Fracture Liaison Services

Implementing the NOS Standards

Mayrine FraserNational Development Manager/Specialist Nurse

National Osteoporosis SocietyScotland

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The consequences of osteoporosis

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• 300,000 fragility #• 85,000 are hip #• 1.8M hospital bed days• 20% hip # die in 4

months• 33% hip # become

totally dependent • £1.9B in hospital costs

Impact of Fractures in the UK

What is the solution?

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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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Why have an FLS?Because one fracture leads to another!

OSTEOPOROSIS

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Why have an FLS?To ensure the first fracture is the last!

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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 50% hip fractures avoided in future

Find them

Assess them

Treat where appropriate Follow-up

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

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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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

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

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 DIAGNOSEDEDUCATIONMEETINGS

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What are the benefits of an FLS?

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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

Aims of the NOS:Aim 1: Every person aged over 50 who breaks a bone is assessed for osteoporosis and managed appropriately.

Priority 1:Extend coverage of Fracture Liaison Services

Priority 2:Improve quality of Fracture Liaison Services and osteoporosis services

Aim 2: People with osteoporosis are empowered to make choices and manage their condition in ways that best meet their own needs.

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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

UK FLS Clinical Standards Summary of Standards

CRITERIA RATIONALE MEASURES OUTCOMES Identification

1 All patients aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture, whether managed as inpatients or outpatients, 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 future fracture burden.

Proportion of fracture patients aged over 50 years identified by the FLS.

Denominator for all fragility fractures can be best estimated by multiplying total hip fractures in over 50 year olds by 5 (1).

Systematic identification of at risk patient population who would benefit from investigation.

Investigation

2 Patients 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.

% of identified patients who have a bone health assessment within 3 months of incident fracture.

% of identified patients who have their need for a falls risk assessment evaluated within 3 months of incident fracture.

Improved identification of the population who will benefit from interventions leading to appropriate targeting of resources.

Information

3 All 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.

% of identified patients given information.

Improved patient understanding leading to confident self-management and engagement with recommended interventions.

Intervention

4 Patients at risk of further fracture will be offered appropriate bone-protection treatments.

Appropriately targeted interventions reduce future fracture risk.

% of assessed patients offered bone-protection treatment.

The right people receive the right interventions for bone health and falls leading to reduced fracture risk and fewer fractures.

Patient mobility and independence is maintained.

5 Patients at risk of further falls will be offered appropriate assessment or interventions to reduce future falls.

Evidence-based falls interventions are effective at reducing falls risk.

% of assessed patients offered referral for assessment or an intervention.

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  Integration      6 Management 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.

Measure of communication – patients copied in/discharge letters

Written/verbal.

Patient feels supported.

Issues with treatment compliance and adherence are identified promptly.

Adherence to treatments is improved leading to greater patient benefit.

 

 

7 Patients who are recommended a drug to reduce risk of fracture will be reviewed within 4 months to ensure appropriate treatment has been started; and every 12 months to monitor concordance 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. Long-term management and follow-up should be carried out in primary care.

% of patients on treatment who are reviewed within 4 months

% of patients on treatment who are assessed annually.

  Quality      8 Core clinical data from patients identified by the FLS will be

recorded on a database. Regular audit and patient experience measures will be performed and the FLS will participate in any national audits undertaken.

Data recorded will allow the FLS to audit and improve the service they provide ensuring that high standards are met and maintained. Initial data will provide a baseline from which improvements can be assessed.

Date of last audit against FLS standards.

Date of last patient satisfaction survey.

Excellent quality of care is provided and best practice is shared.

9 The FLS team will have appropriate competencies in secondary fracture prevention and supported to maintain relevant 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.

Review of competencies and training needs in annual appraisals.

Assessment of CPD attained.

 

10 The 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.

Date of last peer review and progress against an agreed action plan.

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How can the NOS help in your area?

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

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Gap analysis All patients aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture will be systematically and proactively identified.  

outline process for identifying (include numbers seen where able)In-Patient hip fractures 50-75 75+

Outline process for identifying (include numbers seen where able)In-Patient hip fractures 50-75 75+     

In-patient non-hip fracture50-75 75+      

Out-patient fractures50-75 75+      

Spinal fractures  

• 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

http://benefits.nos.org.uk/

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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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

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FLS Mapping

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SDT Activity England NI/IOM Scotland Wales  UK 

Supporting New Service

Development45 0 2 4 51

Supporting Quality

Improvement49 6 12 6 73

Early Engagement with additional sites

28 3 2 6 39

Totals 122 9 16 16 163

New services commissioned 8 0 0 0 8

Existing service improved

(commissioning)1 0 0 0 1

Totals 9 0 0 0 9

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FLS BenefitsArea Population Cohort (50+) Hip fractures

prevented*Total benefits (of hip fractures prevented)*

Bradford 459,142 129,011 119 £1,991,822Colchester 332,923 134,835 142 £2,400,084East Surrey 177,566 63,474 65 £1,154,335East Sussex 374,801 167,905 188 £3,161,972Epsom 405,456 119,974 115 £2,066,895Rotherham 258,781 96,591 92 £1,540,356Salisbury 202,770 83,701 83 £1,412,992Stoke-on-Trent 214,991 88,334 88 £1,466,432Vale of York 348,363 131,411 128 £2,142,848Total 2,774,793 1,015,236 1020 £17,337,736*Over a 5 year period

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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

Does FLS work?

Between 1998 and 2008 the number of hip fractures (as assessed by ISD codes) in Greater Glasgow decreased by 7.3%

This compared to an increase of 17% in the number of hip fractures in England.

Skelton DA, Neil F. Evaluation of GGC Osteoporosis Falls Strategy 2009

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)

• 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

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Thank you