iof malaga 2016 | preventing future fractures: implementing service improvement in fracture liaison...
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Preventing Future Fractures: Implementing service improvement in
Fracture Liaison Services throughout the UK
Henry Mace, Professional Development LeadJo Sayer, Service Development Manager
Tim Jones, Commissioning Advisor
Friday 15th April 2016
The National Osteoporosis Society• The only UK-wide charity dedicated to
improving the prevention, diagnosis and treatment of osteoporosis
• Vision: A future without fragility fractures
• Mission: Working together for a brighter future for people with or at risk of osteoporosis and fragility fractures across the UK, putting an end to preventable broken bones and helping people to live without pain and disability
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• 300,000 fragility fractures a year• 85,000 unplanned hospital
admissions for hip fractures alone• 1.8 million hospital bed days• 1 in 4 people die within a year of
suffering a hip fracture • 33% become totally dependent • £1.9 billion in hospital costs
What is the impact of fractures?
The NHS wants a solution for Secondary Fracture Prevention
Would we accept less than 20% secondary prevention after heart
attack?
What is the solution?
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Fracture Liaison Service (FLS)• An FLS is a proven model for fragility fracture
prevention• 50% of hip fracture patients have had a prior
fragility fracture• All patients > 50 years who fracture are targeted
• Where treatment is initiated
• Up to 25% hip fractures avoided in future
Find them
Assess them
Treat where appropriate Follow-up
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
• FLS Implementation Group• UK FLS Clinical Standards• FLS Implementation Toolkit• FLS Implementation Workshops• Fracture Prevention Practitioner (FPP)
Training• Peer Review• Service Delivery Team
A National Approach to FLS
FLS Implementation Group• National stakeholders & Government• Provide strategic leadership and coordination
across projects• Ensure good communication and partnership
across FLS stakeholders• Plan and deliver agreed actions and
milestones• Ensure delivery of high quality, efficient and
cost-effective FLS
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.’’
• FLS Implementation Group• UK FLS Clinical Standards• FLS Implementation Toolkit• FLS Implementation Workshops• Fracture Prevention Practitioner (FPP)
Training• Peer Review• Service Delivery Team
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 the Charity Supports Implementation
• Provide input to enable the development of an FLS meets the UK FLS Clinical Standards
• Help establish data collection, analysis, evaluation and reporting
• Identify gaps in service provision, put in place improvement plans and monitor against agreed actions
• Peer review
How the Charity Supports Implementation
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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
engaged
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: Some Localities
UK FLS Clinical StandardsThe 5IQ approach describes the key objectives of an FLS:
• Identification
• Investigation
• Information
• Intervention
• Integration
• Quality www.nos.org.uk/fls
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No. Standard Rationale
1 IDENTIFICATIONAll patients aged 50 years and over with a new fragility fracture or a newly reported vertebral fracture 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 the future fracture burden.
2 INVESTIGATIONPatients 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.
3 INFORMATIONAll 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 and prevent further fractures.
4 INTERVENTIONPatients at increased risk of further fracture will be offered appropriate bone-protection treatments.
Appropriately targeted interventions reduce future risk of fracture.
5 INTERVENTIONPatients at increased risk of further falls will be referred for appropriate assessment or interventions to reduce future falls.
Evidence-based falls interventions are effective at reducing risk of falls.
FLS Clinical Standards - summary
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No. Standard Rationale
6 INTEGRATIONManagement plans will be patient-centred and integrated between primary and secondary care.
Effective communication is essential to ensure that long-term management is achieved and that patients are supported to engage with recommended interventions.
7 INTEGRATIONPatients who are recommended drug therapy to reduce risk of fracture will be reviewed within 4 months of initiation to ensure appropriate treatment has been started, and every 12 months to monitor adherence with the treatment plan.
Treatments must be taken consistently and appropriately over many years to be effective. Follow-up allows early identification of issues (side effects, compliance) with prescribed medications, reinforces need to take treatments and supports long-term concordance.
8 QUALITYCore clinical data from patients identified by the FLS will be recorded on a database. Regular audit and patient experience measures will be performed
Data recorded will allow the FLS to audit and improve the service they provide ensuring that high standards are met and maintained.
9 QUALITYThe FLS team will have appropriate competencies in secondary fracture prevention and will maintain relevant Continued Professional Development (CPD).
All staff need appropriate knowledge, skills and experience to fulfil their role. Engagement with relevant CPD activities ensures that these are up to date.
10 QUALITYThe FLS should engage in a regular peer-review process of quality assurance.
Clinical peer review facilitates quality standard assurance, equitable access to services, and provides a means of benchmarking and sharing best practice.
FLS Clinical Standards - summary
Gap Analysis
Generic FLS Pathway
FALLS RISKASSESSMENT
NEW CLINICAL FRACTURE
NEW VERTEBRALFRACTURE
(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 ASSESSMENTONE-STOP CLINIC
WITH DXA
EXERCISECLASSES
Rx FOR FRACTURE 2Y PREVENTION
EDUCATIONPROGRAMME
CARE OF THE
ELDERLY
4 & 12 MONTH FOLLOW UP
CLINIC
COMPLEX CLINIC
(IF REQUIRED)
Assist with Stakeholder Meetings • Lead clinician/local
champion• Consultants:
o Endocrinologisto Rheumatologisto Geriatriciano Radiologisto Orthopaedic surgeon
• Osteoporosis nurse specialists
• DXA radiographers• Service manager/s
• Pharmacist• Prescribing advisors• Physiotherapist• GPs/Primary care• CCGs• Commissioners• Health & Wellbeing
Board/s• Public Health• IT• Site services• Patient rep (NOS!)
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• Comprehensive service review- professional credibility
• Assessment of Service
• Clinical Governance
Quality Assurance
Peer Review
Fracture Prevention Practitioner (FPP) Training
• Officially launched April 2015 • Web-based training at Foundation and
Advanced levels • 478 healthcare professionals registered• 120 accredited FPPs• Accessed by over 130 different hospital trusts
and GP practices • Accessed from across 15 different countries
(US, AUS, NZ, SA, CA, ROI, FR)
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FLS Implementation Toolkit1. 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.
Contents Name Description Format
UK FLS Standards Clinical standards for FLS PDF
The Case for FLS A summary of evidence for providers and commissioners PDF
Service Specification A part populated service specification suitable for use with NHS Standard Contracts
MS Word
Benefits Calculator A financial model demonstrating potential cost savings Web
Cost Calculator A financial model to calculate the service requirements MS Excel
Service Improvement Guide A descriptive guide setting out step-by-step actions for providers to achieve a service improvement
Outcome and Performance Indicators
Practical, evidence-based indicators to demonstrate service improvement
MS Excel
Improvement Project Plan A list of tasks and activities for a development project MS Excel
Business Case Part populated case for investment in FLS MS Word
To secure funding / reimbursement you need to show…
Benefits less
Costs =
Value
Whose benefit? £Payor
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Two calculators• Have been designed by clinicians and payors• Have been used in more than 30 sites• Are regularly updated and revised• Are based on proven service models• Are based on empirical data (not clinical trials)• Use local age-stratified population
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The FLS Benefits Calculator
There is an online version (UK only) at http://benefits.nos.org.uk
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Define populationStep 2 - Select population cohort for analysis (by age/gender)
Male FemaleInclude within analysis? Yes YesAge from 50 - 54 50 - 54Age to 85 + 85 +
Percent of population in
hospital catchment
Population for inclusion
97.0% 234,200
10.0% 7,560
Select one or more from list
NHS Oxfordshire CCG
NHS Aylesbury Vale CCG
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Estimate fracture incidence from population
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Number of fractures expected based on incidence data
324 371 1,292 297
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Estimate number to be treatedReference
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Number of fractures expected based on incidence data
1 765 876 3,047 702
677 463 1515 210Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Proportion of patients to be seen in the FLS
2 88.48% 52.81% 49.72% 29.84%
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Predicted number of FLS patients by category
677 463 1,515 210
Svedbom et al, Epidemiology and Economic Burden of Osteoporosis in UK, Archives of Osteoporosis, 2013 8:137, P212
Incidence is calculated for age bands selected and applied to the input population. Parameters for 'Other site' in Calculator is calculated from 'forearm' and 'other' in source paper above.
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Apply rate of prevention
Department of Health, Fracture prevention services: An economic evaluation, 2009
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Expected proportion of fractures prevented
2.26% 1.13% 1.13% 0.75%
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
2016 31.42% 40.16% 40.16% 31.44%2017 22.29% 19.69% 19.69% 25.71%2018 22.86% 17.32% 17.32% 21.90%2019 14.29% 14.17% 14.17% 13.33%2020 9.14% 8.66% 8.66% 7.62%
All years 100.00% 100.00% 100.00% 100.00%
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Calculate number of fractures prevented
Number of fractures prevented in each of 5 years for patients treated all years
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
2015 6 4 4 22016 11 6 6 42017 16 8 8 52018 19 10 10 62019 21 11 11 7
All years 73 39 39 24
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Multiply by benefits per fracture
References – various, available on request
Estimated costsHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Acute care £7,791 £1,715 £314 £1,867Community and primary care £448 £57 £57 £59Social care £8,237 £150 £150 £2,908All £16,476 £1,922 £521 £4,833
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YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral Total Average benefit per year
Acute care 2016 £162,580 £23,257 £4,264 £13,636 £203,7372017 £284,515 £35,780 £6,560 £23,376 £350,2312018 £414,579 £46,514 £8,528 £33,116 £502,7372019 £495,869 £55,459 £10,168 £40,908 £602,4042020 £552,772 £60,826 £11,152 £44,804 £669,554
All years £1,910,315 £221,836 £40,672 £155,840 £2,328,663 £465,733
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral Total Average benefit per year
Community and 2016 £8,960 £741 £741 £413 £10,855primary care 2017 £15,680 £1,140 £1,140 £708 £18,668
2018 £22,848 £1,482 £1,482 £1,003 £26,8152019 £27,328 £1,767 £1,767 £1,239 £32,1012020 £30,464 £1,938 £1,938 £1,357 £35,697
All years £105,280 £7,068 £7,068 £4,720 £124,136 £24,827
YearHip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral TotalAverage benefit per
yearSocial care 2016 £164,740 £1,950 £1,950 £20,356 £188,996
2017 £288,295 £3,000 £3,000 £34,896 £329,1912018 £420,087 £3,900 £3,900 £49,436 £477,3232019 £502,457 £4,650 £4,650 £61,068 £572,8252020 £560,116 £5,100 £5,100 £66,884 £637,2000
All years £1,935,695 £18,600 £18,600 £232,640 £2,205,535 £441,107
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The FLS Cost Calculator
This is not available on line
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Input data neededEstimated number of cases expected in Year 1
Hip fracture (inpatient)
Other fracture site (inpatient)
Other fracture site (outpatient)
Clinical vertebral
Calculated Total
Patients aged 50 - 74
0
Patients aged 75+
0
Total Patients
Patients aged 50 - 74Patients aged 75+
User input from Benefits Calculator or local audit.
User input if split by type of fracture is not known
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Output - Numbers of staff
WTE = whole time equivalent means one year working full time
Staff WTE required - non-tariff activity2016 2017 2018 2019 2020
WTE - nurse assessment appointments 1.27 0.74 0.63 0.63 1.06WTE - consultant planned activities 0.06 0.06 0.06 0.06 0.06WTE - other nurse activities 0.37 0.37 0.37 0.37 0.37WTE - radiology planned activities 0.06 0.06 0.06 0.06 0.06WTE - administration 0.80 1.12 1.12 1.12 1.12
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Output – numbers of appointments/scans
Summary of tariff activity 2016 2017 2018 2019 2020
Number of Dexa scans at tariff 950 950 950 950 950
Number of consultant appointments at tariff 2 2 2 2 2
Selected speciality
Number of nurse follow up appointments 633 1853 1853 1853 1853
Rheumatology
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Output – costs of service
Total costs2016 2017 2018 2019 2020
TOTAL COSTS £187,070 £200,181 £190,262 £190,262 £205,777
Cost per patient £94 £100 £95 £95 £103
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You can override any dataResource for assessment appointments
Length of appointment (minutes) 2016 2017 2018 2019 2020Default 30 30 30 30 30User defined 25 20 20 20
Length of support time (minutes) 2016 2017 2018 2019 2020Default 30 30 30 30 30User defined 10 10 10
Staff Grade 2016 2017 2018 2019 2020Afc Band of staff Band 6 Band 6 Band 5 Band 5 Band 5Default annual salary £30,186 £30,186 £24,685 £24,685 £24,685User defined annual salary
Productive time % 2016 2017 2018 2019 2020Default 81.00% 81.00% 81.00% 81.00% 81.00%User defined
Employment on-costs 2016 2017 2018 2019 2020Default employment on-costs 27.10% 27.10% 27.10% 27.10% 27.10%User defined employment on-costs
The financial case
• Costs = 37% of benefits
• Break even – 13 – 20 months from start of service
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How will you know if it is working?
Outcomes framework and reporting tool available for download at www.nos.org.uk/toolkit
Outcome Month 3 6 9 12 15 18 24Number of cases treated compared to predictedNumber of patient followed up at 4 monthsAdherence at 4 monthsNumber of patient followed up at 12 monthsAdherence at 12 monthsReduction in hip fractures admittedReduction in other fractures admitted
Outcome detected Outcome detected Statistically significant
with limited confidence outcome
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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
