Fracture Liaison Service

Tackling the ‘Silent Threat’ and building stronger communities through public-private partnerships in Thailand

Chairoj Uerpairojkit

Chairoj Uerpairojkit

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Dr. Chairoj Uerpairojkit is the Director of the Institute of Orthopaedics and Deputy Medical Director of the Lerdsin Hospital, Department of Medical Services, under Thailand’s Ministry of Public Health. He is also President of The Thai Society for Surgery of the Hand and an internationally published researcher

Osteoporosis and fragility fractures are major causes of long-term morbidity and mortality, exerting a huge strain on healthcare systems and economies as societies age. Integrated, multi-sectoral partnerships in the form of fracture liaison services can help ensure patients receive holistic care and close off gaps in care.

The world’s population of people aged 65 and over is growing faster than all other age groups, with complex and wide-ranging implications. Addressing the needs of the elderly population while ensuring a productive society and strong economy is an ever more universal socioeconomic goal, with ramifications across the public and private sectors and impacts on people’s daily lives.

The “silver tsunami” is particularly evident in Thailand, one of the world’s most rapidly ageing countries, which also has an alarmingly low birth rate. In 2022, Thailand was the only Asian country to report a negative birth rate, where the number of births is lower than the number of deaths.

As Thailand’s population gets older, the prevalence of diseases associated with ageing is expected to increase, including osteoporosis. Urbanisation and sedentary lifestyles have also contributed to a significant rise in osteoporosis and related fractures. With people aged over 50 projected to account for 45 per cent of Thailand’s population by 2030, osteoporosis has been at the forefront of the national health priority since 2018.

Fragile bones lead to fragile communities

Osteoporosis is a common condition and a major cause of long-term morbidity. By 2050, more than 50 per cent of the world’s hip fractures are expected to occur in Asia-Pacific and more than 80,000 fractures will happen per year in Thailand by 2035. Hip fractures are considered the most serious type of fracture, as they can lead to a host of serious, life-altering and even life-threatening issues in elderly patients. Of all osteoporosis patients who have experienced at least one fracture, 10 per cent will suffer hip fractures, a quarter of which will be fatal.

Osteoporosis and fragility fractures threaten a significant strain on healthcare systems and economies. In the United States, fractures cause more hospitalisations than heart attacks, strokes and breast cancer combined. In the Thai context, a 2017 systematic review considering indirect and intangible costs suggested that the economic burden of hip fractures exceeds one-third of GDP per capita.

Integrated, multi-sectoral collaboration is critical

To reduce the burden of osteoporosis on healthcare systems and patients, Thailand needs to respond to the rising numbers of fractures and osteoporosis due to ageing. Research shows that tackling bone health through an integrated electronic health network overseen by a coordinator and using a dedicated database to identify, assess, and treat patients is more effective in preventing secondary fractures than an approach involving alerts to patients and/or education only.

This is where the fracture liaison service (FLS) comes in. FLS is a multidisciplinary approach which integrates different elements of osteoporosis diagnosis and management for patients who have experienced a likely fragility fracture. It reduces the risk of secondary fracture risks by giving the patient a comprehensive bone assessment when they are admitted with a bone break and providing timely access to treatment.

This clinical approach involves a multitude of healthcare workers, including orthopaedic surgeons, nurses, internists, geriatricians, and physiotherapists, to ensure optimal care and provide secondary prevention support. In addition to a patient’s in-hospital journey, the FLS approach also addresses the pre and post-fracture stages, assessing the causes of fractures as well as the patient’s risk of secondary fracture, and prescribing treatment plans accordingly.

It has been shown that FLS is an effective, holistic treatment approach that delivers meaningful impacts to patient’s lives. Not only does it help patients recover from their injuries, it also reduces the risk of future fractures, improves quality of life and reduces costs associated with further fractures. FLS also ensures that both the patient and their caregivers have the knowledge and equipment to continue care and fracture prevention at home.

A spotlight on fracture liaison services in Thailand

Engaging with a wide range of stakeholders in the healthcare industry can ensure patients receive holistic care and close off gaps in care. This transformation of osteoporosis prevention and care through multistakeholder support involves high-level policy support and financing.

In 2017, health officials in Thailand recognised the need to take action to address the burden of osteoporosis, and in 2018 they included refracture prevention and osteoporosis treatment as national health goals. The use of refracture prevention protocols and establishment of FLS in the country was promoted.

To facilitate collaboration, partnerships between stakeholders in the health ecosystem (government, health professionals, patient groups and NGOs) were established to ensure related policies and initiatives were supportive and aligned. This includes a Memorandum of Understanding between Thailand’s Ministry of Public Health and Lerdsin Hospital, a centre of excellence for orthopaedics and leading teaching hospital in Thailand, together with Amgen Thailand, a global leader in bone health, to launch a nationwide Refracture Prevention Programme. The Refracture Prevention Programme aims to reduce the burden of fractures by transforming Thailand’s treatment approach and upskilling healthcare workers through the FLS, improving infrastructure to support their work while also increasing public awareness.

A centralised patient registry was also established to improve cross-district communication and data sharing, and to optimise treatment delivery. In 2018, the Thai Fracture Liaison Service Nurses Society was established to facilitate learning and communication between FLS nurses, who play a critical role as the programme managers of FLS programmes.

A host of national and district-wide educational meetings and workshops was also organised, including the recent FLS Forum & Workshop 2023 held in Bangkok. The FLS Forum aimed to bolster the existing FLS system and workforce, and drive FLS expansion into primary and secondary prevention to reduce the economic burden of fractures and strengthen refracture prevention in Thailand.

Proven success of fracture liaison services

FLS programmes have been shown to improve outcomes of osteoporosisrelated fractures, with significant reductions in refracture incidence and mortality. In Thailand, the successful rollout of FLS across the nation has dramatically reduced refracture rates, and FLS has also become a national policy and will continue well beyond the initial three-year partnership. This success is a testament to the key role of publicprivate  partnerships in supporting the world’s increasingly complex healthcare needs as our populations grow older.

The effectiveness of the programme in Thailand has also enabled FLS programmes to be expanded to over 121 FLS teams in 13 healthcare districts across Thailand, with 15 hospitals now accredited by the International Osteoporosis Foundation.

FLS programmes have also proven to be a cost-effective way to reduce the economic burden on healthcare systems. National figures show that a hip fracture costs approximately THB 85,000 (USD $2,500) to treat. However, statistics have shown that FLS’s fasttrack approach yields cost savings of around THB 20,000 (USD $600) per case. The standard of care has also been raised, with greater knowledge sharing and collaboration among healthcare workers and care providers. Patients also experience a shortened wait for treatment or surgery, thus enhancing their quality of life and alleviating the financial burden of osteoporosis.

Tackling the future challenges of osteoporosis

FLS programmes are a prime example of how adopting a preventative healthcare model and multi-sectoral collaboration can lead to significant improvements to healthcare and socioeconomic outcomes. This comes as healthcare systems start to recognise the shift from the traditional reactive acute care (“break and fix” model) to proactive and preventive care (“predict and prevent” model). The support of Thailand’s policymakers in aligning stakeholders, prioritising osteoporosis among different stakeholders, and harnessing help from private sector partners has resulted in FLS’ nationwide implementation and adoption.

Looking ahead, the integration of more FLS programmes worldwide has led to the widespread development and adoption of FLS standards. This may help healthcare providers to benchmark performance over time and is a positive step toward standardising processes and outcomes. Thailand is well-placed to play a role in this benchmarking process, with FLSs in multiple hospitals receiving at least a Bronze rating in FLS best practices, a result that puts it ahead of other countries in the region.

FLS programmes are highly effective, having been shown to benefit patient outcomes, reduce subsequent fragility fractures and increase patients’ quality of life, whilst at the same time reducing the economic burden on healthcare systems. As countries look to implement and scale up FLS programmes in their countries, they can take onboard Thailand’s experience and efforts in ensuring that osteoporosis patients and caregivers receive the care and social support they need to achieve optimum health outcomes.

--Issue 62--