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 2010

  • Putting FLS into context:Patients, professionals and policymakers

  • %In UK >250,000 fractures per yearAnnual cost >2billion

    Chart1

    23.30015109775.0928806328

    16.33188161055.2661985601

    9.88800995474.030752822

    8.55479512932.7908630344

    6.91938494362.839747578

    2.34645809260.9599146743

    2.06648297930.9776908719

    2.03537463340.5466180784

    1.30655052881.1110123545

    1.74206737180.6177228691

    0.71104790690.2621989157

    0.09332503780.0888809884

    0.06666074130.053328593

    0.00444404940

    FEMALE

    MALE

    Sheet1

    FEMALEMALEFEMALE

    Radius/ulna23.30015109775.0928806328524323.300151097711465.0928806328

    Hip16.33188161055.2661985601367516.331881610511855.2661985601

    Humerus9.88800995474.03075282222259.88800995479074.030752822

    Hand/foot8.55479512932.790863034419258.55479512936282.7908630344

    Ankle6.91938494362.83974757815576.91938494366392.839747578

    Tibia/fibula2.34645809260.95991467435282.34645809262160.9599146743

    Vertebra2.06648297930.97769087194652.06648297932200.9776908719

    Pelvis/pubic rami2.03537463340.54661807844582.03537463341230.5466180784

    Clavicle1.30655052881.11101235452941.30655052882501.1110123545

    Femur1.74206737180.61772286913921.74206737181390.6177228691

    Patella0.71104790690.26219891571600.7110479069590.2621989157

    Scapula0.09332503780.0888809884210.0933250378200.0888809884

    Rib0.06666074130.053328593150.0666607413120.053328593

    Sternum0.0044440494010.004444049400

    To 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.

    Chart1

    45.3

    44.6

    45.3833333333

    Percentage

    Percentage of patients with hip fracture reporting prior fragility fracture

    IBD

    Crohn's95CImin SEmax SEUlcerative colitis95CImin SEmax SE

    Hip # 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.

    IBD

    001.350.780.730.48

    001.10.670.70.47

    Hip # OR (adjusted)

    Hip # HR (adjusted)

    Relative risk of hip fracture in inflammatory bowel disease

    Diabetes

    Hip fracture risk in diabetics

    95 CIminmax

    5 studiesType 16.943.2517.483.6910.54

    8 studiesType 21.381.251.530.130.15

    Mean change in BMD Z score

    SpineSEminmaxHipSEminmax

    5 studiesType 1-0.220.01-0.23-0.21-0.370.16-0.53-0.21

    8 studiesType 20.410.010.40.420.270.160.110.43

    Diabetes

    6.9410.543.69

    1.380.150.13

    Relative risk

    Relative risk of hip fracture in diabetics95% confidence intervals

    Sheet1

    -0.220.41

    -0.370.27

    Type 1

    Type 2

    BMD Z score

    Differences in BMD in diabetes (80 studies)+/- standard error

    Fractures

    Influence 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 SD

    Siris, E.,et al. (2007) Osteoporosis International, 18, 761-770.Age 60+ years

    Follow up 15 years

    T score at F/N-2-3-4Agepostural swayF/N BMDFall in last year

    Fracture negative2.22.93.8Women (n=924)1.21.11.62.1

    Fracture positive3.85.06.41.01.01.31.6

    1.31.21.92.7

    Max0.10.10.30.6

    Min0.20.10.30.5

    Men (n=723)1.41.21.21.9

    1.11.011.2

    1.61.31.53.0

    Max0.20.10.31.1

    Min0.30.20.20.7

    Nguyen, 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 al45.3

    Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230.632Edwards et al44.6

    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.701Mclellan et al45.4

    N124744574225159701

    Prior #52.442.746.74644.939.645.4

    00

    00

    00

    Fracture negative

    Fracture positive

    T score at femoral neck

    Absolute non-vert # risk over 23 months

    Influence of prevalent vertebral fracture on absolute non-vertebral fracture risk at different BMDs

    000.10.20.20.3

    000.10.10.10.2

    000.30.30.30.2

    000.60.51.10.7

    Women (n=924)

    Men (n=723)

    RR per SD

    Independent risk factors for fracture in non-osteoporotics (age 60+ years, 15 years follow up)

    0

    0

    0

    Percentage

    Percentage of patients with hip fracture reporting prior fragility fracture

  • The 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 prevention

  • Key components of a FLSFracture case-findingFracture risk assessmentImplementation of fracture secondary prevention

  • Fracture 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/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 FLSPan-Greater Glasgow FLS3 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 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 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, 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):10281034

  • Fracture 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: 156-162

  • Ipswich 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 18984730

  • Kaiser PermanenteFLS Southern California StyleJBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

  • Kaiser 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 18984730

  • Putting FLS into context:Patients, professionals and policymakers

  • NHS Policy on fragility fracturesThroughout the Bone and Joint Decade 2000-2010National 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 people2Nov-2004

    NICE Technology Appraisal 161: Review of treatments for the secondary prevention of osteoporotic fragility fractures in post-menopausal women3Oct-2008

    All 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. Link

  • Fragility 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 risk2

  • Professional consensus guidance on hip fractures2007 Blue Book and National Hip Fracture DatabaseA systematic approach to hip fracture care and prevention1-3

    Hip fracture careBlue Book Chapter 1Effective ortho-geriatric services for hip fracture patientsUniversal National Hip Fracture Database participation

    Hip 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 fractures

    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 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_2008

  • RCP-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_2008

  • RCP-CEEU national organisational audit 2009 Falls and bone health servicesOpportunities to prevent recurrent falls and fractures are being missed

    2. Commi...

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