FLS-DB audit results update

MK JavaidAssociate Professor in Metabolic Bone Disease, University of OxfordHon Consultant Rheumatologist, Nuffield Orthopaedic CentreClinical lead RCP FLS DB audit programmeCo-Chair of IOF Capture the Fracture programmeNational Osteoporosis Society FLS Implementation Group

• These views are my own

• In last five years received honoraria, travel and/or subsistence expenses from: – Amgen, Eli Lilly, Medtronic, Norvartis, Proctor and

Gamble, Servier, Shire, Internis, Consilient Health, Stirling Anglia Pharmaceuticals

Why do we need the audit?

More than 80% of patients after a seeing a doctor with a fragility fracture

receive inadequate care.

van der Velde Bone 2016

UK Incident Use of Alendronate

osteoporosis crisis

ONJ lawsuit

Atr Fib AIM

Television AFF and BP

Jha JBMR 2015; Jarvenin BMJ 2015

Downloaded 2.3.2017

Ma 2017 Nature Scientific Reports

Ma 2017 Nature Scientific Reports

1 cmx 0.7cm

Interesting but

• Cases – Who of 8 BP patients were scanned– Definition of duration of treatment– Were most severe > treated vs. untreated– How orientated core tissue

– Why no more controls

– Real life test of strength is fracture!

Black Lancet 1996

PMO 55- 81Osteoporosis + VF1005 PBO1022 Alendronate 10mg daily

Real world data: effect of Alendronate prescriptions

Hawley 2016 JBMR

10,873 primary hip fracture patients April 1999 and Sept 2012

Real world data: effect of Alendronate prescriptions

Hawley 2016 JBMR

33% reduction in Hip fractures

Black 2016 NEJM; Kharazmi 2016 JBMR;

1 AFF per 137 Hip fractures averted

1: 1000 implantNO mortality

172 AFF vs 952 shaft/subtrochonteric

What about rare side effects?

Can FLS make a difference?

scale of problem for London

2014: 6,058 hip fractures3,495 other inpatient fractures13,747 outpatient fracturesTOTAL: 30,290 fragility fractures

Current investment

11

11

12

0 0.25 0.5 1

Whole time equivalentSpecialist nurses

BromleyKingstonRoyal LondonN. MidNorthwickNewhamSt Thomas’St MaryWhippsWhittington

BarnetEalingSt GeorgesQE WoolHillingdonHomertonKings CroydonRomfordSt HelierUCLC&W

LewishamRoyal Free

Current investment

11

11

12

0 0.25 0.5 1

Whole time equivalentSpecialist nurses

BarnetEalingSt GeorgesQE WoolHillingdonHomertonKings CroydonRomfordSt HelierUCLC&W

LewishamRoyal Free In 2014: 2526 hip fractures12,630 fragility fracture patients

BromleyKingstonRoyal LondonN. MidNorthwickNewhamSt Thomas’St MaryWhippsWhittington

Effective Secondary FracturePrevention

Marsh OI 2011, Eisman JBMR 2012

National Hip Fracture Database

Inpatient Falls Audit

FFFAP

What is an Fracture liaison services (FLSs)?

• Recommended by the Department of Health in 2009

• Improve secondary fracture prevention:– Identify– Investigation– Initiation therapy– Monitor

• Focus in bone health but also falls assessment/ management

Fracture Liaison Service Database Audits

• Part of the Falls and Fragility Fracture Audit Programme (FFFAP)

• a national audit at the Royal College of Physicians• commissioned by HQIP> focus = Quality improvement

• Included in 2015/16 listing for national audits

• Must be reported in the Trust’s Quality Account

• Part of the National Clinical Audit Patient Outcomes Programme (NCAPOP)

FLS-DB workstream

Clinical Lead: Dr M Kassim Javaid RCP : Catherine Gallacger, Sunil Rai, Naomi Vasilakis, Chris Boulton, Roz Stanley, Finbarr Martin

Constituency RCGP -Jonathan Bailey, David StephensBGS – Frances Dockery, Rachael BradleyOrthogeriatrics Celia Gregson BOA – Xavier GriffinBES - Neil GittoesBSR - Gavin ClunieNOS - Sonya Stephenson, Will Carr, Helen Williams, Tim Jones, Jo SayerRCN - Debbie Janaway, Clare CockillPPI – Iona PriceRCS - David Cromwell, Carmen TsangCrowne - Jonathan RobertsWales – Mike Stone

Aims

1. What proportions of fragility fracture patients are assessed for (i) osteoporosis and (ii) falls risk?

2. What proportion of patients is initiated on bone protection therapy within 4 months of fracture?

3. What proportion of patients is initiated on falls prevention intervention within 4 months of fracture?

4. What proportion of patients still persist with (i) bone protection and (ii) fall prevention treatment at 12 months

5. What proportion of patients have a subsequent fracture

Process

• FLS-DB Facilities audit

• FLS-DB Patient audit

Facilities audit: overview

• Funding

• Structure (people)

• Scope (case mix, identification, investigation, initiation, monitoring pathways)

AIM: Ensure the structure of FLS fit for purposeObjective: To describe the structure of an FLS in terms of:

constitution and patient processMethod: Annual facilities audit

Google FLS DB

Results

• 82 sites entered data (estimated to be just under half of eligible sites).

• 52 sites had an FLS. Of these: – 27 reported that they provided a multi-factorial falls

risk assessment (MFRA).– 16 reported that they referred patients on for a MFRA.– 9 did not report doing either.

Reported number of patients identified by FLS (n=52) vs estimated fragility fracture caseload

Most FLSs did not see as many patients as expected: 24% FLSs >80% estimated

caseload

57% FLSs < 50% caseload

FLSDB RCP report 2015

Key findings – Falls interventions

Therapeutic exercise is the best-evidence intervention for falls prevention

• 19 FLSs could refer to exercise programmes• 18/19 FLSs reported this was a validated exercise

programme • Only 4 FLSs reported that the standard total

duration of recommended exercise (supervised and unsupervised) was 50+ hours

Patient audit: overview

• Identification• Investigation• Initiation• Monitoring for prescribing• Re-fracture/ re-falls

AIM: Ensure the FLS works for its patients Objective: To describe the pathway of patients Method: Annual patient audit upload vs. direct data entry

Patient level audit

Why do we need to collect this?

Compare outcomes between sitesneed to take into account these differences

Patient level audit18,356 in fist 6 months38 FLSs Highlight sites with good quality and areas to improve

Reporting Key performance indicators

Demonstrating FLS quality: real time

1.04 NHS N

umber

1.08 CareRes

1.09 DateFLSContact

1.10 DateFLSAsse

ss

1.11 AdmitHosp

1.12 DateDiagnosed

1.13 TypeOfFractu

re

1.14 SiteFirs

tFrac

2.01 Height

2.02 Weight

2.03 PrevFracH

ist

2.04 FamHipFracHist

2.05 Smoker

2.06 BoneSpareTherapy

3.01 DXA

3.02 DXANotOrdered

3.03 DateofDXA

3.04 TScore

3.05 RiskOfFractu

re

4.01 BoneTherapy

4.02 CalciumVitD

Rec

5.01 RiskAsse

sByF

LS

5.10 Referrals

6.01 FollowUp12_16

6.02 Dateof16WeekA

ss0

20406080

100120

Data completeness

Oxford National

Perc

ntag

e of

case

s sub

mitt

ed (%

)

Started bone therapy by first follow-up

First follow-up was within 4 months

Time to first follow-up

Help is at hand

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User group workshops5th May London & 8th May Manchester

1000 Registration1030 Introduction to FLS DB - AG1045 Crown demonstration of website: how to import your data/ run chart1115 How we did it. (Musgrove-London)(Oxford-Manchester)1145 Dos and Don’t for submitting to the FLS DB

1215 Lunch1300 New Webtool Developments1330 Review of data definitions for patient audit1400 Facilities audit update1420 Small group working for practical support 1500 Future plans for data deadlines reports and new run charts1520 Final discussion1530 Close

Sign up today

Report Published 26th April 2017

Next Data upload End June 2017> Published Nov 2017

Patient level audit18,356 in fist 6 months > 35,000

38 FLSs Highlight good quality Highlight effective services Highlight priority for quality improvement

Same money different way More money efficient way

Summary

Run chartsFeedback > KPI• National public soon• Site public….

FLS-DB workstream

Clinical Lead: Dr M Kassim Javaid RCP : Catherine Gallacher, Sunil Rai, Naomi Vasilakis, project coordinator, Chris Boulton, Roz Stanley, Finbarr Martin

Constituency RCGP -Jonathan Bailey, David StephensBGS – Frances Dockery, Rachael BradleyOrthogeriatrics Celia Gregson BOA – Xavier GriffenBES - Neil GittoesBSR - Gavin ClunieNOS - Sonya Stephenson, Will Carr, Helen Williams, Tim Jones, Jo SayerRCN - Debbie Janaway, Clare CockillPPI – Iona PriceRCS - David Cromwell, Carmen TsangCrowne - Jonathan RobertsWales – Mike Stone

Report Published 26th April 2017

Next Data upload End June 2017> Published Nov 2017

Highlight good quality Highlight effective services Highlight priority for quality improvement

Same money different way More money efficient way

Improve quality of services> Fracture reduction

Summary

Run chartsFeedback > KPI• National public soon• Site public….

Work with orthopaedic / radiology colleagues> Support FLS

Key findings – Falls assessments

• Of the FLSs that provide a MFRA there was variation in the content: – 93% (25) asked about the number of falls in the past 12 months– 67% (18) included a medication review – 63% (17) included an assessment of gait, balance and mobility– 52% (14) recorded lying and standing blood pressure– 41% (11) included a formal assessment of cognition– 33% (9) included a vision assessment