Fracture Liaison Service and nhfd Local provision in London

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1 Fracture Liaison Service and nhfd Local provision in London Dr Louise Dolan Consultant Rheumatologist Queen Elizabeth Hospital, Woolwich South London NHS Trust

2 Fracture liaison Service Systematic assessment of patients presenting with fracture for osteoporosis to reduce their future fracture risk McCellan 2003 Osteoporosis Int

3 A systematic approach to fracture prevention Post-menopausal women with new fracture each year Post-menopausal women with prior fracture history 0.2 million 1.8 million Fracture Liaison Services GP case-finding + Direct Access DXA Services Post-menopausal women with osteoporosis Post-menopausal women 3.4 million 11.1 million GP case-finding stratified by risk + Direct Access DXA Services (Adapted from) Curr Med Res Opin 2005;21:4: Brankin E et al

4 The Glasgow FLS Pan-Greater Glasgow FLS 3 centres: population 1M: 6500 fractures/yr >50,000 fracture patients managed by FLS since 1999 Emergency admissions with hip fracture (codes S ) by 7.3% (in context of FLS & falls strategy) Skelton & Neil n% _an%20evaluation_skelton%20and%20neil% pdf

5 FLS: cost-effectiveness evaluation West Glasgow FLS First 8yrs data: 11,096 fracture patients Age , 78% women 80% underwent FLS assessment 49% had DXA + 17% compliance review w/o DXA & 14% treated with Ca/vitD w/o DXA: overall 60% were treated Per 1000 fracture patients 18 fewer fractures (incl 11hip fractures) Cost saving 26,000 (after assessment & drug costs) McLellan et al NOS meeting abst

6 RCP-CEEU national organisational audit 2009 London data on FLS 4/23 FLS 1. National Audit of the Organisation of Services for Falls and Bone Health for Older People Available for download from:

7 Refining the service The Role of the fracture intervention nurse Colles fracture Hip Fracture DEXA SCAN Nurse Assessment Falls assessment Lifestyle advice Education Advice on management to GPs Nurses see those who are osteoporotic. Letters to rest Telephone F.U at 6 weeks to check treatment OK Dexa repeated at 18 months for osteoporotic patients

8 FITOS Word recognition softwear in case finding AUDIT Data was collected on patients attending breast clinics in a 3 month period Oncologist dictates a letter to GP which the secretary types 83 postmenopausal women were identified on AIs 53 of these were referred to Osteoporosis Services. 30 patients were over 80 so their GPs were prompted to initiate treatment to reduce fracture risk. Automatically referred to BMD service Yes FITOS identifies if the patient meets criteria for referral to Dexa services from the text in the letter to the GP No In 7 months prior to FITOS only 17 were identified (2.4/month). Text automatically inserted into letter to the GP with advice on referral for DEXA Text not inserted into letter for the GP FITOS increased referrals to Osteoporosis Services from Oncology by nearly 10 times.

9 Osteoporosis Management at Queen Elizabeth, Woolwich Fracture clinic GPs DEXA SCANNER Fracture liaison service Consultant Osteoporosis clinic Nurse led IV bisphosphonate service Breast service AI patients

10 It is now possible to use Fan beam DXA images to assess spine morphometry at densitometry.

11 FLS Follow up results 288 osteoporotic patients seen by FLS over 18months 279 were commenced on active treatment. 86 patients had been recalled for repeat scans after 18 months, by time of this review. 72 (84%) were continuing treatment (51% weekly Alendronate, 29% weekly Risedronate, 11% Calcium D3 alone, 7% Raloxifene). 7/72 had changed their treatment from initial prescription. Bisphosphonate adherence was 81%. This audit demonstrates a high adherence to osteoporosis treatment (84%) in a FLS clinic setting

12 NHFD data collection FLS nurses visit Ortho wards 3x a week Nurses keep diary of patient information and date of operation. Sticker at day 30 Ward clerk keeps info on discharge destination Contact patient by phone Sticker in diary for day % 30day data Simples!

13 Pre operative assessment

14 Fracture liaison Service A cost effective way of improving post fracture care Easy to integrate into nhfd

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