FLS-DB audit results update

1. FLS-DB audit results update
MK Javaid
Associate Professor in Metabolic Bone Disease, University of Oxford
Hon Consultant Rheumatologist, Nuffield Orthopaedic Centre
Clinical lead RCP FLS DB audit programme
Co-Chair of IOF Capture the Fracture programme
National Osteoporosis Society FLS Implementation Group

2. • These views are my own
• In last five years received honoraria, travel
and/or subsistence expenses from:
– Amgen, Eli Lilly, Medtronic, Norvartis, Proctor and
Gamble, Servier, Shire, Internis, Consilient Health,
Stirling Anglia Pharmaceuticals

3. Why do we need the audit?

5. More than 80% of patients after a
seeing a doctor with a fragility fracture
receive inadequate care.

6. van der Velde Bone 2016
UK Incident Use of Alendronate
osteoporosis crisis

7. ONJ lawsuit
Atr Fib AIM
Television AFF and BP
Jha JBMR 2015; Jarvenin BMJ 2015

9. Downloaded 2.3.2017

10. Ma 2017 Nature Scientific Reports

11. Ma 2017 Nature Scientific Reports
1 cm
x 0.7cm

12. Interesting but
• Cases
– Who of 8 BP patients were scanned
– Definition of duration of treatment
– Were most severe > treated vs. untreated
– How orientated core tissue
– Why no more controls
– Real life test of strength is fracture!

13. Black Lancet 1996
PMO 55- 81
Osteoporosis + VF
1005 PBO
1022 Alendronate 10mg daily

14. Real world data: effect of Alendronate
prescriptions
Hawley 2016 JBMR
10,873 primary hip fracture patients
April 1999 and Sept 2012

15. Real world data: effect of Alendronate
prescriptions
Hawley 2016 JBMR
33% reduction in
Hip fractures

16. Black 2016 NEJM; Kharazmi 2016 JBMR;
1 AFF per 137 Hip fractures averted
1: 1000 implant
NO mortality
172 AFF vs 952 shaft/subtrochonteric
What about rare side effects?

17. Can FLS make a difference?

18. scale of problem
for London
2014:
6,058 hip fractures
3,495 other inpatient fractures
13,747 outpatient fractures
TOTAL: 30,290 fragility fractures

19. Current investment
11
11
12
0 0.25 0.5 1
Whole time equivalent
Specialist nurses
Bromley
Kingston
Royal London
N. Mid
Northwick
Newham
St Thomas’
St Mary
Whipps
Whittington
Barnet
Ealing
St Georges
QE Wool
Hillingdon
Homerton
Kings
Croydon
Romford
St Helier
UCL
C&W
LewishamRoyal Free

20. Current investment
11
11
12
0 0.25 0.5 1
Whole time equivalent
Specialist nurses
Barnet
Ealing
St Georges
QE Wool
Hillingdon
Homerton
Kings
Croydon
Romford
St Helier
UCL
C&W
LewishamRoyal Free
In 2014:
2526 hip fractures
12,630 fragility fracture patients
Bromley
Kingston
Royal London
N. Mid
Northwick
Newham
St Thomas’
St Mary
Whipps
Whittington

21. Effective Secondary Fracture
Prevention
Marsh OI 2011, Eisman JBMR 2012
National Hip Fracture Database
Inpatient Falls Audit
FFFAP

22. What is an Fracture liaison services (FLSs)?
• Recommended by the Department
of Health in 2009
• Improve secondary fracture
prevention:
– Identify
– Investigation
– Initiation therapy
– Monitor
• Focus in bone health but also falls
assessment/ management

23. Fracture Liaison Service Database Audits
• Part of the Falls and Fragility Fracture Audit Programme
(FFFAP)
• a national audit at the Royal College of Physicians
• commissioned by HQIP> focus = Quality improvement
• Included in 2015/16 listing for national audits
• Must be reported in the Trust’s Quality Account
• Part of the National Clinical Audit Patient Outcomes
Programme (NCAPOP)

24. FLS-DB workstream
Clinical Lead: Dr M Kassim Javaid
RCP : Catherine Gallacger, Sunil Rai, Naomi Vasilakis, Chris Boulton, Roz Stanley,
Finbarr Martin
Constituency
RCGP -Jonathan Bailey, David Stephens
BGS – Frances Dockery, Rachael Bradley
Orthogeriatrics Celia Gregson
BOA – Xavier Griffin
BES - Neil Gittoes
BSR - Gavin Clunie
NOS - Sonya Stephenson, Will Carr, Helen Williams, Tim Jones, Jo Sayer
RCN - Debbie Janaway, Clare Cockill
PPI – Iona Price
RCS - David Cromwell, Carmen Tsang
Crowne - Jonathan Roberts
Wales – Mike Stone

25. Aims
1. What proportions of fragility fracture patients are assessed for (i) osteoporosis
and (ii) falls risk?
2. What proportion of patients is initiated on bone protection therapy within 4
months of fracture?
3. What proportion of patients is initiated on falls prevention intervention within 4
months of fracture?
4. What proportion of patients still persist with (i) bone protection and (ii) fall
prevention treatment at 12 months
5. What proportion of patients have a subsequent fracture

26. Process
• FLS-DB Facilities audit
• FLS-DB Patient audit

27. Facilities audit: overview
• Funding
• Structure (people)
• Scope (case mix, identification, investigation,
initiation, monitoring pathways)
AIM: Ensure the structure of FLS fit for purpose
Objective: To describe the structure of an FLS in terms of:
constitution and patient process
Method: Annual facilities audit

28. Google FLS DB

30. Results
• 82 sites entered data (estimated to be just under
half of eligible sites).
• 52 sites had an FLS. Of these:
– 27 reported that they provided a multi-factorial falls
risk assessment (MFRA).
– 16 reported that they referred patients on for a MFRA.
– 9 did not report doing either.

31. Reported number of patients identified by FLS (n=52) vs estimated fragility fracture caseload
Most FLSs did not see as many
patients as expected:
 24% FLSs >80% estimated
caseload
 57% FLSs < 50% caseload
FLSDB RCP report 2015

32. Key findings – Falls interventions
Therapeutic exercise is the best-evidence intervention
for falls prevention
• 19 FLSs could refer to exercise programmes
• 18/19 FLSs reported this was a validated exercise
programme
• Only 4 FLSs reported that the standard total
duration of recommended exercise (supervised and
unsupervised) was 50+ hours

33. Patient audit: overview
• Identification
• Investigation
• Initiation
• Monitoring for prescribing
• Re-fracture/ re-falls
AIM: Ensure the FLS works for its patients
Objective: To describe the pathway of patients
Method: Annual patient audit upload vs. direct data entry

34. Patient level audit

38. Why do we need to collect this?
Compare outcomes between sites
need to take into account these differences

43. Patient level audit
18,356 in fist 6 months
38 FLSs
 Highlight sites with good quality and areas to improve

44. Reporting Key performance
indicators

45. Demonstrating FLS quality: real time

48. 0
20
40
60
80
100
120
Percntageofcasessubmitted(%)
Data completeness
Oxford National

50. Started bone therapy by first follow-up

51. First follow-up was within 4 months

52. Time to first follow-up

53. Help is at hand
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54. User group workshops
5th May London & 8th May Manchester
1000 Registration
1030 Introduction to FLS DB - AG
1045 Crown demonstration of website: how to import your data/ run chart
1115 How we did it. (Musgrove-London)(Oxford-Manchester)
1145 Dos and Don’t for submitting to the FLS DB
1215 Lunch
1300 New Webtool Developments
1330 Review of data definitions for patient audit
1400 Facilities audit update
1420 Small group working for practical support
1500 Future plans for data deadlines reports and new run charts
1520 Final discussion
1530 Close

56. Report Published 26th April 2017
Next Data upload End June 2017> Published Nov 2017
Patient level audit
18,356 in fist 6 months > 35,000
38 FLSs
 Highlight good quality
 Highlight effective services
 Highlight priority for quality improvement
 Same money different way
 More money efficient way
Summary
Run charts
Feedback > KPI
• National public soon
• Site public….

57. FLS-DB workstream
Clinical Lead: Dr M Kassim Javaid
RCP : Catherine Gallacher, Sunil Rai, Naomi Vasilakis, project
coordinator, Chris Boulton, Roz Stanley, Finbarr Martin
Constituency
RCGP -Jonathan Bailey, David Stephens
BGS – Frances Dockery, Rachael Bradley
Orthogeriatrics Celia Gregson
BOA – Xavier Griffen
BES - Neil Gittoes
BSR - Gavin Clunie
NOS - Sonya Stephenson, Will Carr, Helen Williams, Tim Jones, Jo Sayer
RCN - Debbie Janaway, Clare Cockill
PPI – Iona Price
RCS - David Cromwell, Carmen Tsang
Crowne - Jonathan Roberts
Wales – Mike Stone

58. Report Published 26th April 2017
Next Data upload End June 2017> Published Nov 2017
 Highlight good quality
 Highlight effective services
 Highlight priority for quality improvement
 Same money different way
 More money efficient way
 Improve quality of services> Fracture reduction
Summary
Run charts
Feedback > KPI
• National public soon
• Site public….
Work with orthopaedic / radiology colleagues
> Support FLS

59. Key findings – Falls assessments
• Of the FLSs that provide a MFRA there was variation in the
content:
– 93% (25) asked about the number of falls in the past 12 months
– 67% (18) included a medication review
– 63% (17) included an assessment of gait, balance and mobility
– 52% (14) recorded lying and standing blood pressure
– 41% (11) included a formal assessment of cognition
– 33% (9) included a vision assessment