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

Summary

In a nationwide, register-supported stepped-wedge cluster randomized trial including 100,198 fracture patients, implementation of an FLS program reduced subsequent fragility fractures (HR 0.87 in women; 0.90 in men) and all-cause mortality (HR 0.82 in women; 0.85 in men) over up to 4.7 years. These findings support FLS as an effective secondary prevention strategy.

Key Findings

• FLS reduced subsequent fragility fracture risk by 13% in women (HR 0.87, 95% CI 0.83–0.92) and 10% in men (HR 0.90, 95% CI 0.81–0.99).
• FLS reduced all-cause mortality by 18% in women (HR 0.82, 95% CI 0.79–0.86) and 15% in men (HR 0.85, 95% CI 0.81–0.89).
• Stepped-wedge cluster implementation across three clusters over 2015–2018 enabled pragmatic evaluation within routine care using national registry data.

Clinical Implications

Health systems should implement standardized FLS pathways for patients ≥50 years after low-energy fractures to reduce secondary fractures and mortality, integrating osteoporosis assessment and treatment with registry tracking.

Limitations

• Potential residual confounding and misclassification inherent to registry data
• Stepped-wedge design susceptible to temporal trends despite adjustment

Future Directions

Assess cost-effectiveness, implementation fidelity, and equity of FLS at scale; evaluate optimization of pharmacotherapy (e.g., denosumab vs bisphosphonates) within FLS pathways.