Osteoporosis and Fragility Fractures in Older People in Viet Nam: Building Coordinated Secondary Fracture Prevention Across Care Settings

INTEGRATED CARE & CARE TRANSITIONS · MEASUREMENT, IMPLEMENTATION & LEARNING

Last reviewed: October 2026

An older woman undergoes surgery after breaking her hip in a fall at home. The operation is successful, and she begins rehabilitation before returning to her family. Her discharge documents explain how to manage pain, care for the surgical wound and attend follow-up appointments. However, no one has clearly explained whether the fracture may be related to osteoporosis or who will assess her risk of another fracture. Elsewhere, an older man receives treatment for a wrist fracture after a relatively minor fall. Once the cast is removed, he considers the problem resolved. Another patient undergoes chest imaging for an unrelated condition, and a vertebral compression fracture is mentioned in the radiology report but never leads to further assessment.

These situations illustrate a gap that can occur even when the immediate fracture receives appropriate medical treatment. The injury is recognized and managed, but the underlying risk of another fracture may remain unaddressed. Orthopedic treatment, rehabilitation and osteoporosis management are often delivered by different professionals, sometimes in different organizations. Unless someone takes responsibility for connecting these services, the opportunity for secondary prevention can be lost.

A fragility fracture should therefore be viewed as more than an isolated injury. In an older person, it may be an important warning of compromised bone strength and increased future fracture risk. Treating the injury is essential, but successful surgery or fracture healing does not necessarily address the factors that contributed to the fracture or reduce the likelihood of another one.

This distinction is increasingly relevant as Viet Nam's population ages. Hip, vertebral and other fragility fractures can have substantial consequences for mobility, independence, daily functioning and the need for ongoing care. Yet secondary prevention depends not only on whether appropriate investigations and treatments are available, but also on whether patients are identified, assessed, treated and followed up consistently.

Internationally, the Fracture Liaison Service (FLS) has become an important model for addressing this gap. Rather than relying on patients or individual specialists to arrange the next steps independently, FLS provides a coordinated pathway that systematically identifies people with fragility fractures, facilitates assessment of future fracture risk, connects appropriate treatment and supports follow-up.

For Viet Nam, the central question is not simply how to diagnose osteoporosis more frequently. It is how hospitals, specialists, rehabilitation providers and community services can work together to ensure that a fragility fracture leads to an appropriate opportunity to prevent the next one.

A Fragility Fracture Is Not the Same as Every Fracture

A fragility fracture is generally understood as a fracture occurring after low-energy trauma, such as a fall from standing height or less, that would not ordinarily be expected to break healthy bone. Some vertebral fragility fractures occur with minimal or no clearly recognized trauma.

The World Health Organization's September 2024 fact sheet on fragility fractures identifies the spine, hip, distal forearm and proximal humerus among the most common fracture sites. Pelvic, rib and certain other fractures may also indicate skeletal fragility, depending on the circumstances.

However, not every fracture in an older person is a fragility fracture. A fracture following a high-energy road traffic collision may involve a different mechanism, while a pathological fracture related to malignancy or another focal bone disorder requires appropriate investigation. Conversely, experiencing a high-energy fracture does not exclude the possibility that osteoporosis is also present.

The distinction should therefore consider the mechanism of injury, fracture characteristics, medical history and clinical findings rather than age alone.

For FLS, the practical task is to identify fractures that should trigger further evaluation for osteoporosis and future fracture risk while recognizing when another diagnostic pathway is more appropriate.

The International Osteoporosis Foundation (IOF) promotes FLS programs that commonly identify adults aged 50 years and older presenting with fragility fractures. Individual services may define eligibility differently according to their populations and clinical arrangements.

Healthy Longevity Vietnam focuses on older people, generally those aged 60 years and above in the Vietnamese legal and policy context. However, an organization establishing an FLS should consider established international practice when defining its eligible population. Restricting identification only to people aged 60 years and above may exclude some patients who could benefit from earlier secondary fracture prevention.

A reliable pathway begins with clearly defined eligibility criteria, but those criteria should guide appropriate clinical review rather than replace professional judgment.

High Fracture Risk and Osteoporosis Diagnosis Are Related, but Not Identical

One of the most important distinctions in secondary fracture prevention is the difference between diagnosing osteoporosis and estimating the likelihood of another fracture.

Osteoporosis is a skeletal disease characterized by compromised bone strength and increased susceptibility to fracture. Bone mineral density (BMD), commonly measured using dual-energy X-ray absorptiometry (DXA), is an important component of diagnosis and risk assessment.

In postmenopausal women and men aged 50 years and older, a valid DXA T-score of −2.5 or lower at an appropriate skeletal site is generally consistent with a densitometric diagnosis of osteoporosis.

However, future fracture risk depends on more than BMD. Age, previous fractures, glucocorticoid exposure, family history, certain medical conditions, falls and other clinical factors may substantially influence risk.

A person can therefore be at high fracture risk without having a DXA T-score that meets the densitometric threshold for osteoporosis. In an older adult, a low-trauma hip or vertebral fracture may provide strong clinical evidence of skeletal fragility and support treatment after appropriate assessment, even when BMD has not yet been measured or does not meet the osteoporosis threshold.

Conversely, someone diagnosed with osteoporosis by DXA does not necessarily have the same short-term fracture risk as a person who has recently sustained a hip or vertebral fragility fracture.

This distinction matters because the risk of another fracture is often particularly elevated soon after a fragility fracture. Delaying appropriate treatment until every investigation has been completed may create an avoidable gap in selected high-risk patients.

The National Osteoporosis Guideline Group's (NOGG) 2024 UK guideline recommends prompt fracture-risk assessment and treatment consideration following a fragility fracture, particularly in older people. It also recognizes that treatment decisions may proceed without BMD measurement when testing is impractical and clinical risk is sufficiently high.

Tools such as FRAX can support risk assessment by estimating the 10-year probability of hip fracture and major osteoporotic fracture using clinical risk factors, with or without femoral-neck BMD. However, FRAX provides a probability estimate, not a diagnosis. Its predictions depend on the population model used, and intervention thresholds developed for one country should not automatically be applied to another.

This is particularly relevant in Viet Nam, where a dedicated Vietnamese model was not among the country-specific models listed in the conventional FRAX calculator reviewed in October 2026. When clinicians use a model developed for another population, its assumptions, calibration and limitations require consideration. Intervention thresholds from other countries should not be presented as validated Vietnamese treatment thresholds.

A study published in the Vietnam Journal of Community Medicine in April 2026 illustrates growing local interest in fracture-risk assessment. Researchers compared the FRAX and GARVAN models among 94 postmenopausal women with type 2 diabetes receiving care at Nguyen Tri Phuong Hospital in Ho Chi Minh City. Both models demonstrated an ability to distinguish participants with existing fractures from those without them, with no statistically significant difference between their areas under the receiver operating characteristic curves.

The study provides useful preliminary information, but its small sample and cross-sectional design are important limitations. Because it assessed existing fractures rather than prospectively observing future fracture events, it did not establish the accuracy of either model for predicting future fractures in Vietnamese women. Nor did it validate intervention thresholds for the wider population.

A well-designed FLS should therefore avoid reducing clinical decisions to one DXA result or fracture-risk score. It should combine fracture history, clinical findings, appropriate investigations and professional judgment to determine the most suitable secondary prevention plan.

Why Secondary Fracture Prevention Requires a Coordinated Service

A fragility fracture often brings an older person into contact with several healthcare services. Emergency clinicians may identify the injury, orthopedic surgeons provide acute fracture treatment, radiologists interpret imaging, rehabilitation professionals support recovery, and physicians with relevant expertise assess osteoporosis and other medical conditions.

Each service contributes important knowledge, but the overall pathway can become fragmented when responsibility for secondary prevention is unclear.

The orthopedic team may focus appropriately on fracture fixation and postoperative recovery. The patient may assume that osteoporosis assessment will occur during a later appointment. The rehabilitation provider may expect the referring hospital to manage bone health, while the receiving clinician may have incomplete information about previous investigations and treatment decisions.

As a result, a patient can move through several services without anyone ensuring that future fracture risk has been assessed or that appropriate prevention has begun.

Fracture Liaison Services were developed to address this problem. An FLS systematically identifies patients with fragility fractures and coordinates the assessment and management needed to reduce subsequent fracture risk. Its defining feature is not a particular specialty, diagnostic test or medication. It is a service model that assigns responsibility for connecting the necessary steps.

The IOF's Capture the Fracture program, launched in 2012, promotes coordinated secondary fracture prevention internationally. Its Best Practice Framework includes 13 standards addressing important aspects of patient identification, assessment, treatment, communication, long-term management and service organization.

A consensus paper published in Archives of Osteoporosis in 2018 reviewed these standards for the Asia-Pacific region. Participating experts concluded that the standards were generally applicable across the region, while recognizing the need for some modifications and clarifications to reflect different healthcare arrangements.

More recently, on 20 May 2026, IOF reported that 1,310 FLS programs within its Capture the Fracture network collectively identified more than one million patients each year. This demonstrates substantial international expansion of coordinated post-fracture care, although the number identified does not establish how many patients subsequently completed assessment, initiated treatment or achieved improved outcomes.

NOGG 2024 strongly recommends multidisciplinary, coordinator-based FLS programs to facilitate timely assessment, investigation, treatment and monitoring following fragility fractures.

An effective FLS therefore goes beyond providing osteoporosis information or generating specialist referrals. It connects patient identification with completed clinical decisions and continued care.

What Does the Evidence Tell Us About FLS Effectiveness?

International evidence supports coordinated secondary fracture prevention, although the strength of evidence differs between outcomes and service models.

FLS programs have been associated with improvements in identifying eligible patients, completing osteoporosis assessments, initiating treatment and supporting treatment adherence. Programs with active coordination may address gaps that remain when responsibility depends entirely on individual referrals or patient initiative.

An important study published in Osteoporosis International in January 2025 evaluated the Norwegian Capture the Fracture initiative, known as NoFRACT.

This large, pragmatic, registry-supported, stepped-wedge cluster-randomized study included 100,198 women and men with index fractures. The intervention involved implementing standardized FLS arrangements across participating Norwegian hospitals.

The researchers reported that FLS implementation was associated with a 13% lower risk of subsequent fragility fractures among women and a 10% lower risk among men. All-cause mortality was also lower during the intervention period, by approximately 18% among women and 15% among men.

These findings provide important evidence supporting FLS implementation. However, they must be interpreted within the study's design and healthcare context. The reported differences were relative reductions in risk based on the study's analyses, not guaranteed outcomes for every patient or service.

Although NoFRACT used a cluster-randomized implementation design, the fracture and mortality analyses compared outcomes across control and intervention periods using registry data. Their interpretation therefore requires attention to calendar-time effects and other potential sources of bias.

The findings support the potential value of FLS but should not be translated directly into expected reductions in fractures or mortality for a newly established Vietnamese program.

A joint position paper published in European Geriatric Medicine in September 2026, involving seven international organizations, further emphasized the importance of connecting fracture prevention with fall prevention. It highlighted that these closely related activities are often organized through separate care pathways, creating gaps in integrated service delivery.

This does not mean that FLS should replace dedicated fall-prevention services. Rather, it should ensure that relevant assessment and interventions are appropriately connected within the secondary fracture prevention pathway.

For HLVN, the principal implication is that FLS effectiveness depends on implementation. Establishing a program is not enough; organizations need to determine whether eligible patients actually receive appropriate assessment, treatment and follow-up.

FLS Is Already Being Implemented in Viet Nam

Fracture Liaison Services are no longer solely an international concept for Viet Nam. Recent developments demonstrate that Vietnamese healthcare organizations have begun implementing and obtaining international recognition for coordinated secondary fracture prevention.

Thong Nhat Hospital in Ho Chi Minh City has reported substantial progress in developing a model for managing osteoporosis-related fractures.

On 25 April 2025, the hospital announced that its FLS program had received Silver-level recognition from the International Osteoporosis Foundation's Capture the Fracture program. Later that year, the hospital reported receiving Gold-level recognition during the 22nd Annual Scientific Conference of the Vietnam Orthopaedic Association, held in Can Tho on 24–25 October 2025.

The hospital described its program as the first in Viet Nam to achieve that level. Thong Nhat Hospital also appears among the Gold-level programs recognized in IOF's 2025 Capture the Fracture annual report.

Another relevant example is the SAIGON-ITO Hospital System in Ho Chi Minh City. In 2026, SAIGON-ITO reported that its FLS had achieved Silver-level recognition from IOF. The service is also listed in the Capture the Fracture network.

According to its published service description, SAIGON-ITO identifies patients aged 50 years and older presenting with fragility fractures and connects them with appropriate osteoporosis assessment, fracture-risk and fall-risk evaluation, patient education, treatment recommendations and follow-up.

These developments are important because they demonstrate that FLS is being implemented in more than one Vietnamese healthcare organization, including services with different organizational characteristics.

However, the nature of international recognition must be understood accurately. IOF evaluates individual FLS programs against its Capture the Fracture Best Practice Framework. Recognition of an FLS is not accreditation of the hospital as a whole and should not be confused with a Vietnamese regulatory license or mandatory national clinical standard.

Similarly, Gold- or Silver-level recognition indicates that a program has met the relevant assessment criteria. It does not, by itself, establish a particular reduction in subsequent fractures, mortality or healthcare expenditure without corresponding outcome data.

The Vietnamese experience nevertheless provides a valuable foundation for implementation learning. It demonstrates that hospitals can move beyond isolated osteoporosis consultations toward a more structured approach to identifying patients, coordinating clinical assessment and supporting continued treatment after fractures.

The next challenge is to understand which components can be implemented consistently, how they should be adapted to different organizations and whether they lead to measurable improvements in patient care.

Identifying Eligible Patients Is the First Operational Challenge

An FLS cannot improve care for patients it never identifies.

Case finding should therefore be systematic rather than depend entirely on individual clinicians recognizing osteoporosis or referring patients for assessment.

Hospitals may identify potential FLS patients through emergency department records, orthopedic wards, operating theater lists, fracture clinics, rehabilitation referrals and diagnostic imaging reports.

Hip fracture admissions are often a practical starting point because these patients can be identified through established clinical and administrative records. However, an FLS limited to surgically treated hip fractures will miss other people who may benefit from secondary prevention.

Patients with distal forearm, proximal humerus or other relevant low-energy fractures may receive outpatient treatment and leave without admission. If case finding relies only on inpatient records, these individuals may never enter the pathway.

Vertebral fractures create another challenge. Some patients experience acute back pain, while others have few symptoms. Vertebral compression fractures may be discovered incidentally during imaging performed for unrelated reasons.

A radiology report describing a possible vertebral fracture can provide an opportunity for further assessment, but only if the finding is appropriately interpreted, communicated and acted upon.

NOGG recommends attention to vertebral fractures on relevant imaging and the use of standardized reporting methods. For FLS, this suggests the value of a defined process linking radiology findings with appropriate clinical review.

However, not every vertebral deformity represents an osteoporotic fracture. Degenerative changes, malignancy, previous trauma and other conditions may require consideration before the finding is classified as an osteoporotic fragility fracture.

A practical FLS eligibility protocol should therefore define its age range, relevant fracture types, injury mechanisms, identification sources and circumstances requiring additional diagnostic evaluation.

It should also explain how duplicate records, recurrent fractures, patients already receiving osteoporosis treatment and patients declining participation will be handled.

Importantly, a new fragility fracture in someone already receiving osteoporosis medication should not automatically exclude them from further evaluation. It may indicate a need to review treatment adherence, treatment response, current fracture risk or whether another therapeutic strategy is appropriate.

Likewise, a person who does not meet the initial FLS eligibility criteria may still require specialist bone health assessment when other clinical findings suggest significant skeletal disease.

The purpose of case finding is to create a reliable entry point into appropriate care, not to make a definitive diagnosis from an administrative record.

The FLS Coordinator Connects the Entire Pathway

The defining operational feature of an FLS is a clearly assigned coordinating function.

The coordinator may be a nurse, another appropriately trained healthcare professional or a designated member of a multidisciplinary team, depending on the service model and applicable professional requirements.

The role is more than administrative. It involves ensuring that eligible patients are identified, assessments are arranged, clinical recommendations reach the responsible professionals and follow-up does not disappear after discharge.

A coordinator may review fracture lists, contact eligible patients, arrange assessment appointments, facilitate DXA testing when indicated, communicate with participating specialties and track whether treatment recommendations have been implemented.

However, coordinating care does not mean independently making every clinical decision. Diagnosis, prescribing, treatment modification and specialized investigations must remain the responsibility of appropriately qualified professionals acting within their authorized scope of practice.

A well-designed FLS therefore distinguishes the coordinating function from clinical decision-making authority.

Orthopedic clinicians remain responsible for acute fracture management within their professional responsibilities. Physicians with relevant expertise in osteoporosis, internal medicine, geriatrics, endocrinology, rheumatology or other specialties may assess skeletal health and determine treatment. Radiologists contribute fracture identification and imaging interpretation, while pharmacists can assist with medication suitability, administration and continuity.

Rehabilitation professionals contribute to functional recovery and relevant mobility interventions, but these activities should connect with rather than replace osteoporosis management.

The exact allocation of responsibilities will vary between hospitals. What matters is that the patient is not left to connect all these services independently.

An FLS coordinator also needs a clear escalation process. If an investigation suggests malignancy, a metabolic bone disorder or another condition requiring specialist evaluation, the pathway should identify who is responsible for acting on the result.

Similarly, if a patient cannot attend an appointment, experiences medication-related adverse effects or cannot obtain prescribed treatment, the problem should be communicated to the appropriate professional rather than simply recorded as incomplete follow-up.

The value of the coordinator lies in turning several separate clinical activities into one accountable care process.

Fracture-Risk Assessment Should Lead to a Clinical Decision

Once an eligible patient has been identified, the FLS should facilitate an assessment appropriate to the fracture history, medical condition and future risk.

This may include reviewing the fracture mechanism, previous fractures, relevant medications, comorbidities, functional status and other clinical risk factors.

DXA can provide useful information about BMD and establish a baseline for future monitoring. However, its role should be determined by the clinical circumstances.

Some patients require BMD measurement to refine risk assessment or treatment selection. Others, particularly those with recent low-trauma hip or vertebral fractures and high clinical risk, may warrant prompt treatment consideration without waiting for DXA.

This distinction is important when testing is delayed, difficult to access or impractical because of frailty or other medical circumstances.

Assessment should also consider secondary causes of osteoporosis and other metabolic bone disorders. Depending on clinical findings, relevant investigations may include kidney function, calcium status, vitamin D status and selected tests for endocrine or other conditions.

Not every patient requires the same investigations. A standard test panel cannot replace clinical judgment.

The assessment should result in a documented decision about fracture risk and the appropriate next step.

That decision may involve initiating treatment, completing additional investigations, referring for specialist management, modifying existing therapy or determining that a particular intervention is unsuitable.

An FLS should not measure success solely by the number of DXA scans completed or appointments arranged. Assessment is valuable when it produces an informed clinical decision and an actionable care plan.

Treatment Initiation Should Be Timely and Clinically Appropriate

A recent fragility fracture creates an important opportunity to begin secondary prevention.

NOGG 2024 emphasizes that the risk of another fracture is particularly high soon after a fragility fracture and recommends prompt treatment consideration in appropriate patients.

For some people, treatment may begin during hospitalization. For others, initiation may occur shortly after discharge, following necessary assessment and safety checks.

The approach should reflect fracture risk, medical conditions, treatment preferences and available options.

Antiresorptive medicines, including bisphosphonates, are commonly used in osteoporosis treatment. NOGG recommends oral bisphosphonates such as alendronate or risedronate and intravenous zoledronate as important options. It also recommends intravenous zoledronate as a first-line option following hip fracture.

Other treatments may be appropriate in selected circumstances. Denosumab is an alternative antiresorptive treatment, while certain bone-forming therapies may be considered for patients at very high fracture risk, particularly when clinically important vertebral fractures are present.

However, treatment selection should not be reduced to choosing the most potent available medication. Kidney function, calcium status, gastrointestinal conditions, contraindications, administration requirements, adverse-effect risks, treatment costs and patient preferences all require consideration.

Some bisphosphonates may be unsuitable in significant renal impairment. Oral treatment may be difficult for people with certain esophageal disorders or an inability to follow administration instructions safely. Parenteral therapies require appropriate assessment and follow-up.

An important safety issue concerns denosumab. NOGG advises against unplanned discontinuation or substantial delays because stopping treatment without appropriate follow-on therapy can increase vertebral fracture risk. A long-term management plan should therefore be established before treatment begins.

Bone-forming therapies also require appropriate treatment sequencing, including subsequent antiresorptive treatment when indicated.

These examples illustrate why secondary fracture prevention is not completed when the first prescription is issued. The treatment decision must be connected to a feasible plan for administration, monitoring and continuation.

Adequate calcium and vitamin D intake, suitable physical activity and other supportive measures remain relevant, but they should not be presented as substitutes for osteoporosis medication when pharmacological treatment is indicated.

In Viet Nam, decisions must also consider the approved indications, availability, prescribing requirements and reimbursement arrangements for particular medications. International guidance does not establish that every treatment is approved, available or financially accessible to Vietnamese patients.

The role of FLS is to ensure that clinically appropriate treatment decisions can be implemented and maintained, not simply to reproduce an international prescribing algorithm.

Secondary Prevention Must Remain Person-Centered

Not every older person with a fragility fracture will benefit from an identical prevention plan.

A relatively independent patient may prioritize reducing future fracture risk while maintaining activity and independence. Another person with substantial frailty, multiple chronic conditions or limited life expectancy may face a different balance between expected benefits and treatment burdens.

Cognitive impairment can affect communication and treatment support, but dementia should not automatically exclude someone from assessment or appropriate treatment.

Care planning should consider the person's health, preferences, functional goals and ability to participate in treatment, as well as the support available from family or caregivers.

Discussions should explain why another fracture is a concern, what interventions are recommended, what benefits may reasonably be expected and which risks or practical difficulties require attention.

Some patients may decline treatment after appropriate discussion. Others may need additional information or support to understand their options.

A person-centered FLS should document these circumstances respectfully and maintain appropriate opportunities for follow-up when the person's situation changes.

The objective is not to maximize medication use at any cost. It is to help eligible patients receive informed, clinically appropriate secondary fracture prevention.

Discharge Should Transfer Responsibility, Not Just Information

One of the most vulnerable points in the FLS pathway occurs when a patient leaves hospital.

During admission, investigations and specialist consultations may be relatively easy to coordinate. After discharge, the patient may return to another healthcare provider, attend rehabilitation elsewhere or depend on family members to arrange follow-up.

If responsibility is unclear, secondary prevention can stop precisely when long-term management should begin.

A useful discharge or transfer plan should include the fracture diagnosis and mechanism, relevant osteoporosis or fracture-risk assessment findings, treatment decisions, medications started or recommended, outstanding investigations and follow-up arrangements.

It should also identify the professional or service responsible for continuing osteoporosis management.

When treatment has started, the receiving clinician needs to understand the regimen, administration requirements, monitoring needs and planned review. If treatment has not yet begun, the reason and next required action should be documented together with responsibility for completing it.

For patients moving to rehabilitation or transitional care, the secondary prevention plan should accompany the referral rather than remain only within orthopedic records.

Communication with community clinicians and family caregivers is particularly important when medication administration is complex or the patient has cognitive or functional limitations.

A discharge summary stating only "consider osteoporosis treatment" may be insufficient when no receiving clinician has accepted responsibility for the assessment or treatment decision.

The FLS should therefore use a closed-loop process wherever feasible. A referral is made, the receiving service is identified, the next action is tracked and unresolved steps are followed up.

This is especially important when patients receive care across several organizations that do not share the same electronic medical record system.

Continuity is achieved when responsibility passes reliably from one service to another, not merely when information is sent.

Follow-Up Matters as Much as Treatment Initiation

Starting osteoporosis treatment is an important achievement, but it is not the end of secondary prevention.

Patients may stop oral medication because of adverse effects, misunderstand administration instructions or encounter financial and logistical difficulties. Injectable treatment may be delayed because appointments are missed or the patient moves to another provider.

Some people may believe that medication is no longer necessary once their fracture has healed or they feel better.

These problems matter because the benefits of osteoporosis treatments depend on appropriate use, continuation and, when indicated, planned treatment changes.

An FLS should therefore establish follow-up arrangements that reflect the treatment selected and the patient's circumstances.

Follow-up may involve confirming whether treatment was actually started, whether the person understands the regimen, whether adverse effects have occurred and whether future appointments or doses have been arranged.

It may also include reviewing new fractures, changes in risk factors, relevant laboratory findings and BMD reassessment when clinically indicated.

The timing should reflect the treatment and clinical circumstances rather than a rigid schedule applied to everyone.

The distinction between adherence and persistence is useful. Adherence concerns how closely treatment is taken as prescribed, while persistence concerns whether the patient continues therapy over the intended period.

A patient may remain nominally on treatment but miss doses or take medication incorrectly. Another may follow treatment appropriately for several months and then discontinue it without clinical review.

Both situations require attention, but they may need different responses.

Education should explain the purpose of treatment, administration requirements, expected duration, important adverse effects and what to do when difficulties arise.

Follow-up should also recognize barriers that education alone cannot solve. Transport, medication costs, appointment availability and caregiver capacity may affect whether the plan can be maintained.

A reliable FLS does not merely record nonadherence. It seeks to understand why treatment was interrupted and connects patients with appropriate clinical or practical solutions when possible.

Vertebral Fractures Require a Specific Identification Strategy

Vertebral fragility fractures deserve particular attention because many remain unrecognized.

Some people experience acute back pain, height loss or changes in posture. Others have few symptoms, and a vertebral fracture may be identified incidentally during imaging performed for another reason.

When a vertebral compression fracture is reported, it should be interpreted in its clinical context. Degenerative changes, malignancy, previous trauma and other causes of vertebral deformity may require consideration.

However, a confirmed osteoporotic vertebral fracture can provide important information about future fracture risk and substantially influence management.

For FLS, this creates an identification challenge different from hip fractures.

Patients with hip fractures are usually visible in emergency, orthopedic and inpatient records. Patients with vertebral fractures may be distributed across radiology reports, outpatient clinics, general medicine and rehabilitation services.

NOGG recommends systematic attention to vertebral fractures on relevant imaging and standardized reporting of identified fractures.

A Vietnamese hospital developing FLS should therefore consider how radiology findings can reach the responsible clinician and, where appropriate, trigger osteoporosis assessment.

This may involve agreed radiology reporting terminology, electronic notifications, referral rules or regular review of relevant imaging reports, depending on the organization's capabilities.

The pathway should avoid classifying every vertebral deformity as osteoporotic, but it should also avoid overlooking clinically important fractures simply because they were discovered incidentally.

Reliable vertebral fracture identification can extend the reach of FLS beyond patients receiving acute orthopedic treatment.

A Practical Secondary Fracture Prevention Pathway for Viet Nam

A coordinated secondary fracture prevention pathway does not require every hospital to establish a large specialist department from the beginning.

The essential requirement is a reliable process connecting eligible patients with appropriate assessment, treatment decisions and follow-up.

The pathway begins when a possible fragility fracture is identified. Clear eligibility criteria help determine which patients should enter FLS, while alternative diagnoses and fracture mechanisms are directed to appropriate clinical evaluation.

A designated coordinator then ensures that the patient enters the assessment process and that relevant information is available to the responsible clinicians.

Assessment should establish future fracture risk, identify important secondary causes and determine whether treatment is indicated. The clinician responsible for osteoporosis management should make an individualized decision considering clinical evidence, safety requirements and the patient's preferences.

When treatment is recommended, the pathway should ensure that initiation occurs through an appropriate service. If treatment cannot begin immediately, the outstanding action, reason for delay and responsible professional should be documented.

At discharge or transfer, the prevention plan should be communicated to the next provider. Follow-up should confirm that recommendations have been acted upon and that the patient can continue the agreed treatment.

Information about completed and missed steps should then be used to improve the pathway.

Different organizational models may be appropriate. A tertiary hospital may operate a dedicated FLS with a coordinator, access to specialist bone health services and a patient registry. A smaller hospital may begin with a structured arrangement connecting orthopedic services and physicians responsible for osteoporosis care.

An outpatient service may focus on identifying eligible patients and ensuring that assessment and treatment decisions reach the referring clinician.

However, a referral-only arrangement should not automatically be regarded as equivalent to a fully coordinated FLS. Its value depends on whether patients actually complete the necessary steps.

The pathway should therefore be designed around completed care rather than the number of referrals generated.

Measuring FLS Performance Across the Patient Pathway

One of the strengths of FLS is that its performance can be measured systematically.

IOF's Capture the Fracture Best Practice Framework provides 13 standards covering organizational and clinical components of secondary fracture prevention.

A separate position paper published in Osteoporosis International in 2020 introduced 11 patient-level key performance indicators developed by the IOF Capture the Fracture Working Group, the National Osteoporosis Foundation and the Fragility Fracture Network.

These indicators address the identification of patients with nonvertebral and vertebral fractures, fracture-risk assessment, DXA assessment, fall-risk assessment, recommendations for osteoporosis medication, treatment initiation, relevant strength and balance interventions, follow-up and continued treatment.

The eleventh indicator concerns the completeness of data used to evaluate the other measures.

The KPI framework includes several time points, such as fracture-risk and DXA assessment within 12 weeks of the index fracture, treatment initiation and relevant follow-up or strength and balance interventions within 16 weeks, and medication continuation at 52 weeks.

These are international quality-improvement benchmarks. They should not be interpreted as mandatory Vietnamese regulatory deadlines or applied without considering clinical indications and the original indicators' definitions.

For example, a patient for whom DXA is not clinically necessary before treatment should not automatically be classified as receiving inadequate care simply because no scan was performed. Measures also require appropriate denominators that distinguish patients eligible for treatment from those with contraindications, informed refusal or other documented reasons for not initiating therapy.

A useful FLS registry should therefore record not only whether an action was completed, but also why it was not completed when relevant.

For a hospital beginning implementation, a manageable indicator set may be more useful than a complex dashboard. Initial measures could focus on the proportion of eligible patients identified, completion of fracture-risk assessment, documented treatment decisions, treatment initiation when indicated and follow-up after discharge.

As the program matures, organizations can expand measurement to treatment persistence, subsequent fractures, adverse events and patient-centered outcomes.

Long-term outcome comparisons require care. Subsequent fracture rates may be influenced by baseline risk, mortality, follow-up duration and changes in the patient population. A reduction after FLS implementation is encouraging, but it should not automatically be attributed to the program without considering these factors and the evaluation design.

The purpose of measurement is to understand whether patients are receiving the intended care and where the pathway needs improvement.

Viet Nam Has a Clinical Foundation, but FLS Requires Additional Coordination

Viet Nam already has professional guidance relevant to osteoporosis diagnosis and treatment.

Ministry of Health Decision No. 361/QĐ-BYT, issued on 25 January 2014, introduced professional guidance on the diagnosis and treatment of musculoskeletal diseases, including osteoporosis.

The decision provides a clinical reference for healthcare facilities and directs them to develop diagnostic and treatment guidance appropriate to their circumstances.

However, the document predates several developments in contemporary fracture-risk stratification, treatment sequencing and the international expansion of coordinated FLS models. It should not be described as a comprehensive nationwide FLS implementation framework.

More recently, Ministry of Health Decision No. 1976/QĐ-BYT of 1 July 2026 introduced professional guidance on caring for older people at home and in the community. It includes content on osteoporosis, relevant symptoms and risk factors, appropriate daily care and supporting adherence to medical advice.

This is useful for older-person care in community settings, but it does not establish a dedicated national FLS pathway, mandatory coordinator role or standardized secondary fracture prevention registry.

The Law on Medical Examination and Treatment No. 15/2023/QH15, effective from 1 January 2024, provides the broader legal framework for clinical care, patient rights and professional responsibilities.

FLS activities must operate within the applicable Vietnamese regulatory framework. Clinical assessment, prescribing, procedures and follow-up responsibilities should be assigned to appropriately qualified professionals and suitable healthcare facilities as required.

International guidance from IOF, NOGG and other organizations can inform FLS development, but these references do not automatically become binding Vietnamese legal requirements.

Similarly, Capture the Fracture recognition is an international professional benchmarking activity. It is not a condition for obtaining permission to provide osteoporosis treatment in Viet Nam and is not equivalent to accreditation of an entire hospital.

An additional consideration is the management of patient information. FLS commonly involves a registry, communication between clinical departments and follow-up across different services. These activities require appropriate confidentiality, access controls and information-sharing arrangements.

The Law on Personal Data Protection No. 91/2025/QH15, effective from 1 January 2026, and its applicable implementing regulations should be considered when identifiable patient information is collected, processed or shared. The specific responsibilities depend on the nature of the information and the organization's activities.

Diagnostic testing, medication availability and health insurance reimbursement must also be considered under the relevant Vietnamese arrangements. A service model that assumes universal access to particular investigations or treatments may be difficult to implement consistently.

For Viet Nam, the opportunity is to connect existing clinical capabilities with a structured process that ensures patients with fragility fractures receive appropriate secondary prevention across the care continuum.

Implementation Should Begin With a Manageable Scope

Hospitals interested in developing FLS do not necessarily need to introduce a comprehensive hospital-wide program immediately.

A practical approach is to begin with a defined patient population, establish reliable processes and expand after the initial model has been evaluated.

A hospital might start with older adults admitted for hip fractures. These patients are often identifiable through existing clinical records, making it possible to test coordination between orthopedic treatment, fracture-risk assessment, osteoporosis management and discharge planning.

Once the pathway functions reliably, the service may expand to other inpatient fractures, outpatient fractures and vertebral fractures identified through imaging.

A successful pilot needs clear ownership. A senior clinical leader should be accountable for the overall service, while a designated coordinator manages its day-to-day pathway. Participating departments should agree on eligibility criteria, assessment responsibilities, referral processes, treatment decisions and follow-up arrangements.

The pathway should fit existing clinical workflows wherever possible. Fracture identification may use information already recorded by emergency, orthopedic and radiology services rather than depend entirely on additional manual reporting.

A simple registry can support coordination and measurement. It does not need to be technologically complex at the beginning, but the information should be sufficiently complete, accurate and accessible to authorized staff.

Pilot evaluation should examine whether eligible patients are consistently identified, assessments are completed, clinically appropriate treatment begins and follow-up remains reliable after discharge.

It should also examine why steps are missed. Delayed DXA appointments, difficulty arranging specialist consultations, limited coordinator capacity, unclear professional responsibilities, medication costs and patients being lost after transfer may all affect performance.

These findings should guide adjustments before expansion.

Not every healthcare organization will have the same capabilities. Some may initially establish a reliable referral and follow-up pathway rather than a complete dedicated FLS. Such arrangements can be useful when their limitations are recognized and their effectiveness is evaluated.

The most meaningful early achievement is not necessarily enrolling a large number of patients. It is demonstrating that a defined group can move reliably from fracture identification to appropriate assessment, treatment decisions and continued care.

Long-Term Development Should Be Guided by Evidence

International recognition can help FLS programs benchmark their organization and identify opportunities for improvement.

The IOF Capture the Fracture program provides an established mechanism for reviewing services against internationally developed standards. The experiences of Thong Nhat Hospital and SAIGON-ITO provide relevant Vietnamese examples of FLS development and international recognition.

However, recognition should be viewed as part of continuous improvement rather than the endpoint of service development.

An organization may meet important structural and process criteria but still need to demonstrate whether eligible patients consistently receive treatment, remain engaged in follow-up and experience meaningful benefits.

For HLVN, this is an important distinction.

A mature implementation approach should examine organizational readiness, patient identification, completion of the care pathway, treatment persistence, patient experience and the feasibility of sustaining the service over time.

Future implementation research in Viet Nam could compare different coordination approaches, identify barriers to completing treatment and evaluate whether stronger communication between hospitals and community providers improves continuity.

Such research could also assess resource requirements, workforce competency, access to medicines and the cost of delivering secondary fracture prevention under different organizational models.

The findings would help determine which approaches are feasible and effective within Vietnamese healthcare settings rather than assume that a model developed elsewhere will produce identical results.

Ultimately, the contribution of FLS should be judged by the care received by patients and the reliability of the pathway, not simply by the existence of a protocol or an external recognition certificate.

From Treating One Fracture to Preventing the Next

For an older person, recovery after a fracture may be long and demanding. Surgery, pain, reduced mobility, rehabilitation and dependence on family support can disrupt everyday life. Once the immediate injury has healed, patients and families understandably want to return to normal routines.

Yet this is precisely when the underlying risk of another fracture may be overlooked.

A fragility fracture should create an opportunity to consider whether osteoporosis or other factors have increased skeletal vulnerability, whether further assessment or treatment is needed and how the risk of another fracture can be reduced.

For healthcare organizations, the challenge is to ensure that this opportunity does not depend entirely on the initiative of one clinician, patient or family member.

A Fracture Liaison Service provides a practical way to connect the necessary steps. It identifies eligible patients, facilitates appropriate assessment, links clinical decisions with treatment, supports discharge planning and follows whether secondary prevention continues after the patient leaves the original service.

For Viet Nam, the experiences of Thong Nhat Hospital and SAIGON-ITO demonstrate that structured FLS development is possible. The next opportunity is to understand how coordinated secondary fracture prevention can be adapted, evaluated and expanded across hospitals and other care settings.

The central question is not simply whether the fracture has healed or whether osteoporosis has been diagnosed. It is whether the healthcare system recognized the person's risk of another fracture, made an appropriate prevention decision and ensured that the agreed care could be delivered and continued.

High-quality secondary fracture prevention means that treating one fracture becomes the beginning of a coordinated effort to reduce the risk of another.

That is the value of Fracture Liaison Services: moving beyond isolated fracture treatment toward reliable, evidence-informed and person-centered prevention across the care continuum.

References

1. World Health Organization. Fragility Fractures. Fact sheet. 25 September 2024.

2. Åkesson K, Marsh D, Mitchell PJ, et al. Capture the Fracture: A Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporosis International. 2013;24(8):2135–2152.

3. International Osteoporosis Foundation. Capture the Fracture: Best Practice Framework. International Osteoporosis Foundation.

4. Javaid MK, Sami A, Lems W, et al. A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: A position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network. Osteoporosis International. 2020;31(7):1193–1204.

5. Chan DCD, Chang LY, Akesson KE, et al. Consensus on best practice standards for Fracture Liaison Service in the Asia-Pacific region. Archives of Osteoporosis. 2018;13:59.

6. Gregson CL, Armstrong DJ, Avgerinou C, et al. The 2024 UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis. 2025;20:119.

7. National Osteoporosis Guideline Group. NOGG 2024: Clinical Guideline for the Prevention and Treatment of Osteoporosis. Updated December 2024.

8. Andreasen C, Dahl C, Frihagen F, et al. Fracture liaison service (FLS) is associated with lower subsequent fragility fracture risk and mortality: NoFRACT (the Norwegian capture the fracture initiative). Osteoporosis International. 2025;36(3):501–512.

9. International Osteoporosis Foundation. Capture the Fracture Achieves Major Milestone: More Than One Million Patients Identified Annually. 20 May 2026.

10. van der Velde N, Seppala LJ, Bahat G, et al. Position paper: A coordinated approach to fracture and fall prevention from seven international organizations. European Geriatric Medicine. Published online 10 September 2026.

11. Cao Dinh Hung, Tran Quang Khanh, Nguyen Dinh Thong, Vo Chau Duyen. Comparison of the discriminative performance of FRAX and GARVAN models for assessing fracture risk in postmenopausal women with type 2 diabetes mellitus. Vietnam Journal of Community Medicine. 2026;67(Special Issue 4). DOI: 10.52163/yhc.v67iCD4.4855.

12. Thong Nhat Hospital. Bệnh viện Thống Nhất nhận chuẩn Bạc về mô hình chăm sóc bệnh nhân sau gãy xương do loãng xương. 25 April 2025.

13. Thong Nhat Hospital. Bệnh viện Thống Nhất được trao chứng nhận “Tiêu chuẩn Vàng” mô hình quản lý gãy xương do loãng xương. 25 October 2025.

14. International Osteoporosis Foundation. Capture the Fracture: 2025 Annual Report. 2026.

15. SAIGON-ITO Hospital System. Bảo vệ xương chắc khỏe, giảm nguy cơ tái gãy xương với mô hình FLS chuẩn Bạc quốc tế. 17 September 2026.

16. International Osteoporosis Foundation. Capture the Fracture: SaiGon ITO. Map of Best Practice.

17. Ministry of Health of Viet Nam. Decision No. 361/QĐ-BYT issuing professional guidance on the diagnosis and treatment of musculoskeletal diseases. 25 January 2014.

18. Ministry of Health of Viet Nam. Decision No. 1976/QĐ-BYT issuing professional guidance on care for older people at home and in the community. 1 July 2026.

19. National Assembly of Viet Nam. Law on Medical Examination and Treatment No. 15/2023/QH15. Adopted 9 January 2023; effective 1 January 2024.

20. National Assembly of Viet Nam. Law on Personal Data Protection No. 91/2025/QH15. Adopted 26 June 2025; effective 1 January 2026.