Best of Health Staff Awards 2010/11 Best of Health Awards 2013 Dr Abhaya Gupta Consultant Physician Hywel Dda Health Board Title: From zero to comprehensive Fracture Liaison service (FLS) within existing resources Context: A new consultant led patient focussed service for patients with osteoporosis commenced at Glangwili hospital, Carmarthen,in 2010. This first class service and ideal model improves compliance with evidence based guidelines from national societies (NSF for Older People, RCP, BOA, BGS, NOS, NOGG, NICE) for osteoporosis management, helps achieving NSF s and Welsh Assembly Governments targets on Falls and hip fractures prevention. Problem: Osteoporosis has increasing burden of fractures in ageing population. Economic impact of fractures is immense. 50% reduction in hip fractures is achievable during 3 years of bone therapy (meta-analysis). FLS is efficient, cost effective service for fragility fracture patients. Expected cost savings for average population of 320,000 is 56,527 per year FLS operational, with additional benefits from QUALY by preventing falls and fractures. Assessment of problem and analysis of causes: The Royal College of Physicians introduced Osteoporosis management Guidelines as far back as 1999. National Audit 2007, identified 12% patients clinically assessed for osteoporosis risk, 8% had DEXA scan performed, 44% prescribed medication and information provision was low locally. UK recommendations - Primary Care Trusts... commission pathway for secondary prevention of falls and fractures. The NOS advocate universal FLS throughout NHS. However, locally, there was lack of osteoporosis strategy or clinical leadership from clinicians/ General Practitioners. Strategy for change: 1
Dr Abhaya Gupta (AG) identified the need, developed and leads Osteoporosis service at Carmarthen, commencing October 2010 with specialist nurse Alison Lorch (AL). Pathways for case finding using systematic, proactive approach targeting highest risk patients- Respond to first and prevent second fracture, treatment algorithms, management protocols, Aclasta infusion and Denosumab, PTH injection protocols, patient information leaflets developed. Patients above 50 years, with recent fragility fracture identified Via A/E. Vertebral fractures identified by Radiology list. All hip fractures seen on new Acute Hip Fracture Unit. Admitted Fragility fracture patients are assessed in second Trauma-Ward. Referrals are received from GPs/clinicians. Suitable patients attend weekly clinic. Standardised risk assessment questionnaire completed, appropriate investigations performed to exclude secondary causes, DEXA scan requested. WHO recommended FRAX algorithm and National and latest Evidence based Guidelines used for treatment decisions. Verbal,written information given on diagnosis, DEXA scan results, medications, possible side effects, lifestyle, dietary advice, prevention of further falls, on local Carmarthenshire Support Group lead by AL. Written management plans sent to GP. NICE recommendation followed- weekly Alendronic acid as first treatment (cheap, effective). AG sought approval of several osteoporosis drugs in local Formulary. Registers held for audit and juniors educated. Monitoring and adherence to treatments done during outpatient followup Ongoing participation in UK National Audits and performance monitoring, collated by AL. Osteoporosis Support Group set up in 2007 by AL, has regular meetings at Carmarthen. Specialist evidence based exercise programme for postural stability in bone health available locally. Timetable for change: see table 2
Measurement of improvement Table This new FLS provides a large and complete inpatient and outpatient osteoporosis service with the majority of patients identified proactively with a minority of new referrals. A patient survey conducted amongst users of this service has shown high satisfaction and praise. GP s with limited knowledge on osteoporosis/dexa scan results receive advice. Effects of change: A new Fracture Liaison service is established, previously non existent, to close secondary fracture prevention management gap initially devised for Carmarthen population, but referrals now received from Llanelli and Pembroke areas. A comprehensive, proactive systematic approach for managing people at highest risk of osteoporosis established. Signal fracture used as trigger and opportunity is taken to prevent further fractures. High risk patients targeted using Department of Health pyramid risk model. A new consultant led clinic in secondary care established by Consultant despite medical and rehabilitation commitments. A care management pathway and innovative structured approach introduced in tackling osteoporosis. FLS integrates with Hip fracture Unit established by AG. This encouraged referral to Orthogeriatrician led FLS for specialist advice on spectrum of falls and fractures. Improved awareness and expertise of health professionals at primary and secondary care in bone health. FLS promotes training and research opportunities. Improved partnership working between orthopaedic surgeons, GPs, radiologists, MD professionals. An integrated care solution for Bone health has been found in Carmarthen that delivers seamless quality care between hospital and primary care. 3
FLS is in accordance with Hywel Dda HB- Right care, Right place, Right time, every time. The consultant physician has taken on challenge of trauma services by tackling silent epidemic of osteoporosis. Lessons learnt The service is two years since inception and we aim to continuously refine service model to monitor and improve performance. Unlike nurse led FLS in other UK hospitals( who have this service) is gold standard with Consultant and team offering highest quality service with several advantages. Unlike referral or IT approaches used elsewhere, a unique proactive case finding approach through A&E notes used minimising system errors allowing more complete information available. Recurrent fallers are benefitting from Consultant s specialist expertise on comorbidity and poly-pharmacy. A standard falls assessment and multidisciplinary, holistic approach, is extending spectrum of tackling Falls and Bone health which are linked. Very practical approach is used targeting all patients with fragility fractures, ensuring the treatment and care they need. Disappointing numbers from fracture clinic/ orthopaedic consultant referrals opened new and improved avenues, not dampening enthusiasm and determination. Existing local Day hospital facilities are used Frequent communications/reminders needed with A/E receptionists for regular case identification. A new service can be established within existing resources, without need for business plans, unnecessary delays. Message for others: - By strong leadership, determination, enthusiasm highest quality care across primary and secondary care boundaries are possible. - Problems can be turned into opportunities by constructive, sensible problem solving approaches. - Explore new tools and existing resources for creating a system locally. - Rapid change requires local clinical champions. 4
Timetable for change: September 2010 October 2010 November 2010 December 2010 April 2011 June 2011 October 2011 November 2011 November 2011 April 2012 January 2011 to 2012 New Service designed by Dr Abhaya Gupta Approval with management & stakeholders Protocols processes set up Patients started attending clinic Screening for Vertebral fracture patients started New Acute Hip fracture ward started at Carmarthen by AG in collaboration with surgeons AG presented 2 posters at International Osteoporosis Conference Dubai AG invited by National Osteoporosis Society to give presentation at Birmingham on new FLS at Carmarthen AG attended National Osteoporosis Society meeting with AMs at Welsh Assembly Cardiff AG presented posters at International Osteoporosis Conference Bordeaux 2012 AG attended meetings by Delivery Support Unit/Cardiff Activity measurement: Numbers AE cards screened October 2010 to December 2012 Not suitable for clinic attendance (out of area, nursing home resident, not fragility fracture, not fracture)- letters sent to GPs if required 868 674 5
Inpatient Fragility fracture admissions seen Jan 2011 to Dec 2012 Hip fracture admissions Jan 2011 to Dec 2012 Patients attended clinic of AG until Dec 2012 61 288 545 Awaiting clinic visit 64 Declined/no response- letter sent to GPs 53 Spine xrays screened from radiology list since April 2011 Letters sent to GPs for vertebral fractures since April 2011 Not suitable for osteoporosis assessment/not fractures from spine xray reports Patients receiving IV Zoledronate injections yearly at Day Hospital Carmarthen Patients receiving Denosumab injection twice yearly at Day Hospital Carmarthen Patients receiving daily sc PTH injection with Home monitoring Program 3774 350 3424 36 65 8 6
Figure 1 showing Carmarthen Fracture Liaison Service New fracture, acute Hip unit New Fracture orthopaedic ward New fracture A and E Copy of AE card Vertebral fracture through IT list Specialist orthogeriatric service Identification of fragility fracture patients by fracture liaison service Fracture liaison service clinic assessment and investigations Referral by orthopaedics/gp / other IV Aclasta, SC Prolia injection at Day hospital Pharmacological treatment Exercise Education Falls assessment Management plan to GP 7
Figure 2 Showing the Number of Patients Referred and Seen in FLS from January 2011 to December 2012 Spine reports 3774 radiology screened AE cards screened 868 Inappropriate 674 Vertebral Fracture 350 No vertebral Fracture 3424 Appropriate Clinic 194 for GP referrals 67 Consultant referrals 19 Ward referrals 26 FLS Clinic attendances (new + follow up) 545 Awaiting 64 No response/declined 53 Letter to GP 8