Primary care follow-up of patients after attending a fracture liaison service: an integrative review

Abstract

Summary

Based on a small number of predominantly low-to-moderate quality studies with moderate-to-high risk of bias, the FLS-to-primary care transition is portrayed as a challenging time for patients, GPs, and FLS clinicians, who experience numerous barriers to care continuation and coordination at this care juncture.

Purpose

Continuity and coordination of care between fracture liaison services (FLS) and primary care is required for optimal long-term osteoporosis care. This study aims to explore (1) how patients and healthcare providers (HCPs) experience the FLS to primary care transition, (2) the barriers and facilitators to primary care follow-up after FLS, and (3) interventions that enhance integration of FLS with primary care.

Methods

An integrative review was performed and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) Statement 2020. Online bibliographic databases were searched using the terms “osteoporosis”, “primary care”, and “fracture liaison services” and related terms for original English-language studies conducted between January 1, 2003 and December 29, 2023. Manuscripts were assessed for relevance using pre-defined criteria, and for quality and bias using validated instruments. Thematic analysis was used to extract key themes relevant to each research question.

Results

Overall, 14 relevant manuscripts were identified. Among the four studies that addressed patient and HCP experience of the FLS-to-primary care transition, five key themes emerged: (1) time and workload pressures, (2) limited confidence in primary care follow-up, (3) GP knowledge gaps, (4) siloed or disconnected care, and (5) communication issues. Twelve studies addressed barriers and facilitators to primary care follow-up after FLS, which fell into five themes: (1) patient knowledge and understanding (2) miscommunication and misinformation, (3) understanding roles and responsibilities, (4) GP engagement, and (5) GP-patient relationship. Additionally, single studies suggested healthcare policies and funding, accessing primary care from residential facilities, and GP gender influenced primary care follow-up. Five studies detailed interventions to enhance FLS-to-primary care integration. GP education and patient reminders, delivered as part of a multifaceted intervention, appeared to improve integration of acute and primary post-fracture care; however, the contribution of these individual interventions to outcomes remains unclear. While telephone coaching and bone marker monitoring were identified as potential interventions, there was insufficient evidence to conclude they are effective.

Conclusion

Available evidence was generally low-to-moderate quality with moderate-to-high risk of bias. Integration of the available evidence portrays the FLS-to-primary care transition as a challenging time for patients, GPs, and FLS clinicians, who experience a multitude of barriers to care continuation and coordination. There is insufficient data to support any single intervention as effective for enhancing care coordination beyond those considered standard components of FLS models. Knowledge gaps exist regarding the patient experience of the FLS-to-primary care transition, facilitators to primary care follow-up, interventions to support FLS integration with primary care, and how such information may be integrated to optimise care for patients with osteoporosis.