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Fracture Liaison Services in Scotland

Fracture Liaison Services in Scotland. Dr SJ Gallacher Consultant Physician Southern General Hospital; Glasgow. stephen.gallacher@ggc.scot.nhs.uk. Key Points. The health and social care costs of hip fractures estimated at £2.3billion per year 

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Fracture Liaison Services in Scotland

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  1. Fracture Liaison Services in Scotland Dr SJ Gallacher Consultant Physician Southern General Hospital; Glasgow stephen.gallacher@ggc.scot.nhs.uk

  2. Key Points • The health and social care costs of hip fractures estimated at £2.3billion per year  • Hip fractures are associated with significant morbidity and mortality • After a first fracture the risk of fracturing again is increased 2-5 fold

  3. Key Points • Hip fractures account for over 7000 unplanned admissions per year in Scotland  • Hip fractures account for over 416,000 bed days per year in Scotland • Hip fractures cost around £206million annually in Scotland in direct hospital costs (not counting social care costs) • FLS is most effective way to target interventions that reduce subsequent fracture risk by up to 30-50% in people with fragility fractures

  4. Background to Fracture Liaison Services (FLS) • Why is FLS an imperative • Does FLS prevent fractures and is it cost-effective • FLS and NHS Scotland

  5. Background to FLS

  6. Terminology & Definitions • Fracture Liaison Service (FLS) • Secondary Fracture Prevention Programme (SFP)

  7. What is a Fracture Liaison Service (FLS)/ Secondary Fracture Prevention Programme (SFP)? A Fracture Liaison Service (FLS) systematically identifies, treats and refers to appropriate services all eligible patients over 50 within a local population who have suffered fragility fractures, with the aim of reducing their risk of subsequent fractures. Lih et al. Osteoporosis Int 2011;22:849-58 Cooper et al. Osteoporosis Int 2012; 23:97-107

  8. What are the constituent parts of a high quality FLS? • 5IQ • Identify • Investigate • Inform • Intervene • Integrate • Quality

  9. FLS Definition A FLS is a dedicated clinical service that systematically: Identifies all patients over the age of 50 years within a local population who have suffered a fragility fracture

  10. FLS Definition A FLS is a dedicated clinical service that systematically: Investigates to assess bone health and falls risk

  11. FLS Definition A FLS is a dedicated clinical service that systematically: Informs patients to enable them to understand future fracture risk and what can be done to reduce this

  12. FLS Definition A FLS is a dedicated clinical service that systematically: Intervenes to improve bone health and referring to other specialist services including falls prevention

  13. FLS Definition A FLS is a dedicated clinical service that systematically: Integrates patient care across primary and secondary care to ensure long-term management including making sure that patients are concordant with their treatment in order to obtain its benefits

  14. FLS Definition A FLS is a dedicated clinical service that delivers the ‘5Is’ Underpinned by high quality clinical care that is inclusive, responsive and responsible to individual patients and the health economy. Data collection allowing local and national audits will be core to a FLS, promoting continual service improvement.

  15. FLS Definition FLS is therefore an essential component of a comprehensive and integrated approach to preventing falls and fractures among people over the age of 50 years in a local health system. Referral to an FLS should be part of the pathway for all patients with a fragility fracture. Ensuring quality in the delivery and organisation of the FLS is paramount.

  16. Why is FLS an imperative?

  17. Scotland 1911 80-84 70-74 60-64 50-54 Males Age group (years) 40-44 Females 30-34 20-24 10-14 0-4 300 250 200 150 100 50 0 50 100 150 200 250 300 Population in age/sex group (thousands) Scotland 2031 80-84 70-74 60-64 50-54 Age group (years) 40-44 30-34 20-24 10-14 0-4 300 250 200 150 100 50 0 50 100 150 200 250 300 Population in age/sex group (thousands)

  18. 3250 Projected to reach 3.250 million in Asia by 2050 668 400 600 629 1990 1990 1990 1990 2050 2050 2050 2050 100 Why secondary fracture prevention matters Projected incidence of hip fractures by 2050 Total number ofhip fractures:1990 = 1.66 million2050 = 6.26 million 742 378 Estimated no of hip fractures: (1000s) Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289

  19. Hip fracture patients tell us they are coming! Morbidity attributable to ageing alone Hip fracture is all too often the final destination of a thirty year journey fuelled by decreasing bone strength and increasing falls risk J Endocrinol Invest 1999;30:583-588 Kanis JA

  20. Signal fractures amongst patients presenting with hip fracture Percentage of patients with hip fracture reporting prior fragility fracture 100.0 90.0 80.0 70.0 n=2124 n=632 n=701 60.0 Percentage 45.3 45.4 44.6 50.0 40.0 30.0 20.0 10.0 0.0 Lyles et al Edwards et al McLellan et al Lyles KW et al. ASBMR 2006. Abstract SA405 Edwards BJ et al. Clin Orthop Rel Res 2007;461:226-230 McLellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland. 2004. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland

  21. Does a Fracture Liaison Service Prevent Fractures?

  22. Does FLS Prevent Fractures? Main focus of FLS evaluation is around process Some outcome (fracture) outcome data available from: USA (Kaiser Permanente) Glasgow (hip fracture incidence evalaution) New South Wales (Australia) – re-fracture incidence

  23. FLS is Associated with Reduction in Re-Fracture Rates Re-fractures (4-years follow-up): 4.1% (FLS) vs. 19.7% (controls) Lih et al. Osteoporosis Int 2011;22:849-58

  24. Kaiser PermanenteFLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

  25. Kaiser PermanenteFLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

  26. Kaiser PermanenteFLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

  27. Kaiser PermanenteFLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

  28. Kaiser PermanenteCalifornia Dreamin’ ? "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 orthopedic surgeons in osteoporosis disease management. We've seen it; we've done it.” Rick Dell MD JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730

  29. NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006-2010 AN EVALUATION 2007-2009

  30. South Glasgow FLS (10 Year Review) 21887 Patients Identified 12312 Patients identified 1755 Declined (8.0%) 1497 DNA (6.8%) 18635 patients to be assessed 11755 - BMD Measured (63%) 4877 - Treatment Started Without Scanning (26%) 2003 - Already on Treatment Or Previously Assessed (11%) 6409 - Started on Treatment (35%) 5346 – No Treatment Required (28%) % of the 21887 patients presenting

  31. Growth 1.8% per year (2005-8) Hip fractures in the 65+ age group (England) (1998-2008)

  32. Hip fractures (65+) (1998-2008) Greater Glasgow/ Greater Glasgow & Clyde Between 1998 and 2008 the number of hip fractures (as assessed by ISD codes S.72-S.72.2) in Greater Glasgow decreased by 7.3% from 1377 to 1276 fractures. The equivalent figure for Greater Glasgow & Clyde was 3.6%, 2026 fractures in 1998 to 1953 fractures in 2008 (i.e hip fractures increased in Clyde).

  33. FLS: Is it affordable? (can we afford not to do it?)

  34. 1000 patients (Hypothetical Cohort) 686 patients received anti-osteoporosis treatment £83,598 (for assessments) £206,554 (for treatments) 18 fractures (including 11 hip fractures) prevented Overall cost saving - £21,000 Cost of widespread adoption of FLS across UK - £9.7m McLellan et al. OI 2011;22:2083-2098

  35. Cost-Effectiveness (International Models) Data from Australia: Savings of $23,000 AUD in 6 months1 Cost of $20,000-30,000 AUD per QALY gained2 Data from Canada: Cost saving of $50,000 per annum (minimum 350 hip fractures seen)3 1. Vaile et al. Internal Medical Journal 2007;37:717-720 2. Cooper et al. Osteoporosis Int 2012;23:97-107 3. Sander et al. JBJS 2008;90:1197-1205

  36. FLS in Scotland in 2014

  37. DXA Scanners/Health Board Kirkwall Lerwick Inverness Aberdeen Dundee Glasgow Edinburgh

  38. DXA Services – Available Hours of Operation

  39. DXA Services – Available Hours of Operation

  40. Health Boards – FLS Available

  41. Health Boards – FLS Available

  42. Osteoporosis/FLS Specialist Nurse Availability by Health Board

  43. Osteoporosis/FLS Specialist Nurse Availability by Health Board

  44. The Case for FLS is Robust • Fractures are a rapidly increasing problem across the world • Fractures are associated with significant morbidity, mortality and cost • Identifying patients presenting after fracture identifies a population at high risk of future fracture

  45. The Case for FLS is Robust • FLS encourages cost-effective resource utilisation and integration across primary and secondary care • FLS programmes now required through many national/international guidelines • Adoption of FLS across NHS Scotland should be an urgent priority

  46. Whilst we have been talking, 342 people have had a fragility fracture, 60 people have broken their hip And 30/60 let us know they were coming

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