Putting FLS into context: Patients, professionals and policymakers
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Transcript of Putting FLS into context: Patients, professionals and policymakers
Putting FLS into context:Patients, professionals and policymakers
National Osteoporosis Society
FLS Education Programme
October 2010
Putting FLS into context:Patients, professionals and policymakers
%
In UK >250,000 fractures per yearAnnual cost >£2billion
The problemA fracture (any site) is associated with 2-
3x increase in future fracture risk
The opportunityAppropriate targeting of treatment for
osteoporosis halves future fracture risk (including risk of hip fracture)
Missed opportunityPercentage of patients with hip fracture reporting
prior fragility fracture
45.3 44.6 45.4
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10.0
20.0
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40.0
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60.0
70.0
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Lyles et al Edwards et al Mclellan et al
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Lyles KW et al. ASBMR 2006. Abstract SA405
Edwards BJ et al. Clin Orthop Rel Res 2007;461:226-230
McLellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland. 2004.
The Challenge
Can systematic post-fracture assessment for fracture secondary prevention be delivered
cost-effectively to an entire healthcare region?
Aim of the Fracture Liaison Service
To offer all women & men aged 50+ years who present with a new fracture (excluding those
sustained in road traffic accident or in fall from above head height) assessment for treatment for
fracture secondary prevention
Key components of a FLS
• Fracture case-finding
• Fracture risk assessment
• Implementation of fracturesecondary prevention
Fracture Liaison ServiceFAQ
• Is FLS more effective than usual services for effecting fracture secondary prevention?
• Does FLS reduce incidence of fractures?
• Is FLS cost-effective?
Fracture Liaison ServiceFAQ
• Is FLS more effective than usual services for effecting fracture secondary prevention?
• Does FLS reduce incidence of fractures?
• Is FLS cost-effective?
NHS Quality Improvement Scotland national auditSecondary fracture prevention by FLS vs other models
A multi-centre national audit conducted in Scotland compared delivery of secondary prevention for fracture patients attending 6 hospitals with various service models:
– Fracture Liaison Service (Centre W)
– GPs could refer fracture patients for open-access DXA assessment (Centres G,S & A)
– Orthopaedic surgeons advise fracture patient to attend GP for referral for DXA (Centre H)
– No structured service or access to local DXA (Centre I)
NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
NHS Quality Improvement Scotland national auditFLS vs other models: Outcome after hip fracture by centre
NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
Centre operating
FLS
NHS Quality Improvement Scotland national auditFLS vs other models: Outcome after wrist fracture by centre
Centre operating
FLS
NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
NHS Quality Improvement Scotland national auditSecondary fracture prevention by FLS vs other models
• Audit findings:
– 95% of wrist fracture patients were offered assessment and/or treatment at the FLS centre in comparison to 21% at centres without an FLS
– 97% percent of hip fracture offered assessment and/or treatment at the centre with an FLS versus 25% at the centres with other service structures
• Fracture Liaison Service model closed secondary prevention gap for patients presenting to hospital with new fragility fractures
NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
Fracture Liaison ServiceFAQ
• Is FLS more effective than usual services for effecting fracture secondary prevention?
• Does FLS reduce incidence of fractures?
• Is FLS cost-effective?
The Glasgow FLS
• 1999: West Glasgow FLS1 centre: population 250K: 1500 fractures/yr
• 2002: Pan-Greater Glasgow FLS3 centres: population 1M: 6500 fractures/yr
• 2009: Pan-Greater Glasgow & Clyde FLS 5 centres: population 1.4M: 9000 fractures/yr
The Glasgow FLS
Pan-Greater Glasgow FLS• 3 centres: population 1M: 6500 fractures/yr• >50,000 fracture patients managed by FLS since
1999
• 1998-2008: Emergency admissions with hip fracture (codes S.72.0-72.2) by 7.3% in context of FLS & falls strategy
Skelton & Neil 2009http://library.nhsggc.org.uk/mediaAssets/OFPS/NHSGGC%20Strategy%20for%20Osteoporosis%20and%20Falls%20Prevention%202006-2010_An%20Evaluation_Skelton%20and%20Neil%202009.pdf
Fracture Liaison ServiceFAQ
• Is FLS more effective than usual services for effecting fracture secondary prevention?
• Does FLS reduce incidence of fractures?
• Is FLS cost-effective?
FLS: cost-effectiveness evaluation
West Glasgow FLS• First 8 years’ data: 11,096 fracture patients• Age 50-104, 78% women
• 80% underwent FLS assessment• 49% had DXA + 17% compliance review w/o DXA• 14% treated with Calcium and Vitamin D w/o DXA• Overall 60% were treated
Per 1000 fracture patients:• 18 fewer fractures (including 11 hip fractures)• Cost saving £26,000 (after assessment & drug costs)
McLellan et al. 2010 NOS meeting abst
QIPP:Quality, Innovation, Productivity, Prevention
• Fracture Liaison Services deliver innovative, preventative care that will improve quality and reduce costs through a reduction in unscheduled emergency admissions.
• FLS addresses all elements of the QIPP agenda and the overarching objective of the NHS Outcomes Framework.
McLellan AR et al. Osteoporos Int 2003;14(12):1028–1034
Fracture Liaison ServiceFAQ
• Is FLS more effective than usual services for effecting fracture secondary prevention?
• Does FLS reduce incidence of fractures?
• Is FLS cost-effective?
Fracture Liaison ServiceOther exemplars from UK
Clunie, G. & Stevenson, S.
Implementing & running a Fracture Liaison Service: an integrated clinical service providing a comprehensive bone health assessment at the point of fracture management.
J. Ortho. Nursing 2008; 12: 156-162
Fragility fractureOrtho wards
>75y <75y >50y
Medical assessFalls assess
Screening testsRecorded on db
(Treat)
Blood tests
FLS clinic DXA scan if < 75yFalls assess >75y
Further testsRecorded on db
Falls Clinic
Discussion
with doctor
DISCHARGEBONE CLINICIntermediate CareDISCHARGE
Apply NICE orFRAX
algorithm
FLS NurseScreens clinic list
Fragility fractureFracture clinic
Ipswich Hospital NHS Trust FLS
Clunie and Stephenson. Journal of Orthopaedic Nursing (2008) 12, 156–162
Fracture Age range45-59y 60-69y 70-79y 80-89y 90y+ Total Total 2*
Hip 24 44 179 345 154 746 124Forearm 195 171 185 73 12 636 106Humerus 45 41 54 20 6 166 28Lower Limb 133 100 65 28 8 334 56Pelvis 4 3 17 33 13 70 12Spine 5 6 18 11 6 46 8Other 184 120 95 35 3 437 73Not specified
21 16 12 9 1 5910
Total 611 501 625 554 203 2491Total 2* 95 78 98 87 32 390*
*Data adjusted: patients with fracture per 100,000/yr population served by the hospital (approximately 310,000)
Clunie and Stephenson. J Orth Nurs 2008; 12: 156-62
Ipswich Hospital NHS Trust FLSPatients by type of fracture and total numbers 2y data.
Fracture Liaison ServiceOther exemplars from USA Kaiser Permanente - Southern California
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Kaiser PermanenteFLS Southern California Style
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Kaiser PermanenteFLS Southern California Style
“I'd like to dispel the misconception that nothing can be done to prevent or treat osteoporosis.
“It is possible to achieve at least a 25 percent reduction in the hip fracture rate in the United States if a more active role is taken by all orthopaedic surgeons in osteoporosis disease management.
“We've seen it; we've done it.”
Rick Dell MD
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Putting FLS into context:Patients, professionals and policymakers
NHS Policy on fragility fracturesThroughout the Bone and Joint Decade 2000-2010
• National Service Framework for Older People. Section 6 – Falls1
Mar-2001
• NICE Clinical Guideline 21: Clinical practice guideline for the assessment and prevention of falls in older people2 Nov-2004
• NICE Technology Appraisal 161: Review of treatments for the secondary prevention of osteoporotic fragility fractures in post-menopausal women3
Oct-2008
• All highlight need for osteoporosis and falls assessment to be provided to patients with a history of fragility fracture
1. NSF for Older People. Section 6 – Falls. DH. Link
2. NICE Clinical Guideline 21 – Falls. Link
3. NICE Technology Appraisal 161. Secondary prevention. Link
Fragility fracture through the life span1
Osteoporosis + falls = fragility fractures
1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O
2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ
“Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk”2
Morbidity attributable to ageing alone
Additionalmorbidity due to fragility fracture event
Professional consensus guidance on hip fractures2007 Blue Book and National Hip Fracture Database
• A systematic approach to hip fracture care and prevention1-3
• Hip fracture care– Blue Book Chapter 1– Effective ortho-geriatric services for hip fracture patients– Universal National Hip Fracture Database participation
• Hip fracture prevention– Blue Book Chapter 2– An FLS for every hospital to identify all new fragility fracture patients– Pro-active case-finding of all unassessed prior fragility fracture patients
1. BOA-BGS 2007 Blue Book2. National Hip Fracture Database3. NHFD Toolkit – Version 3All available at http://www.nhfd.co.uk/
Professional consensus guidance on hip fractures2007 Blue Book and National Hip Fracture Database
Clinical standards link Blue Book to NHFD1,2:
1. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures
2. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls
1. BOA-BGS 2007 Blue Book2. National Hip Fracture DatabaseBoth available at http://www.nhfd.co.uk/
Guidance applicable throughout UK 2007 Blue Book and National Hip Fracture Database
• The Blue Book highlights the need for consistent delivery of NHFD standards 5 and 61,2:
“…the most practical option available to the NHS to attenuate the rising incidence of hip fractures is to ensure that every patient presenting today with any fragility fracture receives effective secondary preventative care.”
1. BOA-BGS 2007 Blue Book2. National Hip Fracture DatabaseBoth available at http://www.nhfd.co.uk/
“Establishment of an integrated Fracture Liaison Service in every UK hospital, which operates in close collaboration with local general practice, offers the optimal system of healthcare delivery to implement NICE guidance consistently for all patients presenting with fragility fractures.”
RCP-CEEU national organisational audit 2009 Falls and bone health services
National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2009. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008
RCP-CEEU national organisational audit 2009Reported by SHA, NHS Trust and PCT
National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2009. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008
FLS
RCP-CEEU national organisational audit 2009 Falls and bone health services
1. Opportunities to prevent recurrent falls and fractures are being missed
2. Commissioning is patchy, rarely providing a coordinated falls and fracture strategy
3. Many clinical services were not adhering to the NICE CG21 and TA87 (now TA161)
National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2009. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008
RCP-CEEU national organisational audit 2009Recommendations
• Primary care organisations (PCOs) should develop commissioning strategies that include:
− Case finding systems in hospital and community settings to identify high risk fallers
− Adherence to NICE treatment guidelines with monitoring by local audit
− Clinical leaders including a consultant with job plan commitment
− A Fracture Liaison Service
− Widespread and accessible evidence-based exercise programmes
− Targeted use of validated home safety assessments
National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2009. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008
RCP-CEEU national organisational audit 2009Recommendations
• The Department of Health should review how it can best support these developments by:
– Provision of advice on commissioning– Strengthening incentives– Provision of useful metrics for falls prevention,
fractures and osteoporosis treatments
Adoption of FLS across the UKThe NOS manifestos for England/Scotland/Wales/N.I.
National Osteoporosis Society, http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
Falls and fracture care and preventionA road map for a systematic approach
Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care
Falls and fracture care and preventionA road map for a systematic approach
Hip fracture patients
Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards
Non-hip fragility fracture patients
Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care
Individuals at high risk of 1st fragility fracture or other injurious falls
Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention
Older peopleObjective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards
Stepwise implementation - based on sizeof impact
Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care
The Coalition Government and OsteoporosisComments from the new Healthcare Leaders
Andrew Lansley MPMonday 5th Oct 2009
“While we do as well as the rest of Europe on heart disease, we are much worse on deaths from cancer, from lung disease, from osteoporosis and from arthritis.”
Monday 29th June 2009
Osteoporosis: Health Services, Mr. Lansley: To ask the Secretary of State for Health what progress has been made in implementing the osteoporosis diagnosis and prevention scheme provided for in the Primary Medical Services (Directed Enhanced Services) (England) (Amendment) Directions 2009. [282131]
David Cameron MPThursday 20th August 2009
“The growth of long-term conditions: As people live longer they're more likely to live for more of their life with at least one long-term condition like Diabetes, Parkinson's disease or Alzheimer's. It's estimated that by 2025 over six million older people will be suffering from a debilitating long-term illness. The number of people with dementia will have increased to around one million; with osteoporosis to over four million; with hearing loss to around ten million. These are increases of up to fifty per cent from today.”
1. Andrew Lansley MP. Speech in Manchester . 05-10-2009
2. Andrew Lansley MP. Parliamentary Question. 29-06-2009
3. David Cameron MP. Speech in Bolton. 20-08-2009
Hip fracture care and prevention in the UKKey developments
• Publication of RCP-CEEU organisational audit1
• Publication of the NOS Manifesto2
– Chapter one: The management of falls, fragility fractures and osteoporosis in secondary care - “We want a Fracture Liaison Service to be linked to every hospital in England/ Scotland/ Wales/ Northern Ireland”
• Publication of DH Prevention Package for Older People & BPT
• Ongoing Blue Book “Coalition of the Willing” initiatives
1. National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2009. Download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008
2. Protecting fragile bones: A strategy to reduce the impact of osteoporosis and fragility fractures in the UK. 2009.
Download from: http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818&srcid=311