UPMC Division of Endocrinology and Metabolism Fracture Liaison Service at UPMC Mercy Working to Close Osteoporosis Treatment Gaps After Fragility Fractures

Diana Pinkhasova, MD, clinical assistant professor, medicine, UPMC Division of Endocrinology and Metabolism, specializes in metabolic bone disease and is the director of the metabolic bone unit at UPMC. Dr. Pinkhasova has outpatient clinics and is an attending physician on the inpatient endocrinology service at UPMC Mercy. In July 2023, Dr. Pinkhasova and Gele Moloney, MD, associate professor of orthopaedic surgery, UPMC Orthopaedic Care and division chief, orthopaedic surgery, UPMC Mercy, launched a Fracture Liaison Service (FLS) to address a persistent gap in secondary fracture prevention: the failure to initiate prompt treatment for osteoporosis after a fragility fracture.

Also collaborating to create and run the program are: Karen Selk, DO, Lauren Willard, DO, Divya Sistla, MD, Sann Mon, MD, Niveditha Manivannan, MD.

At UPMC Mercy, which houses an American College of Emergency Physicians (ACEP) Level 2 Geriatric Emergency Department Accreditation (GEDA), in addition to being designated as an Age Friendly facility by the American Hospital Association (AHA) through its 4Ms Framework, the FLS came into existence because of a recurring pattern seen in the orthopaedic trauma population. Older adults who underwent surgical repair of a low-energy mechanism (i.e., a fall) hip fracture sometimes returned with another fracture involving the same or contralateral hip. Although the acute injury was effectively treated, the underlying osteoporosis that left the patient vulnerable to another fracture often was not addressed or went undertreated.

“Dr. Moloney was seeing these patients return with repeat and new fragility fractures,” Dr. Pinkhasova says. “The risk of a second fracture is particularly high during the first one to two years after the sentinel event. We developed the FLS to intervene during that first hospitalization, when we have an opportunity to alter the patient’s subsequent risk through targeted osteoporosis treatment and education on the disease and bone health in general.”

The Post-Fragility Fracture Treatment Gap, Risks, and Outcomes

In an adult older than 50, a fracture sustained from standing height or another low-energy mechanism is sufficient to make a clinical diagnosis of osteoporosis, regardless of whether the patient has had a prior bone density screening indicative of osteoporosis. The diagnosis of osteoporosis after a fragility fracture carries with it significant immediate and long-term implications. Approximately half of patients with one osteoporotic fracture will sustain another without treatment, and first-year mortality after a fragility hip fracture has been shown in the literature to be anywhere from 20 to 24%, which is an extraordinarily high rate.

The morbidity seen in fragility fracture patients who survive the immediate injury also is substantial. At one year, 40% of patients may remain unable to walk independently, 60% may require assistance, and 33% may be dependent or living in a nursing or rehabilitation facility. Preventing a secondary fragility fracture is one of, if not the most important outcome linked to preserving a person’s mobility, independence, and quality of life.

Even with this known risk profile in individuals with osteoporosis who suffer a fragility fracture, treatment for the condition remains suboptimal across the entire patient population – men and women, alike.

“Many of these patients have never undergone screening or had a focused discussion about bone health,” Dr. Pinkhasova says. “Others may have had a prior DXA scan showing osteoporosis years earlier, but the finding was never adequately addressed, or treatment was discussed and declined, or if started, abandoned. By the time we see some patients, they have sustained several fractures and that usually translates into very poor outcomes.”

Concerns about rare adverse effects associated with osteoporosis medications, particularly bisphosphonate therapy, also can affect an individual’s decision around treatment. Some patients may hesitate to begin therapy after encountering warnings about osteonecrosis of the jaw and atypical femoral fractures, concerns that may be reinforced through social media exposure related to bisphosphonate therapy. Although both complications are rare, fear of these adverse effects can lead patients to decline treatment even with the high risk of what a recurrent fracture can translate to: functional decline, loss of independence, and mortality.

“When the discussion focuses on absolute clinical risk, many patients view treatment differently,” Dr. Pinkhasova says. “A fragility fracture is often attributed to age or to the fall itself. The ‘that’s just what happens when you get older’ kind of thinking. This is a fallacy. The important clinical point is that the existence of a fragility fracture identifies a very treatable skeletal disease and also a patient at high risk for another, more catastrophic event.”

Building Osteoporosis Treatment Into the Hospitalization Course After a Fragility Fracture

The Fracture Liaison Service created by Dr. Pinkhasova, Dr. Moloney, and team integrates endocrinology into the inpatient fracture pathway. When the orthopaedic surgery service identifies a fragility fracture, it places an immediate endocrinology consult request in the electronic health record and obtains laboratory studies that include the patient’s vitamin D levels and kidney function testing. One of the attending endocrinologists on call at UPMC Mercy evaluates the patient in the hospital within 24 hours, confirms the clinical diagnosis, assesses treatment eligibility, and discusses therapy with the patient and their family caregivers.

The FLS program was deliberately structured around trying to instigate immediate inpatient treatment rather than relying on a subsequent referral to an outpatient osteoporosis clinic. Many patients transition from the hospital to skilled nursing or inpatient rehabilitation. Frailty, impaired mobility, transportation needs, and coordination with family members can make a separate endocrinology visit for follow up assessment and care difficult to complete.

“If we do not evaluate these patients during the hospitalization, the likelihood that we will reach them afterward is very low from what we see in our own system, but the same dynamic occurs everywhere,” Dr. Pinkhasova says. “The logistics of specialty follow-up care can become prohibitive during recovery, particularly for patients who are discharged to a care facility.”

For eligible patients, the FLS offers treatment with intravenous zoledronate. Existing IV access permits administration during a one-time 30-minute infusion, which provide a full year of osteoporosis therapy before the patient is ever discharged from the hospital. The approach closes the interval between the recognition of an osteoporotic fragility fracture and starting treatment for secondary prevention.

“The inpatient setting allows us to complete the evaluation, address the patient’s concerns, and administer treatment while the clinical significance of the fracture is clear and present in their mind,” Dr. Pinkhasova says. “If that decision is deferred, competing medical and logistical priorities frequently intervene and treatment does not happen. That’s what our program works to avoid.”

Program data collected so far supports these clinical concerns around no or undertreatment. In patients who deferred therapy, only 16.5% subsequently completed an endocrinology follow-up visit. Primary care follow-up was higher at 48.3%. Both of these metrics highlight the importance of primary care clinicians in helping to uncover and start the process of further evaluation and treatment - identifying bone loss before it can lead to a fracture.

“I consider primary care clinicians the gatekeepers for bone health,” Dr. Pinkhasova says. “They are more likely to see these patients after discharge and are also positioned to identify risk, obtain screening DXA scans, and initiate management earlier in the disease course. Part of our program is to help reinforce that information with our primary care partners and do as much as we can to advocate for more uniform screening that follow current evidence-based guidelines, and when needed, have the conversation around starting therapy. We know what happens after a fragility fracture, and the outcomes are concerning.”

Early Results

Since it started at UPMC Mercy in July 2023, the FLS has completed (as of the time of this article) 1,169 consultations for fragility fractures (about 30 a month) and has so far treated 253 patients while in the hospital with IV bisphosphonate therapy.

One-year follow-up data from the program also identified a mortality difference between patients who did and did not receive inpatient IV therapy. Mortality was 5.8% in the treated group and 16.8% in the untreated group. As observational program data, the findings do not establish that bisphosphonate therapy alone accounts for the difference, but they support continued evaluation of the inpatient model and its outcomes.

“We are treating patients who otherwise were unlikely to receive osteoporosis therapy,” Dr. Pinkhasova says. “The data also make clear that we have more work to do. Many eligible patients remain untreated, and the counseling and coordination required to reach them are resource intensive.”

Expanding the Service and Moving Prevention Earlier

The next phase of the Fracture Liaison Service is focused on building the infrastructure needed to support more patients and extend the model to other UPMC hospitals.

“As the program grows, a dedicated Fracture Liaison Service coordinator could manage follow-up, DXA testing, and contact after discharge,” Dr. Pinkhasova says. “That continuity will support the program’s growth and expansion.”

Ongoing planning to extend the FLS model at UPMC Mercy to UPMC Presbyterian has also given Dr. Pinkhasova and the team an opportunity to emphasize that the service must continue treating both women and men. Men are screened less often and are less commonly associated with osteoporosis, yet the FLS treats many men with fragility fractures, and mortality after hip fracture is actually higher among men.

“Men develop osteoporosis, experience fragility fractures, and need the same attention to secondary prevention,” Dr. Pinkhasova says. “If we expand the service, men must remain part of the model, particularly because their mortality after hip fracture is higher.”

The broader objective of the FLS program created by Dr. Pinkhasova, Dr. Moloney, and team is to move osteoporosis recognition and treatment earlier in its clinical course.

“Secondary prevention can reduce risk after a fracture, but primary prevention gives us the opportunity to prevent the sentinel fracture from occurring,” Dr. Pinkhasova says. “If we can do that, we’re going to cut down on the incidence of fragility fractures. In an increasingly larger population of older adults in the United States, those numbers are not trivial, nor is the avoidance of all the disability and worse that happens to these individuals as a consequence.

References and Further Reading

• LeBoff MS, et al. The clinicians guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022; 33: 2049–2102.
• Nakayama A, Major G, Holliday E, Attia J, Bogduk N. Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int. 2016; 27(3): 873-879.
• Qaseem, et al. Pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults: a living clinical guideline from the American college of physicians. Ann Intern Med. 2023; 176: 224-238.
• Singer A, Exuzides A, Spangler L, et al. Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the united states. Mayo Clin Proc. 2014; 90: 53-62.
• Danazumi, M.S., Lightbody, N. & Dermody, G. Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis. Osteoporos Int. 202; 35: 1133–1151.
• De Almeida, R.J.R., Grover, A., Agarwal, S. et al. Inequities across the spectrum of osteoporosis care and post-fracture management in men. Curr Osteoporos Rep. 2025; 23: 49.
• Vilaca T, Eastell R, Schini M. Osteoporosis in men. Lancet Diabetes Endocrinol. 2022; 10(4): 273-283.
• Bliuc D, Nguyen ND, Milch VE, Nguyen TV, Eisman JA, Center JR. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009; 301(5):513–521.