Putting FLS into context: Patients, professionals and policymakers National Osteoporosis Society FLS Education Programme October 2010

Putting FLS into context: Patients, professionals and policymakers

% In UK >250,000 fractures per year Annual cost >£2billion

The problem A fracture (any site) is associated with 2- 3x increase in future fracture risk The opportunity Appropriate targeting of treatment for osteoporosis halves future fracture risk (including risk of hip fracture)

Missed opportunity Lyles KW et al. ASBMR Abstract SA405 Edwards BJ et al. Clin Orthop Rel Res 2007;461: McLellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland

The Challenge Can systematic post-fracture assessment for fracture secondary prevention be delivered cost-effectively to an entire healthcare region?

Aim of the Fracture Liaison Service To offer all women & men aged 50+ years who present with a new fracture (excluding those sustained in road traffic accident or in fall from above head height) assessment for treatment for fracture secondary prevention

Key components of a FLS Fracture case-finding Fracture risk assessment Implementation of fracture secondary prevention

Fracture Liaison Service FAQ Is FLS more effective than usual services for effecting fracture secondary prevention? Does FLS reduce incidence of fractures? Is FLS cost-effective?

Fracture Liaison Service FAQ Is FLS more effective than usual services for effecting fracture secondary prevention? Does FLS reduce incidence of fractures? Is FLS cost-effective?

NHS Quality Improvement Scotland national audit Secondary fracture prevention by FLS vs other models A multi-centre national audit conducted in Scotland compared delivery of secondary prevention for fracture patients attending 6 hospitals with various service models: –Fracture Liaison Service (Centre W) –GPs could refer fracture patients for open-access DXA assessment (Centres G,S & A) –Orthopaedic surgeons advise fracture patient to attend GP for referral for DXA (Centre H) –No structured service or access to local DXA (Centre I) NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland McLellan AR et al.

NHS Quality Improvement Scotland national audit FLS vs other models: Outcome after hip fracture by centre NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland McLellan AR et al. Centre operating FLS

NHS Quality Improvement Scotland national audit FLS vs other models: Outcome after wrist fracture by centre Centre operating FLS NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland McLellan AR et al.

NHS Quality Improvement Scotland national audit Secondary fracture prevention by FLS vs other models Audit findings: –95% of wrist fracture patients were offered assessment and/or treatment at the FLS centre in comparison to 21% at centres without an FLS –97% percent of hip fracture offered assessment and/or treatment at the centre with an FLS versus 25% at the centres with other service structures Fracture Liaison Service model closed secondary prevention gap for patients presenting to hospital with new fragility fractures NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland McLellan AR et al.

Fracture Liaison Service FAQ Is FLS more effective than usual services for effecting fracture secondary prevention? Does FLS reduce incidence of fractures? Is FLS cost-effective?

The Glasgow FLS 1999: West Glasgow FLS 1 centre: population 250K: 1500 fractures/yr 2002: Pan-Greater Glasgow FLS 3 centres: population 1M: 6500 fractures/yr 2009: Pan-Greater Glasgow & Clyde FLS 5 centres: population 1.4M: 9000 fractures/yr

The Glasgow FLS Pan-Greater Glasgow FLS 3 centres: population 1M: 6500 fractures/yr >50,000 fracture patients managed by FLS since : Emergency admissions with hip fracture (codes S )  by 7.3% in context of FLS & falls strategy Skelton & Neil %20Prevention% _An%20Evaluation_Skelton%20and%20Neil% pdf

Fracture Liaison Service FAQ Is FLS more effective than usual services for effecting fracture secondary prevention? Does FLS reduce incidence of fractures? Is FLS cost-effective?

FLS: cost-effectiveness evaluation West Glasgow FLS First 8 years’ data: 11,096 fracture patients Age , 78% women 80% underwent FLS assessment 49% had DXA + 17% compliance review w/o DXA 14% treated with Calcium and Vitamin D w/o DXA Overall 60% were treated Per 1000 fracture patients: 18 fewer fractures (including 11 hip fractures) Cost saving £26,000 (after assessment & drug costs) McLellan et al NOS meeting abst

QIPP: Quality, Innovation, Productivity, Prevention Fracture Liaison Services deliver innovative, preventative care that will improve quality and reduce costs through a reduction in unscheduled emergency admissions. FLS addresses all elements of the QIPP agenda and the overarching objective of the NHS Outcomes Framework.

McLellan AR et al. Osteoporos Int 2003;14(12):1028–1034

Fracture Liaison Service FAQ Is FLS more effective than usual services for effecting fracture secondary prevention? Does FLS reduce incidence of fractures? Is FLS cost-effective?   

Fracture Liaison Service Other exemplars from UK Clunie, G. & Stevenson, S. Implementing & running a Fracture Liaison Service: an integrated clinical service providing a comprehensive bone health assessment at the point of fracture management. J. Ortho. Nursing 2008; 12:

Fragility fracture Ortho wards >75y<75y>50y Medical assess Falls assess Screening tests Recorded on db (Treat) Blood tests FLS clinic DXA scan if < 75y Falls assess >75y Further tests Recorded on db Falls Clinic Discussion with doctor DISCHARGE BONE CLINIC Intermediate Care DISCHARGE Apply NICE or FRAX algorithm FLS Nurse Screens clinic list Fragility fracture Fracture clinic Ipswich Hospital NHS Trust FLS Clunie and Stephenson. Journal of Orthopaedic Nursing (2008) 12, 156–162

FractureAge range 45-59y60-69y70-79y80-89y90y+TotalTotal 2* Hip Forearm Humerus Lower Limb Pelvis Spine Other Not specified Total Total 2* * *Data adjusted: patients with fracture per 100,000/yr population served by the hospital (approximately 310,000) Clunie and Stephenson. J Orth Nurs 2008; 12: Ipswich Hospital NHS Trust FLS Patients by type of fracture and total numbers 2y data.

Fracture Liaison Service Other exemplars from USA Kaiser Permanente - Southern California JBJS 2008;90:S4: Dell et al PubMed ID PubMed ID

Kaiser Permanente FLS Southern California Style JBJS 2008;90:S4: Dell et al PubMed ID PubMed ID

Kaiser Permanente FLS Southern California Style “I'd like to dispel the misconception that nothing can be done to prevent or treat osteoporosis. “It is possible to achieve at least a 25 percent reduction in the hip fracture rate in the United States if a more active role is taken by all orthopaedic surgeons in osteoporosis disease management. “We've seen it; we've done it.” Rick Dell MD JBJS 2008;90:S4: Dell et al PubMed ID PubMed ID

Putting FLS into context: Patients, professionals and policymakers

NHS Policy on fragility fractures Throughout the Bone and Joint Decade National Service Framework for Older People. Section 6 – Falls 1 Mar-2001 NICE Clinical Guideline 21: Clinical practice guideline for the assessment and prevention of falls in older people 2 Nov-2004 NICE Technology Appraisal 161: Review of treatments for the secondary prevention of osteoporotic fragility fractures in post- menopausal women 3 Oct-2008 All highlight need for osteoporosis and falls assessment to be provided to patients with a history of fragility fracture 1. NSF for Older People. Section 6 – Falls. DH. LinkLink 2. NICE Clinical Guideline 21 – Falls. LinkLink 3. NICE Technology Appraisal 161. Secondary prevention. LinkLink

Fragility fracture through the life span 1 Osteoporosis + falls = fragility fractures 1. J Endocrinol Invest 1999;30: Kanis JA & Johnell O 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ “Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk” 2 Additional morbidity due to fragility fracture event

Professional consensus guidance on hip fractures 2007 Blue Book and National Hip Fracture Database A systematic approach to hip fracture care and prevention 1-3 Hip fracture care –Blue Book Chapter 1 –Effective ortho-geriatric services for hip fracture patients –Universal National Hip Fracture Database participation Hip fracture prevention –Blue Book Chapter 2 –An FLS for every hospital to identify all new fragility fracture patients –Pro-active case-finding of all unassessed prior fragility fracture patients 1. BOA-BGS 2007 Blue Book 2. National Hip Fracture Database 3. NHFD Toolkit – Version 3 All available at

Professional consensus guidance on hip fractures 2007 Blue Book and National Hip Fracture Database Clinical standards link Blue Book to NHFD 1,2 : 1.All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures 2.All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls 1. BOA-BGS 2007 Blue Book 2. National Hip Fracture Database Both available at

Guidance applicable throughout UK 2007 Blue Book and National Hip Fracture Database The Blue Book highlights the need for consistent delivery of NHFD standards 5 and 6 1,2 : “…the most practical option available to the NHS to attenuate the rising incidence of hip fractures is to ensure that every patient presenting today with any fragility fracture receives effective secondary preventative care.” 1. BOA-BGS 2007 Blue Book 2. National Hip Fracture Database Both available at “ Establishment of an integrated Fracture Liaison Service in every UK hospital, which operates in close collaboration with local general practice, offers the optimal system of healthcare delivery to implement NICE guidance consistently for all patients presenting with fragility fractures.”

RCP-CEEU national organisational audit 2009 Falls and bone health services National Audit of the Organisation of Services for Falls and Bone Health for Older People Available for download from:

RCP-CEEU national organisational audit 2009 Reported by SHA, NHS Trust and PCT National Audit of the Organisation of Services for Falls and Bone Health for Older People Available for download from: FLS

RCP-CEEU national organisational audit 2009 Falls and bone health services 1.Opportunities to prevent recurrent falls and fractures are being missed 2. Commissioning is patchy, rarely providing a coordinated falls and fracture strategy 3. Many clinical services were not adhering to the NICE CG21 and TA87 (now TA161) National Audit of the Organisation of Services for Falls and Bone Health for Older People Available for download from:

RCP-CEEU national organisational audit 2009 Recommendations Primary care organisations (PCOs) should develop commissioning strategies that include: −Case finding systems in hospital and community settings to identify high risk fallers −Adherence to NICE treatment guidelines with monitoring by local audit −Clinical leaders including a consultant with job plan commitment −A Fracture Liaison Service −Widespread and accessible evidence-based exercise programmes −Targeted use of validated home safety assessments National Audit of the Organisation of Services for Falls and Bone Health for Older People Available for download from:

RCP-CEEU national organisational audit 2009 Recommendations The Department of Health should review how it can best support these developments by: –Provision of advice on commissioning –Strengthening incentives –Provision of useful metrics for falls prevention, fractures and osteoporosis treatments

Adoption of FLS across the UK The NOS manifestos for England/Scotland/Wales/N.I. National Osteoporosis Society,

Falls and fracture care and prevention A road map for a systematic approach Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care

Falls and fracture care and prevention A road map for a systematic approach 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 Stepwise implementation - based on size of impact Department of Health Prevention Package for Older People: Falls and Fractures - Effective interventions in health and social care

The Coalition Government and Osteoporosis Comments from the new Healthcare Leaders Andrew Lansley MP Monday 5th Oct 2009 “While we do as well as the rest of Europe on heart disease, we are much worse on deaths from cancer, from lung disease, from osteoporosis and from arthritis.” Monday 29th June 2009 Osteoporosis: Health Services, Mr. Lansley: To ask the Secretary of State for Health what progress has been made in implementing the osteoporosis diagnosis and prevention scheme provided for in the Primary Medical Services (Directed Enhanced Services) (England) (Amendment) Directions [282131] David Cameron MP Thursday 20th August 2009 “The growth of long-term conditions: As people live longer they're more likely to live for more of their life with at least one long-term condition like Diabetes, Parkinson's disease or Alzheimer's. It's estimated that by 2025 over six million older people will be suffering from a debilitating long-term illness. The number of people with dementia will have increased to around one million; with osteoporosis to over four million; with hearing loss to around ten million. These are increases of up to fifty per cent from today.” 1.Andrew Lansley MP. Speech in Manchester Andrew Lansley MP. Parliamentary Question David Cameron MP. Speech in Bolton

Hip fracture care and prevention in the UK Key developments Publication of RCP-CEEU organisational audit 1 Publication of the NOS Manifesto 2 –Chapter one: The management of falls, fragility fractures and osteoporosis in secondary care - “We want a Fracture Liaison Service to be linked to every hospital in England/ Scotland/ Wales/ Northern Ireland” Publication of DH Prevention Package for Older People & BPT Ongoing Blue Book “Coalition of the Willing” initiatives 1. National Audit of the Organisation of Services for Falls and Bone Health for Older People Download from: Protecting fragile bones: A strategy to reduce the impact of osteoporosis and fragility fractures in the UK Download from: