Even within FLS services, many do not have extensive coverage to risk assess all fracture patients. These services are multidisciplinary in nature where there are links between different departments, such as orthopaedics, osteoporosis expertise, bone densitometry, rehabilitation, falls services and primary care. FLS was able to increase the number of people undergoing fracture risk assessment and treatment. The importance of FLS was highlighted by local experts and stakeholders. Its implementation and delivery are supported by a number of national guidelines. FLS is central to our national efforts to reduce the impending fragility fracture crisis in the coming years. Continued effort is needed to increase coverage within FLS services and across the country. Training, awareness of the problem, research, and policy change will support this endeavour.

Fragility Fracture Network Malaysia (FFNM) Fracture Liaison Service (FLS) Framework FFNM promotes multidisciplinary approach on fragility fracture care. It aims to create a national network of fragility fracture care. FLS is a relatively new approach fragility fracture care in Malaysia. The Framework functions as a systematic guide to achieve these goals. It provides a common platform for all FLS to

Fragility Fracture Network Malaysia (FFNM) Fracture Liaison Service (FLS) Framework FFNM promotes multidisciplinary approach on fragility fracture care. It aims to create a national network of fragility fracture care. FLS is a relatively new approach fragility fracture care in Malaysia. The Framework functions as a systematic guide to achieve these goals. It provides a common platform for all FLS to

Active identification of vertebral fracture in the FLS model of care

SummaryThe identification of vertebral fracture is a key point in an FLS. We have analyzed the characteristics of 570 patients according to the route of identification (referral by other doctors, emergency registry or through VFA), concluding that promoting referral by other doctors with a training campaign is effective.PurposeVertebral fractures (VF) are associated with increased risk of further VFs. Our objective was to analyze the characteristics of patients with VF seen in a Fracture Liaison Service (FLS).MethodsAn observational study was carried out on patients with VF referred to the outpatient metabolic clinic (OMC) after a training campaign, identified in the emergency registry, and captured by VF assessment with bone densitometry (DXA-VFA) in patients with non-VFs. Patients with traumatic VF or VF > 1 year, infiltrative or neoplastic disease were excluded. The number and severity of VFs (Genant) were analyzed. Treatment initiation in the first 6 months after baseline visit was reviewed.ResultsOverall, 570 patients were included, mean age 73. The most common route for identifying VF was through referral to OMC (303 cases), followed by the emergency registry (198) and DXA-VFA (69). Osteoporosis by DXA was found in 312 (58%) patients and 259 (45%) had ≥ 2 VFs. The rate of grade 3 VFs was highest among patients on the emergency registry. Those identified through OMC had a higher number of VFs, a higher rate of osteoporosis, more risk factors and greater treatment initiation. Patients with VFs detected by DXA-VFA were mostly women with a single VF and had a lower rate of osteoporosis by DXA.ConclusionsWe present the distribution of VFs by the route of identification in an FLS. Promoting referral by other doctors with a training campaign may help in the quality improvement of the FLS-based model of care.

Physical Functioning in Patients with a Recent Fracture: The “Can Do, Do Do” Framework Applied to Explore Physical Capacity, Physical Activity and Fall Risk Factors

Physical capacity (PC) and physical activity (PA) are associated physical performance measures, and combined, PC and PA are used to categorize physical performance in the “can do, do do” framework. We aimed to explore physical performance of patients attending the fracture liaison service (FLS). In this cross-sectional study, PC was measured by 6-min-walking-test (can’t do/can do) and PA by accelerometer (don’t do/do do). Following quadrants were defined based on predefined cut-off scores for poor performance: (1) “can’t do, don’t do”; (2) “can do, don’t do”; (3) “can’t do, do do”; (4) “can do, do do”. Odds ratios (OR) were calculated and fall and fracture risk factors were assessed between quadrants. Physical performance of 400 fracture patients was assessed (mean age 64; female 70.8%). Patients performed as follows: 8.3% “can’t do, don’t do”; 3.0% “can do, don’t do”; 19.3% “can’t do, do do”; 69.5% “can do, do do”. For the “can’t do” group the OR for low PA was 9.76 (95% CI: 4.82–19.80). Both the “can’t do, don’t do” and “can’t do, do do” group differed significantly compared to the “can do, do do” group on several fall and fracture risk factors and had lower physical performance. The “can do, do do” framework is able to identify fracture patients with an impaired physical performance. Of all FLS patients 20% “can’t do, but “do do” while having a high prevalence of fall risk factors compared to persons that “can do, do do”, which may indicate this group is prone to fall.

Approach to the Patient With Bone Fracture: Making the First Fracture the Last.

The global burden of osteoporosis and osteoporotic fractures will increase significantly as we enter a rapidly aging population. Osteoporotic fractures lead to increased morbidity, mortality, and risk of subsequent fractures if left untreated. However, studies have shown that the majority of patients who suffer an osteoporotic fracture are not investigated or treated for osteoporosis, leading to an inexcusable "osteoporosis care gap." Systematic and coordinated models of care in secondary fracture prevention known as fracture liaison services (FLS) have been established to streamline and improve the care of patients with osteoporotic fractures, and employ core principles of identification, investigation, and initiation of treatment. Our approach to the multifaceted care of secondary fracture prevention at a hospital-based FLS is illustrated through several case vignettes.

The Korean hip fracture registry study

BackgroundThe purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model.MethodsThe KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey.DiscussionKHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants.Trial registrationPresent study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).

Diagnosis and management of osteoporosis in Saudi Arabia: 2023 key updates from the Saudi Osteoporosis Society

SummaryThe Saudi Osteoporosis Society (SOS) has updated its guidelines for the diagnosis and management of osteoporosis in Saudi Arabia (SA), with emphasis on postmenopausal women. This document is relevant to all healthcare professionals in SA involved in the care of patients with osteoporosis and osteoporosis-related fractures.IntroductionThe SOS launched the first national osteoporosis guidelines in 2015 and spearheaded the Gulf Cooperation Council Countries (GCC) osteoporosis consensus report in 2020 which was under the auspices of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO). This paper highlights a major update of the guidelines in the SA setting.MethodsThis guideline is an adaptation of the current guidelines derived from ESCEO, the American Association of Clinical Endocrinologists (AACE), and the GCC osteoporosis consensus report and studies on osteoporosis done in SA. Where accessible, the timeliest systematic review, meta-analysis, and randomized controlled trials were used as evidence.ResultsThe present update includes new recommendations for the assessment of osteoporosis taking into consideration the Saudi model of FRAX for fracture probabilities, appropriate doses for the maintenance of vitamin D status and calcium, the use of representative blood analytes for therapy monitoring, the use of romosozumab and sequential therapy in the pharmacological management strategies, and the establishment of fracture liaison services to prevent secondary fractures.ConclusionThis updated guideline is for all healthcare professionals involved in osteoporosis and post-fracture care and management in SA and harmonized the most up-to-date changes in the field based on evidence-based medicine for use in the local setting.

IMPACT OF THE COVID-19 PANDEMIC ON FRAGILITY HIP FRACTURE MANAGEMENT AND MORTALITY RATE

Background: The COVID-19 pandemic has greatly affected patients without COVID, including osteoporotic hip fractures. Treatment protocols and time for surgery have been disrupted and delayed resulting in unsatisfactory outcomes. This study compared the mortality rate among patients with osteoporotic hip fractures during the COVID-19 pandemic and during the prepandemic periods.
 Methods: The patients’ information recorded in the Fracture Liaison Service (FLS) registry was retrospectively reviewed. We defined the prepandemic group as the admissions between May 2019 and March 2020 and the pandemic group as admissions from April 2020 to February 2021. The demographic data were collected, including serum calcium and 25(OH)D levels. Time to surgery, postoperative complications, length of stay and death were obtained and compared between the two periods.
 Results: We included 813 patients, with 444 and 369 patients in the prepandemic and the pandemic groups, respectively. Mean age, sex and comorbidities were comparable in both groups. The proportion of patients with insufficient and deficient vitamin D was significantly higher in the pandemic group (46.41 vs. 62.85%, p<0.01). Time to surgery and length of hospital stay was significantly longer in the pandemic period (p <0.05). The mortality was higher but did not significantly differ in the pandemic period with an adjusted hazard ratio of 1.08 (95% CI = 0.76-1.54).
 Conclusion: Properly managing hip fractures during the pandemic is crucial to prevent and reduce morbidity and mortality. Inadequate serum vitamin D level has been noted in the pandemic group but was not associated with mortality rate.

Fragility fracture care gap at a tertiary teaching hospital in Malaysia

This study aimed to investigate the clinical burden and secondary fracture prevention of fragility fractures at a tertiary teaching hospital in Malaysia. Electronic medical records of all patients admitted with fragility fractures between 1 January 2017-31 December 2018 were reviewed. Patients < 50years old, with non-fragility fractures, restricted access to medical records, transferred to another hospital or who passed away during admission were excluded. Descriptive statistics were used to summarise patients' characteristics, frequency of fragility fractures, and secondary fracture prevention details. Binomial logistic regression was performed to analyse predictive factors for post-fracture bone health assessments and treatment initiation. 1030 patients [female (767/1030, 74.5%)] presented with 1071 fractures [hip fractures (378/1071, 35.3%)]. 170/993 (17.1%) patients were initiated on anti-osteoporosis medications (AOMs) and 148/984 (15.0%) had bone mineral density (BMD) performed within 1-year post-fracture. Less than half (42.4%) of the patients remained on treatment at 1-year post-fracture.Older patients [65-74 years old: odds ratio (OR) = 2.18, 95%CI 1.05-4.52, p = 0.04; ≥ 75 years: OR = 3.06, 95%CI 1.54-6.07, p < 0.01], hip fractures (OR = 1.95, 95%CI 1.23-3.11, p < 0.01), Chinese ethnicity (OR = 1.90, 95%CI 1.07-3.35, p = 0.03),previously diagnosed with osteoporosis (OR = 2.65, 95%CI:1.32-5.31, p < 0.01) and a BMD test performed (OR = 12.48, 95%CI 8.04-19.37, p < 0.01) were found to have higher AOM initiation. Patients with past diagnosis of osteoporosis(OR = 4.45, 95%CI 2.25-8.81, p < 0.01) and initiated on AOM (OR = 11.34, 95%CI 7.57-16.97, p < 0.01) had a higherlikelihood to undergo BMD testing. The AOM initiation and BMD testing rates were low. There is a need to address the fragility fracture care gap with strategies such as Fracture Liaison Service.

E060 Testing a new prototype osteoporosis shared decision-making intervention in UK Fracture Liaison Services: patient and clinician perspectives of ‘iFraP’

Abstract Background/Aims Shared decision-making (SDM) is a joint process in which a person and healthcare professional work together to reach decisions about care. The Improving uptake of Fracture Prevention drug treatments (iFraP) study developed a prototype theoretically-informed intervention consisting of a computerised decision aid (DA) and Fracture Liaison Service (FLS) clinician training package to improve SDM about osteoporosis medicines. This abstract focuses on the early prototype iFraP in-practice testing phase that explored perceived acceptability of iFraP by those using it, barriers to, and facilitators of, implementation of the prototype iFraP in practice, and necessary changes required ahead of a full-scale randomised controlled trial (RCT). Methods In-practice testing was conducted at one FLS site. Participating FLS clinicians completed the prototype iFraP clinician training package, covering enhanced communication skills (e.g SDM, risk communication and health literacy techniques). Consenting patients with a recent fragility fracture referred for an FLS consultation were eligible to participate. Three cycles of iFraP in-practice testing were completed. Each cycle included observed iFraP consultations and post-consultation patient think-aloud interviews. After each complete cycle, the FLS clinician(s) was interviewed. Data were analysed using a framework approach. The Theoretical Framework of Acceptability and Theoretical Domains Framework facilitated understanding of iFraP acceptability and barriers to, and facilitators of, implementation. Results Four FLS clinicians (3 nurses, 1 allied health professional) completed the iFraP clinician training and delivered 10 iFraP consultations (8 face-to-face, 2 telephone) using the iFraP DA with participating patients (n = 3 cycle 1; n = 3 cycle 2; n = 4 cycle 3). In total, the four FLS clinicians completed 7 interviews, with all 10 patients completing a post-consultation interview. Findings demonstrate that patients and clinicians perceived the prototype iFraP DA as acceptable. Clinicians suggested that the iFraP DA supported them to elicit and address patient perceptions, increase patient involvement, and provide patients with sufficient and accessible information. Patients and clinicians expressed wanting to use iFraP in future FLS appointments, with some clinicians continuing to use the DA outside of iFraP in-practice testing. Identified barriers included: some clinicians questioned both the use of iFraP DA with patients not recommended first-line drug treatment; and, expressed concern that iFraP DA could extend the consultation length. Our findings demonstrated necessary updates to meet user needs and overcome identified barriers to iFraP intervention use, including presentation and structural changes to support integration of the iFraP DA into the consultation flow. Clinicians also provided feedback to improve the training package, including the need to demonstrate the DA in use, and increased allocated time to practice using the DA. Conclusion The iFraP intervention was perceived as acceptable, with the potential to support SDM about osteoporosis medicines. The iFraP RCT will now test our improved iFraP intervention across 3 FLS sites in England. Disclosure L. Bullock: None. N. Tyler: None. M. Thompson: None. S. Ryan: Grants/research support; the General Nursing Council for England and Wales Trust. J. Lefroy: None. S. Leyland: None. J. Fleming: None. E.M. Clark: None. S. Thomas: Other; owns Prescribing Decision Support Ltd that developed the iFraP decision aid. C. Gidlow: None. C.P. Iglesias-Urrutia: None. T.W. O'Neill: Grants/research support; supported by the NIHR Manchester Biomedical Research Centre. C.D. Mallen: Grants/research support; funded by the NIHR Applied Research Collaboration West Midlands, funded by the NIHR School for Primary Care Research. C. Jinks: Grants/research support; part funded by NIHR Applied Research Collaboration (ARC) West Midlands. Z. Paskins: Grants/research support; funded by the National Institute for Health Research (NIHR) [Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy].