Fracture Liaison Service database-first review of patient data

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1 Fracture Liaison Service database-first review of patient data Professor Finbarr C Martin Clinical lead for the National Falls and Fragility Fracture Audit Programme (emeritus consultant geriatrician, Guy s and St Thomas NHS Trust)

2 FLS-DB workstream Clinical Lead: Dr M Kassim Javaid RCP : Catherine Gallagher, Sunil Rai, Naomi Vasilakis, Chris Boulton, Roz Stanley, Finbarr Martin Advisory Structure RCGP Jonathan Bailey, David Stephens BGS Frances Dockery, Rachael Bradley Orthogeriatrics - Celia Gregson BOA Xavier Griffin BES Neil Gittoes BSR Gavin Clunie NOS Sonya Stephenson, Will Carr, Helen Williams, Tim Jones, Jo Sayer RCN Debbie Janaway, Clare Cockill PPI Iona Price RCS David Cromwell, Carmen Tsang Crowne Informatics- Jonathan Roberts Wales Mike Stone

3 The purposes of national audits To produce credible relevant data on clinical performance to enable comparison about processes or outcomes for clinical units or individuals or mangers, with Own performance over time National (benchmarking) comparisons now and historical Standards (eg NICE) Indication to Commissioners (or equivalent) about their use of resources and priorities for investment Quality measures for regulators (eg CQC in England) Transparency for patients and the public Observational data for new knowledge (research) Platform for planned research, eg RCTs

4 A Strategy for Falls and Fragility Fracture Care and Prevention (DH 2009) Limited resource: maximize value ORTHOGERIATRICS FLS FALLS 16% population 84% population Hip fractures 50% 50%

5 Falls risk 4.3 billion/ year More bed days than stroke 500,000 Fragility Fractures in UK Osteoporosis Fall from standing height or less Exclude digits, scaphoid, face, skull 68,000 / yr 20% 1yr mortality 14K in one year Chronic pain +14 GP visits/ yr 50% poor outcome Predict future fracture Dolan P and Torgerson DJ. OI 1998;8: NHFD 2015; Leal OI 2016

6 Anti-osteoporosis medication 20 70% reduction in fractures (cf 28% reduction with antihypertensives for recurrent stroke) Effective secondary fracture prevention in NHS would prevent 54,000 avoidable fragility fractures over 5 years in the UK Great opportunity to address variation improve population health focus local efforts based on data

7 What is a Fracture Liaison Service (FLS)? 2009 Recommended by DH Ensure: identification, investigation initiation of treatment monitoring.. are consistently and systematically delivered Not- education/ advice to other healthcare professionals / patients Sale OI 2011

8 Standards for Secondary Prevention NICE CG 146 on assessing the risk of fragility fracture. NICE Technology Appraisals TA 161, TA204, on drugs NICE CG161 and QS86 on falls prevention National Osteoporosis Society 2015: Effective secondary prevention of fragility fractures: clinical standards for fracture liaison services.

9 FLS Facilities audit sites participated in this audit. 52 sites reported having a dedicated FLS. Key findings: 1. Most FLSs are not seeing numbers expected. 2. Types of fractures seen varied 3. Investigations inconsistent % of FLS completed a falls assessment but not standardised % delegated monitoring to primary care

10 FLS-Database clinical audit report: April st national audit of FLS Participation 52 FLSs participated in the facilities audit. 38 (73%) FLSs submitted patient level data on 18,356 patients.

11 If you did, thanks very much for taking part!!

12 Fracture Liaison Services- Database (FLS-DB) Key questions 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? (from subsequent information)

13 Web based audit design Section 1 - Patient identification Section 2 - Investigation of bone health Section 3 - DXA Section 4 - Treatment initiation Section 5 - Falls risk assessment and outcome Section 6 - Follow-up weeks post index fracture

14 aged 50yrs + Target patient population fragility fracture between 1 January and 30 June 2016 NICE TA definition states Fragility fracture: fracture occurring as the result of a force equivalent to the force of a fall from a height equal to, or less than, the height of an ordinary chair.

15 Data completion The audit had encouraging levels of completeness for data items, both between FLSs and at a national level. Missing Missing Audit question n % 1.10 Date of FLS assessment 4, Current height (metres) 8, Current weight (kg) 8, Previous fragility fracture history in adulthood 6, Family history of hip fracture 6, Current smoker 6, At time of index fracture, patient on/taking bone-sparing therapy 6, Date of DXA* based on 3.01=ordered 2, Was the patient s risk of fracture assessed using FRAX or QFracture? 8, Bone therapy recommended following index fracture 6, Calcium/vitamin D supplement recommended following index fracture 5, Was a falls risk assessment performed by FLS? 5, Referrals following falls risk assessment 9, RED = completion <80% <50% FLS name Number of cases submitted Uploaded in bulk (Y/N) Number of fields (out of 29) with 20% or more missing data Number of fields (out of 29) with 50% or more missing data Barnet Hospital Fracture Liaison Service 156 N 3 0 Bromley Healthcare Falls and Fracture Prevention Service 283 Y 2 1 Broomfield Hospital 382 N 9 9 Dorset County Hospital 536 N East Lancashire Hospitals NHS Trust 273 N 3 1 East Surrey Hospital 233 N 2 2 FLS West Berkshire 358 Y 3 3 Guys and St Thomas' NHS Foundation Trust 284 Y King's College Hospital - Denmark Hill Site 79 N 7 7 Medway NHS Foundation Trust 436 N Milton Keynes University Hospital Foundation Trust 134 Y Musgrove Park Hospital 811 Y 0 0 North Bristol NHS Trust 1111 Y 9 2 North Tees and Hartlepool NHS Foundation Trust 553 N 9 5 Nottingham University Hospitals 1250 Y Oxfordshire Fracture Prevention Service 1210 Y 7 5 Peterborough and Stamford Hospitals NHS Foundation Trust 260 N 2 0 Poole General Hospital 69 Y Portsmouth and Southeast Hampshire 936 Y Queen Elizabeth Hospital, Woolwich 109 N 7 7 Royal Surrey County Hospital 251 N 1 0 Royal Wolverhampton Hospital NHS Trust 285 N Sandwell and West Birmingham Hospitals NHS Trust 86 Y St George's Hospital 725 Y 15 7 Sunderland Royal Hospital 584 N 2 0 The Haywood Hospital Burslem Stoke on Trent 644 N 0 0 The Hillingdon Hospitals NHS Foundation Trust 110 N 0 0 The Ipswich Hospital NHS Trust 944 N 14 4 The Rotherham NHS Foundation Trust 109 N 8 8 United Lincolnshire Trust 1218 Y University Hospital Lewisham 191 N 11 4 University Hospital Llandough 344 N 10 2 University Hospital North Durham and Darlington Memorial Hospita 835 N 14 0 University Hospitals Birmingham NHS Foundation Trust 643 Y 4 2 University Hospitals Bristol NHS Foundation Trust 679 N 12 5 West Suffolk Fracture Liaison Service 219 N 3 0 Wye Valley NHS Trust 231 N 4 2 Yeovil Hospital 795 Y 6 0 Overall

16 % Identification: by fracture type Nottingham United Lincolnshire Oxfordshire North Bristol NHS The Ipswich Portsmouth & University Hospital Musgrove Park Yeovil Hospital St George's University The Haywood University Sunderland Royal North Tees and Dorset County Medway NHS University Trust [221, 47, 946, Fracture Trust [249, 37, 824, Hospital NHS Trust Southeast North Durham & Hospital [213, 34, [158, 112, 525, 0] Hospital [141, 70, Hospitals Bristol Hospital Burslem Hospitals Hospital [136, 25, Hartlepool NHS Hospital [135, 15, Foundation Trust Hospitals [291, 0, 4] Prevention Service 1] [198, 23, 710, 13] Hampshire [46, 14, Darlington 564, 0] 513, 1] NHS Foundation Stoke on Trent [59, Birmingham NHS 396, 27] Foundation Trust 382, 4] [92, 12, 320, 12] 959, 0] [196, 24, 989, 1] 866, 10] Memorial Hospital Trust [160, 51, 465, 83, 497, 5] Foundation Trust [109, 15, 425, 4] [167, 20, 634, 14] 3] [103, 3, 526, 11] Broomfield FLS West Berkshire University Hospital Royal Guys and St Bromley East Lancashire Peterborough and Royal Surrey East Surrey Wye Valley NHS West Suffolk NHS University Hospital Barnet Hospital [3, Milton Keynes The Hillingdon Queen Elizabeth The Rotherham Sandwell and West King's College Poole General Hospital [63, 3, [10, 13, 334, 1] Llandough [6, 8, Wolverhampton Thomas' NHS Healthcare Falls Hospitals NHS Trust Stamford Hospitals County Hospital Hospital [3, 7, 221, Trust [4, 5, 201, 21] Foundation Trust Lewisham [32, 3, 12, 139, 2] University Hospital Hospitals NHS Hospital Lewisham NHS Foundation Birmingham Hospital - Denmark Hospital [2, 5, 62, 280, 36] 320, 10] Hospital NHS Trust Foundation Trust and Fracture [4, 0, 261, 8] NHS Foundation [12, 20, 215, 4] 2] [50, 7, 145, 17] 151, 5] Foundation Trust Foundation Trust [12, 1, 93, 3] Trust [2, 2, 105, 0] Hospitals NHS Trust Hill Site [1, 1, 70, 7] 0] [19, 11, 253, 2] [16, 2, 265, 1] Prevention Service Trust [12, 5, 241, 2] [8, 12, 107, 7] [5, 1, 99, 5] [5, 9, 0, 72] [12, 6, 265, 0] Hip fractures recorded Vertebral fractures recorded Non-hip/non-vertebral fractures recorded Site missing Total number of fractures All FLS [2955, 718, 14368, 315] Marked variation in patient number and type of fracture N 1,200 1,

17 Rate of Identification by fracture type Percentage of estimated fragility fracture patients submitted National results Hip 35.4% Non-Hip 45.5% FLSs should compare the proportion of different fracture sites submitted in time for the next audit report.

18 Percentage assessed by FLS within 90 days of the fracture: by patient number No relationship between time to assessment and volume of patients seen

19 Time to assessment Diagnosis to FLS assessment (days) National Results Within 30 days 46.8% Within 90 days 66.9% FLSs that are not able to assess at least 80% of their patients within 90 days should consider reviewing their patient pathways and liaise with FLSs of a similar estimated fragility fracture caseload to develop local quality improvement project plans.

20 Time to DXA Time to DXA from fracture diagnosis (days) Within 90 days 46.5% National results FLSs that are not able to provide DXA assessment within 90 days of the fragility fracture diagnosis for at least 80% of their patients should review their current patient pathways and discuss options with their DXA provider FLSs that are under-resourced for DXA assessment should work with their local commissioners to develop a business case for improved services

21 Bone therapy recommended: Drug Intervention National results Inappropriate 25.6% On therapy 34.9% Missing data 33.2% Auditor did not know 6.3% FLSs with higher than average recorded inappropriate should review their clinical pathway and liaise with other FLSs with similar case loads to understand if quality improvement is required. FLSs with higher missing therapy decisions should review their data entry methods to the audit.

22 Falls assessments and interventions Falls risk assessment National results Performed/done/referred by the FLS 32.3% Missing 28.5% FLSs not routinely performing or referring for falls risk assessment should review their current clinical pathway. FLSs with high missing data proportion rates should review their data entry process.

23 Monitoring Patients followed-up (of those prescribed bone therapy or referred for further clinical opinion or to GP) National results Yes 36.4% Proportion of patients starting bone therapy within 4 months of fracture National results Yes 22% Patients who are recommended drug therapy to reduce risk of fracture should be reviewed within four months of initiation to ensure appropriate treatment has been started.

24 FLS name Number of cases submitted Barnet Hospital Fracture Liaison Service * Bromley Healthcare Falls and Fracture Prevention Service Broomfield Hospital Dorset County Hospital East Lancashire Hospitals NHS Trust * East Surrey Hospital * * FLS West Berkshire * Guys and St Thomas NHS Foundation Trust * King s College Hospital Denmark Hill site 79 7 * * Medway NHS Foundation Trust * Milton Keynes University Hospital Foundation Trust Musgrove Park Hospital North Bristol NHS Trust 1, North Tees and Hartlepool NHS Foundation Trust Nottingham University Hospitals 1, Oxfordshire Fracture Prevention Service 1, Peterborough and Stamford Hospitals NHS Foundation Trust Poole General Hospital * Portsmouth and Southeast Hampshire Queen Elizabeth Hospital, Woolwich * Royal Surrey County Hospital Royal Wolverhampton Hospital NHS Trust * Sandwell and West Birmingham Hospitals NHS Trust St George s Hospital Sunderland Royal Hospital The Haywood Hospital Burslem Stoke-on-Trent The Hillingdon Hospitals NHS Foundation Trust The Ipswich Hospital NHS Trust The Rotherham NHS Foundation Trust * United Lincolnshire Trust 1, University Hospital Lewisham Number of fields (out of 29) with 20% or greater missing data n Hip case ascertainment % Non-hip case ascertainment % Within 90 days (diagnosis to assessment) % Within 90 days (diagnosis to DXA) % Bone therapy missing % Falls assessment done or referred % Patients followed up (of those prescribed bone therapy or referred for further clinical opinion/gp) % University Hospital Llandough * University Hospital of North Durham and Darlington Memorial Hospital University Hospitals Birmingham NHS Foundation Trust University Hospitals Bristol NHS Foundation Trust West Suffolk Fracture Liaison Service Wye Valley NHS Trust * Yeovil Hospital * Overall (Average) 18, Overall > 80% > 50-79% < 50 % Marked variation = opportunity for improvement

25 Potential patient impact over 5 years If all patients in England received a comparable service to the highest treating FLS: 21,848 fractures would be prevented including 9157 hip fractures. Saving 151 million from just hip fractures

26 Next steps This report is the 1 st step in understanding current secondary fracture prevention care A patient level audit is possible and informative Now have over 47,000 cases from 49 FLSs. Real time web based run charts ready for launch

27 Demonstrating FLS quality: real time Allow FLSs to review and report their activity monthly against national averages

28 Thanks to contributors, stakeholders and the FLS team