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Fracture prevention services An economic evaluation

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Document purpose BestPracticeGuidance

Gateway reference 13081

Title FracturePreventionServices:aneconomicevaluation

Author DH/SC,LG&CPdirectorate/OlderPeopleandDementia

Publication date 25November2009

Target audience PCTCEs,CareTrustCEs,DirectorsofPH,DirectorsofAdultSSs,DirectorsofFinance,AlliedHealthProfessionals

Circulation list

Description Thiseconomicevaluationmodelsthecostsandbenefitsfromestablishingafractureliaisonservice,toreducetheriskofsecondaryfractures.

Cross reference N/A

Superseded documents N/A

Action required N/A

Timing N/A

Contact details GillAylingOlderPeopleandDementiaDepartmentofHealthRoom8E28QuarryHouseQuarryHillLeedsLS27UE01132546068

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©Crowncopyright2009

FirstpublishedNovember2009

ProducedbyCOIfortheDepartmentofHealth

Thetextofthisdocumentmaybereproducedwithoutformalpermissionorchargeforpersonalorin-houseuse.

www.dh.gov.uk/publications

Fracture prevention services An economic evaluation

1

Thiseconomicevaluationassessesthecostsandbenefitsofservicestoreducefracturesamongolderpeople.Localcommunitiescanusethistodeveloptheirownproposals.

Thereisstrongevidenceabouttheimpactandcostbenefitargumentsforfracturepreventioninterventions,basedonsystematicimplementationofnationalguidanceonsecondarypreventionofosteoporoticfracturesandotherinterventionsforatargetedat-riskpopulation.

Thefollowingisasummaryofthemainfindingsofaneconomicmodelfortheimpactofafractureliaisonservice,asdescribedintheguideFalls and fractures: effective interventions in health and social care1.

Inthismodel,overa5yearperiod£290,708issavedinNHSacuteandcommunityservicesandlocalauthoritysocialcarecosts,againstanadditional£234,181revenuecosts(fallingbothinyear1andcoveringdrugtherapyforfiveyearsspentbytheNHSonthispatientcohort).Thisisforanannualpatientcohortof797hip,humerus,spineandforearmfractures,anticipatedfroma320,000population.

Atanationallevel,thisequatestoapproximately£8.5millionsavingover5years.

1

1 Fallsandfractures:effectiveinterventionsinhealthandsocialcare,DepartmentofHealth,2009.

Summary

2

FallsareamajorcauseofdisabilityandmortalityintheUK.Thirtypercentofthoseaged65oroverwholiveinthecommunityfalleachyear,increasingto45percentinthoseaged80orabove1.Themaincauseoffallsisunsteadinessduringmovement.Inaddition,somearecausedbyblackouts(syncope)associatedwithcardiacorcirculationproblems.Bothbecomemorecommonwithage,duetoincreasingprevalenceoffrailtyandotherlongtermconditions.

Recurrentfallsareassociatedwithincreasedmortality,increasedratesofhospitalisation,curtailmentofdailyactivitiesandhigherratesofinstitutionalisation.Thisiscompoundedbythepsychologicalconsequences,suchaslossofconfidence,increasedfearoffallingandlowerqualityoflife2.Halfoffallerswillhaveafurtherfallwithinthenext12months3.Therateoffallsamongpeopleininstitutionsisalmostthreetimesthatofolderpeoplelivinginthecommunity,4withinjuryratesalsoconsiderablyhigher.

Bonedensityandstrengthalsofallwithage,particularlyinthosewithotherlongtermconditionssuchasdiabetes.Thus,thechancethatafallwillresultinafracturewillincrease.Fractureswhichoccurafteralowimpactinjury,suchasafallfromstandingheight,arecalledfragilityfractures.Halfofolderwomenwillexperienceoneintheirlifetime.Themorefrailtheindividual,themorelikelyafracture.Forexample,10-20percentofinstitutionalfallsresultinahipfracture.

2 CummingRG,SalkeldG,ThomasM,SzonyiG.Prospectivestudyoftheimpactoffearoffallinginactivitiesofdailyliving,SF-36scoresandnursinghomeadmission.J Gerontology2000;55:299-305.

3 CloseJ,EllisM,HooperR,GlucksmanE,JacksonS,SwiftC.Preventionoffallsintheelderlytrial(PROFET):arandomisedcontrolledtrial.Lancet1999;353:93-97.

4 TinettiME,SpeechleyM,GinterSF.Riskfactorsforfallsamongelderlypersonslivingwithinthecommunity.NEngJMed1988;319:1701-07.

1. Falls and fractures: who is affected?

3

Thepopulationisgrowingolder.InEngland,thenumberofpeopleagedover65isduetorisebyathirdby2025.Inthesameperiodthenumberofpeopleover80willdoubleandthenumberover100willincreasefourfold.Thiswelcomeincreaseinlifeexpectancyishoweverassociatedwithanincreaseinyearsspentwithsomedisablingillness.Asignificantriseinfallsandassociatedfracturesisthereforelikelyunlessspecificpreventativeinterventions,outlinedbelow,becomewidespread.

Thenumbersarelarge.ForaPCTandlocalauthoritywithapopulationof320,000,therewillbearound45,000peopleagedover65in2009.Ofthese1:

●● 15,500willfalleachyear,6,700twiceormore

●● mostwillnotseekhelp

●● 2,200willattendA&Eoraminorinjuryunit(MIU)

●● asimilarnumberwillcalltheambulanceservice

●● 1,250wiIlhaveafracture,with360oftheselikelytobehipfractures.

Hipfracturesremainthemostseriousconsequenceofafall.Thereisasignificantincreaseinmortality,with30%mortalityat12months.Moreover,approximatelyhalfofthosepeoplewhowerepreviouslyindependentbecomepartlydependentfollowingahipfracture,whileone-thirdbecometotallydependent.

Hipfracturesaccountformorethan20percentoforthopaedicbedoccupancyintheUK,andinwomenover45hipfracturesaccountforahigherproportionofhospitalbedoccupancythanmanycommondisorders.

2. What is the size and cost of the challenge of fractures?

4

Osteoporosisisachronicdiseasethatweakensbonestrengthandaffectsoneinthreewomenandonein12menagedover50,particularlypost-menopausalwomen.Theincidenceinbothsexesrisesrapidlyasthepopulationages.Itsonsetisasymptomaticanditisoftenonlyrecognisedafteranolderpersonfallsandsustainsafracture.Almosthalfofallwomenandoneinsixmenexperienceanosteoporoticfracturebeforedeath.

Severalstudieshaveconsideredfuturefractureriskassociatedwithdifferentkindsoffractures,andidentifiedthatapriorfractureatanysiteisassociatedwithadoublingoffuturefracturerisk.Post-menopausalwomenareathighriskoffracturesbecausetheyareatparticularriskofosteoporosis.

InaPCTpopulationof320,000,therearelikelytobe:

●● 55,000post-menopausalwomen

●● 17,400post-menopausalwomenwithosteoporosis

●● 6,900post-menopausalwomenwithapreviousfractureofanykind

●● 1,000post-menopausalwomenwithanewfractureeachyear.

Thelasttwogroupsaboveconstitutejust16percentofthelocalpopulation.Butitisamongthis16%thathalfofthehipfracturesoccur.Targetingthesegroupsinprimarycareandthroughfractureliaisoncase-findingservicesinhospitalprovidesreadyaccesstothoseatgreatestriskofhipfractures.

3. Why is identification of osteoporosis important?

5

Mostlocalcommunitieslackanysystematiclocalprogramme–suchasafractureliaisonservicecoveringfallerswhofracturepresentingtourgentcareoraprimarycare-basedcase-findingservice–toidentifyandtreatosteoporosisinhigh-riskgroups,particularlypost-menopausalwomen.

Withoutsuchprogrammesorservices,compliancewithNationalInstituteforClinicalEvidence(NICE)guidelinesTA1615andCG216onsecondarypreventionofosteoporoticfragilityfracturesislow.ThishasbeenhighlightedmostrecentlybytheRoyalCollegeofPhysicians(RCP)2009audit7offallsandbonehealthservices.ThisconfirmedthatacrossmuchoftheNHSinEnglandNICEguidanceisnotbeingwidelyemployedand“systems to ensure initiation of secondary prevention medical treatments for osteoporotic fragility fractures are not in place”.

Asaresult,theopportunitytotargetkeygroupsatmostriskofhipfractureandinitiateandoverseeosteoporosistreatmentsthatsignificantlyreducefractureriskisbeingmissed.IntheRCPnationalclinicalauditof2007,only19percentofover5,000patientspresentingtohospitalwithanon-hipfragilityfracturewereontheappropriatebonemedicationthreemonthslater.Thisisamajoropportunitylostasover40%ofpeoplewhosustainahipfracturehavehadapreviousnon-hipfragilityfracture.

5 Technicalappraisal(TA)161Osteoporosis – secondary prevention including strontium ranelateNICE2008http://guidance.nice.org.uk

6 Clinicalguideline21Clinical practice guideline for the assessment and prevention of falls in older peopleNICE2004http://guidance.nice.org.uk

7 National audit of the organisation of services for falls and bone health of older peopleRoyalCollegeofPhysicians2009http://www.rcplondon.ac.uk

4. What is the problem?

6

Theestablishmentoffractureliaisonservice,basedwithacuteservices,isforpatientsagedover50whoareadmittedtohospitalorwhoattendoutpatientclinicsorA&Edepartmentsduetoalowimpact(fragility)fracture,gainedfromafall,sliportrip.Fora320,000populationtheservicewouldassessabout1250olderpeoplewithfragilityfractureseachyear,whowillhaveaclinicalassessmentbyaspecialistFractureliaisonservice(orOsteoporosis)nurseandsomeofwhomwillundergoDXA8bonedensitymeasurementsatthespineandhip(inaccordancewithNICEguidanceTA161).Osteoporosistreatmentistypicallyrecommendedinabout75%ofcases.

Theroleofthespecialistnurseisto:

●● investigate,usingbonescansandlocalprotocols,andstartdrugandothertreatments,accordingtoNICEguidanceforwomenandlocalagreementsformen,toreducetheriskofafuturebreakifsomeonehasosteoporosis

●● linkdirectlywithfallsservices

●● monitorandmaintainmedicationadherence

●● Supportthemonitoringandmaintenanceofmedicationadherenceincollaborationwithprimarycare.

Themaincostsareforthenurse,aconsultantsessionforclinicalsupportandsupervisionandsomedirectpatientcare,someclericalsupport,revenuecostsforthescanningandpharmacycostsofosteoporosistreatment,usuallycomprisedofagenericbisphosphonateincombinationwithcalciumandvitaminD.

Theinputofthenurserelatesprimarilytothefirstyear’smembershipofthecohortprogramme,withminimalcontactthereafter(forexamplethroughlettercontactandoccasionaltelephonecalls).Soitfallstoprimarycaretomakethenecessaryarrangementstomaintainmedicationadherencelongerterm.

8 Dualenergyx-rayabsorptiometry(DXA)scansareusedtomeasurebonemineraldensity

5. The proposal for a fracture liaison service

7

Theinterventionsandtheireffecthavebeenmodelled(Tables1-5)andtheservicecostsestimated.Itisimportanttonotethatthisstudyisbasedonacohortofpeople.Inotherwords,themodellooksatthecostsofaninterventionforthetotalnumberofpeopleidentifiedwhohavefracturedinanyoneyearinalocalpopulation.Thecostssavedarethencalculatedtoreflectthesavingsthatcanbeachievedfromthatcohortoverfiveyears,withtheimplementationofthisintervention.

Localcommunitiescanusetheassumptionsinthismodeltodeveloptheirownproposals,orincludedifferentassumptionsthatmatchlocalcircumstances.Thereisanon-linemodellingtoolforafractureliaisonservicebusinesscaseathttp://fracture-liaison-model.co.uk

Keyassumptionsbuiltintothemodelareasfollows:

●● OutofatypicalPCTpopulationofaround320,000therewill,ashighlightedabove,bearound1,250fragilityfracturesofanytypeperyear. PublisheddatafromanexistingFractureLiaisonService9showsalikelybreakdownbyageandfracturetypeinTable1overaoneyearperiod.

●● Ofthisgroupofaround1,250fractureannually,thiseconomicevaluationisfocusingonthe797hip, humerus, spine and forearm fracturesperyear,asthereisrobustresearchdataontheimpactofafractureliaisonservicesinthesemostsignificantfracturetypes.Thisisintermsofimpactonqualityoflifeandhigherservicecost.Fortheremainingonethirdoffractures(pelvis,lowerlimb,handsandfeet)afractureliaisonservicecouldreasonablyexpecttohaveapositiveimpactinreducingfurtherfracturesbutthecostsorbenefitsarenotmodelledinthisstudy.

●● Allthe797hip,humerus,spineandforearmfractureswillbeassessedbythefractureliaisonnurse,andifnecessarytheconsultant,and20%ofhipfracturepatientsand80%ofhumerus,forearmandspinepatientsareanticipatedtoreceivebonescans.ThisisapragmaticinterpretationofNICETA161combinedwithpracticalexperiencefromexistingfractureliaisonservices.

9 Implementing and running a fracture liaison service,Clunie&Stephenson,JournalofOrthopaedicNursing,(2008)12:156-162

6. Summary of interventions and their effect

8

●● InlinewithNICEguidance5,manybutnotallpatientsscannedwillrequiretreatmentforosteoporosis:estimatedat100%ofthehipfractures(373),50%ofthewristfractures(159),75%ofspines(17)and75%ofhumerus(62):atotalof611outof797.

●● Usingdatafromaretrospectivestudy–fromJohnell10abouttheincidenceofsecondaryfracture,bytype,over5years–thepatternofsecondaryfracturesfora320,000populationforeachannualcohortcanbeidentified(Table2).Thisisbasedontheageprofileexpectedforpatientspresentingwithfracturesattheseskeletalsites.

●● Factoredintothecalculationisa)thepercentageofeachfracturetypetobetreated,rangingfrom100%ofhipfracturestoonly50%offorearmfractures,andb)arelativeriskreductionthroughafractureliaisonserviceof40%(NICETA1615).Fromthistherefore,canbeestimatedthenumberoffracturesactuallyavertedthroughtheserviceover5years(Table3).

●● Anassumptionofonly80%medicationcompliancehasbeenincluded(Table4),givingactualfracturesavertedof18hips,5forearms,6spineand4humerusover5yearsforeachannualcohort.

Table 1: Likely age breakdown by fracture type (Data from Ipswich Fracture Liaison Service)9

Fracture Age Range (years) over 1 year period

45-59 60-69 70-79 80-89 90+ Total

Hip 12 22 90 173 77 373

Forearm 98 86 93 37 6 318

Humerus 23 21 27 10 3 83

LowerLimb 67 50 33 14 4 167

Pelvis 2 2 9 17 7 35

Spine 3 3 9 6 3 23

Other 92 60 48 18 2 219

NotSpecified 11 8 6 5 1 30

Total 306 251 313 277 102 1247

●● Researchevidence5suggeststhatafractureliaisonservicewouldproduceasimilarimpactonthefuturefractureincidenceforthe453otherfracturesites,inadditiontohip,humerus,spineandforearmfractures(forexamplepelvis,ribs,handsandanklefractures).

10Fracture risk following an osteoporotic fracture,Johnell,Kanisetal,OsteoporosisInternational,(2004)15:175-179

Summaryofinterventionsandtheireffect

9

Tabl

e 2:

Stu

dy o

f th

e in

cide

nce

of s

econ

dary

fra

ctur

es b

y ty

pe o

ver

5 ye

ars

(Joh

nell

et a

l 20

04)10

Year

of

stud

y (N

o. S

econ

dary

Fra

ctur

es)

Year

of

stud

y (%

Sec

onda

ry F

ract

ures

)

Site

of

new

fra

ctur

e0

– 1

1 –

22

– 3

3 –

44

– 5

0 –

50

– 1

1 –

22

– 3

3 –

44

– 5

0 –

5

a. P

rior

hum

erus

fra

ctur

e (n

=26

8)

Hip

95

43

425

3.4

1.9

1.5

1.1

1.5

9.3

Fore

arm

133

22

222

4.9

1.1

0.7

0.7

0.7

8.2

Spin

e8

31

31

163.

01.

10.

41.

10.

46.

0

Hum

erus

23

11

18

0.7

1.1

0.4

0.4

0.4

3.0

b. P

rior

spi

ne f

ract

ure

(n=

500)

Hip

1911

2010

565

3.8

2.2

42

113

Fore

arm

35

84

020

0.6

11.

60.

80

4

Spin

e7

1618

94

541.

43.

23.

61.

80.

810

.8

Hum

erus

62

33

115

1.2

0.4

0.6

0.6

0.2

3

c. P

rior

hip

fra

ctur

e (n

=11

50)

Hip

2723

1612

785

2.3

2.0

1.4

1.0

0.6

7.4

Fore

arm

167

23

129

1.4

0.6

0.2

0.3

0.1

2.5

Spin

e18

84

23

351.

60.

70.

30.

20.

33.

0

Hum

erus

115

65

633

1.0

0.4

0.5

0.4

0.5

2.9

d. T

otal

s (n

=19

18)

Hip

5539

4025

1617

52.

92.

02.

11.

30.

89.

1

Fore

arm

3215

129

371

1.7

0.8

0.6

0.5

0.2

3.7

Spin

e33

2723

148

105

1.7

1.4

1.2

0.7

0.4

5.5

Hum

erus

1910

109

856

1.0

0.5

0.5

0.5

0.4

2.9

Tota

ls13

991

8557

3540

77.

24.

74.

43.

01.

821

.2

Fracturepreventionservices:Aneconomicevaluation

10

Tabl

e 3:

Ant

icip

ated

sec

onda

ry f

ract

ures

if

no i

nter

vent

ion

take

s pl

ace

Year

of

stud

y (N

o. S

econ

dary

Fra

ctur

es)

Year

of

stud

y (%

Sec

onda

ry F

ract

ures

)

Site

of

new

fra

ctur

e0

–1

1–

22

–3

3–

44

–5

0–

50

–1

1–

22

–3

3–

44

–5

0–

5

a. P

rior

hum

erus

fr

actu

re (

n=83

)

Hip

32

11

18

3.4

1.9

1.5

1.1

1.5

9.3

Fore

arm

41

11

17

4.9

1.1

0.7

0.7

0.7

8.2

Spin

e2

10

10

53.

01.

10.

41.

10.

46.

0

Hum

erus

11

00

02

0.7

1.1

0.4

0.4

0.4

3.0

b. P

rior

spi

ne

frac

ture

(n=

23)

Hip

11

10

03

3.8

2.2

42

113

Fore

arm

00

00

01

0.6

11.

60.

80

4

Spin

e0

11

00

21.

43.

23.

61.

80.

810

.8

Hum

erus

00

00

01

1.2

0.4

0.6

0.6

0.2

3

c. P

rior

hip

fra

ctur

e (n

=37

3)

Hip

97

54

228

2.3

2.0

1.4

1.0

0.6

7.4

Fore

arm

52

11

09

1.4

0.6

0.2

0.3

0.1

2.5

Spin

e6

31

11

111.

60.

70.

30.

20.

33.

0

Hum

erus

42

22

211

1.0

0.4

0.5

0.4

0.5

2.9

d. P

rior

for

earm

fr

actu

re (

318)

*

Hip

––

––

–17

––

––

–5.

4

*Sec

onda

ryf

ract

ure

expe

rienc

epr

ojec

tion

base

dup

one

stim

ates

inH

aent

jens

et

alJ

BMR

200

4:12

;193

3-19

44

11

Anticipatedsavingsorcostsavertedareasfollows:

●● NHSandlocalauthoritysocialcaredirectsavingscombinedfora320,000populationhavebeencalculatedat£290,708 overthe5years,withthemajorityoffracturesavoided,andconsequentsavingsinthefirstthreeyears(Table4).Therewillinadditionbereducedsocialcarecostsforpeoplewhofundtheirowncare,whichhavenotbeenincludedinthisanalysis.

●● Keyassumptionsoncostsavings(Table4)areasfollows,basedon2009/10costs:

●– Eachhipfractureavertedwillavoidcommissionersincurring£10,170PbRtariffcosts11,reduceNHScommunityservicecostsby£1,600percommunityhospitaladmissionand£400perreferraltointermediatecare,andsave£3,879inlocalauthoritysocialcarecostsover2yearsonaverageperhipfracture(outlinedinAppendixA).

●– Fracturesofthehumerus,spineandforearmavertedwillavoidcommissionersincurringPbRtariffcostsestimatedforcombinedinandoutpatientsof£1,300,£3,246and£1,082respectively,pluslocalauthoritysocialcarereducedby£225percaseonaverageforspineandforearmfractures(outlinedinAppendixA).

●– Theassumptionsaboutcommunityservicesinputasarefollows.Forhipfractures,around20%willhavefollow-upinacommunityunit,foranestimatedstayof8daysatamarginalcostof£200perbedday.Afurther20%willreceiveanintermediatecarepackageof20hours,ataround£20perhour.Communityservicesavingsforhumerus,spineandforearmfracturesareestimatedtobesmallandhavenotbeenincluded.

●● Thecostsacrossprimaryandsecondarycareofrunningafractureliaisonserviceforeachyear’scohortofhip,humerus,spineandforearmfractures(comprisingtwothirdsofallfragilityfractures)is£234,181outlinedinTable5.Thisconsistsof:

●– Staffcosts:twothirdsofthetotalfractureliaisonservicestaffcostsinyear1(withstafftimefortheyear1patientcohortcoveredbyotheryears’cohortcostsfromyear2onwards).Thisreflectsthecostsassociatedwith

11Basedon2009/10PaymentbyResultstariffcostsHA11-14,andincludingaMarketForcesFactorof1.082

7. Summary of cost/benefit position


12

hip, humerus, spine and forearm fractures, which comprise two-thirds of toal fractures in this model.Onthisbasis,staffcostsofrunningaFractureLiaisonServiceforthesefracturetypesfora320,000populationfor1yearare£36,850

●– DXA:bonescanninginyear1isafurther£20,690,basedonamarginalcostperscanof£50.BasedontheageprofileandapragmaticapplicationofNICETA161around20%ofhipfracturepatientswillneedaDXA,withahigherproportion(estimatedat80%)forforearm,spineandhumeruspatients.

●– Drugcosts:Thetotaltreatmentcostdistributedover5yearsiscalculatedinthismodelat£176,641takingintoaccount12%mortality,80%complianceandtheavailabilityoverthenextfewyearsofgenericrisedronate(from2010),ibandronate(2011)andzoledronate(2012),basedonaforecastreductionof50%overalloverfouryearsinthecostofthesedrugs.

●● InadditiontosavingsandcapacityreleasedinNHSacuteandcommunityandlocalauthoritysocialcare,therewillalsobeaverysignificantqualityoflifegainforolderpeoplewhodonotincurasecondaryfracture.ThishasnotbeenreviewedindetailinthiseconomicevaluationbutisdocumentedintheDHpublication:Falls and fractures: effective interventions in health and social care(2009).

●● Thereforeinthismodel,overa5yearperiod£290,708willbesavedinNHSacuteandcommunityservicesandlocalauthoritysocialcarecosts,againstanadditional£234,181revenuecostsinyear1andcoveringdrugtherapyforfiveyearsspentbytheNHSonthispatientcohort.Thisisforanannualpatientcohortof797hip,shoulder,spineandforearmfractures.AsensitivityanalysisofthebasecaseestimateisprovidedinAppendixB.

13

Summaryofcost/benefitposition

Tabl

e 4:

Dir

ect

NH

S an

d lo

cal

auth

orit

y co

sts

save

d

Year

s

Site

of

frac

ture

av

erte

d0–

11–

22–

33–

44–

50–

5

% o

f pa

tien

ts

rece

ivin

g m

edic

atio

nR

RR

**

(%)

Frac

ture

s av

erte

d80

%**

* co

mpl

ianc

e

Acu

te c

are

savi

ngs

(£)

Soci

al c

are

savi

ngs

(£)

NH

S co

mm

unit

y se

rvic

es

savi

ngs

Tota

l sa

ving

s (£

)

Hip

1210

75

455

*10

0.0

40.0

2218

180,

984

69,0

307,

118

£257

,133

Fore

arm

93

22

117

50.0

40.0

75

5,93

40

–£

5,93

4

Spin

e9

42

21

1975

.040

.08

619

,519

1,35

3–

£20

,872

Hum

erus

43

22

214

75.0

40.0

64

5,77

099

9–

£6,

769

Tota

ls34

2013

118

105

4333

212,

208

71,3

827,

118

£290

,708

Thes

ear

eth

enu

mbe

rof

hip

,for

earm

,spi

ne&

hum

erus

fra

ctur

esa

vert

edf

ora

nan

nual

coh

ort

of7

97p

revi

ous

frag

ility

fra

ctur

es,a

ndt

hed

irect

NH

S&

lo

cala

utho

rity

cost

ssa

ved

over

5y

ears

,as

am

edic

atio

nre

gim

eis

fol

low

ed.

*To

talo

f55

hip

fra

ctur

esa

vert

edin

clud

esd

ata

from

prio

rfo

rear

mf

ract

ures

(in

Tab

le3

)w

hich

isn

otb

roke

ndo

wn

byy

ear

over

yea

rs0

-5.

**R

RR

%=

Rel

ativ

eris

kre

duct

ion

(%)

achi

eved

by

drug

reg

ime.

***

80%

Com

plia

nce

=A

ntic

ipat

edc

ompl

ianc

ew

itht

hed

rug

regi

me

over

5y

ears

.

14

Tabl

e 5:

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15

InadditiontothecostsavingsfortheNHSinreducingtheincidenceofhipfracture,thereisalsothepositiveimpactfromreducedhipfracturesonlocalauthority-fundedsocialcareservices.Thesecostsareanintegralpartofthecost-benefitcaseforFLS.

(Thefollowingareillustrativeestimatesonly,andlocalcostsandservicepatternsareknowntovaryconsiderably,notablybasedontheextentofhomecarereablementserviceslocally)

●● Foreach10hipfracturesaverted,theworkingassumptionisthattherewillbealocalauthoritycostsavingof:

●– 0.9carehomeplacements….

Thisisbasedon10%rateofpost-hipfracturedirecttransferfromhospitaltocarehome17andwithinthisgroupa60%rateoflocalauthorityfundedplacements,comparedtoself-funders18.Thedurationofthisplacementcouldvaryfromafewmonthstoseveralyears.Aworkingassumptionisthateachcarehomeplacementisfor2yearsat£600perweek,thoughcostanddurationofaveragestayvariesconsiderablyacrossregionsandbetweenlocalities.

Thus,totallocalauthoritycarehomecosts=£37,440over2yearsforevery10hipfractures,or an average of £3,744 per hip fracture.

●– plusthreehomecarepackages

Thisisbasedon6outof10hipfracturesdischargedfromhospitalbacktotheirownhomerequiringahomecarepackage;andofthese1in2areeligibleforlocalauthorityfunding.Intensityofsupportwillvaryaccordingtoneed–suchasfrailty,needfordoublehandedpackages,andhomeenvironment–andtheextenttowhichreablementservicesarecommissioned.

Aworkingassumptionisthatforeachgroupof10hipfractures3outof10wouldincurcostsofacarepackagecostedasfollows:3x(1hoursperdayonweekdaysfor6weeksat£15perhour19,or£450)x3hipfractures.

17NationalHipFractureDatabase2009andHospitalEpisodeStatistics2007/8,DH.18Older People in the United Kingdom,AgeConcern,200819DepartmentofHealthestimate

Appendix A: Cost benefits for local authority social care from reducing fractures


16

Thistotals£1,350(forevery10hipfractures),or £135 per hip fracture.

Thecombinedvalueofboththecarehomeandthecarepackagesavingelementis£3,744+£135=£3,879per hip fracture

●– Themortalityrateforhipfracturesis30%at12months,so3in10ofavertedhipfractureswouldnotincuranysocialcarecosts.

●● Foreveryanticipatedreductionin2 vertebraoranklefractures(at1in2eligibilityforLAfundingwithintheclientgroup)asimilarlocalauthoritysavinginhomecareisanticipated:of(1hoursperdayonweekdaysfor6weeksat£15perhour,or£450)x50%or£225 per vertebra/ankle fracture

Aworkingassumptionisthatwristfracturesocialcaresupportcanbemetatminimalcost,throughlowcastaidsandadaptationsforexample.

17

ASensitivityAnalysiscanbedefinedasinvestigationintohowprojectedperformancevariesalongwithchangesinthekeyassumptionsonwhichtheprojectionsarebased.ThefollowingSensitivityAnalysisprovidescommissionersofserviceswithanindicationofthepotentialrangeofcostsandsavingsthatmightbeachievedinrealworldpractice.Thebasecaseestimatepresentedinthebodyofthedocumentabovehasbeeninformedbyapragmaticsynthesisofallrelevantresearchevidenceandsoprovidesthemostlikelyindicationofthecost-effectivenessofimplementingaFractureLiaisonService.

Thebasecasemakesthefollowingassumptions:

1. Fracture incidence:Intheabsenceofintervention,thenumberofsecondaryfracturesbysiteis56hip,17forearm,19spineand14humerus.

2. Drug efficacy:TheRelativeRiskReduction(RRR)forsecondarypreventionoffractureis40%forallsecondaryfracturesafterincidentfracturesatallsites.ThisestimateisbaseduponNICETechnologyAppraisalestimates.

3. Drug compliance:SeveralFractureLiaisonServiceshavepresenteddrugcompliancedataaspostersatnationalcongresseswhichsuggest80%compliancewithosteoporosismedicationscanbeachieved20,21,22,23.Accordingly,drugcomplianceissetat80%.

4. Treatment rates:BasedonNICETechnologyAppraisals,theproportionofpatientstreatedbyfracturesitewouldbe100%ofhips,75%ofhumerus,75%ofspinesand50%offorearms.

5. Drug spend:ThecostofgenericalendronateissetaccordingtotheOctober2009NHSDrugTariffpriceof£1.16for28dayssupply(i.e.£15.08peryear).Thecostofacombinedcalciumandvitamin-Dpreparationissetat£50peryear.Therefore,theannualcostofgenericalendronateco-prescribedwithacalciumandvitamin-Dsupplementissetat£65.08peryear.Thecostforanon-alendronatebrandedosteoporosismedicationco-prescribedwitha

20OsteoporosisInt2004;15(S2):S56:P141HarknessMetal21OsteoporosisInt2003;14(S4):S53:P55FraserMetal22OsteoporosisInt2006;17(S3):425:P115LockwoodSetal23OsteoporosisInt2003;14(S4):S12:OC27BartonJetal

Appendix B: Sensitivity Analysis of Base Case Estimate


18

calciumandvitamin-Dsupplementissetat£300peryear.Thecostfor5yearstreatmentinlinewithNICETechnologyAppraisalsfor80%ofpatientswithgenericalendronateandcalciumandvitamin-Dis£112,067.Thecostfor5yearstreatmentfortheremaining20%ofpatientstreatedwithacurrentlybrandeddrugandcalciumandvitamin-Dis£64,574.Thedrugspendassumes80%compliance,12%mortalityandtheavailabilityoverthenextfewyearsofgenericrisedronate(from2010),ibandronate(2011)andzoledronate(2012),basedonaforecastreductionof50%overalloverfouryearsinthecostofthesedrugs.

6. FLS staff costs:Thesereflecttheproportion(twothirds)ofallfracturesconsideredinthiscost/benefitstudy.FractureLiaisonNursesalarysetat£26,800peryear,Lead-Clinicianat1sessionperweeksetat£6,700peryearandclericalsupportsetat£3,350peryear.

7. Bone density scanning (DXA):Bonescanninginyear1isafurther£20,690,basedonamarginalcostperscanof£50.BasedontheageprofileandapragmaticapplicationofNICETA161around20%ofhipfracturepatientswillneedaDEXAscan,withahigherproportion(estimatedat80%)forforearm,spineandhumeruspatients.

Eachoftheabovesourcesofcostandsaving,whereappropriate,willbevariedbyafixedpercentageaboveandbelowthebasecaseestimate.

1. Fracture incidence

Theincidenceofsecondaryfractureswasvariedby±20%(thebasecaseestimatebysitewas56hips,17forearms,19spinesand14humerus).

Ifsecondaryfractureincidencewas20%lowerthanthebasecase,thenumberoffracturesbysiteoverthe5yearperiodwouldbe44hip,14forearm,15spineand11humerus.Thesavingswouldbe£232,566.

Ifsecondaryfractureincidencewas20%higherthanthebasecase,thenumberoffracturesbysiteoverthe5yearperiodwouldbe67hip,21forearm,23spineand17humerus.Thesavingswouldbe£348,850.

Assumingthattheoperationalcostsremainedasestimatedinthebasecase(i.e.234,181),the20%lowerestimatetranslatestotheFLScosting£1,615tooperate.The20%higherestimatetranslatestotheFLSsaving£114,669.

AppendixB:SensitivityAnalysisofBaseCaseEstimate

19

2. Drug efficacy

TheRelativeRiskReduction(RRR)achievedbydrugtreatmentwasmodelledat35%and45%(versus40%inthebasecase).

IfRRRwas35%,thenumberoffracturesavertedbysitewouldbe16hips,5forearms,5spinesand4humerusThesavingwouldbe£254,370.

IfRRRwas45%,thenumberoffracturesavertedbysitewouldbe20hips,6forearms,7spinesand5humerusThesavingwouldbe£327,047.

Assumingthattheoperationalcostsremainedasestimatedinthebasecase(i.e.234,181),the35%RRRestimatetranslatestotheFLSsaving£20,189tooperate.The45%RRRestimatetranslatestotheFLSsaving£92,866.

3. Drug compliance

Drugcompliancewasmodelledat60%and100%.

Ifcompliancewas60%,thenumberoffracturesavertedbysitewouldbe13hips,4forearms,5spinesand3humerusThesavingwouldbe£218,031.Assumingthedrugspendwouldbereducedonaccountofreducedcompliance(i.e.patientswouldnotcollect40%ofprescriptions),theoperationalcostswouldbe£190,021.Inthisscenario,theoverallsavingwouldbe£28,000.

Ifcompliancewas100%,thenumberoffracturesavertedbysitewouldbe22hips,7forearms,8spinesand6humerusThesavingwouldbe£363,385.Assumingthedrugspendwouldbeincreasedonaccountofincreasedcompliance(i.e.patientswouldcollect100%ofprescriptions),theoperationalcostswouldbe£278,341.Inthisscenario,theoverallsavingwouldbe£85,044.

4. Treatment rates

OnaccountofthetreatmentratesbeingalignedtoNICETechnologyAppraisalguidance,thisinputtothemodelwasnotsubjecttovariation.

5. Drug spend

Fourscenarioshavebeenmodelledrelatingtovariationsindrugspendoverthe5yearperiod.

a) 25% Reduction in total drug spend on alendronate treated patients:Thisscenariowouldresultinthedrugspendonpatientstreatedwithalendronate


20

andcalciumandvitamin-Dreducefrom£112,067to£84,050.TotalFLScostswouldreducefrom£234,181to£206,164.

b) 75% Reduction in spend on currently branded drugs:Thisscenariowouldresultinthedrugspendonpatientstreatedwithcurrentlybrandeddrugsandcalciumandvitamin-Dreducefrom£64,574to£32,287.TotalFLScostswouldreducefrom£234,181to£201,894.

c) Combination of scenarios a and b:Thisscenariowouldresultinthetotaldrugspendreducefrom£176,641to£116,337.TotalFLScostswouldreducefrom£234,181to£173,877

d) No new generic drugs available as projected:Thisscenariowouldresultinthedrugspendonpatientstreatedwithcurrentlybrandeddrugsandcalciumandvitamin-Dincreasefrom£64,574to£129,149.TotalFLScostswouldincreasefrom£234,181to£298,756.

Assumingnoimpactuponthesavingsestimatedinthebasecase,themosteconomicallyfavourablescenarioabove(c)wouldresultinanoverallsavingof£116,831over5years.Theleasteconomicallyfavourablescenario(d)wouldresultinFLScosting£8,048over5years.

6. and 7. FLS and bone densitometry operating costs

TheFLSandbonedensitometry(DEXA)scanningcostswerevariedby±20%assumingdrugcostsremainedasinthebasecase.Thisvariationresultsinarangeofoverall5yearoperatingcosts,includingdrugspend,from£222,673to£245,689.Assumingthenumbersoffracturesavertedandassociatedcostsremainedthesameasforthebasecase,theoverallsavingsdeliveredbyFLSwouldbeintherange£45,019to£68,035.

Summary

ThemajorityofscenariosexploredintheSensitivityAnalysissuggestthatimplementationofFractureLiaisonServiceswillbecostsaving.CombiningseveralvariationsininputvaluestotheeconomicmodelprovidesanillustrationofabroaderrangeofthepotentialeconomicimpactofFLS:

Assume 20% lower secondary fracture rate + 35% Relative Risk Reduction + 60% compliance:Thenumberoffracturesavertedbysitewouldbe9hip,3forearm,3spineand2humerus.Theassociatedcostsavingwouldbe£152,622.

AppendixB:SensitivityAnalysisofBaseCaseEstimate

21

TotalFLSoperationalcostsanddrugspendover5yearswouldbe£190,021.Inthisscenario,operatingtheFLS would cost£37,399.

Assume 20% higher secondary fracture rate + 45% Relative Risk Reduction + 100% compliance:Thenumberoffracturesavertedbysitewouldbe30hip,9forearm,10spineand7humerus.Theassociatedcostsavingwouldbe£490,570.TotalFLSoperationalcostsanddrugspendover5yearswouldbe£278,341.Inthisscenario,operatingtheFLS would save£212,229.

TheDrugTariffpriceofgenericalendronatewillcontinuetodeclineandsignificantreductionsincurrentlybrandeddrugspendwilloccuronaccountofnewgenericentriesfrom2010to2012.Accordingly,theleasteconomicallyfavourablescenariodepictedaboveislikelytobecomecost-neutraltomarginallycostsaving,thebasecasescenariosignificantlycostsavingandthemostfavourablescenariosubstantiallycostsaving.

22

1 Fallsandfractures:effectiveinterventionsinhealthandsocialcare,DepartmentofHealth,2009.

2 CummingRG,SalkeldG,ThomasM,SzonyiG.Prospectivestudyoftheimpactoffearoffallinginactivitiesofdailyliving,SF-36scoresandnursinghomeadmission.J Gerontology2000;55:299-305.

3 CloseJ,EllisM,HooperR,GlucksmanE,JacksonS,SwiftC.Preventionoffallsintheelderlytrial(PROFET):arandomisedcontrolledtrial.Lancet1999;353:93-97.

4 TinettiME,SpeechleyM,GinterSF.Riskfactorsforfallsamongelderlypersonslivingwithinthecommunity.NEngJMed1988;319:1701-07.

5 Technicalappraisal(TA)161Osteoporosis – secondary prevention including strontium ranelateNICE2008http://guidance.nice.org.uk

6 Clinicalguideline21Clinical practice guideline for the assessment and prevention of falls in older peopleNICE2004http://guidance.nice.org.uk

7 National audit of the organisation of services for falls and bone health of older peopleRoyalCollegeofPhysicians2009http://www.rcplondon.ac.uk

8 Dualenergyx-rayabsorptiometry(DXA)scansareusedtomeasurebonemineraldensity.

9 Implementing and running a fracture liaison service,Clunie&Stephenson,JournalofOrthopaedicNursing,(2008)12:156-162.

10Fracture risk following an osteoporotic fracture,Johnell,Kanisetal,OsteoporosisInternational,(2004)15:175-179.

11Basedon2009/10PaymentbyResultstariffcostsHA11-14,andincludingaMarketForcesFactorof1.082.

12Bonedensitometry@£50perscan.

13Bonedensitometry@£50perscan.

14Basedontreating100%ofhip,50%offorearm,75%ofspineand75%ofhumerusfracturepatients.Assumes12%mortality.Thedrugspendassumesavailabilityoverthenextfewyearsofgenericrisedronate(from2010),ibandronate(2011)andzoledronate(2012),basedonaforecastreductionof50%overalloverfouryearsinthecostofthesedrugs.

15DrugtariffpriceOctober2009forgenericalendronate=£1.16for28daysupply=£15.08peryear.HighstrengthCa/Vit-Dcosts£50peryear.Combinedtreatmentthereforecosts£65.08peryear.

16CombinationtreatmentofabrandedbisphosphonateorStrontiumRanelateplushighstrengthCa/Vit-Dcosts£300peryear.

17NationalHipFractureDatabase2009andHospitalEpisodeStatistics2007/8,DH.

18Older People in the United Kingdom,AgeConcern,2008.

19DepartmentofHealthestimate.

20OsteoporosisInt2004;15(S2):S56:P141HarknessMetal.

21OsteoporosisInt2003;14(S4):S53:P55FraserMetal.

22OsteoporosisInt2006;17(S3):425:P115LockwoodSetal.

23OsteoporosisInt2003;14(S4):S12:OC27BartonJetal.

End notes

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