fracture liaison service champions summit 2016 #flschampions
TRANSCRIPT
FLS Champions’ Summit 2016
5th February 2016
FLS Implementation Update
Hilary Arden, Head of Service Delivery
5th February 2016
National Osteoporosis SocietyPriorities and Plans for 2016Aim 1: Every person aged over 50 who breaks a bone is assessed for osteoporosis and managed appropriately.Priority 1:
Extend coverage of Fracture Liaison ServicesPriority 2:
Improve quality of Fracture Liaison Services and osteoporosis services
New for 2016…Develop and implement best
practice for identification and management of vertebral fractures
• FLS Implementation Group• FLS Implementation Toolkit• FLS Implementation Workshops• UK FLS Clinical Standards• Fracture Prevention Practitioner (FPP) Training• Peer Review• Service Delivery Team support
A National Approach to FLS
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
• 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 We Help
FLS Cost & Workforce Calculator• Additional resource within the FLS-IT• Designed for use by clinicians and Health
Boards to help develop an FLS• Provides the ‘cost’ side of a cost/benefit table
for the FLS business case • Uses estimates of fracture numbers either
from local audit or from using the FLS Benefits Calculator
• Outputs: the numbers of staff, DXA, follow-ups etc. required, bespoke to the service.
FLS Implementation Workshops2 workshops planned for 2016: South Central & NE London
Rebecca Gear, Osteoporosis specialist nurse practitioner, Care UK: “I feel confident in going forward and have a plan in mind. A must have workshop when wanting to start an FLS.”
Dr Madhavi Vindlacheruvu, Consultant Orthogeriatrician, Cambridge University Hospitals: “Excellent to be able to present 1st draft of business case. Great expertise and support, really well organised.”
• Provide input to support the development of an FLS to meet the Clinical Standards
• Identify gaps in service provision, put in place improvement plans and monitor against agreed actions
• Help establish data collection, analysis, evaluation and reporting
• Peer review.
How We Help
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.
Gap Analysis
Fracture Prevention Practitioner (FPP) Training• Officially launched April 2015 @ BSR• 420 healthcare professionals registered• 98 accredited FPPs• Accessed by 91 different hospital trusts and
GP practices • Endorsed by 10 leading educational and
professional bodies • Accessed from across 15 different countries
(US, AUS, NZ, SA, CA, ROI, FR)
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Peer Review • A means of assessing clinical care against agreed
standards• Addresses agendas of clinical governance, practitioner
revalidation, and service development• Facilitates a quality assured level of care for patients
with osteoporosis and metabolic bone diseases.
www.nos.org.uk/peer-review
17
FLS Coverage England NI/IOM Scotland Wales UK
2015FLS Coverage
47/141 (33%)
4/6 (80%)
7/14 (50%)
6/11 (55%)
64/171 (37%)
Supporting new service
development
38 0 2 4 44
Supporting quality
improvement
40 6 12 6 64
Number of additional sites
in contact
31 3 2 6 42
Total/Potential number of FLS
109/141(77%)
9/9 (100%)
16/16(100%)
16/16(100%)
150/182(82%)
No. of services commissioned
7 0 0 0 7
FLS ImplementationTo Date
18
FLS Mapping
FLS BenefitsArea Population Cohort
(50+)Hip fractures prevented*
Total benefits (of hip fractures prevented)*
Bradford 459,142 129,011 119 £1,960,644East Sussex 374,801 167,905 188 £3,097,488Epsom 405,456 119,974 115 £1,894,740Rotherham 258,751 96,591 66 £1,111,902Salisbury 144,835 59,786 59 £972,084Stoke-on-Trent 214,991 88,334 88 £1,449,888Vale of York 348,363 131,411 128 £2,108,928Total 2,206,339 793,012 763 £12,595,674*Over a 5 year period
20
FLS Cost & Workforce Calculator
Tim Jones Commissioning Advisor
5th February 2016
FLS Cost & Workforce Calculator
This tool has been designed for use by NHS hospitals, community services and commissioning organisations to help develop a local FLS. The calculator will enable you to estimate the costs required to implement or improving an FLS…
Commissioning a Fracture Liaison ServiceSalisbury District Hospital
Dr Zoe Cole
5th February 2016
History2002 Heel ultrasound2007 DXA machine2007 First business case for FLS2011 3rd business case rejected (QOF)2013 New Consultant started
Performance against Best Practice Tariff
2009-2010 (£445 per patient)
1.5%(2)Ranked 98th out of 100 hospitals.
Income: £890
2010-2011 (£890) 58%(131) Ranked 12th out of the 176 hospitals.
Income: £116,590
2011-2012 (£890) 84.7% (205/242) Ranked 1st in the Southwest Region, Ranked 4th Nationally (out of more than 200 NHS Trusts)Income: £187,790
Outcomes• BEST PRACTICE TARIFF % for 2012-2013: 85.7%
(220/257)• Length of stay reduced by 7.82 days from 27.6
days to 20.09 days (April 2012-March 2013) • £509,960 saved: 2,549 bed days at £200 per day • Mortality reduced from 10.1% to 7.4%• Re-admissions reduced from 4 (2010/11) to 2
(2011/12)• Positive Feedback from patients, families and staff.
(Real time feedback and very few complaints)
Bone protection on admission
Area %Slough 22.2
Oxford 21.4
Basingstoke 14.8
Southampton 14.4
IOW 10
Milton Keynes 9.4
Stoke Mandeville 9.1
Reading 8.3
Salisbury 3.2Portsmouth 5.2
Salisbury experience pre and post QOF
2011 Audit
• 56% not investigated• 24% on treatment• 6% re-fractured (2 hip)
2013 Audit• 56% not investigated• 12% treatment• 6% re-fractured
50 patients who presented with colles fractures followed up at 6 months with telephone call to assess what treatment they were on.
2013New business case put together Help from business writing course Health economist HES data Dr Foster data Previous local and national audit DoH FLS economic case
2014• Case presented to Primary care forum
• Presented at Sarum CCG meetingFull support
• Refused at Wiltshire CCG executive meetingEconomic benefits not great enough
Public Health• Wiltshire Falls and Bone health group
External report by NHS EnglandFirst priority FLS£30,000 promised 2015/16 only
NOS Dec 2014• Discussed case with Tim Jones
Strong caseNOS writing new economic modelSalisbury test case
2015
• Jan-Feb: Met with CCGDecided case fitted with Better Care FundWhole new case written (new templates)
Year
2015 2016 2017 2018 2019 All yearsNet benefit
(NHS only)
-£25,634 £77,751 £183,081 £270,574 £346,759 £852,531
Net benefit (NHS and social care)
£61,833 £238,523 £419,539 £570,903 £703,858 £1,994,655
Progress to date
• March: Presented to Better CarePilot funding given for 2 years (verbal)
• August: written confirmation
• Nov: FLS nurse started
• Jan 2016: FLS live
36McLellan et al. Osteporos Int 2003;14:1028–1034
Thank youTim JonesHilary ArdenFizz ThompsonSonya Stephenson
Kassim JavaidFriscyLynn TalbotStuart Eastman
All colleagues at SDH
FLS Champions’: FLS DB audit
MK JavaidAcademic Rheumatologist University of Oxford
Important confidentiality notice
• Data shared is for this meeting only
• No photography
• Information being shared is not for publication on social media or in other form
• No handouts or post meeting slides
• Release date for audit is 10th May 2016
FLS-DB Work-streamClinical Lead: Dr M Kassim Javaid RCP Leads: Naomi Vasilakis (project manager), Rowena Schoo (project co-ordinator), Sunil Rai (data coordinator), Roz Stanley (programme coordinator)
Constituency RCGP -Jonathan Bailey, David StephensBGS – Frances Dockery, Rachael BradleyOrthogeriatrics - Celia Gregson BOA – Xavier GriffinBES - Neil GittoesBSR - Gavin ClunieNOS - Anne Thurston/ Sonya StephensonRCN - Debbie JanawayRCS - David Cromwell, Carmen TsangPatients – Susie, IonaCrowne - Jonathan Roberts
Process
• FLS-DB Facilities audit
• The FLS-DB audit – patient centred
FLS Breakpoint Audit
Opportunities for improving the quality and efficiency of patient care to prevent recurrent fragility fractures
Identification (52/85 had FLS)
Identification: case mixEngland FLS n
England FLS %
Wales FLS n
Wales FLS %
Outpatient Clinic 45 93.8 4 100.0+Non-hip inpatients 24 50.0 3 75.0+Hip inpatients 23 47.9 2 50.0+Clinical vertebral 19 39.6 2 50.0+ Incidental vertebral 10 20.8 2 50.0
Investigation: evidence of chaos?England FLS n
England FLS %
England non FLS
n
England non FLS
%
Wales FLS n
Wales FLS %
Wales non FLS
n
Wales non FLS
%Renal function tests 41 85.4 19 73.1 4 100.0 1 25.0Serum Calcium 40 83.3 18 69.2 4 100.0 1 25.0Liver function tests 38 79.2 18 69.2 4 100.0 1 25.0Full blood count 37 77.1 19 73.1 2 50.0 1 25.0Serum alkaline phosphate 37 77.1 17 65.4 4 100.0 1 25.0Serum phosphate 37 77.1 15 57.7 4 100.0 1 25.0Thyroid function 37 77.1 16 61.5 4 100.0 1 25.0Serum 25OH vitamin D 36 75.0 16 61.5 3 75.0 1 25.0Erythrocyte sedimentation rate / ESR Liver function 29 60.4 9 34.6 1 25.0 1 25.0
Coeliac disease screen 28 58.3 6 23.1 3 75.0 1 25.0Serum Electrophoresis for myeloma screen 27 56.3 15 57.7 4 100.0 1 25.0
Serum Parathyroid hormone 26 54.2 12 46.2 3 75.0 1 25.0Testosterone/ Sex hormone binding globulin 24 50.0 9 34.6 4 100.0 1 25.0
C-reactive protein 20 41.7 11 42.3 2 50.0 0 0.0Other 16 33.3 6 23.1 0 0.0 1 25.0Missing 6 12.5 6 23.1 0 0.0 2 50.024 hour urinary calcium 3 6.3 2 7.7 0 0.0 0 0.0Spot urinary calcium 3 6.3 1 3.8 0 0.0 0 0.0
Identification: Observed vs Expected
Service structure: FLS nurse time and Estimated fragility fractures
Overview
• Shortfall in numbers being seen
• Shortfall in FLS size to meet the demand
• Variation in– Case mix– Investigations– Reporting– Monitoring
Service review to close any
care gap
Identification
Investigation
Initiation
Information
Monitoring
Site specific reportON KEY indicators RCP
FLS site
CCG/ LHB
In patientsHip fractureClinical spineIncidental spine
Blood panelFalls questions
2nd line bone drugsStrength and balance class
Standard reportData management / upload to FLSDB audit
ScopeTiming
Process
• FLS-DB Facilities audit
• The FLS-DB audit – patient centred
FLS-DB 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: Monthly patient audit upload vs. direct data entry
FLS-DB audit: update
• Clinical dataset approved and online
• Direct Web entry on Monday
• NOS supporting – excel spreadsheet
• First upload in March 2016
• Final upload in October 2016
Assessed, 2+ falls, fear, At risk drugspre fracture mobility, visioncontinence, abnormal cardiovascularcognitive, Referrals
Age, genderPost code, Care home status
Fracture – hip, spine, nonhip/spineDates
Fracture diagnosedFLS identified, assessedHeight & weight
Previous fragility fracturesFamily history
SmokingOn anti-osteoporosis therapy
FLS-DB Audit:Patient identifiers
Bone risk factors
Ordered, DateLowest T score, Frax
/ QFracture
Bone therapyCalcium and D
Initiation
DXA
Falls
FLS-DB Audit
DateStarted bone / CaDStarted strength and balance
4 month
DateOn bone / CaD
RefractureRe-falls
12 month
Get the data to RCP
1. Direct web entry
2. Upload monthly
www.fffap.org
•
Uploaders
• Initial effort– Updating data collection tools– Updating database
• Medium long term benefits– Standardized core assessment– Comparability with other services– No duplicate data entry
Uploaders
Download core dataset document and excel
Check against their local dataset
Amend and align dataset and collection
Select fracture data dates
Export as csv using filename OxfordFPS2016v1.0.csv
Upload using web-tool to RCP monthly NOS
User guide
Why monthly upload?
Assessed, 2+ falls, fear, At risk drugspre fracture mobility, visioncontinence, abnormal cardiovascularcognitive, Referrals
Age, genderPost code, Care home status
Fracture – hip, spine, nonhip/spineDates
Fracture diagnosedFLS identified, assessed
Re-fracturesHeight & weightPrevious fragility fractures
Family historySmoking
On anti-osteoporosis therapy
FLS-DB run chartsPatient identifiers
Bone risk factors
Ordered, DateLowest T score, Frax
/ QFracture
Bone therapyCalcium and D
Initiation
DXA
Falls
DateOn bone / CaD
RefractureRe-falls
Mortality
12 month
DateStarted bone / CaDStarted strength and balanceMortality
4 month
Fracture diagnosis
FLS-DB run chartsDNA by age and genderTime interval
FLS contact
FLS Assessment
DXA date
4 month monitoring
FLS assessment
DXA
4 month monitoring
PatientEffectiveCare pathway
ReduceAvoidable Fractures
+ =
✓Data that the FLS has closed the care gap
FLS-DB run charts: suggestions form launch meeting
Numbers and percentages of each of 1. Fracture details (type of fracture/re-fracture – particularly spinal (5), repeat fractures
(3), local v national re-fracture rates) 2. Treatment & assessment (FRAX, DXA (5), treatment recommended (4), still compliant
(2), not started (5) at 4 months (4), intolerant, followed up at 4m and 12m (2), mortality)3. Time between
• Fracture to– Diagnosis (2)– DXA date (5)– FLS assessment (5) within 4 weeks?– FLS first contact– Treatment (4)
• Identification by FLS to DXA date (2)• First contact by FLS and assessment• Referral to treatment • Time to be seen from referral to FLS
4. Falls (S&B, risk assessment (2) , falls in past 12 months, referred to falls clinic (3))5. Site adherence to each relevant FLS standards data being collected on in the database
FLS-DB run charts: suggestions form launch meeting (continued)
Numbers and percentages of each of 6. Patient info / FLS processes
– Informed decline (3)– DNAs (3) - By age and gender– No response to further contact– Patients seen /inputted (3)– Patients assessed at 8 weeks (2)– Patients attended– Residence (4)– Admitted as outpatients– Age (4)
• Average age• Age at time of fracture (3)
– Gender (2)– Family history– Postcode
LUNCH
See you back here at 13.30
Vertebral fractures – missed opportunities: The role of the
Radiology Department in correcting this!Andrew Pearson
NHS Borders, Scotland
Overview• Significance of vertebral fractures• Hip fracture audit• Poor performance of Radiology• Opportunities in Radiology to improve
fracture liaison• Input from DEXA
Requirements for effective Secondary Fracture prevention
• Effective mechanism for identification of first fragility fracture
• Effective communication with clinicians responsible for instigating treatment & follow up
Why is a Radiologist so ‘enthusiastic’ about vertebral fractures?
• Highly predictive of future fracture risk• Account for significant morbidity and
mortality• So common that they are often overlooked
as ‘incidental’ findings• Readily available golden opportunity to
identify patients requiring bone protecting medication
• Identification makes a real contribution to reducing incidence of hip fractures
• Fragility fracture progression can be halted by early identification, saving patient misery
• Represent a huge financial burden on NHS
Scottish Parliament. Written question in 2012 asking number of Hip & Vertebral Fractures, by health board• Answered by Health Minister Nicola Sturgeon
(now first minister)• Scottish Borders: 6 vertebral fractures per
year!• Real local experience: more like 6 a day!• Most insufficiency vertebral fractures are not
included in collected data
What makes vertebral fractures different?
• Most do not present acutely• Many go undiagnosed (50-70%, ref. NICE
TA161)• Inrcremental process• Often arise in absence of specific trauma• Highly predictive of skeletal ‘fragility’• Potentially the most important fractures to
identify• Account for chronic pain and morbidity• Must be actively ‘looked for’
Vertebral Fractures Substantially Increase
the Risk of New Fragility Fractures
A woman with one vertebral fracture has a 4.4 times increased risk of another vertebral fracture and 2.3 times increased risk of hip fracture (NICE TA161)
One woman in five will suffer from another vertebral fracture within a year (Lindsay et al., JAMA, 2001)
Women with low BMD and one fracture have a 25x risk of a women with normal BMD and no fracture
Incidence Rates for Vertebral, Wrist & Hip Fractures in Women
after Age 50
Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999
50 60 70 80
40
30
20
10
Vertebral
Hip
Wrist
Age (Years)
Ann
ual i
ncid
ence
per
10
00 w
omen
Osteoporotic Fractures in Women:
Comparison with Other Diseases
Riggs BL, Melton LJ. Bone 1995Heart and Stroke Facts, 1996, American Heart
AssociationCancer Facts & Figures, 1996, American Cancer
Society
1 500 000*
0
500
1000
1500
2000
Osteoporotic Fractures
*annual incidence all ages † annual estimate women 29+
‡annual estimate women 30+ §1996 new cases, all ages
513 000†
228 000‡ 184 300§750 000
vertebral
250 000 other sites
250 000forearm
250 000hip
HeartAttack
Stroke BreastCancer
Ann
ual i
ncid
ence
x 1
000
All Types of Vertebral Fractures are Associated With Morbidity
Nevitt MC et al., Arch Intern Med.2000, 160:77
Limited ActivityBed Rest
0
25
50
75
100
Patie
nts
(%)
No IncidentFracture
RadiographicFracture
Clinical Fracture
36.8
3.9
76.2
26.9
93.2
52.7Due to back pain
NICE TA161
Vertebral fractures are associated with a 4.4% increased mortality (UK specific data)
Mortality Rates by Number of Prevalent Vertebral Fractures
Kado DM et al., Arch Intern Med 1999,159:1215P for trend < 0.001
Mor
talit
y (p
er 1
000
pers
on-y
ears
)
0
5
10
15
20
2530
3540
0 1 2 3 4 5+
Number of Vertebral Fractures
45
Vertebral fracture morbidity• Chronic pain from multiple ‘incremental’
fractures• Exaggerated kyphosis• Cause reduced mobility, leading to
further bone loss• Impact on respiratory reserve,
especially in COPD patients• Significant increase in GP visits
Vertebral Fractures in Summary
· are the most common osteoporotic fractures· are associated with excess mortality· are associated with significant morbidity, even if
they do not come to clinical attention· increase the risk of subsequent vertebral
fracture(s) by 5 fold and of other fragility fractures (including hip) by 2 fold
· highly predictive of future fracture risk due to the relative absence of trauma in their causation
A Retrospective Study Suggests that Vertebral Fractures are underdiagnosed
Gehlbach et al.,Osteoporos Int 2000, 11:577
934 hospitalised women with a lateral chest x-ray
0
20
40
60
80
100
120
140
Patie
nts
(n)
132
65
23 25
Fractureidentified by studyRadiologists
Fracturenoted in Radiologyreport
Fracturenoted inmedical record
ReceivedOsteoporosistreatment
Borders hip/vertebral fracture audit• 202 hip fractures in 2010• 56 (28%) had body CT in previous 5 years• 22 (39%) CTs showed vertebral fractures • 9 (40%) of 22 vert. fractures documented,
13 (60%) missed• 13 potentially preventable hip fractures in
2010 (£520,000!)
Missed vertebral fractures on whole body CT
Messages from audit• High prevalence (39%) of all CTs showed
vertebral fractures• 60% visible vertebral fractures were
overlooked• Radiologists need to do better at alerting
these fractures to the FLS team• Increasing general use of CT will further
increase opportunities to identify vertebral fractures
• Same opportunities available in MRI• This is opportunistic, without additional
resource requirement, using image data which is already available
• Change in practice of Borders Radiologists has contributed to 20% reduction in hip fractures between 2010 & 2014
Opportunities in Radiology• All clinical and many ‘occult’ vertebral
fractures pass through Radiology• Radiology has instant access to previous
fracture history and previous DEXAs (including referral forms)
• Easy imaging of spine (IVA, plain films, CSI)• Computerised records for easy searching• Opportunistic ‘cross sectional data’ : CT &
MRI• Identification of demineralisation on plain
films• Isotope Bone Scanning
• High fracture risk patients with cancer treatment induced bone loss
CT & MRI data• Large patient throughput• High Osteoporosis risk patients• No amendment to scanning protocol• Instant reconstructions when reporting• Access to previous records (fracture
history, DEXAs etc..)• Smart code referral to FLS or straight
to DEXA
CTPAs
DEXA SCANNING Importance of
Vertebral Morphometry
Lateral Vertebral Assessment
Combining BMD & Vertebral Fracture Assessment:
An Approach to Improve the Diagnosis Rate of Vertebral Fractures
· Improves risk assessment· Identification of occult fractures · Identification of scoliosis· Identification of artefacts
Poor quality IVA?• Plain films (at same attendance)• CT (baseline & follow up)
Differential diagnosis of vertebral fractures
• Osteoporotic fragility fracture• Myeloma• Metastases• Scheurmann’s disease• Schmorl’s nodes• Sickle cell disease, Gaucher’s disease
How can Radiology help reduce Osteoporotic
fractures?
Why in Radiology?• Only location for identification of all
vertebral fractures• Integration with non vertebral fractures
keeps all FLS data together• Access to previous imaging & DEXA to
assess age and significance of fractures• Assessment of alternative causes of
insufficiency fractures
Administrative process in Radiology, NHS Borders• Reporting Radiologist/Radiographer describes
fracture and dictates “insert fragility fracture”• Text string inserted as suffix to report indicating
that patient may be at increased risk of further fractures and will be assessed by the Osteoporosis team
• Radiology Office books these in as “Fracture Liaison” examinations, with other fracture liaison cases
• Osteoporosis Radiologist/Clinician assesses case (access to previous DEXA, fracture history, osteoporosis clinic attendances, current drug treaments) and decides on need to recall for DEXA or go straight to treatment
• Text string in report will automatically generate a DEXA referral or standard text recommending treatment
Requirements for success:
1. Understanding amongst Radiology team members of huge importance of identifying occult vertebral fractures
2. Simple mechanism for reporting Radiologist or Radiographer to identify and highlight presence of vertebral fractures on cross sectional and other imaging
3. Mechanism for ensuring that this information is passed to the Fracture Liaison team for further action
Message for Radiologists
• 11% of hip fractures are dead within 30 days
• 40% of hip fracture patients who previously lived independently in their own home end up in institutional care
• Hip fractures cost £40,000 each• Many hip fractures can be prevented
Why Radiology needs to act now!• Nobody else is in such a good position to help
identify patients at risk of hip fracture• Requires minimal time & effort• 30 seconds to save a life!• Failure to act when such obvious ‘incidental’
pathology is present on scan could be seen as a clinical incident
• All you need to do is:click of the mouse to show sagittal imagebrief look at this imagedictate a few words (e.g.: there are
several mid thoracic vertebral fractures, “insert fragility fracture”)
QUESTIONS
FLS Champions’ Summit
Management of Acute Vertebral Fractures
Professor Opinder SahotaConsultant Physician
QMC, Nottingham University Hospitals
Vertebral Fragility Fractures (VFF)
KyphoticNormal
Location of Vertebral Fractures
1. Nevitt MC et al. Bone. 1999;25:613–619.2. Cooper C et al. J Bone Min Res. 1992;7:221–227.
Are most commonly located at the midthoracic region (T7–T8) and the thoracolumbar junction (T12–L1)1
– Midthoracic region–thoracic kyphosis is most pronounced and loading (stress) during flexion is increased
– Thoracolumbar junction–the relatively rigid thoracic spine connects to the more freely mobile lumbar segments2
Progressive Kyphosis & Spine Compensation
• Impairs gait and mobility• Para spinal muscle fatigue• Increases strain on
posterior facet joints
Back Pain
Knee flexion and contraction of the posterior muscles ofthe lower back to tilt the hips
Long-term Consequences
Acute Fracture
Acute Fracture :Optimise Pain Control
• Paracetamol• Tramadol• NSAIDs• Fentenyl• Buprenorphine
Acute Fracture :Imaging
DXA
•••
•• •
Osteoporosis-Imaging
Lateral Vertebral Assessment
••
Vertebral Fragility Fractures
Genant HK et al. J Bone Miner Res. 1993;8:1137–1148.
Severe(≥40% height loss)
Normal Wedge Biconcave Crush
Moderate(25-40% height loss)
Mild(20-25% height loss)
Measurements used for assessment:Hp=posterior height;Hm=middle height;Ha=anterior height
Hp Hm Ha
Lateral Vertebral Assessment
Osteoporosis-Imaging
LVA Assessment
• 337 patients, presenting with low trauma non-vertebral fractures
• LVA 83 (25%) vertebral fracture confirmed(37 (45%) more than one vertebral fracture
• Of those with vertebral fractures, 75% has deformities of grade 2 or 3
Gallacher SJ et al. Osteop Int . 2006; 18: 185-192
Acute Fracture :Exclude Secondary Metabolic Causes
• FBC / ESR• Biochemisty Profile• TFTs, Coeliac Screen• Calcium (PTH)• Myeloma screen• PSA
Acute Fracture :Admission to Hospital
Acute Fracture :Secondary Care
• Optimise Analgesia• Regular bowel care• Consider urgent MR
Imaging• Discussion with spine
team
Acute Fracture :Discussion with spine team• On call• HCOP Dedicated 4 PAs• Spinal Osteoporosis Specialist Nurse
Vertebral Augmentation
Vertebral Augmentation
• Ms OG
• 82 Female, normally fit and well
• Acute back pain, following light gardening
• Presented to ED-log rolled
• X-ray spine confirmed L4#
• Plan transfer to medicine for analgesia and physio
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
Case Presentation 1
• Ms KH
• 91 Female, normally fit and well, no aids
• Awoke with acute lower back pain
• Managed by GP regular analgesia, 48 hours
• Struggling to mobilise
• Admitted to hospital
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Case Presentation 2
Acute Pelvic Fracture
Acute Pelvic Fracture
Acute Pelvic Fracture
Sacral Fractures Pubic Rami
Fracture
Acute Pelvic Fracture
Pelvic Fractures
• CT• MRI• PARACEMATOL (IV) • SACROPLASTY / SCREW FIXATION• PARATHYROID HORMONE
Pelvic Fractures
• Teriparatide (1-34 parathyroid hormone)• Parathyroid Hormone (1-84)• 65 Patients with pubic / ischial rami fracture• Fracture healing time reduced by 4.6 weeks (p<0.01)• Improved pain scores and Timed Up and Go (p<0.01)
Peichl et al, JBJS, 2011; 93: 1-5
The Optimal Acute Pathway
•Acute Vertebral / Sacral Fracture
•Clinical Assessment
•Analgesia•Investigations
•X-ray Imaging•MR Imaging
•Spinal Augmentation•Intensive rehabilitation
•Secondary prevention
Workshops Workshop 1 – Euston Suite FLS Standard 1: Vertebral Fracture Identification
Workshop 2 – Baker Suite FLS Standard 7: Follow-up
FLS Champions’ Summit 2016
Thank you
5th February 2016