> Below is the English translation of an insightful article 'Las Unidades de Fractura se implantan a ritmo lento en España pese a demostrar su eficacia' by journalist Antonio Morente in El Medico Interactiveo. A summary of the article is also available on the SEIOMM website. 

Fracture Liaison Services are being implemented at a slow pace in Spain despite their proven effectiveness

The widespread implementation of this model in Spain would avoid more than 1,200 fractures due to fragility and would save 18.4 million euros per year.

Among the health professionals dedicated to fighting fragility fractures caused by osteoporosis, there is full agreement: Fracture Liaison Services (FLS) are the best and most cost-effective models and the most suitable for maintaining treatment. This is what the main guides with recommendations state, and it is also what the International Osteoporosis Foundation (IOF) calculations endorse, according to which extending this system in Spain to all those over 50 years of age would make it possible to avoid 1,249 fragility fractures per year, with a cost reduction of 18.4 million euros and a gain of 584 quality adjusted life years (QALY).

"The FLS are the future because they are a model of care management that aspires to excellence in the care of these patients," stresses Dr. Maria Jesus Moro Alvarez, of the Bone Metabolism Unit of the Hospital Infanta Leonor in Madrid, despite which "the pace of creation is still small. And why does this happen despite the strong data? Well, because its implementation is based on the initiatives of health professionals themselves, promoted by scientific societies, but which has not been promoted by the administrations", something that she attributes to the fact that "we are still in the phase of validity of this system so that it can be adopted as a management model".

Therefore, she explains that yes, the FLS are the future, but "if we manage to get a mentality for it on the part of the administrations, if it is not complicated" because all the responsibility for the work is discharged to the unit or case coordinators "and that requires a lot of effort". Like any operating structure, it needs logistics, and even the summons service itself must be systematized.

Believing in the model

Dr. Moro Alvarez, coordinator of the Spanish Registry of Fractures-FLS (REFRA-FLS) of the Spanish Society for Bone and Mineral Metabolism Research (SEIOMM), stresses that the slow speed at which Fracture Liaison Services are created "is a matter of believing in the model rather than economics. "They are cross-sectional health processes that include many professionals in specialized and primary medicine," a complex system that is "complicated to maintain sustainability over time.”

In addition, it "implies a significant change in culture", which means that "many people have to be convinced", starting with the health administrations, but also the patients themselves, "who are often unaware of the seriousness of these fractures, and give more importance to pathologies such as hypertension or diabetes. A feeling, he stresses, sometimes shared by the professionals themselves. So we must also "work on training and improving information on updating the effectiveness of treatments”.

Fracture Liaison Services "provide a model of efficiency in the sense that we are treating the patients who benefit most, which are those who have already had a fracture and, therefore, have a multiple risk of suffering another fracture". "The problem is that many abandon treatment, which in the end means a cost for which no benefit has been obtained", while with the FLS "we ensure that adherence to treatment is adequate and we also improve the safety of the drugs".

The patient at the centre

It is, stresses Dr. Moro Alvarez, "a model in which the patient is the centre and has a series of professionals accessible for everything you need," a coordinated and comprehensive system, as it "develops prevention plans and improves non-pharmacological measures, nutrition and health education. For this reason, he insists that "it is more a question of organization than of cost": in the medium and long-term more treatments can be indicated, "but savings are made on medicines and on fractures, and face-to-face consultations that are not necessary are avoided".

An FLS works as a "multidisciplinary circuit" in which the coordinator and the case manager are the references for the patient. In his opinion, it is not necessary for all the services to be in the same building because "we have the resources for communication", for that there are tools such as electronic history or videoconferencing, the real problem is that "outside the FLS the communication between levels is poor at present". In fact, "among the specialists themselves it is also improvable, it depends a lot on each hospital".

Integral Vision

The Fracture Liaison Service provides a "comprehensive view of the patient", a circuit that begins with the identification made by an orthopaedic surgeon after a fracture, but also involves experts in bone metabolism and rehabilitators to move to a final phase of monitoring that falls to Primary Care in coordination with the FLS itself. "The flow is facilitated," summarizes Dr. Moro Álvarez.

As far as the iimplementation of the FLS in Spain is concerned, there are still very few that can be considered fully complete and "that include attention to all types of fragile fractures, not only hip, but also vertebral, humerus, and wrist.” The rest are orthogeriatric services or bone metabolism units that have been evolving into a FLS, but which are still being developed.

Furthermore, FLS would help put an end to a situation like the current one, in which "follow-up of a patient after a first fracture is scarce," to the point that "only 25 percent of hip fractures are adequately treated and evaluated, and that is the fracture which is easiest to track." A lot of work is being done at the Fracture Liaison Services," he adds, but until now, "little was known about where standard indicators of functioning could be obtained. This has begun to change thanks to a study coordinated by Dr. Antonio Naranjo Hernandez that "proposes indicators of excellence or performance," which paves the way for the FLS to settle once and for all as the future of the fight against osteoporosis and brittle bone fractures.