paul mitchell - synthesis medical nz ltd - reviewing best practice guidelines for hip fracture...

Best practice guidelines for hip

fracture management:

International experience

Paul Mitchell

Deputy Chair, Osteoporosis New Zealand

Adjunct Senior Lecturer, University of Notre Dame Australia

Managing Director, Synthesis Medical Ltd - New Zealand and UK

2nd December 2013

Current trends in hip fracture management guidelines

2nd Annual Hip Fracture Management Conference, Melbourne, Australia

„We are not here to comment upon the world,

We are here to change it‟

Professor David Marsh

President - Fragility Fracture Network

1st FFN Global Congress

6th September 2012, Berlin, Germany

U.N. World Population Prospects 2012 Revision

http://esa.un.org/wpp/

http://esa.un.org/wpp/

Australia and New Zealand

Population ageing

The „Osteoporotic Career‟

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 thirty year journey

fuelled by decreasing bone strength and increasing falls risk’2

Opportunities for intervention

Non-hip fragility fracture

Fracture Free for Life

Hip Fracture Free for Life

Secondary non-hip fragility fracture

Hip fracture

Unrecognised vertebral fragility fracture


Fracture Free Recovery


Second hip fracture

Fracture Free at Fifty

„Signal‟ or „Herald‟ Fractures

An opportunity to break the fragility fracture cycle

Department of Health in England. Herald Fractures: Clinical burden of disease and financial impact. December 2010

Good

outcome Very bad

outcome

Hip fracture care and prevention in the UK

Consensus on the need for a systematic approach

Patient

society

Policy

makers

Professional

organisations

Professional consensus guidance on hip fractures

2007 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 Book

2. National Hip Fracture Database

3. NHFD Toolkit – Version 3

All available at http://www.nhfd.co.uk/

http://www.nhfd.co.uk/

2007 Blue Book and National Hip Fracture Database

Clinical standards link Blue Book1 to NHFD2:

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

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

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 acute 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

1. BOA-BGS 2007 Blue Book

2. National Hip Fracture Database

Both available at http://www.nhfd.co.uk/


Adoption of FLS across the UK

The NOS Manifestos for England/Scotland/Wales/N.I.

http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818

http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818

Hip fracture care and prevention in the UK

A consensus on a systematic approach

Patient

society

Policy

makers

Professional

organisations

1 1 + 4 =

Falls and fracture care and prevention

A road map for a systematic approach in the UK

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 people

Objective 4: Prevent frailty, preserve bone

health, reduce accidents – through

preserving physical activity, healthy lifestyles

and reducing environmental hazards

Stepwise

implementation

- based on size

of impact

DH Prevention Package for Older People

Acute hip fracture care

National Hip Fracture Database Report

Acute care & secondary prevention for >60,000 cases p.a.

NHFD National Report 2013 Available from www.nhfd.co.uk


2013 National Hip Fracture Database Report

Blue Book core standards

1. 50% of patients are admitted to an orthopaedic ward within four hours

2. 86% receive surgery within 48 hours

3. 3.5% are reported as having developed pressure ulcers

4. 47% are reported as assessed pre-operatively by an orthogeriatrician

5. 69% are discharged on bone protection medication

6. 94% received a falls assessment prior to discharge



UK National Hip Fracture Database 2013 National Report

Identifying and understanding variation


Best Practice Tariff: Linking quality to payment

1. Surgery within 36 hours

2. Shared care by surgeon and geriatrician

3. Care protocol agreed by geriatrician, surgeon and anaesthetist

4. Assessment by geriatrician within 72 hours

5. Geriatrician-led multi-disciplinary rehabilitation

6. Secondary prevention of falls

7. Bone health assessment (i.e. osteoporosis)

8. Pre- and post-operative abbreviated mental test score assessment (2012-)




Best Practice Tariff: Linking quality to payment



National Institute for Health and Clinical Excellence

Clinical Guideline 124 and Quality Standard 16

http://www.nice.org.uk

http://www.nice.org.uk/


The purpose of Quality Standards

http://guidance.nice.org.uk/QS16

• Set of specific, concise statements and associated measures

• Aspirational but achievable makers of high-quality, cost effective

patient care

• Derived from best available evidence

• Address three dimensions of quality:

– clinical effectiveness

– patient safety

– patient experience




Quality Standard 16: Quality Statements 1-6


• Statement 1. People with hip fracture are offered a formal Hip Fracture Programme from

admission.

• Statement 2. The Hip Fracture Programme team retains a comprehensive and continuing clinical

and service governance lead for all stages of the pathway of care, including the policies and

criteria for both intermediate care and early supported discharge.

• Statement 3. People with hip fracture have their cognitive status assessed, measured and

recorded from admission.

• Statement 4. People with hip fracture receive prompt and effective pain management, in a

manner that takes into account the hierarchy of pain management drugs, throughout their hospital

stay.

• Statement 5. People with hip fracture have surgery on the day of, or the day after, admission.

• Statement 6. People with hip fracture have their surgery scheduled on a planned trauma list, with

consultant or senior staff supervision.




Quality Standard 16: Quality Statements 7-12


• Statement 7. People with displaced intracapsular fracture receive cemented arthroplasty, with the

offer of total hip replacement if clinically eligible.

• Statement 8. People with trochanteric fractures above and including the lesser trochanter (AO

classification types A1 and A2) receive extramedullary implants such as a sliding hip screw in

preference to an intramedullary nail.

• Statement 9. People with hip fracture are offered a physiotherapist assessment the day after

surgery and mobilisation at least once a day unless contraindicated.

• Statement 10. People with hip fracture are offered early supported discharge (if they are eligible),

led by the Hip Fracture Programme team.

• Statement 11. People with hip fracture are offered a multifactorial risk assessment to identify and

address future falls risk, and are offered individualised intervention if appropriate.

• Statement 12. People with hip fracture are offered a bone health assessment to identify future

fracture risk and offered pharmacological intervention as needed before discharge from hospital.



Systematic hip fracture prevention

Fracture Liaison Service

Service structure

(Adapted from) BOA-BGS 2007 Blue Book. http://www.nhfd.co.uk/

* Older patients, where appropriate, are identified and referred for falls assessment

New Fracture Presentation

Emergency Department

Orthopaedic Trauma

Emergency Department

& X-Ray

Orthopaedics Inpatient ward

1. FLS identifies fracture patients 2. FLS assessment

Outpatient Fracture clinic

Osteoporosis treatment

Falls risk assessment*

Exercise programme

Education programme

Comprehensive communication of management plan to GP supported by fully integrated FLS database system


• Offer assessment to all patients over 50 years presenting with a fragility fracture

• Glasgow FLS is delivered by a Nurse Specialist supported by a Lead Clinician in Osteoporosis

• Nurse Specialist identifies patients with new fragility fractures:

– admitted to the orthopaedic inpatient ward, and

– managed as outpatients through the fracture clinic

• The Nurse Specialist arranges attendance of appropriate patients at the “one stop” FLS clinic

where BMD is measured by DXA to assess future fracture risk

• Treatment for secondary fracture prevention initiated by the FLS when merited on basis of future

fracture risk

• Older patients, where appropriate, are identified and referred onto the falls service/falls pathway

• Long-term management plans agreed by protocol with local general practice

Fracture Liaison Service

The Glasgow Model: aims and service structure

1. Best Prac Res Clin Rheum 2005;19:6:1081-1094 Gallacher SJ

2. Osteoporosis International 2003;14(12):1028-1034 McLellan AR et al

3. Calcif Tissue Int 2007;81:85-91 Langridge CR et al

Centre

operating

FLS

NHS Quality Improvement Scotland national audit

FLS 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.

NHS Quality Improvement Scotland national audit

FLS vs other models: Outcome after wrist 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

Fracture Liaison Services

Effectiveness is dependent in intensity of the model

1. Osteoporos Int. 2013 Feb;24(2):393-406 Ganda K et al

2. Osteoporosis Canada. Make the FIRST break the LAST with Fracture Liaison Services

Model

Description

Proportion receiving

BMD testing

Proportion receiving

osteoporosis

treatment

Status

Quo

Manitoba statistics for

major osteoporotic

fractures (2007/2008) 13% 8%

Type D (Zero

i model)

Only provides osteoporosis

education to the fracture

patient. Primary care

provider (PCP) is not

alerted or educated.

No study on

BMD testing 8%

Type C (1 i model)

1. Identification

The PCP is alerted that a

fracture has occurred and

further assessment is

needed. Leaves the

investigation and initiation

of treatment to the PCP.

43% 23%

Type B (2 i model)

1. Identification

2. Investigation

Leaves the initiation of

treatment for fragility

fracture patients to the

PCP.

60% 41%

Type A

(3 i

model)

1. Identification

2. Investigation

3. Initiation of

osteoporosis treatment

where appropriate.

79% 46%

http://www.osteoporosis.ca/


Significantly reduce re-fracture rates

• Australia: Concord FLS, Sydney

– Repeat fracture rates over a 4 year period were reduced by 80%

– 4.1% in the intervention group compared to 19.7% in the control group

• Canada: St. Michael‟s Hospital, Toronto

– Modelling of the FLS reported a 9% reduction of secondary hip fracture rates

within the first year of operation

• United Kingdom: Glasgow FLS, Scotland

– Between 1998 and 2008, hip fracture rates in Glasgow decreased by 7.3%

compared to a 17% increase during the same time period in England, where only

37% of localities operated an FLS by late 2010

• United States of America: Kaiser Permanente

– In 2008, a 37% reduction in the expected hip fracture rate was reported for the

population served by the Kaiser Permanente Southern California system

– This corresponds to the prevention of 935 hip fractures in the year 2006 (2,510

hip fractures were predicted by actuarial analysis, and 1,575 fractures were

actually observed)

References available on request. Email [email protected]

mailto:[email protected]

Incorporation of FLS into national policy

Department of Health Prevention Package

Department of Health. Prevention Package for Older People resources. Link.

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/dh_103146

International Osteoporosis Foundation

World Osteoporosis Day Report 2012

http://www.iofbonehealth.org/capture-fracture-report-2012








IOF Capture the Fracture Campaign

Best Practice Framework

Osteoporos Int. 2013 Aug;24(8):2135-52. PubMed ID 23589162

IOF Capture the Fracture Campaign

Globally endorsed standards of care

Osteoporos Int. 2013 Aug;24(8):2135-52. Åkesson K

Systematic approaches to hip fracture

care and prevention for

Australia and New Zealand

BoneCare 2020: Osteoporosis New Zealand

A systematic approach for New Zealand

http://www.bones.org.nz/


Hip

fracture

patients

Objective 1: Improve outcomes and quality

of care after hip fractures by delivering ANZ

professional standards of care monitored by

a new NZ National Hip Fracture Registry

Non-hip fragility

fracture patients

Objective 2: Respond to the first fracture to

prevent the second through universal access

to Fracture Liaison Services in every

District Health Board in New Zealand

Individuals at high risk of

1st fragility fracture or

other injurious falls

Objective 3: GPs to stratify fracture risk

within their practice population using fracture

risk assessment tools supported by local

access to axial bone densitometry

Older people

Objective 4: Consistent delivery of public

health messages on preserving physical

activity, healthy lifestyles and reducing

environmental hazards

Maximise cost-

effectiveness by

stepwise delivery


A systematic approach for New Zealand



Australian and New Zealand Hip Fracture Registry

A systematic approach to hip fracture care

http://www.anzhfr.org/


ANZ Guideline for Hip Fracture Care

Public Consultation until 13 December 2013



Australian and New Zealand Hip Fracture Registry

NZ Clinicians want it!

N Z Med J. 2013 Oct 18;126(1384):77-83. De Silva CU et al

„We advocate the

development of a

multicentre audit in NZ

hospitals‟


Fracture Liaison Services in New Zealand

http://www.national.org.nz/Article.aspx?ArticleId=41324

Another way we can help older people remain independent at home for longer

is by reducing the impact of osteoporosis and fragility fractures. To achieve

this goal, we have made it a priority for district health boards to implement

Fracture Liaison Services as part of their annual planning processes.

Fracture Liaison Services take a proactive approach to treating and

preventing fragility fractures in our older population. Led by nurse

practitioners, the services assess and treat fragility fractures and then,

importantly, carry out interventions to reduce the person‟s risk of future

fractures.

I look forward to seeing how Waikato DHB uses the new facilities and services

here at the Older Persons and Rehabilitation service to successfully

implement a Fracture Liaison Service and help reduce the number and

impact of fragility fractures amongst older people in Waikato.

http://www.national.org.nz/Article.aspx?ArticleId=41324

What happens next?

Peak oil

Peak hip fracture

Peak hip fracture

Objective:

Global peak hip fracture to be attained before the 28th FFN Global Congress

Additional slides


A cost-saving intervention

• In May 2011, a formal cost-effectiveness

analysis of the Glasgow FLS was published

• This study concluded that 18 fractures were

prevented, including 11 hip fractures, and

£21,000 was saved per 1,000 patients managed

by the Glasgow FLS versus UK „usual care‟

Osteoporos Int. 2011; 22(7):2083-98 Wolowacz SE et al

paul mitchell - synthesis medical nz ltd - reviewing best practice guidelines for hip fracture...

Health & Medicine

acute hip fracture care

interventionhip fracture

fracture liaison services

blue book standardsobjective

efficiency of care

blue book1

falls care pathway

urgent care services