Table 1 Clinical standards for fracture liaison service in Egypt
Standard | Principle | Basis | Parameters | Clinical Measures |
|---|---|---|---|---|
Identification | Who are the targeted patients? | Identification of the targeted patients meeting the criteria of the FLS service. The patients can be recruited from: -Orthopedics/orthogeriatrics inpatients (hip/non hip fractures) -Outpatients *Fracture clinic *A&E -Radiology: X-ray reports *Referrals | Targeted patients: women and men of 50 years and older who sustained a fragility fracture. These patients will be proactively and systematically identified as candidates for the FLS; including: -Identification (all fragility fractures) -Identification of vertebral fractures -Imminent fracture risk -Repeated fractures -Incidental vertebral fractures noted in X-ray reports | This includes patients presenting with fractures to -Accident and Emergency Departments (hospital), -Private/community-based accident and emergency medical clinics -Primacy care centres -Accidentally identified in X-ray Department. * In the occasion that in a local population, if the total fragility fractures number is not known, it can be estimated by multiplication of the total number of hip fractures occurring in men and women aged 50 years and over by a factor of 5 [24]. |
Investigation | Evaluation of the secondary fracture risk | Investigations to evaluate both the fracture as well as falls risks with further assessment of associated secondary causes for osteoporosis, are offered to the patients reviewed under the FLS. | Fragility fracture sufferers will undergo an assessment for: -Fracture risk probability (Table 2) -Bone mineral density -Trabecular bone score -Vertebral fracture assessment -Falls risk assessment (Table 3) -Sarcopenia risk -Cognitive assessment -Blood test for bone profile and kidney functions. -Functional disability assessment (Table 4) | The proportion of fragility fracture sufferers identified who undergo: *Bone mineral density measurement within 12 weeks of the fracture presentation in accordance with the Egyptian Guidelines for osteoporosis management [16]. In some cases, the treating HCP may decide that clinical assessment of a specific patient might be sufficient to commence osteoporosis therapy without measuring the patient’s bone mineral density (BMD) testing to confirm the diagnosis of osteoporosis, e.g., those patients who have had BMD assessment in the last 2 years; or subjects for who, proceeding to immediate osteoporosis management is considered clinically appropriate. *Falls risk assessment within 12 weeks of the fracture presentation *Assessment of sarcopenia risk by using SARC-F questionnaire (Table 5) |
Intervention | Initiation of treatment including medical therapy | Interventions to decrease the risk of sustaining a fragility fractures are presented to the patients as required. | * Onset of therapeutic effect * Effective follow-up * Exercise to promote bone strength *Patients with very high or high fracture risks will be offered therapeutic management according to the guidelines [16]. *Patient with high falls risk: referred for interventions to reduce falls risk. *Supplementary therapy *Patient with vitamin D deficiency should be managed according to the guidelines [16]. | Osteoporosis therapy should be commenced within 12 weeks of the new fracture presentation in accordance with the national guidelines [16]. There is a growing evidence that starting osteoporosis therapy under an FLS in the instant post-fracture period is associated with improved adherence to therapy [18, 25,26,27,28]. -Special care should be given to osteoporotic patients who fracture whilst they are on osteoporosis therapy. -Patients with high falls risk, should be referred for evidence-based interventions to lessen falls risk within 12 weeks of the presenting fracture. -Post-fracture rehabilitation program |
Integration | Patient pathway and follow-up | Integrating with the healthcare system at a wider scale to ensure the inclusion of patient pathway; facilitate operative case finding, onward referrals and long-term plan of treatment of osteoporosis. | Long-term management plan should be agreed with the patient and care team aiming at: -Reduction of the fracture risk -Reduction of the falls risk -Adjustment of any metabolic bone abnormality (serum calcium/ vitamin D) -Follow-up plan for monitoring of therapy -Long-term osteoporosis therapy management plan. | To include: *Patient centred care. *Reassess at 16-weeks and 52 weeks. *Monitoring of functional disability and HRQoL. *Monitoring of the response to the post-fracture rehabilitation program. *Monitoring of the sarcopenia measures. *Assessment of compliance to therapy. |
Information | Patient/carer education Medical Staff education | Informative data and care are offered to the patients, reviewed under the FLS. Support is also provided to carers whenever appropriate | Providing targeted information tailored to the patient’s needs. Patients who sustained a fragility fracture, their family/carers will be provided with leaflets to inform them of the following: -Bone health, -Muscle Health -Nutrition - Lifestyle measures - Osteoporosis therapy options. -self management: 1. Understanding of where to get more information; 2. Involvement in management plan; 3. Patient motivation -Group education -Falls and fragility fracture newsletters. | -Information package available in the patient’s preferred format: - Written/brochures - Electronic - YouTube channel of Bone Health. - Social media page -Website illustration of an evidence-based information resource [16]. |
Quality | Performance indicators | The FLS proves clinical liability, effective governance, service enhancement and professional progress | *Annual audit of the outcomes/adherence to therapy *Annual audit of the of the quality of FLS service delivery according to adherence to Standards 1–5 *maintenance of the FLS staff appropriate CPD (Continuing Professional Development). | To include the following: *Yearly audit against the FLS Clinical Standards. * The first year audit of the FLS will provide a baseline for future assessment of the performance against the 5 standards. *Review of relevant CPD undertaken by FLS staff and identification of training needs |