More than 80% of patients after a seeing a doctor with a fragility fracture receive inadequate care.

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1 Background- why we need fracture liaison services (FLS) 500,000 + fragility fractures per year Fracture liaison service development MK Javaid Associate Professor in Metabolic Bone Disease, University of Oxford Hon Consultant Rheumatologist, Nuffield Orthopaedic Centre Lead Clinician for FRiSCy H Mace Professional Development Lead National Osteoporosis Society NICE approved drugs that reduce the risk of fracture from 20-70% Having a fragility fracture doubles the risk of future fracture < 20% of patients are on any treatment at 6 months National FLS coverage would prevent 46,000 fractures / 5 year including 19,000 hip fractures > 180 million saving Less than 50% of fracture patients are assessed for osteoporosis AND YET More than 80% of patients after a seeing a doctor with a fragility fracture receive inadequate care. Less than 50% of patients who start treatment are still on it at 1 year Treml 2012 Would we accept less than 20% secondary Prevention after heart attack? Why Lack of prioritization of economic benefits Lack of evidence for clinically effective FLS model Lack of evidence for cost effective FLS model The NHS wants a solution for Secondary Fracture Prevention 1

2 Isn t effectiveness obvious? 80% reduction Regional Evaluation of Fracture Reduction Services after hip Fracture (REFRESH) Andrew Judge M Kassim Javaid, Cyrus Cooper, Nigel Arden, Dani Prieto-Alhambra, Andrew Farmer, Janet Lippett, Rachael Gooberman-Hill, Jose Leal, Jasroop Chana, Alastair Gray, Michael Goldacre, Laura Graham, Sam Hawley, Sally Sheard, Sarah Drew Hospital coding: Primary hip fractures at 11 hospitals What was the effect of FLS on re-fracture rates? Example: hospital 8 Hospital Total , , , , , , , , , , ,506 Total 3,041 3,041 3,136 3,178 3,483 3,368 3,476 3,401 3,579 3,450 33,153 Mortality (1-year) Mortality (30-day) Hawley Age & Aging 2016 Findings: second fracture within 2-years before and after FLS implementation Unable to detect a change in hip re-fracture rates after introduction of an FLS with over 33,000 hip fractures hospital Fracture Laison Nurse Forest plot of Hazard Ratios for 2-year secondary hip fracture, by type of change in service delivery timepoint May 2008 June 2007 May 2009 Apr 2005 Aug 2007 Subtotal (I-squared = 0.0%, p = 0.876) Hazard Ratio (95% CI) 0.99 (0.64, 1.52) 0.98 (0.69, 1.38) 0.96 (0.47, 1.98) 1.40 (0.77, 2.56) 0.95 (0.51, 1.73) 1.02 (0.82, 1.27) % Weight Observational study: Before/ after time series design Hip fractures too late Qualitative study Adherence is a major issue No FLS delivered monitoring Services pre-dated FLS standards Hawley Age & Aging 2016 Hawley Age & Aging 2016; Lyels NEJM 2007; Drew OI

3 Secondary fracture prevention is complex Not every FLS is automatically effective How big should the FLS be? Local decisions for an FLS > vs. Identification is key Identify In person Lists/ IT Clinic patients Emergency room Ward patients Geriatrics Orthopaedic Medicine Different Hospitals Investigate As part of trauma visit Invite to separate appointment DXA scan Availability Who does/ pays for bloods Initiate Recommend to or Initiate treatment? Oral +/- injectables Affordability of therapy Need to find them all. Monitor Telephone Prescribing records Letter Clinic Ownership of patient Access to patient How big should the FLS be? Naranjo OI 2015 Adherence matters: UK CPRD Prescriptions post hip fracture: Real world data for Alendronate Percentage of patients on antiosteoporosis drugs (%) 2b) < 4 months 12 months 24 months 36 months 60 months Time since primary fracture (months) England London East Midlands East of North East North West Northern Ireland Scotland South Central 66,116 PMO women Li Menopause 2012 Shah OI

4 Potential reduction in re-fracture rate (%) a) Minimum investment Maximum benefit b) More investment > higher benefit Cost of an FLS (%) c) Reach Plateau > then need more to maximize benefit d) Minimal benefit unless whole package 100 Primary care? QOF 2013/13= 24% treated QOF 2013/14= 22% treated 78% patients not identified of the 22% treated = any prescription in last 6 months Fracture liaison service Systems approach Specialist nurses Small number for large patient group Dedicate and responsive to changes in evidence Systematic application of secondary fracture prevention Co-morbidity independent GP Deskill- primary prevention/ longer term adherence Cost neutral within 18 months Scope Population Single high level aim Objectives Criteria Standards Validity (measure what it should) vs. Feasibility of collecting so much data excellent standard minimal acceptable achievable FLS = system solution How Scope Population 50+ with a fragility fracture Single high level aim Objectives Criteria Fall from standing height or less Everyone is: Identified Investigated Initiated Monitored Political Prioritization Get Funded Get Started Improve and sustainable Standards Any site except digits, skull or face for at least 5 years 4

5 two questions Fracture Liaison Service Implementation Group Falls & Fragility Fractures Systems Annual Report 10% of the UK what is the benefit what is the cost Falls and Fragility Audit Programme FLS-Database NOS Fracture Prevention Practitioner Online Course & Certification FLS Toolkit Economic benefit CCG commission effective services + FLS Standards BOA National NOS & International IOF What is the benefit? What is the benefit? Benefit vs. Cost Benefit Benefit Trust CCG Social care cash releasing (Fractures avoided) non cash releasing (Ambulance) Patient 5 years Oxford economic model What do you need? Population of 620,000 Case mix +Vertebral Fractures Database / Organizational +Outpatient Fractures +Other Inpatient Fractures Hip Fractures Service scope UK National Osteoporosis Society Economics Benefit Calculator

6 What sort of service What sort of service Understand the local Patient flow Ward patients To see and assess the patients? Clinic patients New patient Recommend or Initiate treatment? Emergency room Prescribing records Letter To monitor the patients? Telephone Clinic Orthopaedic Geriatric Medicine Hospital(s) To reduce re-fracture rates? 1. Volume Emergency Care Xray Secondary care: Inpatient OPD trauma 2. Distribution 1. Number of hospital/gp sites 2. Type of OPD clinic Trauma Other New F/U Community: Residence GP surgery Care home Community hospital Missing tribe a. Pelvic fracture b. Spine fracture c. Inpatient fracture 24 hours pre-hip fracture network 48 hours pre-discharge: having a fracture is a full time job Fracture Liaison service May 2014 Minimally disruptive Intervention May

7 Community PILOT can it work in your hospital Hospital Community Case find Assessment Treatment start Monitoring Plan Do Study Orthopaedic Plaster Trauma nurse OT/PT Radiology Minimally disruptive Maximize Efficiency Act? FPS Size of FLS proportional to number of fragility fracture patients Number of Patients Plan for the peaks in activity J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J 2011 (151/mth) 4 WTE nurses admin + Elfin 620,000 population 3 hospitals 2012 (186/mth) (2,226) N= 3,000/ years 2013 (224/mth) (2,689) 2014 (260/mth) (1,820) System 2 getting it done Stakeholder map Networks Stakeholders Meetings Geriatrics Radiology/ DXA Department Trauma Indirect Aging Demetia Direct Charities Patients Carers 1 o care GPs GP trainee District Nurse Practice Physio/ Falls Occupational Therapy Pathway Rheum Endo Other Departments Hospital Stakeholder Mapping Pharmacy Actual care process Physical documentation Other Medicine Audit Senior Approvals Executive Finance General Manager Funder Board Government Public Health Kaizan: relentless pursuit of better quality Coding Information Sources Directorate lead Social Services Current activity 7

8 3/22/17 Meetings Who do you need to meet? CCG- long term lead Local Authority/ Public health Sustainability & Transformation Plan NOS Service Delivery team +????????????? Help is at hand IOF standards Aim: Set the standard for FLS Guidance Benchmarking and Quality improvement Akesson OI 2013 Google FLS DB 8

9 SUMMARY Focus on secondary fracture prevention Effective pharmacological therapies Population approach not hospital based Primary or secondary care but needs DEDICATED TEAM Use the NOS (toolkit, implementation team, events) Engage with the FLS DB audit > quality / efficiency of servicses 9