model of support for fracture liaison development and improvement
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Model of support for Fracture Liaison
Development and Improvement
Mayrine FraserNational Development Manager/Specialist Nurse
National Osteoporosis SocietyScotland
The National Osteoporosis Society• The only UK-wide charity dedicated to
improving the prevention, diagnosis and treatment of osteoporosis
• Vision: A future without fragility fractures
• Mission: Working together for a brighter future for people with or at risk of osteoporosis and fragility fractures across the UK, putting an end to preventable broken bones and helping people to live without pain and disability
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The consequences of osteoporosis
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• 300,000 fragility fractures a year• 85,000 unplanned hospital
admissions for hip fractures alone• 1.8 million hospital bed days• 1 in 4 people die within a year of
suffering a hip fracture • 33% become totally dependent • £1.9 billion in hospital costs
What is the impact of fractures?
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What is the impact of fractures?
OSTEOPOROSIS
10
X
What is the solution?
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Fracture Liaison Service (FLS)• An FLS is a proven model for fragility fracture
prevention• 50% of hip fracture patients have had a prior
fragility fracture• All patients > 50 years who fracture are targeted
• Where treatment is initiated
• Up to 25% hip fractures avoided in future
Find them
Assess them
Treat where appropriate Follow-up
National Osteoporosis SocietyPriorities and Plans for 2016Aim 1: Every person aged over 50 who breaks a bone is assessed for osteoporosis and managed appropriately.Priority 1:
Extend coverage of Fracture Liaison ServicesPriority 2:
Improve quality of Fracture Liaison Services and osteoporosis services
Key recommendations
• People with a history of fragility fractures over 50 years should be offered DXA scanning to evaluate the need for anti-osteoporosis therapy
• Fracture-risk assessment should be carried out, preferably using QFracture, prior to DXA in patients with clinical risk factors and in whom treatment is to be considered
• Measurement of BMD by DXA at hip and spine should be carried out following fracture risk assessment in patients in whom treatment is considered.
• Repeat DXA after 3 years may be considered to assess response to treatment.
• Patients over 50 with a fragility fracture should be managed within a formal integrated system of care that incorporates a fracture liaison service.
SIGN 142 Management of osteoporosis and the prevention of fragility fractures
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Definition of a Fracture Liaison Service
An 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.
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What are the benefits of an FLS?
An FLS:• Improves patients’ quality of care• Provides targeted intervention• Enables appropriate prescribing • Prevents pain/suffering• Reduces hospital admissions• Reduces hospital and social costs
FLS’s are proven to be cost effective.
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Further benefits
• Timely assessment for bone health/falls• Appropriate referral to DXA• Long-term reduction in fragility fractures• Prevention of further falls and fractures• Improves adherence to prescribed medication• Improves quality of life, health & well-being • Potential reduction in mortality rate
What is the Impact of an FLS?
• Reduction in hip fractures • Hip fractures cost £1.9 billion/year• For every 1000 FLS patients assessed in
FLS • 18 fractures are prevented• 11 of those are hip fractures
• FLS Implementation Group• UK FLS Clinical Standards• FLS Implementation Toolkit• FLS Implementation Workshops• Fracture Prevention Practitioner (FPP)
Training• Peer Review• Service Delivery Team
A National Approach to FLS
• FLS Implementation Group• UK FLS Clinical Standards• FLS Implementation Toolkit• FLS Implementation Workshops• Fracture Prevention Practitioner (FPP)
Training• Peer Review• Service Delivery Team
A National Approach to FLS
Service Delivery Team
Sonya StephensonService Development
Project Manager
Will CarrService Development
Project Manager
Hilary ArdenHead of
Service Delivery
Tim Jones Commissioning
Advisor
Mayrine FraserService Development
Project Manager
Debbie StoneService Development
Project Manager
Fiona GardnerOperation Projects
Officer
Henry MaceProfessional
Development Lead
Jo SayerService Development
Project Manager
• Facilitate stakeholder engagement• Help establish patient/care pathway• Project manage commissioning/funding:
o The economic and business caseo Service specificationo Resource and capacity planning
• Work with commissioners to ensure services are sustained.
How the Charity Supports Implementation
• Provide input to enable the development of an FLS meets the UK FLS Clinical Standards
• Help establish data collection, analysis, evaluation and reporting
• Identify gaps in service provision, put in place improvement plans and monitor against agreed actions
• Peer review
How the Charity Supports Implementation
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FLS Coverage England NI/IOM Scotland
Wales UK
2015FLS Coverage
47/141 (33%)
4/6 (80%)
7/14 (50%)
6/11 (55%)
64/171 (37%)
Supporting New Service Development
44 0 2 4 50
Supporting Quality
Improvement
48 6 12 6 72
Number of additional sites
engaged
24 3 2 6 35
Total/Potential number of FLS
116/141(82%)
9/9 (100%)
16/16(100%)
16/16(100%)
157/182(86%)
No. of services commissioned
7 0 0 0 7
How Good is the FLS?
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Clinical Standards for FLS
UK FLS Clinical StandardsThe 5IQ approach describes the key objectives of an FLS:
• Identification
• Investigation
• Information
• Intervention
• Integration
• Quality www.nos.org.uk/fls
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No. Standard Rationale
1 IDENTIFICATIONAll patients aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture will be systematically and proactively identified.
Patients who have sustained a fracture are at higher relative risk of fracture than those who have not. Targeted interventions in this population will have most impact on reducing the future fracture burden.
2 INVESTIGATIONPatients will have a bone health assessment and their need for a comprehensive falls risk assessment will be evaluated within 3 months of the incident fracture.
Assessments need to be conducted promptly as the risk of having a further fracture is increased in the first year.
3 INFORMATIONAll patients identified will be offered written information about bone health, lifestyle, nutrition and bone-protection treatments.
Anyone aged over 50 years who has had a fracture needs to be aware of the steps they can take to maintain healthy bones and prevent further fractures.
4 INTERVENTIONPatients at increased risk of further fracture will be offered appropriate bone-protection treatments.
Appropriately targeted interventions reduce future risk of fracture.
5 INTERVENTIONPatients at increased risk of further falls will be referred for appropriate assessment or interventions to reduce future falls.
Evidence-based falls interventions are effective at reducing risk of falls.
FLS Clinical Standards - summary
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No. Standard Rationale
6 INTEGRATIONManagement plans will be patient-centred and integrated between primary and secondary care.
Effective communication is essential to ensure that long-term management is achieved and that patients are supported to engage with recommended interventions.
7 INTEGRATIONPatients who are recommended drug therapy to reduce risk of fracture will be reviewed within 4 months of initiation to ensure appropriate treatment has been started, and every 12 months to monitor adherence with the treatment plan.
Treatments must be taken consistently and appropriately over many years to be effective. Follow-up allows early identification of issues (side effects, compliance) with prescribed medications, reinforces need to take treatments and supports long-term concordance.
8 QUALITYCore clinical data from patients identified by the FLS will be recorded on a database. Regular audit and patient experience measures will be performed
Data recorded will allow the FLS to audit and improve the service they provide ensuring that high standards are met and maintained.
9 QUALITYThe FLS team will have appropriate competencies in secondary fracture prevention and will maintain relevant Continued Professional Development (CPD).
All staff need appropriate knowledge, skills and experience to fulfil their role. Engagement with relevant CPD activities ensures that these are up to date.
10 QUALITYThe FLS should engage in a regular peer-review process of quality assurance.
Clinical peer review facilitates quality standard assurance, equitable access to services, and provides a means of benchmarking and sharing best practice.
FLS Clinical Standards - summary
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Gap AnalysisGap Analysis establishes to what degree an existing service is ‘performing’ against the Standards• Informative• Detailed • Specific• Targeted• Constructive
Gap Analysis
The FLS model/pathwayNEW
CLINICAL FRACTURE
NEW VERTEBRALFRACTURE
(RADIOLOGY REPORT)
ORTHO IP
Virtual/#CLINIC
‘CASE-FINDING’ BY FLS‘CASE-FINDING’ BY COTE
CARE OF THE
ELDERLY
The FLS model/pathwayNEW
CLINICAL FRACTURE
NEW VERTEBRALFRACTURE
(RADIOLOGY REPORT)
PREVIOUS FRACTURE OR FRACTURE NOT PRESENTING
TO ACUTE CARE
ORTHO IP
Virtual/#CLINIC
‘CASE-FINDING’ BY FLS‘CASE-FINDING’ BY COTE
‘CASE-FINDING’ BY GP/SEC CARE/CH
FLS RISK ASSESSMENTONE-STOP CLINIC
WITH DXA
CARE OF THE
ELDERLY
FLS Nurse Led Clinic
• Patient brings completed self history questionnaire • Height & weight measurements • DXA scan - radiographer• Bloods as per protocols?• Patient meets with osteoporosis nurse specialist• Questionnaire• DXA scan result
FLS Nurse Led Clinic• Discuss risk factors for falls and fracture• Discuss results of DXA scan • Discuss treatment if required as per protocols & FRAX• Provide lifestyle advice/education• Provide literature
Drug treatments Lifestyle Fall prevention NOS
• Arrange follow up at 4& 12 months• Refer for physiotherapy?• Refer to Community Falls Prevention Programme?• Refer onto Bone Metabolism Clinic if required?
Hospital-based Exercise Classes
• Assessed by a physiotherapist before starting the classes
• 12 week introductory programme
• Run by a physiotherapist
Leisure centre exercise classes
• Suitable for long term conditions• Continue long term
Stage 1General education (1:1)
Linking their fracture with need for assessment for osteoporosis
Stage 2 Specific education (1:1)
Personalising education, with interpretation of DXA, fracture risk
& need for treatment
Stage 3 Empowerment (Group)
2.5hr interactive education programme 6-12mo after starting Rx
14.00 Welcome 14.05 Treatment options14.30 Pharmacy review14.50 Exercise classes/falls prevention15.15 Pain management15.30 National Osteoporosis Society 15.45 Q & As
Newly diagnosed education meetings
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Community Falls Prevention Programme
• Specialist Falls service
• Over 65, live at home and had a fall in last year
• Aim to prevent further falls
• Falls screening, health education, exercise, rehab and onward referral
• Home visit within 7 days
The FLS model/pathway
FALLS RISKASSESSMENT
NEW CLINICAL FRACTURE
NEW VERTEBRALFRACTURE
(RADIOLOGY REPORT)
PREVIOUS FRACTURE OR FRACTURE NOT PRESENTING
TO ACUTE CARE
ORTHO IP
Virtual/#CLINIC
‘CASE-FINDING’ BY FLS‘CASE-FINDING’ BY COTE
‘CASE-FINDING’ BY GP/SEC CARE/CH
FLS RISK ASSESSMENTONE-STOP CLINIC
WITH DXA
EXERCISECLASSES
Rx FOR FRACTURE 2Y PREVENTION
EDUCATIONPROGRAMME
CARE OF THE
ELDERLY
4 & 12 MONTH FOLLOW UP
CLINIC
COMPLEX CLINIC
(IF REQUIRED)
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Challenges• Different models suit different services• Who and to what age for DXA?• 75+ No DXA (NICE) • No age restriction for DXA (SIGN)• Pathway - explicit when/whom to refer falls • Responsibility of blood tests - FLS/GP/referrer?• Following up complex cases – who is
responsible?
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Challenges• Inpatient hips• Other inpatients (k-wiring and plates)• Patients included who fall/fracture on other wards• Fracture/virtual clinic• Spinal fractures • Radiology – incidental spinal fractures
Who may be missed?• Patients attending emergency department not
having any follow up i.e. clavicle, ribs, pubic rami.• Patients admitted for other reason and fracture
identified on an X-ray …….
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How can the NOS help in your area?
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FLS Mapping
Assist with Stakeholder Meetings • Lead clinician/local
champion• Consultants:
o Endocrinologisto Rheumatologisto Geriatriciano Radiologisto Orthopaedic surgeon
• Osteoporosis nurse specialists
• DXA radiographers• Service manager/s
• Pharmacist• Prescribing advisors• Physiotherapist• GPs/Primary care• CCGs• Commissioners• Health & Wellbeing
Board/s• Public Health• IT• Site services• Patient rep (NOS!)
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• Comprehensive service review- professional credibility
• Assessment of Service
• Clinical Governance
Quality Assurance
Peer Review
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Fracture PreventionPractitioner Training
Fracture Prevention Practitioner (FPP) Training• Officially launched April 2015 • Web-based training at Foundation and Advanced
levels • 478 healthcare professionals registered• 120 accredited FPPs• Accessed by over 130 different hospital trusts and GP
practices • Accessed from across 15 different countries (US, AUS,
NZ, SA, CA, ROI, FR)
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FLS Implementation Toolkit1. Promotes commissioning of effective high-quality
services that are integrated within a system-wide approach
2. Ensures services are in accord with the evidence base and able to demonstrate outcomes
3. Stimulates provision of services that are sustainable
4. Make implementation easier, cheaper and more effective for commissioners and providers.
Contents Name Description Format
UK FLS Standards Clinical standards for FLS PDF
The Case for FLS A summary of evidence for providers and commissioners PDF
Service Specification A part populated service specification suitable for use with NHS Standard Contracts
MS Word
Benefits Calculator A financial model demonstrating potential cost savings Web
Cost Calculator A financial model to calculate the service requirements MS Excel
Service Improvement Guide A descriptive guide setting out step-by-step actions for providers to achieve a service improvement
Outcome and Performance Indicators
Practical, evidence-based indicators to demonstrate service improvement
MS Excel
Improvement Project Plan A list of tasks and activities for a development project MS Excel
Business Case Part populated case for investment in FLS MS Word
To secure funding / reimbursement you need to show…
Benefits less
Costs =
Value
FLS Benefits Calculator & Cost Calculator• Offer help and support based on Gap Analysis Tool to
develop or improve an FLS
• Estimates the benefits in terms of reduced fragility fracture incidence and cost savings that can be realised as a result of implementing an effective FLS.
• Calculates the cost of resources required (in progress)
• Produce an ‘Output report’, ‘Case for FLS’, SBAR and business plan if requested that can be submitted to Management
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Two calculators• Have been designed by clinicians and payors• Have been used in more than 30 sites• Are regularly updated and revised• Are based on proven service models• Are based on empirical data (not clinical trials)• Use local age-stratified population
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The FLS Benefits Calculator
There is an online version (UK only) at http://benefits.nos.org.uk
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Define populationStep 2 - Select population cohort for analysis (by age/gender)
Male FemaleInclude within analysis? Yes YesAge from 50 - 54 50 - 54Age to 85 + 85 +
Percent of population in
hospital catchment
Population for inclusion
97.0% 234,200
10.0% 7,560
Select one or more from list
NHS Oxfordshire CCG
NHS Aylesbury Vale CCG
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Estimate fracture incidence from population
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Number of fractures expected based on incidence data
324 371 1,292 297
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Estimate number to be treatedReference
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Number of fractures expected based on incidence data
1 765 876 3,047 702
677 463 1515 210Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Proportion of patients to be seen in the FLS
2 88.48% 52.81% 49.72% 29.84%
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Predicted number of FLS patients by category
677 463 1,515 210
Svedbom et al, Epidemiology and Economic Burden of Osteoporosis in UK, Archives of Osteoporosis, 2013 8:137, P212
Incidence is calculated for age bands selected and applied to the input population. Parameters for 'Other site' in Calculator is calculated from 'forearm' and 'other' in source paper above.
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Apply rate of prevention
Department of Health, Fracture prevention services: An economic evaluation, 2009
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Expected proportion of fractures prevented
2.26% 1.13% 1.13% 0.75%
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
2016 31.42% 40.16% 40.16% 31.44%2017 22.29% 19.69% 19.69% 25.71%2018 22.86% 17.32% 17.32% 21.90%2019 14.29% 14.17% 14.17% 13.33%2020 9.14% 8.66% 8.66% 7.62%
All years 100.00% 100.00% 100.00% 100.00%
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Calculate number of fractures prevented
Number of fractures prevented in each of 5 years for patients treated all years
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
2015 6 4 4 22016 11 6 6 42017 16 8 8 52018 19 10 10 62019 21 11 11 7
All years 73 39 39 24
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Multiply by benefits per fracture
References – various, available on request
Estimated costsHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Acute care £7,791 £1,715 £314 £1,867Community and primary care £448 £57 £57 £59Social care £8,237 £150 £150 £2,908All £16,476 £1,922 £521 £4,833
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YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral Total Average benefit per year
Acute care 2016 £162,580 £23,257 £4,264 £13,636 £203,7372017 £284,515 £35,780 £6,560 £23,376 £350,2312018 £414,579 £46,514 £8,528 £33,116 £502,7372019 £495,869 £55,459 £10,168 £40,908 £602,4042020 £552,772 £60,826 £11,152 £44,804 £669,554
All years £1,910,315 £221,836 £40,672 £155,840 £2,328,663 £465,733
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral Total Average benefit per year
Community and 2016 £8,960 £741 £741 £413 £10,855primary care 2017 £15,680 £1,140 £1,140 £708 £18,668
2018 £22,848 £1,482 £1,482 £1,003 £26,8152019 £27,328 £1,767 £1,767 £1,239 £32,1012020 £30,464 £1,938 £1,938 £1,357 £35,697
All years £105,280 £7,068 £7,068 £4,720 £124,136 £24,827
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral TotalAverage benefit per
yearSocial care 2016 £164,740 £1,950 £1,950 £20,356 £188,996
2017 £288,295 £3,000 £3,000 £34,896 £329,1912018 £420,087 £3,900 £3,900 £49,436 £477,3232019 £502,457 £4,650 £4,650 £61,068 £572,8252020 £560,116 £5,100 £5,100 £66,884 £637,2000
All years £1,935,695 £18,600 £18,600 £232,640 £2,205,535 £441,107
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The FLS Cost Calculator
This is not available on line
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What investment is required?• Cost of staff required:
• Manager? • Consultant – clinical supervision• Nurse specialist/fracture practitioner• Clerical/admin
• Set up costs – FLS accommodation, IT, DXA scanner and other associated costs:• DXA scans/reporting• Other diagnostics• Drug costs
The financial case
• Costs = 37% of benefits
• Break even – 13 – 20 months from start of service
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FLS BenefitsArea Population Cohort
(50+)Hip fractures prevented*
Total benefits (of hip fractures prevented)*
Bradford 459,142 129,011 119 £1,960,644East Sussex 374,801 167,905 188 £3,097,488Epsom 405,456 119,974 115 £1,894,740Rotherham 258,751 96,591 66 £1,111,902Salisbury 144,835 59,786 59 £972,084Stoke-on-Trent 214,991 88,334 88 £1,449,888Vale of York 348,363 131,411 128 £2,108,928Total 2,206,339 793,012 763 £12,595,674*Over a 5 year period
Conclusion
• Targeting people at the highest risk of further fracture
• Transforms post fracture care – providing a holistic approach to care – thinking long term
• Equal opportunity to all patients within catchment area - not postcode driven (not relying on GP’s or Orthopaedic surgeons to refer pts)
• Drug treatments/lifestyle advice are recommended appropriately dependent on scan result
• NOS are here to help!
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Abstract deadline: 3 June 2016Early-bird registration deadline: 5 August 2016
www.nos.org.uk/conference
Thank you
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Mayrine FraserNational Osteoporosis SocietyCamertonBathBA2 0PJ
Tel: 07515 574789
Email: m.fraser@nos.org.uk
Website: www.nos.org.uk
Contact information
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