Fragility Fracture Network - FFN A Global Multidisciplinary Network to Improve Fragility Fracture

Management and Prevention

Ami Hommel

RN, CNS, PhD, Associate Professor Lund University & Skane university hospital, Lund, Sweden Chair International Collaboration of Orthopaedic Nursing Scientific Board member, the Fragility Fracture Network

• Hip fractures – 87% of total cost of all fragility fractures

• Often considerably increased dependency

Hip Fractures Are the Key

50 60 70 80 90 Age

No fractures –

increasing morbidity

due to ageing alone

Age Adapted from Kanis JA, Johnell O; 1999

The fragility fracture ‘career’ - a chronic disease Morbidity

Dependence

The fragility fracture ‘career’ - a chronic disease Morbidity

Dependence

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age

No fractures –

increasing morbidity

due to ageing alone

Added morbidity from

fractures

Age Adapted from Kanis JA, Johnell O; 1999

• Despite falling age-adjusted incidence, ageing will lead to massive increase in burden over the next 25 years

– Double the number of cases

– Treble the cost

• Unless we do something about it

Adapted from Cooper C et al,

Osteoporosis Int, 1992; 2:285-9

Total number of

hip fractures:

1990 = 1.66 million

2050 = 6.26 million

1990 2050

600

325

0

1990 2050

668

400

1990 2050

1990 2050

10 0

629 378

742

Projected Osteoporotic Hip Fractures Worldwide

Mission

To promote globally the optimal multidisciplinary management of the patient with a fragility fracture,

including secondary prevention

Aims

• to disseminate globally the best multidisciplinary practice in preventing and managing fragility fractures

• to promote research aimed at better treatments for osteoporosis, sarcopenia and fracture

• to drive policy change that will raise fragility fractures higher up the healthcare agenda in all countries

Membership • Open to professionals in any field relevant to

fragility fractures, eg:

– Orthopaedic surgeons

– Other doctors: geriatricians, osteoporosis doctors etc

– Nurses and allied health professionals

– Scientists

– Industry

• Application for membership via the website – www.ff-network.org - €50

Members by global region

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Europe NorthAmerica

ANZ Asia Middle East LatinAmerica

43%

12% 14% 13% 12%

4%

Members by discipline

0%

10%

20%

30%

40%

50%

1% 3%

31%

11%

44%

6% 5%

• First Global Congress 6-8 Sep 2012 Berlin

• Attended by >350

• Workshops

• First Global Congress 6-8 Sep 2012 Berlin

• Attended by >350

• Workshops

• Second Global Congress 29-31 August 2013 Berlin

• Attended by >400

• Workshops

Progress

• “Blue Book” on fragility fracture care

• National Hip Fracture Database

– Sweden started in 1988

• Fracture Liaison Services

Goals of the NHFD

• To change clinical behaviour – raise standards

• To raise the political profile of fragility fractures

• To provide a platform for clinical research

Four big messages Multidisciplinary approach to the management of fragility fracture patients Reliable secondary prevention Osteoporosis and falls Chronic disease model Quality assurance the NHFD

Six standards for hip fracture care

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation (2h)

2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours (24h)

3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer

4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission

5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures

6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls

Objective 1: Improve outcomes and

improve efficiency of care after hip

fractures – by following the 6 “Blue

Book” standards

Hip fracture patients

Objective 2: Respond to the first

fracture, prevent the second – through

Fracture Liaison Services in

acute and primary care

Non-hip fragility fracture patients Objective 3: Early intervention to restore

independence – through falls care

pathway linking acute and urgent

care services to secondary falls

prevention

Individuals at high risk of 1st fragility fracture or other

injurious falls Objective 4: Prevent frailty, preserve

bone health, reduce accidents –

through preserving physical

activity, healthy lifestyles and

reducing environmental hazards

Older people

Package for older people Top priority

Prevent next fracture

• We need to prevent hip fractures as well as treat them well if they happen

– By responding to earlier fractures we could reduce the future incidence by ~25%

– This requires a Fracture Liaison Service model

– Can a FLS-database drive change similarly? 19

Earlier fractures signal the hip fracture Morbidity

Dependence

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age

No fractures –

increasing morbidity

due to ageing alone

Added morbidity from

fractures

Age Adapted from Kanis JA, Johnell O; 1999

Secondary prevention

• Secondary prevention is more cost-effective than primary prevention

45.3 44.6 45.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Lyles et al Edwards et al Mclellan et al

Per

cent

age

Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006

Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230

McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.

n=2124 n=632 n=701

Prevalence of prior fractures among patients presenting with hip fracture

National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London

0

10

20

30

40

50

60

Osteoporosis assessment

DXA referral (65-74 years)

Supplementation with calcium + D3

Treatment with osteoporosis medication

Per

cent

age

hip (n = 3184)

non-hip (n = 5642)

Target 100% 100% 100% ~70%

Interventions after fragility fracture

Capturing patients reliably

• Employment of a dedicated coordinator in the fracture service is the most effective system

NEW FRACTURE

EDUCATION PROGRAMME

EXERCISE CLASSES

FALLS RISK ASSESSMENT

INPATIENT ORTHO/TRAUMA WARD

OUTPATIENT FRACTURE CLINIC

PRESCRIPTION ISSUED BY GP

Rx FOR FRACTURE 2Y PREVENTION

McLellan et al OI 2003, 14:1028-1034.

Secondary prevention

• Secondary prevention is more effective than primary prevention

• A systems approach is needed, where capture of patients is automatic

• When it is done vigorously, it is cost-saving

Cost-saving

• Per 1000 fragility fracture patients, 18 fractures (11 hip) prevented – net saving £21,000

Central role of nurses • Acute care of elderly fracture patients

– Pathways

– Orthogeriatric liaison

– Trauma coordinator

• Secondary prevention – FLNs in fracture units

– FLNs in primary care

– Falls prevention

The FFN needs nurses • Only way to cope with the numbers

• Many parts of the world where nurses not allowed much independent action

• Great opportunity to spread good practice

Next Global Congress in Madrid

4-6th Sep 2014 www.ff-network.org