Fracture liaison service (FLS) is associated with lower subsequent fragility fracture risk and mortality: NoFRACT (the Norwegian capture the fracture initiative)

Camilla Andreasen^{1

2}, Cecilie Dahl³, Frede Frihagen^{4

5}, Tove T Borgen⁶, Trude Basso⁷, Jan-Erik Gjertsen^{8

9}, Wender Figved^{5

10}, Torbjørn Wisløff^{5

11}, Gunhild Hagen¹², Ellen M Apalset^{13

14}, Jens M Stutzer¹⁵, Ida Lund¹⁶, Ann K Hansen^{1

2}, Frida I Nissen^{1

2

17}, Ragnar M Joakimsen^{2

18}, Unni Syversen^{19

20}, Erik F Eriksen^{21

22}, Lars Nordsletten^{5

16}, Tone K Omsland³, Åshild Bjørnerem^{2

17

23}, Lene Bergendal Solberg²⁴

Affiliations

¹ Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway.
² Department of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway.
³ Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway.
⁴ Department of Orthopedic Surgery, Østfold Hospital Trust, Grålum, Norway.
⁵ Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
⁶ Department of Rheumatology, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway.
⁷ Department of Orthopedic Surgery, St. Olavs University Hospital, Trondheim, Norway.
⁸ Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.
⁹ Department of Clinical Medicine, University of Bergen, Bergen, Norway.
¹⁰ Department of Orthopedic Surgery, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway.
¹¹ Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.
¹² Department of Health Services, Norwegian Institute of Public Health, Oslo, Norway.
¹³ Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease, Department of Rheumatology, Haukeland University Hospital, Bergen, Norway.
¹⁴ Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
¹⁵ Department of Orthopedic Surgery, Møre and Romsdal Hospital Trust, Hospital of Molde, Molde, Norway.
¹⁶ Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway.
¹⁷ Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.
¹⁸ Department of Medicine, University Hospital of North Norway, Tromsø, Norway.
¹⁹ Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
²⁰ Department of Endocrinology, St. Olavs University Hospital, Trondheim, Norway.
²¹ Spesialistsenteret Pilestredet Park, Oslo, Norway.
²² Faculty of Dentistry, University of Oslo, Oslo, Norway.
²³ Norwegian Research Centre for Women's Health, Oslo University Hospital, Oslo, Norway.
²⁴ Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway. lenser@ous-hf.no.

PMID: 39808195
PMCID: PMC11882684
DOI: 10.1007/s00198-024-07376-y

Multicenter Study

Fracture liaison service (FLS) is associated with lower subsequent fragility fracture risk and mortality: NoFRACT (the Norwegian capture the fracture initiative)

Camilla Andreasen et al. Osteoporos Int. 2025 Mar.

. 2025 Mar;36(3):501-512.

doi: 10.1007/s00198-024-07376-y. Epub 2025 Jan 14.

Authors

Affiliations

¹ Department of Orthopedic Surgery, University Hospital of North Norway, Tromsø, Norway.
² Department of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway.
³ Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway.
⁴ Department of Orthopedic Surgery, Østfold Hospital Trust, Grålum, Norway.
⁵ Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
⁶ Department of Rheumatology, Vestre Viken Hospital Trust, Drammen Hospital, Drammen, Norway.
⁷ Department of Orthopedic Surgery, St. Olavs University Hospital, Trondheim, Norway.
⁸ Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.
⁹ Department of Clinical Medicine, University of Bergen, Bergen, Norway.
¹⁰ Department of Orthopedic Surgery, Vestre Viken Hospital Trust, Bærum Hospital, Gjettum, Norway.
¹¹ Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.
¹² Department of Health Services, Norwegian Institute of Public Health, Oslo, Norway.
¹³ Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease, Department of Rheumatology, Haukeland University Hospital, Bergen, Norway.
¹⁴ Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
¹⁵ Department of Orthopedic Surgery, Møre and Romsdal Hospital Trust, Hospital of Molde, Molde, Norway.
¹⁶ Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway.
¹⁷ Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.
¹⁸ Department of Medicine, University Hospital of North Norway, Tromsø, Norway.
¹⁹ Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
²⁰ Department of Endocrinology, St. Olavs University Hospital, Trondheim, Norway.
²¹ Spesialistsenteret Pilestredet Park, Oslo, Norway.
²² Faculty of Dentistry, University of Oslo, Oslo, Norway.
²³ Norwegian Research Centre for Women's Health, Oslo University Hospital, Oslo, Norway.
²⁴ Division of Orthopedic Surgery, Oslo University Hospital, Oslo, Norway. lenser@ous-hf.no.

PMID: 39808195
PMCID: PMC11882684
DOI: 10.1007/s00198-024-07376-y

Abstract

Subsequent fracture rates and associated mortality were compared before and after the introduction of fracture liaison service (FLS). In 100,198 women and men, FLS was associated with 13% and 10% lower risk of subsequent fragility fractures and 18% and 15% lower mortality. The study suggests that FLS may prevent fractures.

Purpose: Efficient fracture prevention strategies are warranted to control the global fracture burden. We investigated the effect of a standardized fracture liaison service (FLS) intervention on subsequent fracture risk and mortality.

Methods: The NoFRACT study was designed as a multicenter, pragmatic, register-supported, stepped-wedge cluster-randomized trial. The FLS intervention was introduced in three clusters with 4-month intervals starting May 2015 through December 2018 and included evaluation of osteoporosis and treatment in patients over 50 years with a low-energy fracture. Based on data from the Norwegian Patient Registry, patients with index fractures were assigned to the control period (2011-2015) or intervention period (2015-2018) depending on the time of fracture. Rates of subsequent fragility fractures (distal forearm, proximal humerus, or hip) and all-cause mortality were calculated.

Results: A total of 100,198 patients (mean age 69.6 years) suffered an index fracture of any type. During a maximum follow-up of 4.7 years, 11% (6948) of the women and 6% (2014) of the men experienced a subsequent fragility fracture, and 20% (14,324) of the women and 22% (8,326) of the men died. FLS was associated with 13% lower subsequent fragility fracture risk in women (hazard ratio (HR) 0.87, 95% confidence intervals (CI) 0.83-0.92) and 10% in men (HR 0.90, 95% CI 0.81-0.99) and 18% lower mortality in women (HR 0.82, 95% CI 0.79-0.86) and 15% in men (HR 0.85, 95% CI 0.81-0.89).

Conclusion: A standardized FLS intervention was associated with a lower risk of subsequent fragility fractures and mortality and may contribute to reduce the global fracture burden.

Keywords: fracture liaison service; fragility fractures; osteoporosis; post-fracture mortality; secondary fracture prevention; stepped-wedge cluster-randomized trial.

PubMed Disclaimer

Conflict of interest statement

Declarations. Ethical approval: All procedures performed in the study were in accordance with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Regional Committee of Medical and Health Research Ethics (REK 2015/334). The merging of data using the personal identification number and exemption from obtaining consent for the collection of data was approved by the Regional Committee of Medical and Health Research Ethics (REK 2015/334). A Data Protection Impact Assessment (DPIA) in agreement with the General Data Protection Regulation was performed by The University of Oslo. The study was approved by the Patient Data Protection Officer (PVO) at each of the hospitals and the PVO provided exemption from obtaining consent from the participants and authorized a secure research server for storage of the audit data. Conflict of interest: CA, CD, TB, TW, GH, JMS, IL, AKH, FIN, LN, TKO, and ÅB no support from any organization for the submitted work; FF reports lecturing fees from UCB and Amgen; TTB reports speaker fees from UCB, Amgen, Roche Diagnostics, and Pharma Prim and participation in an advisory board for UCB. Further, FF is president of the Fragility Fracture Network which is sponsored by Amgen, UCB, and Danone; JEG reports lecture fees from Ortomedic Norway, Smith and Nephew, Heraeus Medical, and LINK Norway; WF reports lecture fees from Ortomedic Norway and Zimmer Biomet Norway; EMA reports participation in the advisory board for UCB and Amgen; RMJ reports consulting fees from Norwegian Directorate of Health, Norwegian Diabetes Association, and Northern Norway Regional Health Authority and lecture fees from Novo Nordisk, Eli-Lilly, Astra-Zeneca, and Sanofi; US reports speaker and consulting fees from Amgen, UCB, and Novartis; EFE reports consultant fees from Novartis, UCB, Amgen, Takeda, and Pharma Medico and research support from Takeda and Amgen. Further, EFE has worked as a medical consultant for the Norwegian Osteoporosis Society; LBS reports speaker fees from Eli Lilly, Amgen, and UCB. Further, LBS is the president of Fragility Fracture Network Norway.

Figures

**Fig. 1**
Study design of the NoFRACT intervention as recommended by the Consolidated Standards of Reporting Trials (CONSORT) extension for stepped-wedged cluster randomized trials (SW-CRTs)

**Fig. 2**
Flowchart of patients with an index fracture treated at a NoFRACT hospital in 2011–2018. *4059 patients were included in both the intervention and the control period

See this image and copyright information in PMC

References

1. Wu A-M, Bisignano C, James SL, Abady GG, Abedi A, Abu-Gharbieh E et al (2021) Global, regional, and national burden of bone fractures in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Healthy Longev 2(9):e580–e592 - PMC - PubMed
1. Sambrook P, Cooper C (2006) Osteoporosis. Lancet 367(9527):2010–2018 - PubMed
1. Svedbom A, Borgstöm F, Hernlund E, Ström O, Alekna V, Bianchi ML et al (2018) Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS. Osteoporos Int 29(3):557–566 - PubMed
1. Alarkawi D, Bliuc D, Tran T, Ahmed LA, Emaus N, Bjornerem A et al (2020) Impact of osteoporotic fracture type and subsequent fracture on mortality: the Tromso Study. Osteoporos Int 31(1):119–130 - PubMed
1. Kanis JA, Johansson H, Oden A, Harvey NC, Gudnason V, Sanders KM et al (2018) Characteristics of recurrent fractures. Osteoporos Int 29(8):1747–1757 - PMC - PubMed

Publication types

Actions
Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Fracture liaison service (FLS) is associated with lower subsequent fragility fracture risk and mortality: NoFRACT (the Norwegian capture the fracture initiative)

Affiliations

Fracture liaison service (FLS) is associated with lower subsequent fragility fracture risk and mortality: NoFRACT (the Norwegian capture the fracture initiative)

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Substances

Grants and funding

LinkOut - more resources

Full Text Sources

Medical