model of support for fracture liaison development and improvement

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

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

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


(RADIOLOGY REPORT)

PREVIOUS FRACTURE OR FRACTURE NOT PRESENTING

TO ACUTE CARE

ORTHO IP

Virtual/#CLINIC


‘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


(RADIOLOGY REPORT)

PREVIOUS FRACTURE OR FRACTURE NOT PRESENTING

TO ACUTE CARE

ORTHO IP

Virtual/#CLINIC


‘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)

FPP Training

Endorsed by:

www.nos.org.uk/fpp

http://www.nos.org.uk/fpp

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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

PDF

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

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




Clinical vertebral

Number of fractures expected based on incidence data

1 765 876 3,047 702

677 463 1515 210Hip fracture (inpatient)



Clinical vertebral

Proportion of patients to be seen in the FLS

2 88.48% 52.81% 49.72% 29.84%




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




Clinical vertebral

Expected proportion of fractures prevented

2.26% 1.13% 1.13% 0.75%

YearHip fracture (inpatient)



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




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)



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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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




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




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

http://www.nos.org.uk/conference

Thank you

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Mayrine FraserNational Osteoporosis SocietyCamertonBathBA2 0PJ

Tel: 07515 574789

Email: [email protected]

Website: www.nos.org.uk

Contact information

mailto:[email protected]

http://www.nos.org.uk/

model of support for fracture liaison development and improvement

Healthcare