Current Position
• Chief of Osteoporosis and Geriatric excellent
center at Police General Hospital
• Founder and leader of PGH’s FLS
• General Secretary of Fragility Fracture
Network (FFN) Thailand
• Member of MBOG and TOPF
• Advisory board of Asia-Pacific Bone Academy
(APBA)
• Member of Asia-Pacific consortium of
Osteoporosis (APCO)
• Thailand Clinical expert cascade (CEC) faculty Pol.Lt.Col. Dr.
Tanawat Amphansap
Get Mapped:
How to Get Best Practice Recognition for your FLS
POL.LT.COL. DR. TANAWAT AMPHANSAP
CHIEF OF OSTEOPOROSIS AND GERIATRIC EXCELLENT CENTER, PGH
18 FEBRUARY 2020
Learning Objectives of this Webinar
• How to apply for global recognition and get mapped
• Understanding the needs and key principles of FLS
implementation
• Applying the Best Practice Framework to set up the most
effective FLS
• Mastering how to complete the FLS questionnaire
• Raising awareness of the tools available to you on the Capture
the Fracture® website
4 Challenges of the Care Gap
• Adherence (C/P)
• Side effects (Drug holiday)
• Re-fracture
• Falls
• Lack of awareness
• Restrictive criteria for OP treatment
• Reimbursement policy
• Blood test for 2nd OP
• DXA access/availability
• Reimbursement policy
• Hip fracture (dementia)
• Other Inpatients (various wards)
• Outpatient (which clinics/ER)
• Vertebral (radiologist reporting)
Identify Investigate
InitiationMonitor
What is the Fracture Liaison Service
(FLS)?
• Multidisciplinary management
• Aim to
– Close the secondary fracture prevention care gap
– Ensuring the patient receive appropriate
assessment and intervention
– To reduce the future fracture risk
A Proven Solution: Fracture Liaison Service (FLS)
Role of an FLS:
FLS models have been shown to be effective and cost-saving
Outcome After FLS Implementation
1.4 1.57
3.14
0
PGH SIRIRAJ LERDSIN VICHAIYUT
Secondary fracture in 1-year follow up (%)
General reference1 = 6
3.4
7.58
4.38 0
PGH SIRIRAJ LERDSIN VICHAIYUT
Death rate at 1 year (%)
General reference2 = 18
79.5
57.12
85.75
20
PGH SIRIRAJ LERDSIN VICHAIYUT
BMD Intervention (%)
General reference1 = 23
[1] E. Lonnroos,H. Kautiainen, Incidence of Second hip fractures. A population-based study, Osteoporos Int (2007) 18:1279-1285[2] T. Vaseenon et al, Mortality after Hip fracture and associate risk factor, J Clin Densitom, Vol 13, 2010[3] Bessette L et al, The care gap in diagnosis and treatment of women with fragility fracture, OsteoporosInt.2008;19(1):79-86
PGH 429 Siriraj 765Lerdsin 478 Vichaiyut 103
35 26.14
100
30
79.8
PGH SIRIRAJ LERDSIN VICHAIYUT
Osteoporosis treatment at 1 year (%)
General reference3
15-30
FLS
Data from Department of Medical Service, Thailand. 2018
Number of Hip Fractures
Before and After FLS Implementation
National Policy / Initiatives
For Post-fracture Care
National Policy / Initiatives
For Post-fracture Care
National Policy / Initiatives
For Post-fracture Care
FLS implementation in Thailand
97Hospitals
Update 2 Feb 2020
Step to implement an FLS model of care
Purpose of the Best Practice Framework
Aim:
1. Set the standard for FLS
2. Guidance
3. Benchmarking and fine-tuning
5 domains, 13 standards
- Hip fracture patients
- Inpatient
- Outpatient
- Vertebral fracture patient
- Organization
BPF Translations
- Available in 13 languages
Best Practice Framework
The 13 CTF Best Practice Standards
1. Patient Identification
2. Patient Evaluation
3. Post-fracture Assessment
Timing
4. Vertebral Fracture
5. Assessment Guidelines
6. Secondary Causes of
Osteoporosis
7. Falls Prevention Services
8. Multifaceted health and
lifestyle risk-factor
Assessment
9. Medication Initiation
10. Medication Review
11. Communication Strategy
12. Long-term Management
13. Database Standard
Standard Bronze Silver Gold
Patient Identification 50-70% patients
identified, may or may
not be tracked
70-90% patients
identified, are tracked
90% patients identified,
are tracked
Standard 1: Patient identification
- Fracture patients are identified to enable delivery of secondary fracture prevention
Standard 2: Patient evaluation
- Identified patients are assessed for future fracture risk (e.g. DXA-BMD, FRAX or other fracture risk assessment, blood test)
Standard Bronze Silver Gold
Post Fracture
Assessment Timing Within 13-16 weeks Within 9-12 weeks Within 8 weeks
Standard 3: Post Fracture Assessment Timing
- Post-fracture assessment is conducted in a timely fashion after clinical fracture presentation
Standard 4: Vertebral fracture identification
- System to identify vertebral fractures
Standard Bronze Silver Gold
Vertebral Fracture (VF)
identification Clinical VF identifiedNon-VF patients screened
for VF Radiologists identify VF
Standard Bronze Silver Gold
Assessment GuidelinesLocal Regional National
Standard 5: Assessment Guidelines
- Secondary fracture prevention assessment is consistent with guidelines
Standard 6: Secondary cause of osteoporosis
- Patients screened for underlying causes of low BMD, i.e. blood tests
Standard Bronze Silver Gold
Secondary Causes of
Osteoporosis 50% of patients screened 70% of patients screened 90% of patients screened
Standard Bronze Silver Gold
Falls Prevention Services50% of patients evaluated 70% of patients evaluated 90% of patients evaluated
Standard 7: Fall prevention services
- Patients at risk for falls are evaluated and sent for prevention
Standard 8: Multifaceted risk-factor assessment
- Patients are screened and referred for existing lifestyle changes to reduce future fractures (Smoking, alcohol use, poor nutrition, lack of exercise, poor coordination and poor balance)
Standard Bronze Silver Gold
Multifaceted risk-factor
Assessment 50% of patients screened 70% of patients screened 90% of patients screened
Standard Bronze Silver Gold
Medication Initiation 50% of patients initiated 70% of patients initiated 90% of patients initiated
Standard 9: Medication initiation
- Patients, not on treatment at time of fracture, are initiated on osteoporosis treatment
Standard 10: Medication review
- Patients, already on treatment, undergo reassessment of medication compliance, consideration of alternative medication and non-pharmacological intervention
Standard Bronze Silver Gold
Medication Review 50% of patients reassessed 70% of patients reassessed 90% of patients reassessed
Standard Bronze Silver Gold
Communication Strategy Communicated to primary
and secondary physicians
Communicated to primary
and secondary physicians &
contains 50% of criteria*
Communicated to primary
and secondary physicians &
contains 90% of criteria*
Standard 11: Communication strategy
- FLS management plan is communicated to primary and secondary care clinicians
Standard 12: Long term Management
- Protocol for long-term follow-up and patient adherence
Standard Bronze Silver Gold
Long-term Management Long-term follow-up at years
1, 2 or beyond
Short-term follow-up at 6-12
months & long-term follow-
up at years 1, 2 or beyond
Standard Bronze Silver Gold
Database Local database Regional database National database
Standard 13: Database
- Fragility fractures are recorded in a database
BPF Standard Hip Inpatient Outpatient Vertebral Organizational
1. Patient Identification
2. Patient evaluation
3. Post fracture assessment timing
4. Vertebral Fracture (VF) ID
5. Assessment Guidelines
6. Secondary Causes of Osteoporosis
7. Falls Prevention Services
8. Multifaceted Assessment
9. Medication Initiation
10. Medication Review
11. Communication Strategy
12. Long-term management
13. Database
Overall Performance
Police General Hospital
72%
BPF Standard Hip Inpatient Outpatient Vertebral Organizational
1. Patient Identification
2. Patient evaluation
3. Post fracture assessment timing
4. Vertebral Fracture (VF) ID
5. Assessment Guidelines
6. Secondary Causes of Osteoporosis
7. Falls Prevention Services
8. Multifaceted Assessment
9. Medication Initiation
10. Medication Review
11. Communication Strategy
12. Long-term management
13. Database
Overall Performance
Siriraj Hospital
90%
BPF Standard Hip Inpatient Outpatient Vertebral Organizational
1. Patient Identification
2. Patient evaluation
3. Post fracture assessment timing
4. Vertebral Fracture (VF) ID
5. Assessment Guidelines
6. Secondary Causes of Osteoporosis
7. Falls Prevention Services
8. Multifaceted Assessment
9. Medication Initiation
10. Medication Review
11. Communication Strategy
12. Long-term management
13. Database
Overall Performance
Lerdsin Hospital
75%
BPF Standard Hip Inpatient Outpatient Vertebral Organizational
1. Patient Identification
2. Patient evaluation
3. Post fracture assessment timing
4. Vertebral Fracture (VF) ID
5. Assessment Guidelines
6. Secondary Causes of Osteoporosis
7. Falls Prevention Services
8. Multifaceted Assessment
9. Medication Initiation
10. Medication Review
11. Communication Strategy
12. Long-term management
13. Database
Overall Performance
Vichaiyut Hospital
58%
How to get mapped: The process
Step 1: FLS submits online questionnaire
Step by Step Guide to Completing the
Questionnaire
Final steps
1. Save the questionnaire with the hospital name and
date in the title: PGHFLS2016.pdf
2. Email to: [email protected]
Benefited from CTF in Thailand
Step 2: FLS marked in green on the map while
being reviewed
Scoring: 5 Domains
Step 3: FLS is scored and recognized on the map
Step 3: FLS is scored and recognized on the map
Scoring: Global / Service Perspective
Recognize
Excellence
Drive
Improvement
Step 4: FLS is recognized on the map
320 Complete
81 Under review 71 Under development
✓ Algeria
✓ Argentina
✓ Australia
✓ Belgium
✓ Brazil
✓ Canada
✓ China
✓ Colombia
✓ Czech Republic
✓ Denmark
✓ Egypt
✓ Finland
✓ France
✓ Germany
✓ Greece
✓ Hong Kong
✓ Iceland
✓ India
✓ Ireland
✓ Israel
✓ Italy
✓ Japan
✓ Lebanon
✓ Malaysia
✓ Mexico
401 FLS (46 Countries) on CTF Map
66 87 96
✓ Netherlands
✓ New Zealand
✓ Norway
✓ Philippines
✓ Poland
✓ Portugal
✓ Russia
✓ Saudi Arabia
✓ Singapore
✓ South Africa
✓ South Korea
✓ Spain
✓ Sri Lanka
✓ Sweden
✓ Switzerland
✓ Taiwan
✓ Thailand
✓ Trinidad & Tobago
✓ Turkey
✓ UAE
✓ UK
✓ USA
✓ United States
Minor Outlying
IslandsJanuary 24, 2020
NANรพ. น่าน
BGHรพ. กรุงเทพ
SIRIRAJรพ.ศริิราช
PGHรพ.ต ารวจ
Charoenkrung Pracharak
รพ. เจริญกรุงประชารักษ์
Lerdsinรพ.เลิดสิน
PMKรพ.พระมงกฎุเกล้า
Vichaiyutรพ.วิชยัยทุธ
Bangkok
8 Sites in Thailand
Webinar video and Slide deck
• Please go to www.capturethefracture.org/webinars
Thank you
THANK YOU
