Capture

Figure 2 displays the flow of patients captured in our FLS. Over the 2 years, 2363 patients sustaining a fracture of the hip, pelvis, spine, forearm, or shoulder were identified and their records reviewed by the coordinators. First, a total of 484 patients (21%) were excluded due to the trauma mechanism or because they were residing outside the hospital district. Following, further 630 patients were triaged and found ineligible due to e.g. terminal illness or severe co-morbidity, making osteoporosis investigation irrelevant or difficult through an FLS setup. Other reasons included a prior diagnosis of osteoporosis with ongoing appropriate treatment, referral for DXA by the primary care physician, or having undergone a DXA within the past 2 years with T-scores greater than − 2.0 (see Table 1 for a more detailed description of these patients).

Fig. 2

Flow diagram of the 2363 patients captured by the Fracture LiaisonService program at Aarhus University Hospital. Patients highlighted in red and yellow boxes weretriaged and not found eligible for further bone health assessment. Those with a priordiagnosis of osteoporosis were either invited for treatment optimization orscheduled for a new DXA scan as the initial step. For patients without a known history ofosteoporosis, the first step is a DXA scan. After excluding patients who declined, did not respond, orfailed to attend, a total of 890 DXA scans were performed over the 2-year period

Tabel 1 Patients evaluated by the FLS team and not eligible for DXA or further osteoporosis evaluation in the FLS Setting, n (%)

Of the remaining 1267 consecutive patients with a fragility fracture eligible for the FLS program 935 (74%) accepted an invitation to a DXA. A total of 269 patients (21%) declined or did not respond to the invitation. Based on a DXA within the last 2 years showing osteoporosis, 32 (of 37) patients accepted an invitation for treatment optimization in the outpatient unit. The median time from the index fracture to their first contact with FLS was 26 days (IQR 20;36). From the telephone consultation to a DXA, the median time was 32 days (IQR 32;47). By April 30, 2024, 70% of eligible patients had had a DXA performed.

Baseline Characteristics

During the 2 years, 890 patients with a new fragility fracture had a DXA performed as part of the FLS program. Patients who did not attend (n = 45) were excluded. A total of 16% had normal BMD (n = 144) and 53% had osteopenia (n = 473).

Baseline characteristics of patients with osteoporosis (the newly diagnosed patients, patients with DXA > 2 years ago, and patients invited for treatment optimization) are shown in Table 2. T-scores presented in Table 2 only accounts for the patients, who had a DXA performed (n = 273).

Table 2 Characteristics of all patients with osteoporosis

The majority of the patients with osteoporosis were women (87%) with a mean age of 70 years (SD 9.18). The most common fracture location was the distal forearm (59%), followed by proximal humerus (25%) and fractures of the vertebrae (7%). Forty-six patients with a non-vertebral fracture were found to have a vertebral fracture identified on the VFA, defined as a vertebral body height loss of > 20%. Ten of these patients had T-scores above − 2.5.

Of the 890 patients attending a DXA, 198 were diagnosed with osteoporosis after participating in the FLS program (Table 3). This includes patients with T-scores in the osteopenic range but who suffered a fragility fracture of the hip or spine. 473 patients had osteopenia without vertebral or hip fracture. According to Danish guidelines these patients are not offered treatment unless they are treated chronically with glucocorticoids.

Table 3 Characteristics of patients diagnosed with osteoporosis in FLSa

The majority were women (n = 165, 83%), and the mean age was 69 years (SD 9.16). A fracture of the distal radius was the most common type. By the 30th of September 2024, treatment was prescribed for the majority of the newly diagnosed patients (n = 171, 85%). The median time from the DXA to treatment initiation was 57 days (IQR 35;97).

One hundred sixty-five patients (13%) declined the service, providing the primary reasons for declining as (i) lack of interest in the program and (ii) inability to attend due to physical limitations. Compared to FLS attenders, these patients were older (77 years versus 70 years, p < 0.001) and more frequently men (21% vs. 13%, p = 0.032). The number of individuals with previous fragility fractures was balanced between the two groups (15% decliners versus 16% attenders). According to the medical records, 44 of the patients declining the service had been diagnosed with osteoporosis before FLS capture. A large percentage of these patients with osteoporosis did not receive treatment at the time of their index fracture (43%).

Treatment at the Endocrinological Outpatient UnitPatients with Previously Unrecognized Osteoporosis

Figure. 3 shows treatment flow of patients with osteoporosis. Eighty-one newly diagnosed patients were directly referred to the outpatient clinic. In 61 cases, bone anabolic treatment with romosozumab or teriparatide was initiated (Fig. 3A). For the remaining patients (n = 17), an antiresorptive drug was opted for. Five patients preferred alendronate due to personal reasons, such as fear of adverse events. The treating endocrinologist opted for bisphosphonates due to the patient’s cardiovascular risk factors or history of stroke or acute myocardial infarction in six cases. Three patients declined any treatment.

Fig. 3

Treatment initiation status for 305 patients, categorized by site ofinitiation—either the Endocrinology Outpatient Clinic (A) or the patient’sprimary care physician (B)—and by whether the patient had a priordiagnosis of osteoporosis before attending the FLS program. Three patients werereferred to the outpatient unit by their PCP

Screening for secondary causes of osteoporosis prompted a referral to further diagnostic investigation for primary hyperparathyroidism or hematological disease in four patients. In the meantime, these patients were treated with an infusion of zoledronate.

Captured Patients with Prior Osteoporosis Diagnosis

A total of 55 patients diagnosed with osteoporosis before their index fracture were referred to the outpatient clinic. The patients were either referred by their PCP (n = 3) or the osteoporosis specialist (n = 52), who had reviewed the patient’s DXA (Fig. 3A).

From the initial 55 referred patients, 33 (61%) were prescribed romosozumab or teriparatide and 17 (30%) antiresorptives. Two patients preferred bisphosphonates due to personal reasons, such as fear of adverse events. In the remaining cases (n = 15), the treating endocrinologist opted for bisphosphonates due to the patient’s cardiovascular risk factors or history of stroke or acute myocardial infarction. Five patients declined treatment initiation.

Management of Patients in the Primary Care SettingPatients with Previously Unrecognized Osteoporosis

One hundred and seventeen patients were initially referred to the PCP for treatment initiation (Fig. 3B). In 49 cases, the PCP was advised to consider the patient’s eligibility for anabolic treatment and make a referral to the outpatient unit if the criteria were fulfilled and the patient was interested. Only three were referred back to the endocrinological outpatient clinic. The remaining non-referred newly diagnosed patients were started on an oral bisphosphonate or denosumab. Treatment was not initiated in 26 (23%) patients by September 30, 2024. Screening for secondary causes of osteoporosis was performed in 80% of patients before treatment started (blood samples within three months).

Fifty-two patients were already diagnosed with osteoporosis before being captured by the FLS service. The majority of these patients continued or had an oral bisphosphonate prescribed by their PCP. Eight patients did not receive any osteoporosis treatment either before or after their participation in the FLS program.