1. Fracture Liaison Services in Scotland Dr SJ Gallacher Consultant Physician Southern General Hospital; Glasgow stephen.gallacher@ggc.scot.nhs.uk

2. The health and social care costs of hip fractures estimated at £2.3billion per year Hip fractures are associated with significant morbidity and mortality After a first fracture the risk of fracturing again is increased 2-5 fold Key Points

3. Hip fractures account for over 7000 unplanned admissions per year in Scotland Hip fractures account for over 416,000 bed days per year in Scotland Hip fractures cost around £206million annually in Scotland in direct hospital costs (not counting social care costs) FLS is most effective way to target interventions that reduce subsequent fracture risk by up to 30-50% in people with fragility fractures Key Points

4. Background to Fracture Liaison Services (FLS) Why is FLS an imperative Does FLS prevent fractures and is it cost-effective FLS and NHS Scotland

5. Background to FLS

6. Terminology & Definitions Fracture Liaison Service (FLS) Secondary Fracture Prevention Programme (SFP)

7. What is a Fracture Liaison Service (FLS)/ Secondary Fracture Prevention Programme (SFP)? Lih et al. Osteoporosis Int 2011;22:849-58 Cooper et al. Osteoporosis Int 2012; 23:97-107 A Fracture Liaison Service (FLS) systematically identifies, treats and refers to appropriate services all eligible patients over 50 within a local population who have suffered fragility fractures, with the aim of reducing their risk of subsequent fractures.

8. 5IQ Identify Investigate Inform Intervene Integrate Quality What are the constituent parts of a high quality FLS?

9. A FLS is a dedicated clinical service that systematically: Identifies all patients over the age of 50 years within a local population who have suffered a fragility fracture FLS Definition

10. A FLS is a dedicated clinical service that systematically: Investigates to assess bone health and falls risk FLS Definition

11. A FLS is a dedicated clinical service that systematically: Informs patients to enable them to understand future fracture risk and what can be done to reduce this FLS Definition

12. A FLS is a dedicated clinical service that systematically: Intervenes to improve bone health and referring to other specialist services including falls prevention FLS Definition

13. A FLS is a dedicated clinical service that systematically: Integrates patient care across primary and secondary care to ensure long-term management including making sure that patients are concordant with their treatment in order to obtain its benefits FLS Definition

14. A FLS is a dedicated clinical service that delivers the ‘5Is’ Underpinned by high quality clinical care that is inclusive, responsive and responsible to individual patients and the health economy. Data collection allowing local and national audits will be core to a FLS, promoting continual service improvement. FLS Definition

15. FLS is therefore an essential component of a comprehensive and integrated approach to preventing falls and fractures among people over the age of 50 years in a local health system. Referral to an FLS should be part of the pathway for all patients with a fragility fracture. Ensuring quality in the delivery and organisation of the FLS is paramount. FLS Definition

16. Why is FLS an imperative?

17. Males Females Scotland 1911 300250200150100500 100150200250300 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age group (years) Population in age/sex group (thousands) Scotland 2031 300250200150100500 100150200250300 0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 Age group (years) Population in age/sex group (thousands)

18. Why secondary fracture prevention matters Projected incidence of hip fractures by 2050 Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289 Estimated no of hip fractures: (1000s) Projected to reach 3.250 million in Asia by 2050 19902050 600 3250 19902050 668 400 19902050 742 378 19902050 100 629 Total number of hip fractures: 1990 = 1.66 million 2050 = 6.26 million

19. Hip fracture patients tell us they are coming! J Endocrinol Invest 1999;30:583-588 Kanis JA Hip fracture is all too often the final destination of a thirty year journey fuelled by decreasing bone strength and increasing falls risk Morbidity attributable to ageing alone

20. Signal fractures amongst patients presenting with hip fracture Percentage of patients with hip fracture reporting prior fragility fracture n=2124 n=632 n=701 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 alEdwards et alMcLellan et al Percentage Lyles KW et al. ASBMR 2006. Abstract SA405 Edwards BJ et al. Clin Orthop Rel Res 2007;461:226-230 McLellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland. 2004. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland

21. Does a Fracture Liaison Service Prevent Fractures?

22. Does FLS Prevent Fractures? Main focus of FLS evaluation is around process Some outcome (fracture) outcome data available from: USA (Kaiser Permanente) Glasgow (hip fracture incidence evalaution) New South Wales (Australia) – re-fracture incidence

23. FLS is Associated with Reduction in Re- Fracture Rates Re-fractures (4-years follow-up): 4.1% (FLS) vs. 19.7% (controls) Lih et al. Osteoporosis Int 2011;22:849-58

24. Kaiser Permanente FLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730PubMed ID 18984730

25. Kaiser Permanente FLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730PubMed ID 18984730

26. Kaiser Permanente FLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730PubMed ID 18984730

27. Kaiser Permanente FLS Southern California Style JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730PubMed ID 18984730

28. Kaiser Permanente California Dreamin’ ? JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730PubMed ID 18984730 "I'd like to dispel the misconception that nothing can be done to prevent or treat osteoporosis. It is possible to achieve at least a 25 percent reduction in the hip fracture rate in the United States if a more active role is taken by all orthopedic surgeons in osteoporosis disease management. We've seen it; we've done it.” Rick Dell MD

29. NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006-2010 AN EVALUATION 2007-2009

30. South Glasgow FLS (10 Year Review) 12312 Patients identified 1755 Declined (8.0%)1497 DNA (6.8%) 21887 Patients Identified18635 patients to be assessed 11755 - BMD Measured (63%) 2003 - Already on Treatment Or Previously Assessed (11%) 4877 - Treatment Started Without Scanning (26%) 6409 - Started on Treatment (35%) 5346 – No Treatment Required (28%) % of the 21887 patients presenting

31. Hip fractures in the 65+ age group (England) (1998-2008) Growth 1.8% per year (2005-8)

32. Hip fractures (65+) (1998-2008) Greater Glasgow/ Greater Glasgow & Clyde Between 1998 and 2008 the number of hip fractures (as assessed by ISD codes S.72-S.72.2) in Greater Glasgow decreased by 7.3% from 1377 to 1276 fractures. The equivalent figure for Greater Glasgow & Clyde was 3.6%, 2026 fractures in 1998 to 1953 fractures in 2008 (i.e hip fractures increased in Clyde).

33. FLS: Is it affordable? (can we afford not to do it?)

34. 1000 patients (Hypothetical Cohort) 686 patients received anti-osteoporosis treatment £83,598 (for assessments) £206,554 (for treatments) 18 fractures (including 11 hip fractures) prevented Overall cost saving - £21,000 Cost of widespread adoption of FLS across UK - £9.7m McLellan et al. OI 2011;22:2083-2098

35. Cost-Effectiveness (International Models) Data from Australia: Savings of $23,000 AUD in 6 months 1 Cost of $20,000-30,000 AUD per QALY gained 2 Data from Canada: Cost saving of $50,000 per annum (minimum 350 hip fractures seen) 3 1. Vaile et al. Internal Medical Journal 2007;37:717-720 2. Cooper et al. Osteoporosis Int 2012;23:97-107 3. Sander et al. JBJS 2008;90:1197-1205

36. FLS in Scotland in 2014

37. DXA Scanners/ Health Board

38. DXA Services – Available Hours of Operation BOARD Radiographers (WTE) Hours scanning BOARD Radiographers (WTE) Hours scanning A&A2.7640Highland2.0*30 Borders0.514 Lanarkshire 1.040 D&G1.05Lothian?? Fife1.040Orkney00 Forth Valley 0.410Shetland00 Grampian2.0?Tayside2.0? GGC5.020-40Western Isles 00

39. DXA Services – Available Hours of Operation BOARD Radiographers (WTE) Hours scanning BOARD Radiographers (WTE) Hours scanning A&A2.7640Highland2.0*30 Borders0.514 Lanarkshire 1.040 D&G1.05Lothian?? Fife1.040Orkney00 Forth Valley 0.410Shetland00 Grampian2.0?Tayside2.0? GGC5.020-40Western Isles 00

40. Health Boards – FLS Available BOARDFLSDADSBOARDFLSDADS A&AYes HighlandYes BordersYes Lanarkshire Yes D&GYes LothianYes FifeNo?OrkneyNo Forth Valley NoYesShetlandNo GrampianYes TaysideNoYes GGCYes Western Isles No

41. Health Boards – FLS Available BOARDFLSDADSBOARDFLSDADS A&AYes HighlandYes BordersYes Lanarkshire Yes D&GYes LothianYes FifeNo?OrkneyNo Forth Valley NoYesShetlandNo GrampianYes TaysideNoYes GGCYes Western Isles No

42. BOARDNurses (WTE)BOARDNurses (WTE) A&A0Highland0 Borders1.0Lanarkshire2 D&G1.0Lothian2.2 Fife1.0Orkney0 Forth Valley 0Shetland0 Grampian1.0Tayside2.0 GGC6.8Western Isles0 Osteoporosis/FLS Specialist Nurse Availability by Health Board

43. BOARDNurses (WTE)BOARDNurses (WTE) A&A0Highland0 Borders1.0Lanarkshire2 D&G1.0Lothian2.2 Fife1.0Orkney0 Forth Valley 0Shetland0 Grampian1.0Tayside2.0 GGC6.8Western Isles0 Osteoporosis/FLS Specialist Nurse Availability by Health Board

44. Fractures are a rapidly increasing problem across the world Fractures are associated with significant morbidity, mortality and cost Identifying patients presenting after fracture identifies a population at high risk of future fracture The Case for FLS is Robust

45. FLS encourages cost-effective resource utilisation and integration across primary and secondary care FLS programmes now required through many national/international guidelines Adoption of FLS across NHS Scotland should be an urgent priority The Case for FLS is Robust

46. Whilst we have been talking, 342 people have had a fragility fracture, 60 people have broken their hip And 30/60 let us know they were coming