1. UNIVERSITY of DERBY The evidence What is the prevalence of fragility fracture 1

2. UNIVERSITY of DERBY UNIVERSITY of DERBY 2 Estimated or measured prevalence of females ≥ 50 with prior fragility fracture years 1 Hippis;ley-Cox, J et al. (2007) Information Centre. 2 Brankin, E. et al. (2005) CMRO. 3 Eisman, J. et al. (2004) Journal of Bone and Mineral Research. 4 Leslie, W. D. et al (2007) Bone. 5 Amamra, N. et al (2004) Joint Bone Spine.

3. UNIVERSITY of DERBY The evidence Are the right patients getting treatment?

4. UNIVERSITY of DERBY UNIVERSITY of DERBY 4 Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre. n = 7860/31094 n = 1476/15025 n = 2551/15025 n = 1862/2551 n = 261/14651 n = 700/14651 n = 305/700

5. UNIVERSITY of DERBY UNIVERSITY of DERBY 5 National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London

6. UNIVERSITY of DERBY UNIVERSITY of DERBY 6 Many hip fractures have had a prior fragility fracture 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

7. UNIVERSITY of DERBY UNIVERSITY of DERBY 7 Many non-hip fractures have had a prior fragility fracture % 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.

8. UNIVERSITY of DERBY UNIVERSITY of DERBY 8 RCP-CEEU national organisational audit Falls and bone health services 2009 “Important public health information on fracture rates is inadequate or not collated “Only 39% of commissioning Trusts report being compliant with the NICE technology appraisal on secondary prevention of osteoporotic fragility fractures” In the Annual Health Check 95% do. “This public reassurance about fracture prevention services turns out to be misleading, since only 24% (40/169) of PCOs have audited local bone health prescribing and only 9 know their local fragility fracture rates”. Only 24% of Trusts have a Fracture Liaison Service Recommendations for adherence to NICE treatment guidelines with monitoring by local audit, and a Fracture Liaison Service National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2009. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Pages/Audit.aspx#round2_audit_2008

9. UNIVERSITY of DERBY Primary Prevention 9

10. UNIVERSITY of DERBY UNIVERSITY of DERBY 10 2.8% 62.2% 12.5% Primary prevention: aspects of management in 312,517 over 65 year old women with strong clinical risk factors for osteoporosis Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre.

11. UNIVERSITY of DERBY The Residential and Nursing Care Home Population

12. UNIVERSITY of DERBY UNIVERSITY of DERBY 12 The residential and nursing care home environment Hip fracture risk 3-4 fold higher Brennan J et al. Osteoporos Int (2003) 14:515-9 Norton R et al. Age and Ageing (1999) 28:135-9 Osteoporosis is common – 70% Falls risk is high Rubenstein LZ et al Ann Int Med (1994) 121:442-51 Calcium and D3 prescription is uncommon – 12% at best Definitive treatment is virtually non-existent Aspray T et al. Age and Ageing (2006) 35: 37-41 The number of older people in institutions will rise by 57% by the year 2031, from nearly 400,000 to 627,000 PSSRU, July 2003 This is an easily identifiable but poorly coded population on GP systems: even amongst those on GP registers, only 1 in 3 receive calcium and D3. Hippisely-Cox et al. Information Centre (2006)

13. UNIVERSITY of DERBY UNIVERSITY of DERBY 13 368/1745834/3040101/36844/95 Mayes N, Walker K, Bayly J R. Evaluating and Improving Clinical Standards in the Management of Fracture Risk in Older People in Residential Care Settings. J Bone Miner Res. 2009;24 (Suppl 1):SU0397.

14. UNIVERSITY of DERBY Trends in Falls admissions 14

15. UNIVERSITY of DERBY UNIVERSITY of DERBY 15 New Contract * Estimated from ratio of FCEs by age HES source data: Copyright © 2009, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved

16. UNIVERSITY of DERBY UNIVERSITY of DERBY 16 Aspects of integrated falls care in patients 75 and over (n = 270,028) Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre.

17. UNIVERSITY of DERBY Do we have the right model for fallers clinics and falls services?

18. UNIVERSITY of DERBY UNIVERSITY of DERBY 18 SDO systematic review of falls clinics ….. the current evidence base cannot be interpreted as a foundation for the widespread implementation of the Falls Prevention Programmes to reduce the incidence of falls related injuries and the associated morbidity, mortality and resource use Lamb S et al. Scoping Exercise on Fallers’ Clinics: Report to the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO), 2007.

19. UNIVERSITY of DERBY UNIVERSITY of DERBY 19 SDO systematic review of falls clinics Small effect on falls incidence (RR 0.9, CI 0.8-1.0) No effect on – falls related injuries including fracture (0.97, CI 0.73- 1.28) – mortality (RR 1.0, CI 0.78-1.27) – transition to institutional care (RR 0.92, CI 0.66-1.29) – A and E attendance (RR 0.98, CI 0.74-1.29) – Hospital admissions (RR 0.98, CI 0.69-1.04) Do increase GP attendances ( RR 1.38, CI 1.11-1.74) Little good quality evidence about the performance of any of the screening tools most commonly used by falls clinics in the UK Cost/benefit analysis not possible Lamb S et al. Scoping Exercise on Fallers’ Clinics: Report to the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO), 2007.

20. UNIVERSITY of DERBY UNIVERSITY of DERBY 20 What is the evidence for fallers’ clinic 1 202 studies - 18 suitable for analysis No clear advantage – by location/setting – by risk grading of patients – by presence of doctor Recurrent falls (4 studies) 34% reduction (RR 0.76; 0.58-0.99) The one study with a doctor - 66% reduction But falls services are only seeing 1.7 new patients/100,000/week 2 1) Lamb S et al. Scoping Exercise on Fallers’ Clinics: Report to the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO), 2007. 2) Royal College of Physicians’ London. National Audit of the Organisation of Services for Falls and Bone Health for Older People. 2006.

21. UNIVERSITY of DERBY What is happening to the prescribing rate?

22. UNIVERSITY of DERBY UNIVERSITY of DERBY 22 Prescribed items: 28 day equivalents Prescription Cost Analysis, NHS Information Centre http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions Charts courtesy of P Mitchell £ millions

23. UNIVERSITY of DERBY UNIVERSITY of DERBY 23 Prescribing costs attributable to bone re-modelling drugs Prescription Cost Analysis, NHS Information Centre http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions Charts courtesy of P Mitchell £ millions

24. UNIVERSITY of DERBY UNIVERSITY of DERBY 24 Statins market £ millions Charts courtesy of P Mitchell Prescription Cost Analysis, NHS Information Centre http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions

25. UNIVERSITY of DERBY UNIVERSITY of DERBY 25 HES source data: Copyright © 2009, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved

26. UNIVERSITY of DERBY UNIVERSITY of DERBY 26 HES source data: Copyright © 2009, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved

27. UNIVERSITY of DERBY UNIVERSITY of DERBY 27 HES source data: Copyright © 2009, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved

28. UNIVERSITY of DERBY Demographics: future trends 28

29. UNIVERSITY of DERBY UNIVERSITY of DERBY 29 Percentage of elderly in Europe Source: OECD

30. UNIVERSITY of DERBY UNIVERSITY of DERBY 30 Source: Government Actuary Department

31. UNIVERSITY of DERBY UNIVERSITY of DERBY 31 Source: Government Actuary Department

32. UNIVERSITY of DERBY UNIVERSITY of DERBY 32 The priority given to trauma and musculoskeletal disorders GMS services NHS spending Local variations in priorities: an update. The Kings Fund; September 2008 Trauma Musculoskeletal

33. UNIVERSITY of DERBY.... and is that a good argument for a systems-based approach? Could it be we are targeting the wrong patients? 33

34. UNIVERSITY of DERBY UNIVERSITY of DERBY 34 1 in 4 bisphosphonate prescriptions directed at those under age 65

35. UNIVERSITY of DERBY UNIVERSITY of DERBY 35 The REAL study Silverman, S. et al. (2007). Osteoporosis International, 18, 25-34. Cumulative hip fracture incidence in the REAL study Pooled NNT = 570

36. UNIVERSITY of DERBY UNIVERSITY of DERBY 36 Comparison of baseline characteristics between cohorts in study CharacteristicsCohorts RisedronateAlendronate Osteoporosis diagnosis37.7 33.8 Osteopenia diagnosis12.510.5 Proportion of patients in REAL study with low BMD

37. UNIVERSITY of DERBY UNIVERSITY of DERBY 37 Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first Fractures (n)2029628247372590354 * More than 24 months persistence

38. UNIVERSITY of DERBY UNIVERSITY of DERBY 38 Are we treating the right populations? Adapted from Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first * More than 24 months persistence

39. UNIVERSITY of DERBY The need to consider more than just initiation of therapies

40. UNIVERSITY of DERBY UNIVERSITY of DERBY 40 Time dependency of re-fracture First fracture Second fracture Van Geel T et al ASBMR 2008 and An Rheum Dis August 2008 On-line first 4140 post menopausal women age 50-90 23% re-fractures 54% re-fractures

41. UNIVERSITY of DERBY UNIVERSITY of DERBY 41 Persistence (continuous adherence): Daily or Weekly alendronate Months of treatment Percentage DIN-LINK Report: Osteoporosis - Report 4 [GSK_OSP_004.DN2]. May 2004

42. UNIVERSITY of DERBY UNIVERSITY of DERBY 42 Clinical Effectiveness 38,000 adults with ≥ 2 scripts for a BP (80% OAW, 75% ALN) on GPRD 43% > 70 years and 81% female 58.3% persistent at 1 year, 23.6% at 5 years No persistence of effect after discontinuation Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first

43. UNIVERSITY of DERBY UNIVERSITY of DERBY 43 The fracture pyramid in the GP’s list for females over 50 years6 39 93 307 Patients with new fragility # per year Patients with prevalent fragility # Prevalent postmenopausal Osteoporotics ± # Postmenopausal women 10-14% intervention rate

44. UNIVERSITY of DERBY UNIVERSITY of DERBY 44 Mapping patients to policies to programmes Hip fracture patients Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Non-hip fragility fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Individuals at high risk of 1 st fragility fracture or other injurious falls Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Older people Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards NSF, TA161, CG21, Blue Book & NHFD NSF, TA161, CG21 & Blue Book NSF, TA160 & CG21 NSF

45. UNIVERSITY of DERBY UNIVERSITY of DERBY 45 By 2014 the cost of 10 year’s delay in implementing a systematic approach in the UK 300,000 hip fractures will have occurred with a history of a prior fragility fracture If 20% (60,000) will have had guideline care (DXA or treatment) If treatment reduces hip fracture risk by 33%. 240,000 patients not receiving care with 33% efficacy equates to 80,000 preventable hip fractures per year …. or 2,000,000 bed days. …. or with 20% mortality 16,000 potentially avoidable deaths …. or with 40% dependency 32,000 unable to live independently.