marsh - global challenge

7/31/2019 Marsh - Global Challenge

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David Marsh

Emeritus Professor of Clinical Orthopaedics, University College London

Royal National Orthopaedic Hospital, Stanmore

International Ambassador for the Bone and Joint DecadePresident of the Fragility Fracture Network

The Global Challengeof Fragility Fractures

ECOOG 2012

of the Bone and Joint Decade


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Adapted from Cooper C et al,Osteoporosis Int, 1992; 2:285-9

Total number ofhip fractures:1990 = 1.66 million2050 = 6.26 million

1990 2050

600

3250

1990 2050

6

68

400

1990 2050

1990 2050

100

6293

78

742

Projected Osteoporotic

Hip Fractures Worldwide


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The number of hip fracturesdepends on two things

Age-specific incidence Secular change

Age structure of the population

Demographic change


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General increase in age-adjusted incidence in

the last century

Mixed picture since then

Some plateau, some fall, some continue to rise


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Rochester MN


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Japan


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Assuming 0.43%annual secular fall


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Summary of the challenge

Despite falling age-adjusted incidence, ageing

will lead to massive increase over next 25 years

In Europe:

Double the number of cases

Treble the cost

In Asia and Latin America 6-fold increase

Unless we do something about it


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TheFragility Fracture Network

of the Bone and Joint Decade

Mission: To promote globally the optimal

multidisciplinary management of the patient with

a fragility fracture, including secondary prevention


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Aims

to disseminate globally the best multidisciplinary

practice in preventing and managing fragility

fractures to promote research aimed at better treatments for

osteoporosis, sarcopenia and fracture

to drivepolicy change that will raise fragility

fractures higher up the healthcare agenda in all

countries


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Membership

Open to professionals in any field relevant to

fragility fractures, eg:

Orthopaedic surgeons

Geriatricians

Osteoporosis doctors

Nurses and allied health professionals Industry


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Outline

The nature of fragility fractures

The opportunity for secondary prevention

Integrated care of the acute episode

Changing policy, changing behaviour


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The nature of fragility fractures

A chronic disease

Modifiable risk factors

The potential for prevention

Challenges of treatment

The need for multidisciplinary care


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50 60 70 80 90 Age

No fractures increasing morbiditydue to ageing alone

Age Adapted from Kanis JA, Johnell O; 1999

The fragility fracture career

- a chronic diseaseMorbidityDependence


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The fragility fracture career

- a chronic diseaseMorbidityDependence

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age


Added morbidity fromfractures



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Why Hip Fractures are the key

Hip fractures 87% of

total cost of all fragility

fractures

(2.0 billion in UK)

1.2 million bed days per

year in UK

Often considerably

increased dependency


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Comparison with other priorities

Issues: Strokes Heart Fragility

& TIAs attacks fractures

-----------------------------------------------------------------------------------------

Incidence/year 110,000 275,000 310,000

Current trend Falling Falling Rising

NHS bed days* 1.85m 1.15m 1.2m(hips)

Annual costs 2.8bn 1.7bn 2bn

UK figures from the Department of Health


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Risk of fragility fracture

Bone Density

Bone Turnover

Bone Architecture

Skeletal Geometry

Mineralisation

Postural Instability

Slow Responses

Frailty

Environment

Lack of Padding

BoneStrength

Falls

Risk

Osteoporosistreatment

Strength andbalance training


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Sarcopenia

Traditionally defined as the loss of muscle mass with age

Extended to include loss of strength or performance


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FRAILTY

SARCOPENIA


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FRAGILITY

SARCOPENIA

OSTEOPOROSIS


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Sarcopenia, frailty, rehabilitation

Falls really are as important as osteoporosis Rehabilitation after fracture is inadequate

Drug companies are more excited about anti-

sarcopenic drugs than anti-osteoporotic Except bone anabolics

Muscle-building effects of exercise work in

the elderly


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Earlier fractures signal the hip fractureMorbidity

Dependence

50 60 70 80 90

Colles' fracture

Vertebral fracture

Hip fracture

Age


Added morbidity fromfractures



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Secondary prevention

Secondary prevention is more cost-effectivethan primary prevention


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Prevalence of prior fractures among patientspresenting with hip fracture

45.3 44.6 45.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Lyles et al Edwards et al Mclellan et al

Percentage

Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006

Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & RelatedResearch, 461, 226-230

McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS99/03). NHS Quality Improvement Scotland.

n=2124 n=632 n=701


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Post-menopausalwomen 11.1 million

0.2 million

Post-menopausal

women with newfracture each year

3.4 million

Post-menopausalwomen with

osteoporosis

1.8 million

Post-menopausalwomen with prior

fracture history

50% of hip

fractures from

16% of the

population

50% of hip

fractures from

84% of the

population

16% of women over 50 have had at

least one low trauma fracture

UK figures


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National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London

0

10

20

30

40

50

60

Osteoporosisassessment

DXA referral (65-74 years)

Supplementationwith calcium + D3

Treatment withosteoporosismedication

Percentage

hip (n = 3184)

non-hip (n = 5642)

Target 100% 100% 100% ~70%

Interventions after low trauma fracture


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Secondary prevention is more effectivethan primary prevention

A systems approach is needed, wherecapture of patients is automatic


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Capturing patients reliably

Employment of a dedicated coordinator in the

fracture service is the most effective system


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NEW FRACTURE

EDUCATION

PROGRAMME

EXERCISE

CLASSES

FALLS RISK

ASSESSMENT

INPATIENT

ORTHO/TRAUMA WARD

OUTPATIENT

FRACTURE CLINIC

PRESCRIPTION ISSUED BY GP

Rx FOR FRACTURE

2Y PREVENTION

McLellan et al OI 2003, 14:1028-1034.


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Secondary prevention is more effectivethan primary prevention

A systems approach is needed, wherecapture of patients is automatic

When it is done vigorously,it is cost-saving


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Cost-saving

Per 1000 fragility fracture patients, 18 fractures (11

hip) prevented net saving 21,000


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38% reduction in expected hip fracture incidence


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If universally applied, coordinator-based systems in

fracture units could

Prevent ~25% of the burden of disease from hip fractures

Save money


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Treatment of the acute episode

A multidisciplinary approach is needed

Senior input from physicians

Good surgery

Coordinated rehabilitation and discharge

Treating fragility fractures well ischeaper than treating them badly


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days from injury to death

300200

1000

140

120

100

80

60

40

20

0

Royal VictoriaHospital, Belfast

1999-2003

1003 deaths byone year in 5553

patients

Mortality after hip fracture


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Complexity of elderly patients

Mean age hip fracture = 80 yrs

Comorbidities

(median ASA 3) Cardiac murmurs

Renal - Dialysis

COPD - home O2

Diabetes

Delirium / dementia

Pseudo-obstruction

Alcohol abuse

Impaired metabolic response to

injury

Hyponatraemia Management problems

Consent

Theatre scheduling

Discharge planning

Polypharmacy Warfarin

Plavix

Neurotropics


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Acute medical management

Difficult judgement balance between medicaloptimisation and prompt surgery

Inexperienced surgical trainees not the bestpeople to look after such people and preparethem for surgery

Ideal solution is close supervision by seniorphysicians having expertise with elderly patients

pre- and peri-operatively, not just for rehabilitation


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Senior medical backup

Can come from different specialists,

depending on health care system Anaesthesia

Internal medicine

Geriatrics

Orthogeriatricsa key role in UK, Spain andseveral other countries


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Compared four types of model

Integrated care on an orthopaedic ward gave the best Mortality rate

Length of stay

Time to surgery


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J Am Geriatric Soc 2008

Geriatric Fracture Center in Rochester, USA

Comparison with other fracture services in locality

In-hospital mortality 1.5% vs 3.2%

Readmission 9.7% vs 19.4%

Length of stay 4.6 vs 5.2 days


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Orthogeriatric co-management of the

acute episode

Gives the patient a better quality of carewith better outcomes

Saves money by enabling

more efficient use of resources

fewer readmissions


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Four big messages

Multidisciplinary approach to themanagement of fragility fracturepatients

Reliable secondary preventionosteoporosisfalls

Chronic disease model

Quality assurance

the NHFD


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BOA-BGS Blue Book

six standards for hip fracture care

1. All patients with hip fracture should be admitted to an acuteorthopaedic ward within 4 hours of presentation

2. All patients with hip fracture who are medically fit should havesurgery within 48 hours of admission, during normal working hours

3. All patients with hip fracture should be assessed and cared for with aview to minimising their risk of developing a pressure ulcer4. All patients presenting with a fragility fracture should be managed on an

orthopaedic ward with routine access to orthogeriatric medical supportfrom the time of admission

5. All patients presenting with fragility fracture should be assessed to

determine their need for bone-protective therapy to prevent futureosteoporotic fractures6. All patients presenting with a fragility fracture following a fall

should be offered multidisciplinary assessment and interventionto prevent future falls


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UK National Hip Fracture Database

(NHFD) Project- jointly led by BOA and BGS

Measures compliance with Blue Book standards

A web-based national database, now including

every fracture unit in England, Wales and N. Ireland

Feed back to units their performance compared to national

A professional steering group to manage analysis of,

and access to the data

Extensile for research

Adopted by government as a national clinical audit


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Smart commissioning

Alliance between multidisciplinary providersand healthcare commissioners can tacklefragility fractures and drive change

Prioritisation

Incentivisation


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Objective 1: Improve outcomes andimprove efficiency of care after hip

fractures by following the 6 Blue

Book standards

Hipfracturepatients

Objective 2: Respond to the first

fracture, prevent the second throughFracture Liaison Services inacute and primary care

Non-hip fragilityfracture patients

Objective 3: Early intervention to restore

independence through falls carepathway linking acute and urgentcare services to secondary fallsprevention

Individuals at highrisk of 1st fragility

fracture or otherinjurious falls

Objective 4: Prevent frailty, preservebone health, reduce accidents

through preserving physicalactivity, healthy lifestyles andreducing environmental hazards

Older people

UK DoH package for older people

Top priority


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Best Practice Tariff (BPT)

From April 2010

Reimbursement to Hospitals for each case of hip

fracture will vary according to the quality of care

Two criteria will be used

Time to theatre less than 36 hours

Involvement of orthogeriatrics in the acute phase Compliance for each case will be determined from

the record in the National Hip Fracture Database


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Now the hospital CEO gives a damn

Nationalaverage

cost

before April

2010

~500 BPTsupplement

PAYMENTPER CASE


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UK National Hip Fracture Database

Annual Report 2010-2011

Eligible

hospitals

Hospitals

achievingBPT

Number of

pts submitted

Number of pts

achieving BPT

Qtr 1 162 92 (57%) 9455 2303 (24%)

Qtr 2 165 105 (64%) 11839 3328 (28%)

Qtr 3 163 111 (68%) 13136 4502 (34%)

Qtr 4 167 118 (71%) 12680 4671 (37%)


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Incentivisation

Next year the BPT differential will double to 900

But the base tariff will be reduced

More carrot but also more stick

Extra drive to introduce modern multidisciplinary

services will benefit our patients


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Adapted from Cooper C et al,

Osteoporosis Int, 1992; 2:285-9

Total number ofhip fractures:1990 = 1.66 million2050 = 6.26 million

1990 2050

6

00

3250

1990 2050

668

400

1990 2050

1990 2050

100

6293

78

742

Projected Hip Fractures Worldwide


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Launch meeting

Berlin, 8-9 Sep 2011

Discipline No

Orthopaedic surgeons 54Geriatricians 20

Osteoporosis doctors 6

Nurses 3

Scientists 6

Industry partners 12

Total 101


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Countries represented

Australia 3 Japan 4Austria 1 Lebanon 1

Belgium 1 Netherlands 3

Brazil 2 New Zealand 1

Canada 1 Norway 3China 2 Philippines 1

Denmark 1 Slovenia 1

Finland 1 Spain 6

France 2 Sweden 3Germany 16 Switzerland 5

Hong Kong 3 Thailand 1

Ireland 1 Turkey 1

Italy 23 UK 9

USA 6


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Global Regions

Europe 75

N America 7

S America 2Middle East 2

Asia-Pacific 15

Middle East Forum of the Bone and Joint Decade

Ghassan Maalouf FFN Board memberVice-chair of the Scientific Committee

Coordinator for the Middle East North Africa region


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Aims

to disseminate globally the best multidisciplinary

practice in preventing and managing fragility

fractures to promote research aimed at better treatments

for osteoporosis, sarcopenia and fracture

to drivepolicy change that will raise fragilityfractures higher up the healthcare agenda in all

countries


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Global dissemination

of best practice

Obviously, conditions differ between countries

But there is much in common and all countriescan learn from each other

There is no time to rediscover the wheel a

hundred times This is the philosophy of the Bone and Joint

Decade


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Two main issues

Multidisciplinary care of the

acute fracture episode Particularly hip fractures

Secondary prevention - reduce risk of

another fracture in a patient who has

already had one, by addressing

Osteoporosis

Falls risk


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First Global

Congress

6-8 Sep 2012

Berlin Please come and

share your

experience


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The first FFN Global Congress

Berlin 6-8 Sep 2012

International speakers giving state of the art

on all relevant aspects

Workshops on practical ways forward

Submitted abstracts on research and audit of

different service models


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To register for the Global Congressand submit abstracts online, please

go to

www.ffn-congress.com
http://www.ffn-congress.com/http://www.ffn-congress.com/http://www.ffn-congress.com/http://www.ffn-congress.com/


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If you want to get involved:

Go to www.ff-network.org

Download newsletter

Link to congress

Join FFN (50)

Contact me at [email protected]

or Ghassan Maalouf at

[email protected]
http://www.ff-network.org/mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.ff-network.org/http://www.ff-network.org/http://www.ff-network.org/


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Summary

Fragility fractures will present an unmanageable

problem all over the world unless we act now

Secondary prevention and multidisciplinarymanagement are the keys to success

The international forum for exchanging ideas and

stimulating action is the Fragility FractureNetwork of the Bone and Joint Decade

[email protected]
mailto:[email protected]:[email protected]://www.ff-network.org/http://www.ff-network.org/http://www.ff-network.org/

marsh - global challenge

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