Putting FLS into context: Patients, professionals and policymakers

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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 year Annual cost > 2billion. %. - PowerPoint PPT Presentation

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Putting FLS into context:Patients, professionals and policymakersNational Osteoporosis SocietyFLS Education Programme October 2010Putting FLS into context:Patients, professionals and policymakers%In UK >250,000 fractures per yearAnnual cost >2billionChart123.30015109775.092880632816.33188161055.26619856019.88800995474.0307528228.55479512932.79086303446.91938494362.8397475782.34645809260.95991467432.06648297930.97769087192.03537463340.54661807841.30655052881.11101235451.74206737180.61772286910.71104790690.26219891570.09332503780.08888098840.06666074130.0533285930.00444404940FEMALEMALESheet1FEMALEMALEFEMALERadius/ulna23.30015109775.0928806328524323.300151097711465.0928806328Hip16.33188161055.2661985601367516.331881610511855.2661985601Humerus9.88800995474.03075282222259.88800995479074.030752822Hand/foot8.55479512932.790863034419258.55479512936282.7908630344Ankle6.91938494362.83974757815576.91938494366392.839747578Tibia/fibula2.34645809260.95991467435282.34645809262160.9599146743Vertebra2.06648297930.97769087194652.06648297932200.9776908719Pelvis/pubic rami2.03537463340.54661807844582.03537463341230.5466180784Clavicle1.30655052881.11101235452941.30655052882501.1110123545Femur1.74206737180.61772286913921.74206737181390.6177228691Patella0.71104790690.26219891571600.7110479069590.2621989157Scapula0.09332503780.0888809884210.0933250378200.0888809884Rib0.06666074130.053328593150.0666607413120.053328593Sternum0.0044440494010.004444049400To resize chart data range, drag lower right corner of range.To resize chart data range, drag lower right corner of range.The problemA fracture (any site) is associated with 2-3x increase in future fracture riskThe opportunityAppropriate targeting of treatment for osteoporosis halves future fracture risk (including risk of hip fracture)Missed opportunityLyles KW et al. ASBMR 2006. Abstract SA405Edwards BJ et al. Clin Orthop Rel Res 2007;461:226-230McLellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland. 2004.Chart145.344.645.3833333333PercentagePercentage of patients with hip fracture reporting prior fragility fractureIBDCrohn's95CImin SEmax SEUlcerative colitis95CImin SEmax SEHip # OR (adjusted)1.861.083.210.781.351.40.922.130.480.73Van Staa, et al. (2003) Inflammatory bowel disease and the risk of fracture. Gastroenterology, 125, 1591-1597.Hip # HR (adjusted)1.681.012.780.671.11.410.942.110.470.7Card, T., et al.(2004) Gut, 53, 251-255.IBD001.350.780.730.48001.10.670.70.47Hip # OR (adjusted)Hip # HR (adjusted)Relative risk of hip fracture in inflammatory bowel diseaseDiabetesHip fracture risk in diabetics95 CIminmax5 studiesType 16.943.2517.483.6910.548 studiesType 21.381.251.530.130.15Mean change in BMD Z scoreSpineSEminmaxHipSEminmax5 studiesType 1-0.220.01-0.23-0.21-0.370.16-0.53-0.218 studiesType 20.410.010.40.420.270.160.110.43Diabetes6.9410.543.691.380.150.13Relative riskRelative risk of hip fracture in diabetics95% confidence intervalsSheet1-0.220.41-0.370.27Type 1Type 2BMD Z scoreDifferences in BMD in diabetes (80 studies)+/- standard errorFracturesInfluence of a prevalent vertebral fracture on absolute non-vertebral fracture risk over 23 monthsIndependent risk factors for fracture in non-osteoporotics: change in risk per SDSiris, E.,et al. (2007) Osteoporosis International, 18, 761-770.Age 60+ yearsFollow up 15 yearsT score at F/N-2-3-4Agepostural swayF/N BMDFall in last yearFracture negative2.22.93.8Women (n=924)1.21.11.62.1Fracture positive3.85.06.41.01.01.31.61.31.21.92.7Max0.10.10.30.6Min0.20.10.30.5Men (n=723)1.41.21.21.91.11.011.21.61.31.53.0Max0.20.10.31.1Min0.30.20.20.7Nguyen, N. D., et al. (2007) J Clin Endocrinol Metab, 92, 955-962.Prior # and hip #Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 20062124Lyles et al45.3Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230.632Edwards et al44.6McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.701Mclellan et al45.4N124744574225159701Prior #52.442.746.74644.939.645.4000000Fracture negativeFracture positiveT score at femoral neckAbsolute non-vert # risk over 23 monthsInfluence of prevalent vertebral fracture on absolute non-vertebral fracture risk at different BMDs000.10.20.20.3000.10.10.10.2000.30.30.30.2000.60.51.10.7Women (n=924)Men (n=723)RR per SDIndependent risk factors for fracture in non-osteoporotics (age 60+ years, 15 years follow up)000PercentagePercentage of patients with hip fracture reporting prior fragility fractureThe ChallengeCan systematic post-fracture assessment for fracture secondary prevention be delivered cost-effectively to an entire healthcare region?Aim of the Fracture Liaison ServiceTo 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 preventionKey components of a FLSFracture case-findingFracture risk assessmentImplementation of fracture secondary preventionFracture Liaison ServiceFAQIs FLS more effective than usual services for effecting fracture secondary prevention?Does FLS reduce incidence of fractures?Is FLS cost-effective?Fracture Liaison ServiceFAQIs 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 modelsA 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 centreNHS 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 wrist fracture by centreNHS 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 modelsAudit findings:95% of wrist fracture patients were offered assessment and/or treatment at the FLS centre in comparison to 21% at centres without an FLS97% percent of hip fracture offered assessment and/or treatment at the centre with an FLS versus 25% at the centres with other service structuresFracture Liaison Service model closed secondary prevention gap for patients presenting to hospital with new fragility fracturesNHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.Fracture Liaison ServiceFAQIs FLS more effective than usual services for effecting fracture secondary prevention?Does FLS reduce incidence of fractures?Is FLS cost-effective?The Glasgow FLS1999: West Glasgow FLS1 centre: population 250K: 1500 fractures/yr2002: Pan-Greater Glasgow FLS3 centres: population 1M: 6500 fractures/yr2009: Pan-Greater Glasgow & Clyde FLS 5 centres: population 1.4M: 9000 fractures/yrThe Glasgow FLSPan-Greater Glasgow FLS3 centres: population 1M: 6500 fractures/yr>50,000 fracture patients managed by FLS since 19991998-2008: Emergency admissions with hip fracture (codes S.72.0-72.2) by 7.3% in context of FLS & falls strategySkelton & 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 ServiceFAQIs FLS more effective than usual services for effecting fracture secondary prevention?Does FLS reduce incidence of fractures?Is FLS cost-effective?FLS: cost-effectiveness evaluationWest Glasgow FLSFirst 8 years data: 11,096 fracture patientsAge 50-104, 78% women 80% underwent FLS assessment49% had DXA + 17% compliance review w/o DXA14% treated with Calcium and Vitamin D w/o DXAOverall 60% were treatedPer 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, PreventionFracture 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):10281034Fracture Liaison ServiceFAQIs 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 UKClunie, 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: 156-162Ipswich Hospital NHS Trust FLSClunie and Stephenson. Journal of Orthopaedic Nursing (2008) 12, 156162*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: 156-62Ipswich Hospital NHS Trust FLSPatients by type of fracture and total numbers 2y data. FractureAge range45-59y60-69y70-79y80-89y90y+TotalTotal 2*Hip2444179345154746124Forearm1951711857312636106Humerus45415420616628Lower Limb1331006528833456Pelvis431733137012Spine5618116468Other1841209535343773Not specified211612915910Total6115016255542032491Total 2*9578988732390*Fracture Liaison ServiceOther exemplars from USA Kaiser Permanente - Southern CaliforniaJBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730Kaiser PermanenteFLS Southern California StyleJBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730Kaiser PermanenteFLS Southern California StyleI'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 MDJBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730Putting FLS into context:Patients, professionals and policymakersNHS Policy on fragility fracturesThroughout the Bone and Joint Decade 2000-2010National Service Framework for Older People. Section 6 Falls1 Mar-2001NICE Clinical Guideline 21: Clinical practice guideline for the assessment and prevention of falls in older people2Nov-2004NICE Technology Appraisal 161: Review of treatments for the secondary prevention of osteoporotic fragility fractures in post-menopausal women3Oct-2008All highlight need for osteoporosis and falls assessment to be provided to patients with a history of fragility fracture1. NSF for Older People. Section 6 Falls. DH. Link2. NICE Clinical Guideline 21 Falls. Link3. NICE Technology Appraisal 161. Secondary prevention. LinkFragility fracture through the life span1Osteoporosis + falls = fragility fractures1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJHip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk2Professional consensus guidance on hip fractures2007 Blue Book and National Hip Fracture DatabaseA systematic approach to hip fracture care and prevention1-3Hip fracture careBlue Book Chapter 1Effective ortho-geriatric services for hip fracture patientsUniversal National Hip Fracture Database participationHip fracture preventionBlue Book Chapter 2An FLS for every hospital to identify all new fragility fracture patientsPro-active case-finding of all unassessed prior fragility fracture patients1. 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 DatabaseClinical standards link Blue Book to NHFD1,2:All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fracturesAll patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls1. 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 DatabaseThe 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 servicesNational 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_2008RCP-CEEU national organisational audit 2009Reported by SHA, NHS Trust and PCTNational 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_2008RCP-CEEU national organisational audit 2009 Falls and bone health servicesOpportunities to prevent recurrent falls and fractures are being missed2. Commissioning is patchy, rarely providing a coordinated falls and fracture strategy3. 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_2008RCP-CEEU national organisational audit 2009RecommendationsPrimary care organisations (PCOs) should develop commissioning strategies that include:Case finding systems in hospital and community settings to identify high risk fallersAdherence to NICE treatment guidelines with monitoring by local auditClinical leaders including a consultant with job plan commitment A Fracture Liaison ServiceWidespread and accessible evidence-based exercise programmesTargeted use of validated home safety assessmentsNational 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_2008RCP-CEEU national organisational audit 2009RecommendationsThe Department of Health should review how it can best support these developments by:Provision of advice on commissioningStrengthening incentivesProvision of useful metrics for falls prevention, fractures and osteoporosis treatmentsAdoption 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 approachDepartment of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social careFalls and fracture care and preventionA road map for a systematic approachDepartment of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social careThe Coalition Government and OsteoporosisComments from the new Healthcare LeadersAndrew Lansley MPMonday 5th Oct 2009While 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 2009Osteoporosis: 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 2009The 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.Andrew Lansley MP. Speech in Manchester . 05-10-2009Andrew Lansley MP. Parliamentary Question. 29-06-2009David Cameron MP. Speech in Bolton. 20-08-2009Hip fracture care and prevention in the UKKey developmentsPublication of RCP-CEEU organisational audit1Publication of the NOS Manifesto2Chapter 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 IrelandPublication of DH Prevention Package for Older People & BPTOngoing Blue Book Coalition of the Willing initiatives1. 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_20082. 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=311Context of patient experiencecost, type of fracturesfracture leads to increased fracture riskAppropriate treatment = reduced riskevidence in 2 major studies. Hip fractures could have been prevented?Can we reverse thisage threshold debate higher threshold if resources are tight. Defer this question for further exploration in workshops*These are the questions that will come uppresentation seeks to answer these.*Audit in Scotland 200-2003 by NHS QIS. Bullet points raise the key points of this audit. illustrated in subsesquent slides *FLS = more likely to result in post FNOF assessment*FLS again lead to increase of assessment for wrist fracture*FLS closes secondary care gapThe evolution of the Glasgow FLSaudit has found reduction 7.3% combining FLS and falls measures. In England hip fracture rates continue to rise by 17%.Consideration given to whether other factors could have influenced this outcome. Looking at demographic information to test whether information is robust.Health economic analysis modelled over 8 year of data. Highly cost effective and cost saving. Multiply this up by populations and the savings are more significant for a population of 9000 = loads! QALY reductions Modelling based on NICE for compliance etc. More sophisticated modelling than DH cost effectiveness which was quite simplistic. Very robust. Though not dissimilar output. NET financial gain. Nurse delivered model - doctors are cost ineffective!align with QIPP agenda*One model doesnt fit all. There are many other examples within the UK of sustainable services. The next presentation will explore how FLS has been implemented in the specific region where the meeting is being held. Here we will give more detail about the Ipswich FLS which is another well documented service, where the service is provided differently to Glasgow. The effect is the same.Configuration of Ipswich FLS. The same team of nurses that operate the orthogeriatrician care input on the ward, screen inpatients for The FLS. Outpatients with fracture are invited by letter to a further (FLS) clinic, having been picked up from clinic lists. DXA scan in those