of the Bone and Joint Decade The Global Challenge of Fragility Fractures and the Role of Fragility fracture Network

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1 of the Bone and Joint Decade The Global Challenge of Fragility Fractures and the Role of Fragility fracture Network

2 The Fragility Fracture Network of the Bone and Joint Decade Mission: To promote globally the optimal multidisciplinary management of the patient with a fragility fracture, including secondary prevention

3 Aims to disseminate globally the best multidisciplinary practice in preventing and managing fragility fractures to promote research aimed at better treatments for osteoporosis, sarcopenia and fracture to drive policy change that will raise fragility fractures higher up the healthcare agenda in all countries

4 Our six themes Peri-operative care in the acute episode Surgical treatment of fragility fractures Rehabilitation after fracture Prevention of the next fracture Research and education Changing healthcare policy

5 Style of work The same as the parent Bone and Joint Decade A network of activists Not competing with existing organisations Catalyst for collaboration between disciplines, professions and countries Aiming for change in healthcare policy

6 Membership Open to professionals in any field relevant to fragility fractures, eg: Orthopaedic surgeons (~50%) Geriatricians Osteoporosis doctors Nurses and allied health professionals Industry

7 Membership We categorise members by discipline/ profession Orthopaedic surgeon Non-surgical MDs Nurses and nurse practitioners Allied Health Professionals Scientists (clinical and basic) Industry workers

8 Membership and by global region Europe North America Latin America Middle East / North Africa Asia NZA

9

10 Distribution by region

11 Our website Major redesign in last few months Reflects our network nature Members area with original resource content Literature registry Planned live interactive sessions

12 Special Interest Group in Hip Fracture Audit Convenor Colin Currie (geriatrician, UK NHFD) Open to all interested activists Work by / teleconference Workshop and plenary lecture at Congress Has defined a global minimum common dataset Entirely compatible with IHFD

13 The FFN Hip Fracture Audit project Produce a global database, with input and reporting features modelled on the UK NHFD Incorporating the minimum common dataset Provide free to pilot sites in ~4 countries, where sufficient champions and organisation exist Translation as needed (Prof Hagino in Japan) Demonstrate the concept in Madrid, with data from UK and other existing databases Seek funding for global roll-out Develop international bench-marking

14 Outline The scale of the global challenge The two main issues Acute multidisciplinary care Secondary prevention Mission of the Fragility Fracture Network

15 The Scale of the Global Challenge

16 Predicted burden of disease Projected Osteoporotic Hip Fractures Worldwide Total number of hip fractures: 1990 = 1.66 million 2050 = 6.26 million Adapted from Cooper C et al, Osteoporosis Int, 1992; 2:285-9

17 Hip Fractures Are the Key Hip fractures 87% of total cost of all fragility fractures ( 2.0 billion in UK) 1.2 million bed days per year in UK Often considerably increased dependency

18 The number of hip fractures depends on two things Age-specific incidence Secular change Age structure of the population Demographic change

19 General increase in age-adjusted incidence in the last century Mixed picture since then Some plateau, some fall, some continue to rise

20 Assuming 0.43% annual secular fall

21 ate/100,000 Denmark/Sweden 600 Annual Incidence of Hip Fracture in Women UK >300/100, Japan /100,000 <200/100,000 Brazil Denmark Sweden Austria Norway Switzerland Ireland Iran Slovakia Taiwan Argentina Iceland Czech Republic Hungary Turkey Belgium Malta UK Slovenia Germany Italy Singapore Greece Hong Kong Lebanon Oman Finland France Canada New Zealand Lithuania Malaysia South Korea Portugal Japan Israel US Australia Russia Netherlands Kuwait Spain Mexico Estonia Poland Chile Thailand Brazil Romania Jordan Croatia Indonesia China India Saudi Arabia Philippines Colombia Morocco Ecuador Tunisia South Africa Nigeria Kanis JA, et al. Osteoporos Int 2012;23:

22 An epidemiological emergency The ageing population will lead to massive increase in hip fractures over next 25 years In Europe and USA: 2X the number of cases In Asia and South America 6X increase Current systems will not be able to cope Unless we do something about it

23 The first main issue Multidisciplinary treatment of the acute episode

24 Complexity of elderly patients Mean age hip fracture = 83 yrs Comorbidities (median ASA 3) Cardiac murmurs Renal - Dialysis COPD - home O 2 Diabetes Delirium / dementia Pseudo-obstruction Alcohol abuse Impaired metabolic response to injury Hyponatraemia Management problems Consent Theatre scheduling Discharge planning Polypharmacy Warfarin Plavix Neurotropics

25 The Need for Multidisciplinary Elderly hip fracture patients are among the most medically complicated patients in the hospital Difficult judgement balance between medical optimisation and prompt surgery Inexperienced surgical trainees are not the best people to look after such people and prepare them for surgery Patients need involvement of senior physicians having expertise with elderly patients pre- and peri-operatively, not just for rehabilitation

26 Senior medical input Orthogeriatrics is the ideal Expertise in care of the elderly Special interest in musculoskeletal disorders Can come from different specialists, depending on health care system Anaesthesia Internal medicine But geriatric competencies are essential

27 Geriatric competencies Holistic approach: Wide, multi-system medical expertise Psycho-social as well as medical Understanding of frailty Loss of physiological compensation capacity Sarcopenia Rehabilitation and discharge-planning Major theme of FFN Global Congress in Madrid More about this in my talk this afternoon

28 The second main issue - prevent as many hip fractures as possible

29 Earlier fractures signal the hip fracture Morbidity Dependence Hip fracture Vertebral fracture Added morbidity from fractures Colles' fracture No fractures increasing morbidity due to ageing alone Age Age Adapted from Kanis JA, Johnell O; 1999

30 Secondary prevention Part of the management of an incident fracture is to take action to prevent further fractures Secondary prevention is more cost-effective than primary prevention

31 Prevalence of prior fractures among patients presenting with hip fracture 100,0 n=2124 n=632 n=701 75,0 Percentage 50,0 45,3 44,6 45,4 25,0 0,0 Lyles et al Edwards et al Mclellan et al Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006 Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 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.

32 16% of women over 50 have had at least one low trauma fracture Post-menopausal women with new fracture each year Post-menopausal women with prior fracture history 0.2 million 1.8 million 50% of hip fractures from 16% of the population Post-menopausal women with osteoporosis Post-menopausal women 3.4 million 11.1 million 50% of hip fractures from 84% of the population UK figures

33 Interventions after fragility fracture Target 100% 100% 100% ~70% Percentage hip (n = 3184) non-hip (n = 5642) 0 Osteoporosis assessment Supplementation with calcium + D3 National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London

34 Secondary prevention Secondary prevention is more effective than primary prevention A systems approach is needed, where capture of patients is automatic

35 Capturing patients reliably Employment of a dedicated coordinator in the fracture service is the most effective system

36 NEW FRACTURE INPATIENT ORTHO/TRAUMA WARD OUTPATIENT FRACTURE CLINIC Fracture Liaison Nurse?DXA scan OSTEOPOROSIS SERVICE FALLS PREVENTION SERVICE EDUCATION PROGRAMME GP FOR LONG-TERM FOLLOW-UP

37 Secondary prevention Secondary prevention is more effective than primary prevention A systems approach is needed, where capture of patients is automatic When it is done vigorously, it is cost-saving

38 Cost-saving Per 1000 fragility fracture patients, 18 fractures (11 hip) prevented net saving 21,000 (3.5m JPY)

39 FLS coverage in the UK Is there further assessment and management of all appropriate fracture patients coordinated by a fracture liaison nurse or similar designated person? Scotland: 66% Northern Ireland: 67% England: 35% Wales: 43%

40 Summary Fragility fractures will present an unmanageable problem all over the world unless we act now Secondary prevention and multidisciplinary management are the keys to success The international forum for exchanging ideas and stimulating action is the Fragility Fracture Network

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