Royal College of Physicians Conference 2016 #Medicine2016
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A Fracture Liaison Service (FLS) systematically identifies, treats, and refers patients over 50 who have suffered a fragility fracture to reduce their risk of subsequent fractures. An FLS follows a proven model where all fracture patients are assessed and 50% of future hip fractures could potentially be prevented with treatment. The document discusses the impact of fractures in the UK, how an FLS works according to a standard definition and clinical pathway, and how establishing an FLS requires engaging stakeholders, developing the patient care pathway, and ongoing data collection and evaluation to demonstrate the clinical and cost effectiveness of the program in preventing future fractures.
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Royal College of Physicians Conference 2016 #Medicine2016
- 1. Preventing Future Fractures Implementing a Fracture Liaison Service Wednesday 16th March 2016 Sonya Stephenson Service Development Manager / Specialist Nurse
- 2. 2 • T&O • Rheumatology • Fracture Liaison Service • National Osteoporosis Society (NOS) Introduction
- 3. 3
- 4. 4
- 5. 5
- 6. • 300,000 fragility fractures • 85,000 are hip fracture • 1.8m hospital bed days • 1 month post hip fracture 1 in 13 patients will have died and only half will have gone home • £1.9bn hospital costs Impact of Fractures in the UK
- 7. What is the solution?
- 8. 8 FLS - to ensure the first fracture is the last! X
- 9. Definition of an FLS ‘‘A Fracture Liaison Service (FLS) systematically identifies, treats and refers to appropriate services all eligible patients aged over 50 years within a local population who have suffered a fragility fracture, with the aim of reducing their risk of subsequent fractures.’’
- 10. A Fracture Liaison Service (FLS) • A proven model for fragility fracture prevention • All patients > 50 years who fracture are targeted • 50% of hip fracture patients have had a prior fragility fracture • Where treatment is initiated, up to 50% hip fractures could be avoided in future • Clinically and cost effective Find them Assess them Treat where appropriate Follow- up
- 11. Priorities and Plans for NOS in 2015 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 in the UK Priority 2: Improve quality of Fracture Liaison Services and osteoporosis services
- 12. 12 FLS Mapping
- 13. Some Hospitals/Areas already have
- 14. FLS Implementation • Engage with sites wanting to set-up FLS • Set up a stakeholder meeting • Establish patient/care pathway • Project manage/commissioning and funding • Assist with economic and business case • Service specification • Resource and capacity planning including staffing • Work with providers ensuring FLS is sustained • Data collection, analysis, reporting and evaluation • Ensure service meets FLS Clinical Standards
- 15. The impact of FLS is both clinically & cost effective
- 16. 16
- 17. UK FLS Clinical Standards The 5IQ approach describes the key objectives of an FLS: • Identification • Investigation • Information • Intervention • Integration • Quality www.nos.org.uk/fls
- 18. 18 Gap Analysis Gap Analysis establishes to what degree an existing service is ‘performing’ against the Standards • Informative • Detailed • Specific • Targeted • Constructive
- 19. Generic FLS Pathway FALLS RISK ASSESSMENT NEW CLINICAL FRACTURE NEW VERTEBRAL FRACTURE (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 ASSESSMENT ONE-STOP CLINIC WITH DXA EXERCISE CLASSES Rx FOR FRACTURE 2Y PREVENTION EDUCATION PROGRAMME CARE OF THE ELDERLY 4 & 12 MONTH FOLLOW UP CLINIC COMPLEX CLINIC (IF REQUIRED)
- 20. 20 Most hospital with/without FLS • Inpatient hips • Fracture clinic Challenges • Other inpatients (k-wiring and plates)* • Patients included who fall/fracture on other wards • Spinal fractures • Radiology – incidental spinal fractures* Who may be missed? • Patients attending ED no follow up i.e. clavicle, ribs pubic rami. • Patients admitted for other reason and fracture identified on an X-ray …….
- 21. 21 What is the Impact of FLS • Glasgow model • Glasgow assessed more than 50,000 fractures between 2000-2010 • Hip fracture rates reduced by 7.3% vs 17% increase in England • For every 1,000 patients • 18 fractures were prevented • 11 hips fractures
- 22. 22 What are the economic benefits? • Hip fractures alone have an estimated health and social care cost of £2.3 billion/year Benefits Calculator (http://benefits.nos.org.uk)
- 23. 23 DGH 300,000, 50+ 105,000, 332 hip #’s
- 24. 24
- 25. What Investment is Required? STAFF • Consultant for complex patients/mentor/supervise service • Nurse specialist • Clerical/admin Set up costs – FLS accommodation, IT, DXA scanner and other associated costs: • DXA scans/reporting • Other diagnostics – bloods urine • Drug costs
- 26. 26 Use the FLS Implementation Toolkit 1. 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.
- 28. 28 Abstract deadline: 3 June 2016 Early-bird registration deadline: 5 August 2016 www.nos.org.uk/conference
- 29. Thank you
Editor's Notes
- Service Delivery Team
- This is more bed days than heart attack and stroke combined for men and breast cancer for women Currently rising to £2.2 billion by 2025
- Alistair McClellan initiated the first FLS and education group in the late 1999 To maintain the health and bone health of the population Secondary prevention is the key – identifying patients who suffer a fracture so we can target therapy However once case finding is systematic it can be extended to primary prevention
- So the first fracture does not lead to a hip or vertebral fracture.
- This was first task of FLSIG to define the definition of FLS – so we are all working towards the same goal – consistency of approach.
- SS
- Campaign started 2015 Currently 40% of UK has an FLS By the end of 2017 > 90% coverage All will have same standards of service How has the charity worked to deliver the solution???
- March 153 sites Green = new services being developed from scratch (nothing) Blue = contact only at this stage Purple = quality improvement of service through peer support Yellow = quality improvement of service through additional commissioning
- - A part service (just a slice a cake ) - Others have a very full service which covers all aspects of the NOS standards (icing and cherries on top on their cake) - Others somewhere in the middle
- 2014 NOS bought together national and local stakeholders, Organise for a big meeting with interested parties find the mover and shaker to lead clinical and patient representatives to form the FLS implementation group to cover all of UK NHSE; PHE So this is what the NOS does……….as part of the FLSIG
- National and international* evaluations showing Nakayama and Major paper ‘evidence of effectiveness of a fls to reduce the refracture rate ‘ osteo international nov 2015 Improved case-finding Improved treatment of osteoporosis Fewer fractures Cost savings Mature examples show long term benefits
- IDENTIFY – Find the patients INVESTIGATE – Assess the patient INFORM – Explain to the patient INTERVENE – Treat the patient INTEGRATE – Follow-up the patient QUALITY – Is the key to it all KNOW WHEN TO REFER ON FALLS/COMPLEX CASES…….
- In UK Gap Analysis is structured questioning with key clinical staff to establish degree of existing service against the Standards Informative – information for the Charity; highlights the Standards to services unaware of them Detailed – precise questioning, into all aspects of sub-categories within main Standards Specific – to the site involved; inclusive of associated services Targeted – goals/actions following consultation in line with what service wants to achieve Constructive – never critical; suggestive
- SS
- Other patients – consultant walk past k wiring patient in next bed to a hip fracture Radiology – consider a weekly vertebral fracture search if radiologists are reporting in a similar way Incidental #’s where patient is admitted for a copd and found to have a spinal fracture on x ray needs including or referral made to FLS Which ever pathway , it needs to follow 5IQ and NOS 10 standards
- NOS developed benefits calculator to Estimate fracture incidence for specific UK CCG populations Estimate number of fractures prevented over 5 years Estimate financial benefit based on fractures prevented
- 101 hip fractures saved over 5 years total saved £1,965,188 to acute, community and primary care + social
- Costs are approx. 40% of benefits Choose 2 x 0.6 over 1.2 WTE to give continuity Consider lower grade if no experience Grow your own from ortho/rheum/medicine Mandatory training (+FPP as a minimum) Annual leave Study leave Term time contracts Other roles – senior nurse bleep holder Travel to clinics if on other sites , Plan for succession planning/turnover of staff , Maternity/Paternity leave Make the service attractive to work for!............
- FLS Implementation Toolkit developed to support providers and commissioners to enable commissioning of services This tool – like a fishing rod
- Officially launched April 2015 @ BSR Accessed by hospitals and GP practices Endorsed by 10 leading educational and professional bodies Accessed from across 15 different countries including US, AUS, NZ, SA, CA, ROI, FR…….. Standard and Advanced modules
- Acknowledgements – SDT - Hilary, Tim, Jo, Mayrine, Debbie, Henry, Fiona; and all at NOS