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Fracture Liaison Services in Scotland Dr SJ Gallacher Consultant Physician Southern General Hospital; Glasgow Fracture Liaison Services in Scotland Dr SJ Gallacher Consultant Physician Southern General Hospital; Glasgow stephen. [email protected] scot. nhs. uk

Key Points • The health and social care costs of hip fractures estimated at Key Points • The health and social care costs of hip fractures estimated at £ 2. 3 billion per year • Hip fractures are associated with significant morbidity and mortality • After a first fracture the risk of fracturing again is increased 2 -5 fold

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

 • Background to Fracture Liaison Services (FLS) • Why is FLS an imperative • Background to Fracture Liaison Services (FLS) • Why is FLS an imperative • Does FLS prevent fractures and is it costeffective • FLS and NHS Scotland

Background to FLS Background to FLS

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

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

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

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

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

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

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

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

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

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

Why is FLS an imperative? Why is FLS an imperative?

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

668 400 742 629 600 378 199 205 0 0 10 0 Total number 668 400 742 629 600 378 199 205 0 0 10 0 Total number of hip fractures: 1990 = 1. 66 million 2050 = 6. 26 million 3250 Why secondary fracture prevention matters Projected incidence of hip fractures by 2050 199 205 0 0 1990 2050 Estimated no of hip fractures: (1000 s) Adapted from Cooper C et al, Osteoporosis Int, 1992; 2: 285 -289 Projected to reach 3. 250 million in Asia by 2050

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

Signal fractures amongst patients presenting with hip fracture 100. 0 90. 0 80. 0 Signal fractures amongst patients presenting with hip fracture 100. 0 90. 0 80. 0 Percentage 70. 0 60. 0 Percentage of patients with hip fracture reporting prior fragility fracture n=2124 n=632 45. 3 44. 6 Lyles et al 50. 0 Edwards et al n=701 45. 4 40. 0 30. 0 20. 0 10. 0 Mc. Lellan et al Lyles KW et al. ASBMR 2006. Abstract SA 405 Edwards BJ et al. Clin Orthop Rel Res 2007; 461: 226 -230 Mc. Lellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland. 2004. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland

Does a Fracture Liaison Service Prevent Fractures? Does a Fracture Liaison Service Prevent Fractures?

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

FLS is Associated with Reduction in Re. Fracture Rates Re-fractures (4 -years follow-up): 4. FLS is Associated with Reduction in Re. Fracture Rates Re-fractures (4 -years follow-up): 4. 1% (FLS) vs. 19. 7% (controls) Lih et al. Osteoporosis Int 2011; 22: 849 -58

Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell et al Pub. Med ID 18984730

Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell et al Pub. Med ID 18984730

Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell et al Pub. Med ID 18984730

Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell Kaiser Permanente FLS Southern California Style JBJS 2008; 90: S 4: 188 -194 Dell et al Pub. Med ID 18984730

Kaiser Permanente California Dreamin’ ? Kaiser Permanente California Dreamin’ ? "I'd like to dispel the misconception that nothing can be done to prevent or treat osteoporosis. It is possible to achieve at least a 25 percent reduction in the hip fracture rate in the United States if a more active role is taken by all orthopedic surgeons in osteoporosis disease management. We've seen it; we've done it. ” Rick Dell MD JBJS 2008; 90: S 4: 188 -194 Dell et al Pub. Med ID 18984730

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

South Glasgow FLS (10 Year Review) 12312 Patients identified 21887 Patients Identified 1755 Declined South Glasgow FLS (10 Year Review) 12312 Patients identified 21887 Patients Identified 1755 Declined (8. 0%) 1497 DNA (6. 8%) 18635 patients to be assessed 11755 - BMD Measured (63%) 6409 - Started on Treatment (35%) 4877 - Treatment Started Without Scanning (26%) 2003 - Already on Treatment Or Previously Assessed (11%) 5346 – No Treatment Required (28%) % of the 21887 patients presenting

Hip fractures in the 65+ age group (England) (1998 -2008) Growth 1. 8% per Hip fractures in the 65+ age group (England) (1998 -2008) Growth 1. 8% per year (2005 -8)

Hip fractures (65+) (1998 -2008) Greater Glasgow/ Greater Glasgow & Clyde Between 1998 and Hip fractures (65+) (1998 -2008) Greater Glasgow/ Greater Glasgow & Clyde Between 1998 and 2008 the number of hip fractures (as assessed by ISD codes S. 72 -S. 72. 2) in Greater Glasgow decreased by 7. 3% from 1377 to 1276 fractures. The equivalent figure for Greater Glasgow & Clyde was 3. 6%, 2026 fractures in 1998 to 1953 fractures in 2008 (i. e hip fractures increased in Clyde).

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

1000 patients (Hypothetical Cohort) 686 patients received anti-osteoporosis treatment £ 83, 598 (for assessments) 1000 patients (Hypothetical Cohort) 686 patients received anti-osteoporosis treatment £ 83, 598 (for assessments) £ 206, 554 (for treatments) 18 fractures (including 11 hip fractures) prevented Overall cost saving - £ 21, 000 Cost of widespread adoption of FLS across UK - £ 9. 7 m Mc. Lellan et al. OI 2011; 22: 2083 -2098

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

FLS in Scotland in 2014 FLS in Scotland in 2014

DXA Scanners/ Health Board 1 NHS Ayrshire and Arran 2 NHS Borders 3 NHS DXA Scanners/ Health Board 1 NHS Ayrshire and Arran 2 NHS Borders 3 NHS Dumfries and Galloway 4 NHS Western Isles 5 NHS Fife 6 NHS Forth Valley 7 NHS Grampian 8 NHS Greater Glasgow and Clyde 9 NHS Highland 10 NHS Lanarkshire 11 NHS Lothian 12 NHS Orkney 13 NHS Shetland 14 NHS Tayside Irvine Melrose Dumfries Travel to Dingwall/DX recently installed Western Isles hospital Stornoway(Q 2 Q 3 2014 service under development Kirkcaldy Larbert Aberdeen and Elgin WIG/GRH//Stobhill/ SGH, RAH, ( Paisley), IRH(Greenock, Dingwall Wishaw Edinburgh Travel to Aberdeen/mobile scann project begins Q 4 2014/Lerwick Dundee and Perth Clydebank

DXA Services – Available Hours of Operation BOARD Radiographers (WTE) Hours scanning A&A 2. DXA Services – Available Hours of Operation BOARD Radiographers (WTE) Hours scanning A&A 2. 76 40 Highland 2. 0* 30 Borders 0. 5 14 Lanarkshire 1. 0 40 D&G 1. 0 5 Lothian ? ? Fife 1. 0 40 Orkney 0 0 Forth Valley 0. 4 10 Shetland 0 0 Grampian 2. 0 ? Tayside 2. 0 ? GGC 20 -40 Western Isles 0 0 5. 0

DXA Services – Available Hours of Operation BOARD Radiographers (WTE) Hours scanning A&A 2. DXA Services – Available Hours of Operation BOARD Radiographers (WTE) Hours scanning A&A 2. 76 40 Highland 2. 0* 30 Borders 0. 5 14 Lanarkshire 1. 0 40 D&G 1. 0 5 Lothian ? ? Fife 1. 0 40 Orkney 0 0 Forth Valley 0. 4 10 Shetland 0 0 Grampian 2. 0 ? Tayside 2. 0 ? GGC 20 -40 Western Isles 0 0 5. 0

Health Boards – FLS Available BOARD FLS DADS A&A Yes Highland Yes Borders Yes Health Boards – FLS Available BOARD FLS DADS A&A Yes Highland Yes Borders Yes Lanarkshire Yes D&G Yes Lothian Yes Fife No ? Orkney No No Forth Valley No Yes Shetland No No Grampian Yes Tayside No Yes GGC Yes Western Isles No No

Health Boards – FLS Available BOARD FLS DADS A&A Yes Highland Yes Borders Yes Health Boards – FLS Available BOARD FLS DADS A&A Yes Highland Yes Borders Yes Lanarkshire Yes D&G Yes Lothian Yes Fife No ? Orkney No No Forth Valley No Yes Shetland No No Grampian Yes Tayside No Yes GGC Yes Western Isles No No

Osteoporosis/FLS Specialist Nurse Availability by Health Board BOARD Nurses (WTE) A&A 0 Highland 0 Osteoporosis/FLS Specialist Nurse Availability by Health Board BOARD Nurses (WTE) A&A 0 Highland 0 Borders 1. 0 Lanarkshire 2 D&G 1. 0 Lothian 2. 2 Fife 1. 0 Orkney 0 Forth Valley 0 Shetland 0 Grampian 1. 0 Tayside 2. 0 GGC 6. 8 Western Isles 0

Osteoporosis/FLS Specialist Nurse Availability by Health Board BOARD Nurses (WTE) A&A 0 Highland 0 Osteoporosis/FLS Specialist Nurse Availability by Health Board BOARD Nurses (WTE) A&A 0 Highland 0 Borders 1. 0 Lanarkshire 2 D&G 1. 0 Lothian 2. 2 Fife 1. 0 Orkney 0 Forth Valley 0 Shetland 0 Grampian 1. 0 Tayside 2. 0 GGC 6. 8 Western Isles 0

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

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

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