Best practice guidelines for hip
fracture management:
International experience
Paul Mitchell
Deputy Chair, Osteoporosis Ne...
„We are not here to comment upon the world,
We are here to change it‟

Professor David Marsh
President - Fragility Fractur...
U.N. World Population Prospects 2012 Revision

http://esa.un.org/wpp/
Australia and New Zealand
Population ageing
The „Osteoporotic Career‟

Opportunities for intervention

‘Hip fracture is all too often the final destination of a thirt...
„Signal‟ or „Herald‟ Fractures
An opportunity to break the fragility fracture cycle
Fracture Free at Fifty

Non-hip
fragil...
Hip fracture care and prevention in the UK
Consensus on the need for a systematic approach

Professional
organisations

Pa...
Professional consensus guidance on hip fractures
2007 Blue Book and National Hip Fracture Database
• A systematic approach...
2007 Blue Book and National Hip Fracture Database
Clinical standards link Blue Book1 to NHFD2:
1.

All patients with hip f...
Adoption of FLS across the UK
The NOS Manifestos for England/Scotland/Wales/N.I.

http://www.nos.org.uk/NetCommunity/Page....
Adoption of FLS across the UK
The NOS Manifestos for England/Scotland/Wales/N.I.

http://www.nos.org.uk/NetCommunity/Page....
Adoption of FLS across the UK
The NOS Manifestos for England/Scotland/Wales/N.I.

http://www.nos.org.uk/NetCommunity/Page....
Hip fracture care and prevention in the UK
A consensus on a systematic approach

Patient
society

Professional
organisatio...
Falls and fracture care and prevention
A road map for a systematic approach in the UK
Stepwise
implementation
- based on s...
Acute hip fracture care
National Hip Fracture Database Report
Acute care & secondary prevention for >60,000 cases p.a.

NHFD National Report 2013 ...
2013 National Hip Fracture Database Report
Blue Book core standards
1.

50% of patients are admitted to an orthopaedic war...
UK National Hip Fracture Database 2013 National Report
Identifying and understanding variation
UK National Hip Fracture Database 2013 National Report
Best Practice Tariff: Linking quality to payment
1.

Surgery within...
UK National Hip Fracture Database 2013 National Report
Best Practice Tariff: Linking quality to payment

NHFD National Rep...
UK National Hip Fracture Database 2013 National Report
Best Practice Tariff: Linking quality to payment

NHFD National Rep...
National Institute for Health and Clinical Excellence
Clinical Guideline 124 and Quality Standard 16

http://www.nice.org....
National Institute for Health and Clinical Excellence
The purpose of Quality Standards
• Set of specific, concise statemen...
National Institute for Health and Clinical Excellence
Quality Standard 16: Quality Statements 1-6
•

Statement 1. People w...
National Institute for Health and Clinical Excellence
Quality Standard 16: Quality Statements 7-12
•

Statement 7. People ...
Systematic hip fracture prevention
Fracture Liaison Service
Service structure

Orthopaedic
Trauma
New Fracture
Presentation

Osteoporosis
treatment

Orthopae...
Fracture Liaison Service
The Glasgow Model: aims and service structure
•

Offer assessment to all patients over 50 years p...
NHS Quality Improvement Scotland national audit
FLS vs other models: Outcome after hip fracture by centre

Centre
operatin...
NHS Quality Improvement Scotland national audit
FLS vs other models: Outcome after wrist fracture by centre

Centre
operat...
Fracture Liaison Services
Effectiveness is dependent in intensity of the model
Model
Status
Quo

Type D
(Zero
i model)

Ty...
Fracture Liaison Services
Significantly reduce re-fracture rates
•

Australia: Concord FLS, Sydney
– Repeat fracture rates...
Incorporation of FLS into national policy
Department of Health Prevention Package

Department of Health. Prevention Packag...
International Osteoporosis Foundation
World Osteoporosis Day Report 2012

http://www.iofbonehealth.org/capture-fracture-re...
IOF Capture the Fracture Campaign
Best Practice Framework

Osteoporos Int. 2013 Aug;24(8):2135-52. PubMed ID 23589162
IOF Capture the Fracture Campaign
Globally endorsed standards of care

Osteoporos Int. 2013 Aug;24(8):2135-52. Åkesson K
Systematic approaches to hip fracture
care and prevention for
Australia and New Zealand
BoneCare 2020: Osteoporosis New Zealand
A systematic approach for New Zealand

http://www.bones.org.nz/
BoneCare 2020: Osteoporosis New Zealand
A systematic approach for New Zealand

Maximise costeffectiveness by
stepwise deli...
Australian and New Zealand Hip Fracture Registry
A systematic approach to hip fracture care

http://www.anzhfr.org/
ANZ Guideline for Hip Fracture Care
Public Consultation until 13 December 2013

http://www.anzhfr.org/
Australian and New Zealand Hip Fracture Registry
NZ Clinicians want it!

„We advocate the
development of a
multicentre aud...
BoneCare 2020: Osteoporosis New Zealand
Fracture Liaison Services in New Zealand
Another way we can help older people rema...
What happens next?
Peak oil
Peak hip fracture
Peak hip fracture
Objective:
Global peak hip fracture to be attained before the 28th FFN Global Congress
Additional slides
Fracture Liaison Services
A cost-saving intervention

• In May 2011, a formal cost-effectiveness
analysis of the Glasgow F...
Paul Mitchell - Synthesis Medical NZ Ltd - Reviewing Best Practice Guidelines For Hip Fracture Management: The UK Experience
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Paul Mitchell - Synthesis Medical NZ Ltd - Reviewing Best Practice Guidelines For Hip Fracture Management: The UK Experience

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Paul Mitchell, Director, Synthesis Medical NZ Ltd delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting.

Find out more at http://www.healthcareconferences.com.au/hipfracture2013

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Paul Mitchell - Synthesis Medical NZ Ltd - Reviewing Best Practice Guidelines For Hip Fracture Management: The UK Experience

  1. 1. Best practice guidelines for hip fracture management: International experience Paul Mitchell Deputy Chair, Osteoporosis New Zealand Adjunct Senior Lecturer, University of Notre Dame Australia Managing Director, Synthesis Medical Ltd - New Zealand and UK 2nd December 2013 Current trends in hip fracture management guidelines 2nd Annual Hip Fracture Management Conference, Melbourne, Australia
  2. 2. „We are not here to comment upon the world, We are here to change it‟ Professor David Marsh President - Fragility Fracture Network 1st FFN Global Congress 6th September 2012, Berlin, Germany
  3. 3. U.N. World Population Prospects 2012 Revision http://esa.un.org/wpp/
  4. 4. Australia and New Zealand Population ageing
  5. 5. The „Osteoporotic Career‟ Opportunities for intervention ‘Hip fracture is all too often the final destination of a thirty year journey fuelled by decreasing bone strength and increasing falls risk’2 1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ
  6. 6. „Signal‟ or „Herald‟ Fractures An opportunity to break the fragility fracture cycle Fracture Free at Fifty Non-hip fragility fracture Secondary non-hip fragility fracture Good outcome Fracture Free for Life Unrecognised vertebral fragility fracture Hip fracture Secondary non-hip fragility fracture Hip Fracture Free for Life Fracture Free Recovery Very bad outcome Secondary non-hip fragility fracture Second hip fracture Department of Health in England. Herald Fractures: Clinical burden of disease and financial impact. December 2010
  7. 7. Hip fracture care and prevention in the UK Consensus on the need for a systematic approach Professional organisations Patient society Policy makers
  8. 8. Professional consensus guidance on hip fractures 2007 Blue Book and National Hip Fracture Database • A systematic approach to hip fracture care and prevention1-3 • Hip fracture care – Blue Book Chapter 1 – Effective ortho-geriatric services for hip fracture patients – Universal National Hip Fracture Database participation • Hip fracture prevention – Blue Book Chapter 2 – An FLS for every hospital to identify all new fragility fracture patients – Pro-active case-finding of all unassessed prior fragility fracture patients 1. BOA-BGS 2007 Blue Book 2. National Hip Fracture Database 3. NHFD Toolkit – Version 3 All available at http://www.nhfd.co.uk/
  9. 9. 2007 Blue Book and National Hip Fracture Database Clinical standards link Blue Book1 to NHFD2: 1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation 2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours 3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer 4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission 5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures 6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls 1. BOA-BGS 2007 Blue Book 2. National Hip Fracture Database Both available at http://www.nhfd.co.uk/
  10. 10. Adoption of FLS across the UK The NOS Manifestos for England/Scotland/Wales/N.I. http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
  11. 11. Adoption of FLS across the UK The NOS Manifestos for England/Scotland/Wales/N.I. http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
  12. 12. Adoption of FLS across the UK The NOS Manifestos for England/Scotland/Wales/N.I. http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
  13. 13. Hip fracture care and prevention in the UK A consensus on a systematic approach Patient society Professional organisations 1 + 1 Policy makers = 4
  14. 14. Falls and fracture care and prevention A road map for a systematic approach in the UK Stepwise implementation - based on size of impact Hip fracture patients Non-hip fragility fracture patients Individuals at high risk of 1st fragility fracture or other injurious falls Older people Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards DH Prevention Package for Older People
  15. 15. Acute hip fracture care
  16. 16. National Hip Fracture Database Report Acute care & secondary prevention for >60,000 cases p.a. NHFD National Report 2013 Available from www.nhfd.co.uk
  17. 17. 2013 National Hip Fracture Database Report Blue Book core standards 1. 50% of patients are admitted to an orthopaedic ward within four hours 2. 86% receive surgery within 48 hours 3. 3.5% are reported as having developed pressure ulcers 4. 47% are reported as assessed pre-operatively by an orthogeriatrician 5. 69% are discharged on bone protection medication 6. 94% received a falls assessment prior to discharge NHFD National Report 2013 Available from www.nhfd.co.uk
  18. 18. UK National Hip Fracture Database 2013 National Report Identifying and understanding variation
  19. 19. UK National Hip Fracture Database 2013 National Report Best Practice Tariff: Linking quality to payment 1. Surgery within 36 hours 2. Shared care by surgeon and geriatrician 3. Care protocol agreed by geriatrician, surgeon and anaesthetist 4. Assessment by geriatrician within 72 hours 5. Geriatrician-led multi-disciplinary rehabilitation 6. Secondary prevention of falls 7. Bone health assessment (i.e. osteoporosis) 8. Pre- and post-operative abbreviated mental test score assessment (2012-) NHFD National Report 2013 Available from www.nhfd.co.uk
  20. 20. UK National Hip Fracture Database 2013 National Report Best Practice Tariff: Linking quality to payment NHFD National Report 2013 Available from www.nhfd.co.uk
  21. 21. UK National Hip Fracture Database 2013 National Report Best Practice Tariff: Linking quality to payment NHFD National Report 2013 Available from www.nhfd.co.uk
  22. 22. National Institute for Health and Clinical Excellence Clinical Guideline 124 and Quality Standard 16 http://www.nice.org.uk
  23. 23. National Institute for Health and Clinical Excellence The purpose of Quality Standards • Set of specific, concise statements and associated measures • Aspirational but achievable makers of high-quality, cost effective patient care • Derived from best available evidence • Address three dimensions of quality: – clinical effectiveness – patient safety – patient experience http://guidance.nice.org.uk/QS16
  24. 24. National Institute for Health and Clinical Excellence Quality Standard 16: Quality Statements 1-6 • Statement 1. People with hip fracture are offered a formal Hip Fracture Programme from admission. • Statement 2. The Hip Fracture Programme team retains a comprehensive and continuing clinical and service governance lead for all stages of the pathway of care, including the policies and criteria for both intermediate care and early supported discharge. • Statement 3. People with hip fracture have their cognitive status assessed, measured and recorded from admission. • Statement 4. People with hip fracture receive prompt and effective pain management, in a manner that takes into account the hierarchy of pain management drugs, throughout their hospital stay. • Statement 5. People with hip fracture have surgery on the day of, or the day after, admission. • Statement 6. People with hip fracture have their surgery scheduled on a planned trauma list, with consultant or senior staff supervision. http://guidance.nice.org.uk/QS16
  25. 25. National Institute for Health and Clinical Excellence Quality Standard 16: Quality Statements 7-12 • Statement 7. People with displaced intracapsular fracture receive cemented arthroplasty, with the offer of total hip replacement if clinically eligible. • Statement 8. People with trochanteric fractures above and including the lesser trochanter (AO classification types A1 and A2) receive extramedullary implants such as a sliding hip screw in preference to an intramedullary nail. • Statement 9. People with hip fracture are offered a physiotherapist assessment the day after surgery and mobilisation at least once a day unless contraindicated. • Statement 10. People with hip fracture are offered early supported discharge (if they are eligible), led by the Hip Fracture Programme team. • Statement 11. People with hip fracture are offered a multifactorial risk assessment to identify and address future falls risk, and are offered individualised intervention if appropriate. • Statement 12. People with hip fracture are offered a bone health assessment to identify future fracture risk and offered pharmacological intervention as needed before discharge from hospital. http://guidance.nice.org.uk/QS16
  26. 26. Systematic hip fracture prevention
  27. 27. Fracture Liaison Service Service structure Orthopaedic Trauma New Fracture Presentation Osteoporosis treatment Orthopaedics Inpatient ward Emergency Department & X-Ray 1. FLS identifies fracture patients 2. FLS assessment Emergency Department Outpatient Fracture clinic Falls risk assessment* Exercise programme Education programme Comprehensive communication of management plan to GP supported by fully integrated FLS database system (Adapted from) BOA-BGS 2007 Blue Book. http://www.nhfd.co.uk/ * Older patients, where appropriate, are identified and referred for falls assessment
  28. 28. Fracture Liaison Service The Glasgow Model: aims and service structure • Offer assessment to all patients over 50 years presenting with a fragility fracture • Glasgow FLS is delivered by a Nurse Specialist supported by a Lead Clinician in Osteoporosis • Nurse Specialist identifies patients with new fragility fractures: – admitted to the orthopaedic inpatient ward, and – managed as outpatients through the fracture clinic • The Nurse Specialist arranges attendance of appropriate patients at the “one stop” FLS clinic where BMD is measured by DXA to assess future fracture risk • Treatment for secondary fracture prevention initiated by the FLS when merited on basis of future fracture risk • Older patients, where appropriate, are identified and referred onto the falls service/falls pathway • Long-term management plans agreed by protocol with local general practice 1. Best Prac Res Clin Rheum 2005;19:6:1081-1094 Gallacher SJ 2. Osteoporosis International 2003;14(12):1028-1034 McLellan AR et al 3. Calcif Tissue Int 2007;81:85-91 Langridge CR et al
  29. 29. NHS Quality Improvement Scotland national audit FLS vs other models: Outcome after hip fracture by centre Centre operating FLS NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
  30. 30. NHS Quality Improvement Scotland national audit FLS vs other models: Outcome after wrist fracture by centre Centre operating FLS NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
  31. 31. Fracture Liaison Services Effectiveness is dependent in intensity of the model Model Status Quo Type D (Zero i model) Type C (1 i model) Type B (2 i model) Type A (3 i model) Description Manitoba statistics for major osteoporotic fractures (2007/2008) Only provides osteoporosis education to the fracture patient. Primary care provider (PCP) is not alerted or educated. 1. Identification The PCP is alerted that a fracture has occurred and further assessment is needed. Leaves the investigation and initiation of treatment to the PCP. 1. Identification 2. Investigation Leaves the initiation of treatment for fragility fracture patients to the PCP. 1. Identification 2. Investigation 3. Initiation of osteoporosis treatment where appropriate. Proportion receiving BMD testing Proportion receiving osteoporosis treatment 13% 8% No study on BMD testing 8% 43% 23% 60% 41% 79% 46% 1. Osteoporos Int. 2013 Feb;24(2):393-406 Ganda K et al 2. Osteoporosis Canada. Make the FIRST break the LAST with Fracture Liaison Services
  32. 32. Fracture Liaison Services Significantly reduce re-fracture rates • Australia: Concord FLS, Sydney – Repeat fracture rates over a 4 year period were reduced by 80% – 4.1% in the intervention group compared to 19.7% in the control group • Canada: St. Michael‟s Hospital, Toronto – Modelling of the FLS reported a 9% reduction of secondary hip fracture rates within the first year of operation • United Kingdom: Glasgow FLS, Scotland – Between 1998 and 2008, hip fracture rates in Glasgow decreased by 7.3% compared to a 17% increase during the same time period in England, where only 37% of localities operated an FLS by late 2010 • United States of America: Kaiser Permanente – In 2008, a 37% reduction in the expected hip fracture rate was reported for the population served by the Kaiser Permanente Southern California system – This corresponds to the prevention of 935 hip fractures in the year 2006 (2,510 hip fractures were predicted by actuarial analysis, and 1,575 fractures were actually observed) References available on request. Email pauljames.mitchell@icloud.com
  33. 33. Incorporation of FLS into national policy Department of Health Prevention Package Department of Health. Prevention Package for Older People resources. Link.
  34. 34. International Osteoporosis Foundation World Osteoporosis Day Report 2012 http://www.iofbonehealth.org/capture-fracture-report-2012
  35. 35. IOF Capture the Fracture Campaign Best Practice Framework Osteoporos Int. 2013 Aug;24(8):2135-52. PubMed ID 23589162
  36. 36. IOF Capture the Fracture Campaign Globally endorsed standards of care Osteoporos Int. 2013 Aug;24(8):2135-52. Åkesson K
  37. 37. Systematic approaches to hip fracture care and prevention for Australia and New Zealand
  38. 38. BoneCare 2020: Osteoporosis New Zealand A systematic approach for New Zealand http://www.bones.org.nz/
  39. 39. BoneCare 2020: Osteoporosis New Zealand A systematic approach for New Zealand Maximise costeffectiveness by stepwise delivery Hip fracture patients Non-hip fragility fracture patients Individuals at high risk of 1st fragility fracture or other injurious falls Older people Objective 1: Improve outcomes and quality of care after hip fractures by delivering ANZ professional standards of care monitored by a new NZ National Hip Fracture Registry Objective 2: Respond to the first fracture to prevent the second through universal access to Fracture Liaison Services in every District Health Board in New Zealand Objective 3: GPs to stratify fracture risk within their practice population using fracture risk assessment tools supported by local access to axial bone densitometry Objective 4: Consistent delivery of public health messages on preserving physical activity, healthy lifestyles and reducing environmental hazards http://www.bones.org.nz/
  40. 40. Australian and New Zealand Hip Fracture Registry A systematic approach to hip fracture care http://www.anzhfr.org/
  41. 41. ANZ Guideline for Hip Fracture Care Public Consultation until 13 December 2013 http://www.anzhfr.org/
  42. 42. Australian and New Zealand Hip Fracture Registry NZ Clinicians want it! „We advocate the development of a multicentre audit in NZ hospitals‟ N Z Med J. 2013 Oct 18;126(1384):77-83. De Silva CU et al
  43. 43. BoneCare 2020: Osteoporosis New Zealand Fracture Liaison Services in New Zealand Another way we can help older people remain independent at home for longer is by reducing the impact of osteoporosis and fragility fractures. To achieve this goal, we have made it a priority for district health boards to implement Fracture Liaison Services as part of their annual planning processes. Fracture Liaison Services take a proactive approach to treating and preventing fragility fractures in our older population. Led by nurse practitioners, the services assess and treat fragility fractures and then, importantly, carry out interventions to reduce the person‟s risk of future fractures. I look forward to seeing how Waikato DHB uses the new facilities and services here at the Older Persons and Rehabilitation service to successfully implement a Fracture Liaison Service and help reduce the number and impact of fragility fractures amongst older people in Waikato. http://www.national.org.nz/Article.aspx?ArticleId=41324
  44. 44. What happens next?
  45. 45. Peak oil
  46. 46. Peak hip fracture
  47. 47. Peak hip fracture Objective: Global peak hip fracture to be attained before the 28th FFN Global Congress
  48. 48. Additional slides
  49. 49. Fracture Liaison Services A cost-saving intervention • In May 2011, a formal cost-effectiveness analysis of the Glasgow FLS was published • This study concluded that 18 fractures were prevented, including 11 hip fractures, and £21,000 was saved per 1,000 patients managed by the Glasgow FLS versus UK „usual care‟ Osteoporos Int. 2011; 22(7):2083-98 Wolowacz SE et al

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