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Journal of Bone Metabolism logoLink to Journal of Bone Metabolism
. 2020 Aug 31;27(3):187–199. doi: 10.11005/jbm.2020.27.3.187

What is the Role of Coordinators in the Secondary Fracture Prevention Program?

Yong Han Cha 1,*, Yong-Chan Ha 2,*, Ki-Soo Park 3, Jun-Il Yoo 4,✉
PMCID: PMC7571241  PMID: 32911583

Abstract

Background

The purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.

Methods

A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ’secondary prevention’. Finally, 65 studies are included in this study.

Results

At the coordinator-based fracture liaison service (FLS) center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.

Conclusions

The coordinator in the FLS program plays an important role in the multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

Keywords: Nurses, Osteoporotic fractures, Secondary prevention

INTRODUCTION

Secondary fracture preventions (fracture liaison service [FLS]) including anti-osteoporotic medication and patient education are important for fragility fractured patients because of the high rates of re-fracture after the first fracture [1]. Among fragility fractures including spine, hip, wrist, and proximal humerus, hip fractures are notorious to high mortality, morbidity, and a socioeconomic burden in an aging society. According to recent studies, numbers of fragility fractures are expected to increase trends in the future [2,3]. Secondary fracture prevention programs can be configured in a variety of forms depending on the country's medical system and hospital capacity, and are currently operating in 35 countries around the world [4]. Reported secondary fracture prevention programs can be divided into two main categories. The first is to report the clinical outcomes such as changes in the rate of evaluation and management of osteoporosis or changes in the re-fracture rate after the second fracture prevention program [3,5-7]. The second is proven the economic effect of the second fracture prevention program [8]. Those programs have the same purpose of operation but vary in the way they operate and their members.

Although the management of the secondary fracture prevention program is performed in various ways, the coordinator is important for multidisciplinary management [2]. The role of the coordinator is considering assessment of the past medical history of patients, arrangement of the necessary examinations for osteoporosis, engagement in communication with the primary physician after discharge, and communication among the medical staff in the hospital. They can also help patients to understand the need for osteoporosis evaluation and anti-osteoporotic medication use and to maintain the continuity of patient care. However, there are only a few reports of what role coordinators perform in these secondary fracture prevention programs, and there is no globally recognized training program for them. The hypothesis of this study is that the role and assignment of the coordinator will vary among FLS studies.

Therefore, the purpose of this study is to search for reports on the clinical effectiveness of FLS being implemented worldwide through the systematic review, analyze the roles of coordinators in each study, and provide basic data for the development of future coordinator education programs.

METHODS

A systematic search of the literature using the Medline, PubMed, and EMBASE databases and the Cochrane Library was conducted for publications (January 2000–October 2019 inclusive) using the following keywords: ‘osteoporosis’ AND ‘fractures’ AND ‘secondary prevention’. The detailed search method is shown in the Supplementary Appendix 1. Relevant papers have also been searched for other local repositories, blogs, and gray literature outlets. The systematic reviews adhere to the Cochrane Collaboration approach.

Inclusion criteria for the trials were: performed in patients ≥50 years of age with all forms of osteoporosis-related fractures; randomized or non-randomized stage 1 to 4 studies; retrospective or prospective observational studies. Excluded are research relating to the prevention of primary fractures or other bone-associated diseases, forms of narrative analyses, systematic reviews, meta-analysis, opinion articles, editorials, case reports, letters, and publications in languages other than English. Two independent reviewers selected the studies by first screening the title and abstract followed by full-text articles. The discrepancy between the 2 reviewers was resolved by consensus or by a third independent reviewer, if necessary. Data analysis used the parameters Population, Procedure, Contrast, Outcomes, Environment (PICOS) and included general information about the article (e.g., authors, publication year), study characteristics (e.g., design, sample size), patient characteristics (e.g., fracture type, osteoporosis duration), and outcomes (bone mineral density testing, treatment initiation, adherence, persistence, rates of re-fracture, and mortality).

Data synthesis and findings were reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Quality assessments of eligible study methodologies were conducted using the Newcastle – Ottawa scale for non-randomized studies. These 2 authors independently assessed the quality of all studies.

RESULTS

1. Searched Studies of FLS in Various Countries

The initial search identified 755 references from the selected databases. The 681 references were excluded by screening the abstracts and titles for duplicates, unrelated articles, case reports, systematic reviews, and non-comparative studies. The remaining 74 studies underwent full-text reviews, and subsequently, nine studies were excluded. Finally, 65 studies are included in this study. The details of the identification of relevant studies are shown in the flow chart of the study selection process (Fig. 1). Seventeen randomized controlled studies, 26 comparative studies, and 22 cohort observation studies were selected for further investigation [1-3,5-7,9-66]. The main characteristics and outcomes of the studies included in this systematic review are presented in Table 1.

Fig. 1.

Fig. 1.

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Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram details the process of relevant clinical study selection.

Table 1.

Demographic data of included studies

Reference Year Country Study design Age limitation Included fracture
 Number of patients
Hip Vertebra Wrist Humerus Others
Chevalley et al. [49] 2002 Switzerland Cohort observational study No age limit Yes Yes Yes Yes Low trauma fracture 385
Hawker et al. [33] 2003 Canada Comparative study >40 Yes Yes Yes Yes Ankle 278
Jachna et al. [20] 2003 USA Comparative study - Yes No No No No 82
Majumdar et al. [14] 2004 Canada RCT >50 No No Yes No No 102
Cuddihy et al. [57] 2004 USA Cohort observational study >45 No No Yes No No 59
Murray et al. [52] 2005 UK Comparative study >50 Yes No No Yes No 271
Gardner et al. [42] 2005 USA RCT >65 Yes No No No No 72
Harrington et al. [58] 2005 USA Comparative study >50 Yes Yes Yes Yes Rib, pelvis, long bone 92
Johnson et al. [38] 2005 USA Comparative study - Yes Yes Yes Yes Patients with history of a fracture 262
Jones et al. [19] 2005 Australia Comparative study >70 Yes No No No No 254
Vidán et al. [22] 2005 Spain RCT >65 Yes No No No No 319
Feldstein et al. [23] 2006 USA RCT 50-89 Yes Yes Yes Yes No 327
Streeten et al. [40] 2006 USA Comparative study - Yes No No No No 78
Fisher et al. [54] 2006 Australia Comparative study >60 Yes No No No No 951
Laslett et al. [37] 2007 Australia Comparative study >45 Yes Yes Yes Yes Low trauma fracture 121
Davis et al. [31] 2007 Canada RCT >60 Yes No No No No 48
Majumdar et al. [55] 2007 Canada Comparative study >50 No No Yes No No 102
Quintos-Macasa et al. [35] 2007 USA Cohort observational study >54 Yes No No No No 78
Kuo et al. [64] 2007 Australia Cohort observational study >20 Yes Yes Yes Yes Low trauma fracture (no fingers, toes, skull) 155
Harrington and Lease [50] 2007 USA Cohort observational study >50 Yes Yes Yes Yes Rib, pelvis, long bone 1,019
Majumdar et al. [55] 2007 Canada RCT >50 Yes No No No No 220
Cranney et al. [45] 2008 Canada RCT Postmenopausal women No No Yes No No 261
Majumdar et al. [44] 2008 Canada RCT >50 No No Yes No No 272
Miki et al. [48] 2008 USA RCT - Yes No No No No 62
Tosi et al. [9] 2008 USA Comparative study - Yes Yes Yes Yes Low trauma fracture 635
Collinge et al. [51] 2008 USA Cohort observational study >18 Yes Yes Yes Yes All fracture 238
Morrish et al. [28] 2009 Canada RCT >50 Yes No No No No 220
Haaland et al. [12] 2009 Canada Cohort observational study >50 Yes No No No No 342
Jaglal et al. [17] 2009 Canada Comparative study >40 Yes Yes Yes Yes No 274
Carpintero et al. [41] 2009 Spain Comparative study >50 Yes Yes Yes Yes Low trauma fracture (no facial bone, skull) 82
Bessette et al. [7] 2011 Canada RCT >50 Yes Yes Yes Yes Scapula, clavicle, sternum, pelvis, sacrum, proximal and distal tibia, fibula (including ankle), or foot 1,174
Wallace et al. [25] 2011 UK Comparative study >75 Yes No No No No 88
Roy et al. [47] 2011 USA Comparative study - Yes No No No No 140
Lih et al. [65] 2011 Australia RCT >45 Yes No Yes Yes No 403
Boudou et al. [43] 2011 France Cohort observational study >50 Yes No Yes Yes No 155
Ojeda-Bruno et al. [63] 2011 Spain Cohort observational study >50 Yes Yes Yes Yes Fragility fracture (no facial bones, skull, ribs, hand, foot) 380
Huntjens et al. [34] 2011 Netherlands Comparative study >55 Yes No Yes Yes No skull 3,255
Jaglal et al. [32] 2012 Canada RCT >40 Yes Yes Yes Yes Rib, sternum, pelvis, lower leg, ankle 267
Leslie et al. [11] 2012 Canada RCT >50 Yes Yes Yes Yes No 4,264
Heilmann et al. [6] 2012 USA Comparative study >67 Yes Yes Yes Yes Low trauma fracture (no facial bone, skull, fingers, toes) 1,129
Astrand et al. [60] 2012 Sweden Comparative study 50-75 Yes Yes Yes Yes No 458
Roux et al. [56] 2013 Canada RCT >50 Yes Yes Yes Yes No 881
Queally et al. [39] 2013 Ireland Comparative study Women: >40/ Men: >50 Yes Yes Yes Yes Any fracture of osteoporosis on plain radiographs 61
Chandran et al. [62] 2013 Singapore Cohort observational study >50 Yes Yes Yes Yes No 287
Goltz et al. [24] 2013 Germany Comparative study - - - - - Osteoporosis fracture 4,910
Sarfani et al. [10] 2014 USA Cohort observational study >50 No No Yes No No 151
Van Der Kallen et al. [3] 2014 Australia Comparative study >50 Yes Yes Yes Yes Low trauma fracture 460
Lee et al. [53] 2014 USA Cohort observational study >50 Yes Yes Yes Yes ICD-9 codes 733.93–733.95, 767.3, 800–829; V54.13 444
Ganda et al. [13] 2014 Australia RCT >45 Yes Yes Yes Yes Low trauma fracture 102
Dehamchia-Rehailia et al. [61] 2014 France Cohort observational study No age limit Yes Yes Yes Yes Low trauma fracture 335
Huntjens et al. [5] 2014 Netherlands RCT >50 Yes No Yes Yes No 3,322
Eekman et al. [46] 2014 Netherlands Cohort observational study >50 Yes Yes Yes Yes Low trauma fracture (no facial bone, skull, foot, hand) 2,207
Ruggiero et al. [29] 2015 Italy Comparative study >65 Yes No No No No 382
Olenginski et al. [30] 2015 USA Cohort observational study >50 Yes Yes No No No 1,241
Naranjo et al. [66] 2015 Spain Cohort observational study >50 Yes Yes Yes Yes Low trauma fracture (no facial bone, skull, ribs, hand, foot) 759
Axelsson et al. [21] 2016 Sweden Comparative study >50 Yes Yes Yes Yes pelvis 5,329
Amphansap et al. [26] 2016 Thailand Cohort observational study >50 Yes No No No No 75
Kim et al. [36] 2016 New Zealand Cohort observational study >50 Yes Yes Yes Yes No rib, sternum, clavicle, skull, hand, foot 301
Shipman et al. [16] 2016 UK Cohort observational study >50 Yes No Yes Yes No 1,773
Chandran et al. [18] 2016 Singapore Cohort observational study >50 Yes Yes Yes Yes No 938
Nakayama et al. [27] 2016 Australia Comparative study >50 Yes Yes Yes Yes Low trauma fracture 931
Beaton et al. [2] 2017 Canada Comparative study >50 Yes Yes Yes Yes Low trauma fracture (pelvis, ankle, other) 1,130
Cosman et al. [59] 2017 USA Comparative study >50 Yes No No No No 135
Fraser and Wong [1] 2017 Australia Cohort observational study >50 Yes Yes Yes Yes Low trauma fracture 166
Henderson et al. [15] 2017 Ireland Cohort observational study 44-96 Yes No No No No 248
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RCT, randomized clinical trials; ICD-9, International Classification of Diseases 9th revision.

Reported studies for second fracture prevention programs were performed in the USA, Canada, and Australia et al. from 2002 to 2017. The most common type of fracture in included studies was hip (57 studies), followed by wrist (43 studies) and humerus (38 studies) fracture.

The most used name of the program was FLS in 18 studies (Table 2). There were also 16 programs containing “intervention”. There were 9 studies involving the expression "integrated" or "multidisciplinary" or "multifaceted". There were also 5 studies that included the expression "fracture prevention" or "secondary prevention".

Table 2.

Name of fracture liaison services and roles of coordinators in included studies

Reference Year FLS name Coordinator name Explaining to need osteoporosis evaluation and management Encouraging to follow-up with primary physician Patients identification Data collection Patients assessment Study consent obtain Casual link or regular follow-up Discuss with physician or transfer information to physician Arrangement test Text about coordinator education
Chevalley et al. [49] 2002 Osteoporosis clinical pathway Coordinator nurse Yes No No No No No No No No -
Hawker et al. [33] 2003 Fracture clinic intervention Coordinator Yes Yes Yes Yes Yes No No No No -
Jachna et al. [20] 2003 Hospitalist consultation - No No No No No No No No No -
Majumdar et al. [14] 2004 Intervention - No No No No No No No No No -
Cuddihy et al. [57] 2004 Secondary prevention Coordinator Yes Yes Yes No No No Yes No Yes -
Murray et al. [52] 2005 FLS Specialist nurse No No No No No No No No No -
Gardner et al. [42] 2005 Intervention Coordinator No No No No No No No No No Trained regarding the discussion of the role of osteoporosis in hip fractures, the importance of preventing future fractures, and the effectiveness of currently available therapies
Harrington et al. [58] 2005 Osteoporosis care Rheumatology nurse man0ager No No No No Yes No Yes No No -
Johnson et al. [38] 2005 Intervention Recruiter Yes No Yes No No Yes No No No -
Jones et al. [19] 2005 Fracture protocol - (person name) No No No Yes Yes No No No No -
Vidán et al. [22] 2005 Comprehensive geriatric intervention Orthopedic nurses - No No No No No No No No -
Feldstein et al. [23] 2006 Electronic medical record reminder - No No No No No No No No No -
Streeten et al. [40] 2006 Inpatient consultation - No No No No No No No No No -
Fisher et al. [54] 2006 Geriatric medicine cocare Orthogeriatric geriatric medicine registrar No No Yes No No No No No No -
Laslett et al. [37] 2007 Intervention - No No No No No No No No No -
Davis et al. [31] 2007 Patient empowerment and physician alert intervention - No No No No No No No No No -
Majumdar et al. [55] 2007 Multifaceted intervention - No No No No No No No No No -
Quintos-Macasa et al. [35] 2007 Mandatory rheumatology osteoporosis consultation - No No No No No No No No No -
Kuo et al. [64] 2007 Intervention - No No No No No No No No No -
Harrington and Lease [50] 2007 Osteoporosis care service Nurse manager Yes Yes No Yes No No Yes No No -
Majumdar et al. [55] 2007 Case manager intervention Osteoporosis case manager Yes No No No No No No No No -
Cranney et al. [45] 2008 Multifaceted intervention Coordinator No No No No No No No No No -
Majumdar et al. [44] 2008 Multifaceted intervention Experienced registered nurse (person name) Yes Yes No No No Yes No No No Experienced registered nurse who had additional training and expertise in the diagnosis and treatment of osteoporosis
Miki et al. [48] 2008 Inpatient osteoporosis evaluation - No No No No No No No No No -
Tosi et al. [9] 2008 FLS Nurse practitioner No No No No No No No No No -
Collinge et al. [51] 2008 Osteoporosis Protocol Nurse clinician Yes No Yes No No No Yes No No -
Morrish et al. [28] 2009 Case manager intervention Case manager No No No No No No No No Yes -
Haaland et al. [12] 2009 Fracture think osteoporosis program - No No No No No No No No No -
Jaglal et al. [17] 2009 Educational intervention Coordinator Yes Yes No No No No Yes Yes No Trained to carry out the educational outreach visits according to the principles outlined
Carpintero et al. [41] 2009 Prevent project - No No No No No No No No No -
Bessette et al. [7] 2011 Educational interventions - No No No No No No No No No -
Wallace et al. [25] 2011 FLS Fracture liaison nurse No No No No Yes No No Yes Yes -
Roy et al. [47] 2011 Hospitalist-orthopaedic surgeon integrated model of care - No No No No No No No No No -
Lih et al. [65] 2011 Targeted intervention Investigator No No No Yes Yes No No No No -
Boudou et al. [43] 2011 FLS Nurse No No Yes No No No No No No -
Ojeda-Bruno et al. [63] 2011 Secondary prevention program - No No No No No No No No No -
Huntjens et al. [34] 2011 FLS Fracture nurse Yes Yes No No Yes No No No No Trained in osteoporosis management and fall risk-assessment
Jaglal et al. [32] 2012 Multidisciplinary osteoporosis program Coordinator Yes Yes No Yes Yes Yes No No No -
Leslie et al. [11] 2012 Intervention - No No No No No No No No No -
Heilmann et al. [6] 2012 Clinical-pharmacy-based osteoporosis management service Primary care clinical pharmacy specialist No No No No No No Yes Yes No -
Astrand et al. [60] 2012 Osteoporosis screening program Nurse and secretary No No No No No No No No No -
Roux et al. [56] 2013 Integrated multidisciplinary approach Coordinator Yes Yes No No No No Yes No No -
Queally et al. [39] 2013 Screening for osteoporosis in a community fracture clinic setting - No No No No No No No No No -
Chandran et al. [62] 2013 FLS Case manager (specialist nurse) No No Yes No No No No No No -
Goltz et al. [24] 2013 Program of integrated care - No No No No No No No No No -
Sarfani et al. [10] 2014 Integrated model of care Patient educator Yes No Yes No No Yes No No No -
Van Der Kallen et al. [3] 2014 Fracture prevention service Fracture prevention nurse Yes No No No Yes No Yes No No -
Lee et al. [53] 2014 Osteoporosis electronic consult service - No No No No No No No No No -
Ganda et al. [13] 2014 FLS - No No No No No No No No No -
Dehamchia-Rehailia et al. [61] 2014 FLS FLS nurse No No Yes No No No No No No -
Huntjens et al. [5] 2014 FLS Fracture nurse Yes No Yes No No No No No No -
Eekman et al. [46] 2014 FLS Fracture nurse Yes No Yes No Yes No No No No -
Ruggiero et al. [29] 2015 Fracture prevention service (multidisciplinary integrated model of care) - Yes No No No No No Yes No No -
Olenginski et al. [30] 2015 High-risk osteoporosis clinic: improving osteoporosis and post-fracture care with an organized, programmatic approach Clinical nurse specialists or nurse manager No No No No No No No No No -
Naranjo et al. [66] 2015 FLS Nurse No No No No Yes No No No No Trained nurse
Axelsson et al. [21] 2016 FLS Coordinator No No No No No No No No No -
Amphansap et al. [26] 2016 FLS - No No No No No No No No No -
Kim et al. [36] 2016 FLS FLS coordinator Yes No Yes No No No No No No -
Shipman et al. [16] 2016 FLS - No No No No No No No No No -
Chandran et al. [18] 2016 FLS - No No No No No No No No No -
Nakayama et al. [27] 2016 FLS - No No No No No No No No No -
Beaton et al. [2] 2017 Fragility fracture screening program Coordinator No No Yes No No No No No No -
Cosman et al. [59] 2017 FLS Geriatric NP (person name) No No No No No No No No No Well-trained geriatric NP
Fraser and Wong [1] 2017 Secondary fracture prevention Fracture liaison coordinator No No Yes No No No No No No -
Henderson et al. [15] 2017 Orthogeriatric service - No No No No No No No No No -
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FLS, fracture liaison service; NP, nurse practitioners.

2. Naming and Roles of Coordinators in FLS

Coordinator is mentioned in various ways in each study (Table 2). Expression including “nurse” is observed in 20 studies and 11 studies include “coordinator”. In the 6 studies, they were called “manager”, and there were 26 studies that did not mention them. Three studies have also mentioned their real names directly.

There were 31 studies describing the role of the coordinator directly, but 34 studies did not describe the role of the coordinator directly. The described roles of coordinator in included studies can be categorized into 9 roles (Table 3). The most common description is “explaining to the patient the need for osteoporosis evaluation and management” and “identifying the patients to be included in the secondary fracture prevention program” was described in 18 studies. “Casual link with patients” and “patient assessment” are also described as coordinator roles.

Table 3.

Roles of coordinator in included studies

Role of coordinator Number of reports
Explain to need osteoporosis evaluation and management 18
Find the patients 14
Casual link with patients 9
Patients assessment 9
Encouraged to follow-up with their primary physician 8
Data collection 5
Study consent obtain 4
Discuss with health care provider or transfer information 4
Arrange the test 3
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3. Results of Quality Assessment

The quality assessment for retrospective observational comparison studies using the modified Newcastle-Ottawa Score Tool is measured. All of the included studies were described as observational studies. Sample size calculations were not performed in all studies. The representation of the selected samples was considered appropriate in all included studies. The ascertainment of the assessment tool for sarcopenia was considered as adequate in all observational studies. The response rate, consideration of important confounding factors, ascertainment of assessment tool, and statistical evaluation were reported in all studies. Overall, all of the included individual studies were considered to have a low risk of bias.

DISCUSSION

In this systematic review, the program of FLS was found to be reported in various forms. There was a model in which patients were screened by pharmacists and evaluated for osteoporosis while a consultation program was provided to the hospitalist or rheumatologist for evaluation and treatment of osteoporosis [20,35,67]. There was also an electronic medical record reminder to increase osteoporosis management in fragility fracture patients [23]. Most of the patients with fractures under the program were older than 50 years of age, but there were programs with inclusion of lower age limits of 40 or 45 years old, and one study had no age limitation [33,51,61,65].

At the coordinator-based FLS center, the coordinator (often a nurse) acts as a central player in the establishing of patient connections, orthopedic surgeons, radiologists, and attending physicians. Coordinators help bridge the nursing gap by supporting identification, investigation, initiation of treatment, and patient follow-up. Medics has opened the way to effectively manage patients at high risk of developing another fracture. In addition, nurses are in a unique and important role as nurses responsible for enhancing their daily lives by building relationships with patients and families.

Based on the results of this systematic review, the role of the FLS coordinator are summarized by explaining the need for osteoporosis evaluation and management, promoting follow-up with primary physicians, recognizing patients, collecting data, evaluating patients, obtaining research approval, casual or daily follow-up, consulting with physicians or transferring information to physicians, coordinating the test. Yuksel et al. [67] reported that osteoporosis assessment was increased, but there were many patients who did not receive appropriate care. For this reason, the authors of these studies attempted to explain the lack of knowledge of the patient and general practitioner, a lack of awareness of current treatment guidelines by both family physicians and orthopedic surgeons, and a perception by orthopedic surgeons. practitioners, poor compliance with prescribed medications and a general lack of communication between all health care providers involved in managing a patient with a fragility fracture. There is a lack of understanding and communication between the patient and the medical staff about this condition, and continuous management of the patient is needed, and this can be done by the coordinator. So, as the results of our study, the most commonly mentioned and important role of the coordinator may be explaining the need for osteoporosis evaluation and management to patients and their families.

Mentions of Coordinator training were observed in 6 studies [17,34,42,44,59,66]. A study by Gardner et al. [42] mentioned that coordinators trained regarding the discussion of the role of osteoporosis in hip fractures, the importance of preventing future fractures, and the effectiveness of currently available therapies. Majumdar et al. [55] stated that the experienced nurse had additional training and expertise in the diagnosis and treatment of osteoporosis. Huntjens et al. [34] described that fracture nurse trained in osteoporosis management and fall risk-assessment [17,34, 42,44]. Mentioned only trained nurses and did not give specific details [59,66].

Although the exact career is not described in many studies, the most commonly mentioned career is a nurse. In terms of medical experience, a nurse may be very suitable for the coordinator and may not require much additional training. Depending on the names of specialist nurses, rheumatology nurse managers, orthopedic nurses, and fracture liaison nurses, you can estimate the major department of nurse affiliation or program operation [22,25,52,58].

In the included studies, the types of fractures for the prevention program also varied. In the study of Kuo et al. [64], all minimal trauma fractures were included, but fractures of finger, toe, and skull were excluded. The subjects of Eekman et al. [46] were similar to that of Kuo’s study, but were excluded facial bone fractures. Because the study of Collinge et al. [51] covers all fracture patients over the age of 18, all fractures in addition to low energy trauma were included in the study. Surely, hip was the most frequently mentioned fracture sites managed by the FLS program. In some studies, vertebral fractures were excluded because they did not increase mortality [5,34]. Hurrington and Lease [50] and Beaton et al. [2] included pelvic fractures in the subjects.

This study has several limitations. First, only limited information could be extracted from these selected papers. Although included studies have reported the role of the FLS coordinator, most studies do not mention detailed protocols of an education program for FLS coordinator. Therefore, it is important to share information on the role of FLS coordinator, and actual educational programs of the FLS coordinator through consensus meetings and academic meeting on different continents. Second, we only included papers that were found after a systematic search against scientific databases. Thus, grey literature on this topic, including abstracts of presentations at meetings on FLS, was not included in this systematic review. Third, we have included retrospective studies, and it may make some biases for data analysis. But, we didn’t perform statistical analysis and just collected for the descriptions of the role of coordination in FLS. Thus, we believe that there are a few possibility for risk of bias by including retrospective studies in our study.

The importance of FLS has been proven in many studies. In addition, it is also reasonable to say that the coordinator is a member who plays a key role in the successful progress of the fracture prevention program between doctors and patients. However, it seems showed that the roles of coordinators and educational programs were not unified worldwide. In our best knowledge, this is the first study for analysis about the roles of coordinator and their education. Based on the results of this study, it is considered that the role of the coordinator should be clearly defined, and efforts should be made to activate the educational program for coordinator training.

CONCLUSIONS

In conclusion, the coordinator in the FLS program plays an important role in multidisciplinary management of vulnerable fractures, as well as in the diagnosis and treatment of osteoporosis and in maintaining continuity of treatment. In the future, the broader role of coordinators should be systematically organized and developed into accredited educational programs.

Footnotes

Ethics approval and consent to participate

Not applicable.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

SUPPLMENTARY MATERIAL

Supplementary Appendix 1.

Detailed search strategies for each database. MeSH terms, search terms, and combinations of the 2 were used for each database search

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