How Does Fracture Liaison Service Improve Secondary Prevention, What Clinical Audits Show, and How Does This Compare With Standard Follow-Up? 🦴📋🏥

This article is written by mr.hotsia, a long term traveler and storyteller who runs a YouTube travel channel followed by over a million followers. Over the years he has crossed borders and backroads throughout Thailand, Laos, Vietnam, Cambodia, Myanmar, India and many other Asian countries, sleeping in small guesthouses, village homes and roadside inns. Along the way he has listened to real life health stories from locals, watched how people actually live day to day, and collected simple lifestyle ideas that may help support better wellbeing in practical, realistic ways.

In real life, a fragility fracture is often not the end of one problem. It is the beginning of the next one. A wrist fracture may be followed by a spine fracture. A spine fracture may be followed by a hip fracture. Many families think the first break was just bad luck, but osteoporosis care has learned something important over the years: after one fragility fracture, the next one often comes sooner than people expect. That is why secondary prevention matters so much.

This is exactly where a Fracture Liaison Service, often called FLS, comes in. An FLS is a coordinated post-fracture care system designed to find people over 50 who have had a fragility fracture, assess their bone health and falls risk, start appropriate treatment, and follow them long enough to make sure the plan is actually happening. It is not just a referral. It is a pathway. The 2025 NOGG guideline describes FLS as part of the model of care for fracture prevention, and the IOF Capture the Fracture framework presents coordinator-based FLS care as the preferred model for secondary prevention after fragility fracture.

The simplest answer is this: fracture liaison services improve secondary prevention by closing the dangerous gap between the first fragility fracture and the treatment that could help prevent the next one. Compared with standard follow-up, FLS models consistently improve case finding, bone assessment, treatment recommendation, treatment initiation, and follow-up monitoring. Systematic review evidence also suggests they reduce refracture risk over time, and some studies suggest lower mortality as well.

That may sound administrative, but it is actually very human. Standard follow-up after a fracture is often fragmented. The orthopaedic team fixes the immediate injury. The emergency department handles the acute event. The patient goes home. Somewhere in that handoff, the deeper question can get lost: why did this bone break so easily, and what should happen now to stop another fracture? In many ordinary systems, nobody fully owns that question. FLS exists because that gap kept swallowing patients.

The research comparing FLS with usual care gives a strong overall signal. A 2024 systematic review and meta-analysis found that the risk of a second fragility fracture was lower with FLS than with non-FLS care. At 1 year, pooled studies showed a relative risk of 0.26, and at 2 years or more, pooled studies showed a relative risk of 0.68. The authors rated the longer-term evidence as moderate certainty. In plain language, FLS was associated with fewer subsequent fractures than standard or non-FLS follow-up, especially when patients were observed long enough for the service to do its work.

That result fits the logic of the model. FLS does not magically harden bone overnight. It improves the chain of care. It identifies the patient, assesses risk, orders or recommends DXA when appropriate, addresses falls, starts anti-osteoporosis therapy in high-risk patients, and checks whether treatment was actually started and continued. Standard follow-up often misses one or more of those steps. FLS tries to make the chain less leaky.

Clinical audits show this very clearly. The 2025 FLS-DB annual report from England, Wales, and Northern Ireland included 77,268 patient records from 69 FLSs for 2023. Of those, 45,401 were recommended or referred for anti-osteoporosis treatment, and 15,599 were started on treatment within 16 weeks of fracture diagnosis. The report also states that FLS-DB now includes more than 500,000 patient episodes overall. This is not a tiny pilot world. It is a large real-world audit picture of how secondary prevention is being delivered and measured.

The same audit shows both the strength and the honesty of FLS. It improves care, but it also exposes how much work remains. In the 2025 report, 35.4% of patients had commenced anti-osteoporosis medication within 16 weeks, up from 30.9% the previous year. Monitoring contact within 12 to 16 weeks was 28.0%, and timely DXA within 90 days was 33% overall, with notable variation by setting and region. These are not perfect numbers. But that is exactly the point. FLS creates a system where these numbers are visible, auditable, and improvable. Standard follow-up often fails more quietly because the pathway is not being measured in one coordinated frame.

The 2024 FLS-DB annual report told a similar story. Among 65,844 patients from 69 FLSs with fragility fracture in 2022, 67% were assessed by the FLS within 90 days, 32% had DXA within 90 days, 46% had monitoring contact within 16 weeks, and 32% had commenced or continued anti-osteoporosis medication within 16 weeks. Again, these are not victory-lap numbers. They are service-improvement numbers. They show that FLS provides a structured route for assessment, medication recommendation, and monitoring, while also making it painfully obvious where the system still needs strengthening.

This is one of the most important differences between FLS and standard follow-up. Standard follow-up often means the patient is seen for the fracture but not systematically tracked for the osteoporosis beneath it. FLS means the fracture becomes a trigger for a coordinated secondary prevention program. The Royal Osteoporosis Society clinical standards spell this out clearly: high-risk patients should be offered appropriate osteoporosis drug treatment, willing patients should be offered treatment within 16 weeks of fracture diagnosis, high-risk fallers should be referred for falls prevention, and patients should be reviewed 4 to 8 weeks after recommendation and again at 52 weeks to confirm treatment has started and is being taken appropriately.

That follow-up element is crucial. Standard care often ends too early. A medication recommendation is not the same as medication initiation. A prescription is not the same as adherence. An FLS is designed to keep asking the annoying but life-saving questions: Was the DXA done? Was the medicine started? Was it tolerated? Was falls risk addressed? Is the person still taking treatment at 12 months? The whole architecture of FLS is built around not assuming that advice automatically becomes action.

When compared with standard follow-up, the biggest advantage of FLS is not one single test or one single drug. It is accountability. The system knows who should have been assessed and by when. It knows who should have been offered treatment and by when. It knows whether follow-up happened. Standard follow-up is often more passive. FLS is active and coordinator-led.

The older literature helps show how poor routine care can be without a dedicated service. Reviews of usual care pathways have reported that osteoporosis diagnosis after fragility fracture is often only around 5% to 30% without an FLS, while diagnosis rates can rise above 80% within organized FLS models. That enormous gap helps explain why guideline groups and international frameworks keep returning to FLS as the preferred secondary prevention model.

There is also evidence that FLS may improve outcomes beyond process measures. The 2021 review of FLS clinical impact found consistent improvements in investigation and treatment rates, and noted studies reporting reduced refracture and lower mortality, though not every study was methodologically clean and results were not perfectly uniform. In other words, the direction of travel is favorable, even if real-world service studies naturally carry some noise.

A 2023 study from a rural Asian setting reached a similar practical conclusion, reporting that FLS had been shown to improve quality of care and clinical outcomes including subsequent fractures and fracture-related mortality, while exploring its effectiveness in a resource-limited environment. That matters because it suggests FLS is not only a big-city academic idea. It can matter in ordinary hospitals too, where the consequences of a second fracture may be even harder for families to absorb.

So how does this compare with standard follow-up in plain language?

Standard follow-up usually treats the fracture episode. FLS treats the fracture as a warning signal.

Standard follow-up may leave bone health assessment to chance, to the GP, or to whether the patient asks the right question later. FLS embeds bone health assessment into the post-fracture pathway itself.

Standard follow-up may recommend treatment without checking whether it began. FLS is built to monitor whether treatment was initiated and continued.

Standard follow-up may miss falls prevention entirely. FLS standards specifically require referral of high-risk patients to falls prevention services and ongoing review.

That difference is why FLS is often described as a care-gap solution. The fracture itself becomes the passport into a structured service rather than a one-off orthopaedic event.

Clinical audits also reveal a subtle truth: FLS is not automatically excellent just because the label exists. Some services still struggle with timely DXA, early treatment initiation, or 52-week adherence monitoring. But even that is better than invisible failure. With audits like FLS-DB, services can see where they are weak and improve. Standard follow-up usually has no equivalent dashboard. It can underperform without anyone seeing the full pattern.

This is where the comparison becomes almost philosophical. Standard follow-up is often reactive and dispersed. FLS is proactive and coordinated. Standard follow-up can depend heavily on luck, patient advocacy, or individual clinician interest. FLS tries to make secondary prevention a routine responsibility of the system itself.

The most honest conclusion is not that FLS solves everything. It does not. The UK audit data show that many outcomes still remain lower than ideal, especially timely treatment initiation and follow-up completion. But compared with standard follow-up, FLS gives patients a much better chance of being found, assessed, treated, and tracked after a fragility fracture. And that is exactly what secondary prevention needs.

So the clean conclusion is this: fracture liaison services improve secondary prevention mainly by turning a missed opportunity into a managed pathway. Clinical audits show better case identification, better assessment, better medication initiation, and better monitoring than fragmented usual care, even though many services still have room to improve. Compared with standard follow-up, FLS is more systematic, more accountable, and more likely to reduce the chance that a first fragility fracture quietly becomes a second one.

10 FAQs About Fracture Liaison Service and Secondary Prevention

1. What is a fracture liaison service?
It is a coordinator-led post-fracture program that identifies people with fragility fractures, assesses bone health and falls risk, starts appropriate treatment, and follows patients to improve secondary prevention.

2. Does FLS really reduce refracture risk?
Yes, the best recent meta-analysis found lower risk of subsequent fragility fracture with FLS than non-FLS care, especially over 2 years or more.

3. How is FLS different from standard follow-up?
Standard follow-up often treats the fracture only. FLS adds systematic bone assessment, falls review, treatment initiation, and monitored follow-up.

4. What do clinical audits show?
Large national audits such as FLS-DB show that FLS can deliver measurable assessment, DXA, treatment, and follow-up pathways, while also identifying gaps that need improvement.

5. How many patients are covered in the UK audits?
The 2025 FLS-DB annual report included 77,268 patient records from 69 FLSs for 2023, and the database has collected over 500,000 patient episodes since it began.

6. Does FLS guarantee fast treatment for everyone?
No. Audit data show improvement, but timely treatment initiation is still below ideal in many services. That is why ongoing audit matters.

7. Does FLS also address falls?
Yes. Clinical standards state that people at high risk of falling should be referred to falls prevention services within 16 weeks of fracture.

8. Is FLS mainly about DXA scans?
No. DXA is one part of the pathway, but FLS is broader: assessment, medication decisions, falls prevention, follow-up, and adherence review all matter.

9. Can FLS improve mortality too?
Some studies suggest lower mortality with FLS, but this evidence is less uniform than the process and refracture findings.

10. What is the simplest takeaway?
Standard follow-up may fix the first fracture. FLS is designed to stop the next one.

I’m Mr.Hotsia, sharing 30 years of travel experiences with readers worldwide. This review is based on my personal journey and what I’ve learned along the way. Learn more