Falls and Fracture Prevention Summit Prof. Keith Willett Prof. David Oliver October 2011

FF Summit 4 October 2011 The Starting Point 1: – First-rate advocacy and leadership from charities and professions

FF Summit 4 October 2011 Starting Point 2: Good practice guidelines Assessment and prevention of falls in older people (2004) Osteoporosis primary prevention in postmenopausal women 2011 Osteoporosis secondary prevention of fractures in postmenopausal women 2011 (update of 2008) Assessment of risk and prevention of osteoporotic fractures in those at high risk (in development) The management of hip fracture in adults 2011

FF Summit 4 October 2011 The starting point 3. The power of data showing care gaps and unwarranted variation

The Key Questions: Who are the patients? Where can we find them? What have we achieved to date? What is the financial cost of: –possible interventions? –of doing nothing, the natural history? How do we implement nationally? 5 FF Summit 4 October 2011

The Key Questions: Who are the patients? Where can we find them? What have we achieved to date? What is the financial cost of: –possible interventions? –of doing nothing, the natural history? How do we implement nationally? 6 FF Summit 4 October 2011

Falls Epidemiology 1 in 3 people >65 and 1 in 2 >80 fall yearly 40% of ambulance calls in over-65s due to falls 7% of over 65s attend A&E with a fall 40% of Nursing Home residents fall twice a year or more Falls account for 35% of all patient safety incidents in hospital (270,000 in 2008/9) Predominantly a problem of ageing and frailty 7 FF Summit 4 October 2011

Falls Epidemiology 8 FF Summit 4 October 2011 Falls/Falls-injuries account for more bed days than MI, CVA/HF combined

The epidemic FF Summit 4 October % lifetime risk of fragility fracture 1 in 3 have had a herald fracture first More women over 50 will have a hip fracture than breast cancer Hip fracture patients

The importance of prevention strategies FF Summit 4 October 2011 Hip fracture patients

The demographics FF Summit 4 October 2011 Hip fracture patients 1 in 2 women; 1 in 5 men over 50 will fracture 230,000 fragility fractures; 80,000 in hip The typical hip fracture patient is medically complex and frail Median age 84 10% die in 1 month 25% die in 12 months 30% need long term care 70% new permanent dependency in 2+ Activities of Daily Living 30% delirium post-op 30% demented pre-op

The Key Questions: Who are the patients? Where can we find them? What have we achieved to date? What is the financial cost of: –possible interventions? –of doing nothing, the natural history? How do we implement nationally? 12 FF Summit 4 October 2011

Primary Care Post-menopausal women who are at risk of FALLS 15,500 will fall; half more than twice 360 hip fractures Post-menopausal with NEW fracture each year 4200 will call ambulance; half will be conveyed to A&E Post-menopausal with SILENT osteoporosis Curr Med Res Opin 2005;21:4: Brankin E et al Hospital patients FF Summit 4 October 2011 Where can we find them? In an average 320,000 pop PCT in ONE year: 1100 fractures (wrist, hip, spine)

In hospital: 2008: 1 in 3 patients waited more than 2 days for surgery Median hospital stay (spell) was 23 days Mean total stay (superspell) 28 days 33% need more care support 15-20% change residence 14 FF Summit 4 October 2011 Unacceptable

The Key Questions: Who are the patients? Where can we find them? What have we achieved to date? What is the financial cost of: –possible interventions? –of doing nothing, the natural history? How do we implement nationally? 15 FF Summit 4 October 2011

DH Systematic approach to falls and fracture care & prevention: four key objectives 13 June 2016 Objective 1: Improve outcomes and improve efficiency of care after hip fractures – “Blue Book” standards Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1 st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Older people Improve the care, experience and outcomes after hip fracture Hip fracture patients

FF Summit 4 October 2011 The best practice tariff aimed to… Reduce unexplained variation in quality and universalise best practice  Best practice tariff characteristics – entirely consistent with new NICE Guidance on Hip Fractures  Key clinical characteristics: Surgery within 36 hours Involvement of an (ortho)- geriatrician AND

FF Summit 4 October 2011 From April 2011 … Reduction in base tariff for national compliance rate Additional payment for best practice Base tariff for each HRG Payment per patient National average cost  NHFD captures compliance with clinical practice  PCTs to monitor and make additional payments quarterly  Base payment adjusted to recognise compliance £890 £89k per 100

FF Summit 4 October 2011 How have we used it ? LOCAL HOSPITAL Commissioners National Hip Fracture Database NHS number Individual patient data BPT compliance Cross check with HES Additional payments quarterly

FF Summit 4 October 2011 NHFD Report

FF Summit 4 October 2011 Despite the demonstrable progress with hip fracture Sustained focus on Falls and Fractures 90% of Acute / PCT/Community Health providers participated in Falls and Bone Health Audit 100% of hospitals in England registered with NHFD Still major unwarranted variations and care gaps in this group And with non-hip fractures (over 9,000 in “falling standards broken promises”) significant gaps in care for individual patients And provision of services to deliver this Same applies to people who fall and have not fractured A long way to go…..

The Key Questions: Who are the patients? Where can we find them? What have we achieved to date? What is the financial cost of: –possible interventions? –of doing nothing, the natural history? How do we implement nationally? 22 FF Summit 4 October 2011

Annual national perspective (£) hip fractures – top 10 DRGs 87% of cost of all fragility fractures 1.57 million NHS bed days £426 million acute care –£13 million per PCT acute care –£50 million on-going care £2.0 billion total care cost 23 FF Summit 4 October 2011 Hip fracture patients

Cost effectiveness of Fracture Liaison Services We predict approximately 0.75m new fractures in 5 years Diminishing risk over time; highest in first 2-3 years Generic oral bisphosphonates cost £15 per year Hip fracture NHS cost £12,000 each Based on Kaiser Permanente model 25% reduction in 5 years UK Glasgow evidence supports similar population Cost analysis based on NICE; PCT FLS staff (1 Consultant, nurse, clerk) DXA 20% hips, 80% other Treatment rate (75%), efficacy (RR 40%), compliance (80%) ANNUAL COST £235k, SAVINGS £290k Primary Care Osteoporosis nurse case finding: ANNUAL COST £195k, SAVING £ FF Summit 4 October 2011

The Key Questions: Who are the patients? Where can we find them? What have we achieved to date? What is the financial cost of: –possible interventions? –of doing nothing, the natural history? How do we implement nationally? Opportunities under the Coalition..? 25 FF Summit 4 October 2011

Opportunities from 2010 Fragility fractures in the elderly, especially in women 4.67 The introduction of the best practice tariff for hip fracture in 2010 has proved successful in transforming the care on admission of those who suffer fragility fractures. PCTs are also asked to take steps to reduce incidence. The best way to prevent this transformative injury is to recognise precursor or “herald” fractures and give patients a bone health assessment and treatment when they first show clear signs of being at risk. 26 FF Summit 4 October 2011

Opportunities go get this right in the reformed health/social care system Coalition focus on independence and wellbeing Ministers & parliamentarians interested Focus on outcomes –Several NHS outcome indicators relevant e.g. “Recovery from fragility fractures” Focus on information NICE Quality standards –Hip fracture, Falls in care settings, ? Fragility fracture Continuation of best practice tariff Continued funding for audit and NHFD Delivering the £15-20bn efficiency/QIPP challenge. You can’t ignore such a big spend with such big variation

Opportunities NHS Operating framework includes fragility fractures for first time Clinical Commissioning Groups New monies to reablement and to social care via NHS Public health Health and wellbeing boards Focus on prevention, early intervention and integration in response to Dilnot and Health Futures forum Pilot Quality and Outcomes Framework for bone fragility. If this goes into the contract, then GPs will be central in delivering fracture prevention

Coalition Government: Fragility Fractures Quality Outcomes Framework (GPs) From June 2010: INDICATOR DEVELOPMENT: Recommendations worked up by National Primary Care Research and Development Centre and York Health Economics Consortium From October 2010 INDICATOR PILOTING: Sample GP practices - assessed against the experiences of GPs and patients, and capacity and technical feasibility March-May 2011 PUBLIC CONSULTATION: The consultation process has had an influence on outcomes. June 2011 PRIMARY CARE QOF ADVISORY COMMITTEE MEETING: Decide whether to include the indicator. Autumn 2011 BMA - NHS CONTRACT NEGOTIATION 29 FF Summit 4 October 2011 GPs and primary care become central in delivering fracture prevention services

Despite all these policy levers Much of the change is in the hands of clinical and professional leaders and campaigning charities i.e. us in this room and our colleagues What we needs are affordable, effective, commissionable, deliverable models so over to you 30 FF Summit 4 October 2011

DH Systematic approach to falls and fracture care & prevention: four key objectives 13 June 2016 Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1 st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Older people

FF Summit 4 October 2011 Post-menopausal women 10.6 million 0.2 million Post-menopausal with NEW fracture each year 3.2 million Post-menopausal with SILENT osteoporosis 1.3 million Post-menopausal with PRIOR fracture Curr Med Res Opin 2005;21:4: Brankin E et al Fracture liaison services? Public health approaches Strategies to case-find new and prior fracture patients could identify 50% of all potential hip fracture cases from just 16% of the population 50% of hip fractures 16% of the population 50% of hip fractures 84% of population FF Summit 4 October 2011 The options? GP