Closing the Osteoporosis Care Gap: System-Level Fracture Liaison Service Implementation and a Patient Education...

Background Osteoporosis impacts millions of individuals in the United States and is linked to significant morbidity and mortality after fragility fractures. Despite the availability of effective treatments, a majority of patients remain untreated. Fracture liaison services (FLS) have been shown to improve post-fracture management, particularly in integrated healthcare systems, yet evidence from open systems remains limited. This study evaluated the impact of FLS implementation at the Loma Linda University Health (LLUH), an open healthcare system, and examined whether a patient-level educational flyer could further improve treatment initiation.  Methods  A retrospective and prospective cohort study of patients aged ≥50 years who were admitted with hip or vertebral fragility fractures between September 2015 and February 2020 was conducted. Data from September 2015 to February 2017 comprised the pre-FLS cohort. The post-FLS cohort included data from September 2017 to February 2020, excluding a six-month washout period. Data collection did not include the period following the onset of the COVID-19 pandemic in the United States. The flyer intervention was tested from 2019 to 2020, with age- and sex-matched controls receiving only standard verbal education. The primary outcome was initiation of anti-osteoporotic pharmacologic therapy within six months of hospital discharge, defined as documentation of a new prescription or medication order in the electronic health record (EHR). Secondary outcomes included completion of an outpatient follow-up visit (rheumatology or other provider) within six months of discharge and the type of anti-osteoporotic therapy initiated.  Results  A total of 404 patients were included (pre-FLS (n=216), post-FLS (n=188)). In the pre-FLS-cohort, 57% (n=124) had no documented follow-up in the EHR and 10.2% (n=22) initiated anti-osteoporotic therapy using conservative non-responder imputation. In the post-FLS cohort, 19.7% of patients initiated osteoporosis therapy, compared with 10.2% in the pre-FLS cohort. In the post-FLS cohort, patients who were seen by a rheumatologist after hospital discharge initiated therapy 57% of the time, whereas those seen by a provider outside of the LLUH system initiated therapy 40% of the time. An educational flyer Plan-Do-Study-Act initiative did not increase uptake of osteoporosis therapy (26% vs 24%, p=0.916), though outpatient rheumatology follow-up was numerically higher (59% vs 31%, p=0.235). Those seen by a rheumatologist were more likely to be treated with therapy beyond bisphosphonates.  Conclusion Implementation of an FLS in an open health system was associated with double the odds of initiating osteoporosis treatment, although absolute rates remained low compared with those observed in closed systems. Specialist follow-up emerged as the most significant predictor of therapy initiation. The flyer intervention did not affect treatment rates, underscoring the need for integrated referral pathways and enhanced cross-network communication. Comprehensive, system-level interventions are essential to bridging the osteoporosis care gap in open health systems.