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Fracture Liaison Services - potential network quick win David Marsh ARMA President Anne Thurston NOS Health Sector Relations Manager MSK 2013
Fracture Liaison Services - potential network quick win
David Marsh ARMA President
Anne Thurston NOS Health Sector Relations Manager
MSK 2013
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 Latin America – up to 6X increase
– An unmanageable problem with current systems
• Unless we do something about it
Earlier fractures signal the hip fracture Morbidity
Dependence
50 60 70 80 90
Colles' fracture
Vertebral fracture
Hip fracture
Age
No fractures – increasing morbidity due to ageing alone
Added morbidity from fractures
Age Adapted from Kanis JA, Johnell O; 1999
Secondary prevention
• Secondary prevention is more cost-effective than primary prevention
Prevalence of prior fractures among patients presenting with hip fracture
45.3 44.6 45.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Lyles et al Edwards et al Mclellan et al
Per
cent
age
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, 226-230
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.
n=2124 n=632 n=701
Post-menopausal
women 11.1 million
0.2 million
Post-menopausal
women with new
fracture each year
3.4 million
Post-menopausal
women with
osteoporosis
1.8 million
Post-menopausal
women with prior
fracture history
50% of hip fractures from
16% of the population
50% of hip fractures from
84% of the population
16% of women over 50 have had at least one low trauma fracture
UK figures
2⁰
1⁰
National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London
0
10
20
30
40
50
60
Osteoporosis assessment
DXA referral (65-74 years)
Supplementation with calcium + D3
Treatment with osteoporosis medication
Perc
enta
ge
hip (n = 3184)
non-hip (n = 5642)
Target 100% 100% 100% ~70%
Interventions after low trauma fracture
• Osteoporosis secondary prevention was the lowest achieving denominator of all domains
• Only 48,242 fragility fractures were identified in general practice in England in 2012-13 • We would expect about 4 or 5 times that number.
• Only 9 points for osteoporosis domain • Equivalent to about £150 per 1000 patients
Next year’s recommended QOF changes
Secondary prevention • Secondary prevention is more effective
than primary prevention
• A systems approach is needed, where capture of patients is automatic
Capturing patients reliably
• Employment of a dedicated coordinator in the fracture service is the most effective system
NEW FRACTURE
EDUCATION PROGRAMME
OSTEOPOROSIS TREATMENT
?DXA scan
INPATIENT ORTHO/TRAUMA WARD
OUTPATIENT FRACTURE CLINIC
GP FOR LONG-TERM FOLLOW-UP
FALLS PREVENTION SERVICE
modified from McLellan et al 2003. Osteoporosis Int, 14:1028-1034.
Fracture Liaison Nurse
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
Cost-saving
• Per 1000 fragility fracture patients, 18 fractures (11 hip) prevented – net saving £21,000
Secondary prevention
• Anti-osteoporosis treatment reduces the incidence of further fractures by ~50%
• If universally applied, coordinator-based systems in fracture units could
– Prevent ~25% of the burden of disease from hip fractures
– Save money
FLS coverage in the UK
Scotland: 66%
England: 35%
Northern Ireland: 67%
Wales: 43%
Is there further assessment and management of all appropriate fracture patients coordinated by a fracture liaison nurse or similar designated person?
“We want a FLS linked to every hospital that
receives fragility fractures, to ensure that every
fragility fracture patient gets the treatment and
care they need.”
How do we work together to achieve this?
Tackling the gaps
National Osteoporosis Society
• National influencing
• Building a picture of FLSs across the UK
• Building support for local service
development
MSK Clinical Networks
• Raise local awareness
• Influence local commissioning decisions
A role for MSK Clinical Networks?
