paul mitchell - synthesis medical nz ltd - reviewing best practice guidelines for hip fracture...
DESCRIPTION
Paul Mitchell, Director, Synthesis Medical NZ Ltd delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting. Find out more at http://www.healthcareconferences.com.au/hipfracture2013TRANSCRIPT
Best practice guidelines for hip
fracture management:
International experience
Paul Mitchell
Deputy Chair, Osteoporosis New Zealand
Adjunct Senior Lecturer, University of Notre Dame Australia
Managing Director, Synthesis Medical Ltd - New Zealand and UK
2nd December 2013
Current trends in hip fracture management guidelines
2nd Annual Hip Fracture Management Conference, Melbourne, Australia
„We are not here to comment upon the world,
We are here to change it‟
Professor David Marsh
President - Fragility Fracture Network
1st FFN Global Congress
6th September 2012, Berlin, Germany
Australia and New Zealand
Population ageing
The „Osteoporotic Career‟
1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O
2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ
‘Hip fracture is all too often the final destination of a thirty year journey
fuelled by decreasing bone strength and increasing falls risk’2
Opportunities for intervention
Non-hip fragility fracture
Fracture Free for Life
Hip Fracture Free for Life
Secondary non-hip fragility fracture
Hip fracture
Unrecognised vertebral fragility fracture
Secondary non-hip fragility fracture
Fracture Free Recovery
Secondary non-hip fragility fracture
Second hip fracture
Fracture Free at Fifty
„Signal‟ or „Herald‟ Fractures
An opportunity to break the fragility fracture cycle
Department of Health in England. Herald Fractures: Clinical burden of disease and financial impact. December 2010
Good
outcome Very bad
outcome
Hip fracture care and prevention in the UK
Consensus on the need for a systematic approach
Patient
society
Policy
makers
Professional
organisations
Professional consensus guidance on hip fractures
2007 Blue Book and National Hip Fracture Database
• A systematic approach to hip fracture care and prevention1-3
• Hip fracture care
– Blue Book Chapter 1
– Effective ortho-geriatric services for hip fracture patients
– Universal National Hip Fracture Database participation
• Hip fracture prevention
– Blue Book Chapter 2
– An FLS for every hospital to identify all new fragility fracture patients
– Pro-active case-finding of all unassessed prior fragility fracture patients
1. BOA-BGS 2007 Blue Book
2. National Hip Fracture Database
3. NHFD Toolkit – Version 3
All available at http://www.nhfd.co.uk/
2007 Blue Book and National Hip Fracture Database
Clinical standards link Blue Book1 to NHFD2:
1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation
2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours
3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer
4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission
5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures
6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls
1. BOA-BGS 2007 Blue Book
2. National Hip Fracture Database
Both available at http://www.nhfd.co.uk/
Adoption of FLS across the UK
The NOS Manifestos for England/Scotland/Wales/N.I.
http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
Adoption of FLS across the UK
The NOS Manifestos for England/Scotland/Wales/N.I.
http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
Adoption of FLS across the UK
The NOS Manifestos for England/Scotland/Wales/N.I.
http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818
Hip fracture care and prevention in the UK
A consensus on a systematic approach
Patient
society
Policy
makers
Professional
organisations
1 1 + 4 =
Falls and fracture care and prevention
A road map for a systematic approach in the UK
Hip
fracture
patients
Objective 1: Improve outcomes and improve
efficiency of care after hip fractures – by
following the 6 “Blue Book” standards
Non-hip fragility
fracture patients
Objective 2: Respond to the first fracture,
prevent the second – through Fracture
Liaison Services in acute and primary care
Individuals at high risk of
1st fragility fracture or
other injurious falls
Objective 3: Early intervention to restore
independence – through falls care pathway
linking acute and urgent care services to
secondary falls prevention
Older people
Objective 4: Prevent frailty, preserve bone
health, reduce accidents – through
preserving physical activity, healthy lifestyles
and reducing environmental hazards
Stepwise
implementation
- based on size
of impact
DH Prevention Package for Older People
Acute hip fracture care
National Hip Fracture Database Report
Acute care & secondary prevention for >60,000 cases p.a.
NHFD National Report 2013 Available from www.nhfd.co.uk
2013 National Hip Fracture Database Report
Blue Book core standards
1. 50% of patients are admitted to an orthopaedic ward within four hours
2. 86% receive surgery within 48 hours
3. 3.5% are reported as having developed pressure ulcers
4. 47% are reported as assessed pre-operatively by an orthogeriatrician
5. 69% are discharged on bone protection medication
6. 94% received a falls assessment prior to discharge
NHFD National Report 2013 Available from www.nhfd.co.uk
UK National Hip Fracture Database 2013 National Report
Identifying and understanding variation
UK National Hip Fracture Database 2013 National Report
Best Practice Tariff: Linking quality to payment
1. Surgery within 36 hours
2. Shared care by surgeon and geriatrician
3. Care protocol agreed by geriatrician, surgeon and anaesthetist
4. Assessment by geriatrician within 72 hours
5. Geriatrician-led multi-disciplinary rehabilitation
6. Secondary prevention of falls
7. Bone health assessment (i.e. osteoporosis)
8. Pre- and post-operative abbreviated mental test score assessment (2012-)
NHFD National Report 2013 Available from www.nhfd.co.uk
UK National Hip Fracture Database 2013 National Report
Best Practice Tariff: Linking quality to payment
NHFD National Report 2013 Available from www.nhfd.co.uk
UK National Hip Fracture Database 2013 National Report
Best Practice Tariff: Linking quality to payment
NHFD National Report 2013 Available from www.nhfd.co.uk
National Institute for Health and Clinical Excellence
Clinical Guideline 124 and Quality Standard 16
http://www.nice.org.uk
National Institute for Health and Clinical Excellence
The purpose of Quality Standards
http://guidance.nice.org.uk/QS16
• Set of specific, concise statements and associated measures
• Aspirational but achievable makers of high-quality, cost effective
patient care
• Derived from best available evidence
• Address three dimensions of quality:
– clinical effectiveness
– patient safety
– patient experience
National Institute for Health and Clinical Excellence
Quality Standard 16: Quality Statements 1-6
http://guidance.nice.org.uk/QS16
• Statement 1. People with hip fracture are offered a formal Hip Fracture Programme from
admission.
• Statement 2. The Hip Fracture Programme team retains a comprehensive and continuing clinical
and service governance lead for all stages of the pathway of care, including the policies and
criteria for both intermediate care and early supported discharge.
• Statement 3. People with hip fracture have their cognitive status assessed, measured and
recorded from admission.
• Statement 4. People with hip fracture receive prompt and effective pain management, in a
manner that takes into account the hierarchy of pain management drugs, throughout their hospital
stay.
• Statement 5. People with hip fracture have surgery on the day of, or the day after, admission.
• Statement 6. People with hip fracture have their surgery scheduled on a planned trauma list, with
consultant or senior staff supervision.
National Institute for Health and Clinical Excellence
Quality Standard 16: Quality Statements 7-12
http://guidance.nice.org.uk/QS16
• Statement 7. People with displaced intracapsular fracture receive cemented arthroplasty, with the
offer of total hip replacement if clinically eligible.
• Statement 8. People with trochanteric fractures above and including the lesser trochanter (AO
classification types A1 and A2) receive extramedullary implants such as a sliding hip screw in
preference to an intramedullary nail.
• Statement 9. People with hip fracture are offered a physiotherapist assessment the day after
surgery and mobilisation at least once a day unless contraindicated.
• Statement 10. People with hip fracture are offered early supported discharge (if they are eligible),
led by the Hip Fracture Programme team.
• Statement 11. People with hip fracture are offered a multifactorial risk assessment to identify and
address future falls risk, and are offered individualised intervention if appropriate.
• Statement 12. People with hip fracture are offered a bone health assessment to identify future
fracture risk and offered pharmacological intervention as needed before discharge from hospital.
Systematic hip fracture prevention
Fracture Liaison Service
Service structure
(Adapted from) BOA-BGS 2007 Blue Book. http://www.nhfd.co.uk/
* Older patients, where appropriate, are identified and referred for falls assessment
New Fracture Presentation
Emergency Department
Orthopaedic Trauma
Emergency Department
& X-Ray
Orthopaedics Inpatient ward
1. FLS identifies fracture patients 2. FLS assessment
Outpatient Fracture clinic
Osteoporosis treatment
Falls risk assessment*
Exercise programme
Education programme
Comprehensive communication of management plan to GP supported by fully integrated FLS database system
• Offer assessment to all patients over 50 years presenting with a fragility fracture
• Glasgow FLS is delivered by a Nurse Specialist supported by a Lead Clinician in Osteoporosis
• Nurse Specialist identifies patients with new fragility fractures:
– admitted to the orthopaedic inpatient ward, and
– managed as outpatients through the fracture clinic
• The Nurse Specialist arranges attendance of appropriate patients at the “one stop” FLS clinic
where BMD is measured by DXA to assess future fracture risk
• Treatment for secondary fracture prevention initiated by the FLS when merited on basis of future
fracture risk
• Older patients, where appropriate, are identified and referred onto the falls service/falls pathway
• Long-term management plans agreed by protocol with local general practice
Fracture Liaison Service
The Glasgow Model: aims and service structure
1. Best Prac Res Clin Rheum 2005;19:6:1081-1094 Gallacher SJ
2. Osteoporosis International 2003;14(12):1028-1034 McLellan AR et al
3. Calcif Tissue Int 2007;81:85-91 Langridge CR et al
Centre
operating
FLS
NHS Quality Improvement Scotland national audit
FLS vs other models: Outcome after hip fracture by centre
NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary
Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
NHS Quality Improvement Scotland national audit
FLS vs other models: Outcome after wrist fracture by centre
NHS Quality Improvement Scotland. Effectiveness of Strategies for the Secondary
Prevention of Osteoporotic Fractures in Scotland. 2004. McLellan AR et al.
Centre
operating
FLS
Fracture Liaison Services
Effectiveness is dependent in intensity of the model
1. Osteoporos Int. 2013 Feb;24(2):393-406 Ganda K et al
2. Osteoporosis Canada. Make the FIRST break the LAST with Fracture Liaison Services
Model
Description
Proportion receiving
BMD testing
Proportion receiving
osteoporosis
treatment
Status
Quo
Manitoba statistics for
major osteoporotic
fractures (2007/2008) 13% 8%
Type D (Zero
i model)
Only provides osteoporosis
education to the fracture
patient. Primary care
provider (PCP) is not
alerted or educated.
No study on
BMD testing 8%
Type C (1 i model)
1. Identification
The PCP is alerted that a
fracture has occurred and
further assessment is
needed. Leaves the
investigation and initiation
of treatment to the PCP.
43% 23%
Type B (2 i model)
1. Identification
2. Investigation
Leaves the initiation of
treatment for fragility
fracture patients to the
PCP.
60% 41%
Type A
(3 i
model)
1. Identification
2. Investigation
3. Initiation of
osteoporosis treatment
where appropriate.
79% 46%
Fracture Liaison Services
Significantly reduce re-fracture rates
• Australia: Concord FLS, Sydney
– Repeat fracture rates over a 4 year period were reduced by 80%
– 4.1% in the intervention group compared to 19.7% in the control group
• Canada: St. Michael‟s Hospital, Toronto
– Modelling of the FLS reported a 9% reduction of secondary hip fracture rates
within the first year of operation
• United Kingdom: Glasgow FLS, Scotland
– Between 1998 and 2008, hip fracture rates in Glasgow decreased by 7.3%
compared to a 17% increase during the same time period in England, where only
37% of localities operated an FLS by late 2010
• United States of America: Kaiser Permanente
– In 2008, a 37% reduction in the expected hip fracture rate was reported for the
population served by the Kaiser Permanente Southern California system
– This corresponds to the prevention of 935 hip fractures in the year 2006 (2,510
hip fractures were predicted by actuarial analysis, and 1,575 fractures were
actually observed)
References available on request. Email [email protected]
Incorporation of FLS into national policy
Department of Health Prevention Package
Department of Health. Prevention Package for Older People resources. Link.
International Osteoporosis Foundation
World Osteoporosis Day Report 2012
http://www.iofbonehealth.org/capture-fracture-report-2012
IOF Capture the Fracture Campaign
Best Practice Framework
Osteoporos Int. 2013 Aug;24(8):2135-52. PubMed ID 23589162
IOF Capture the Fracture Campaign
Globally endorsed standards of care
Osteoporos Int. 2013 Aug;24(8):2135-52. Åkesson K
Systematic approaches to hip fracture
care and prevention for
Australia and New Zealand
BoneCare 2020: Osteoporosis New Zealand
A systematic approach for New Zealand
http://www.bones.org.nz/
Hip
fracture
patients
Objective 1: Improve outcomes and quality
of care after hip fractures by delivering ANZ
professional standards of care monitored by
a new NZ National Hip Fracture Registry
Non-hip fragility
fracture patients
Objective 2: Respond to the first fracture to
prevent the second through universal access
to Fracture Liaison Services in every
District Health Board in New Zealand
Individuals at high risk of
1st fragility fracture or
other injurious falls
Objective 3: GPs to stratify fracture risk
within their practice population using fracture
risk assessment tools supported by local
access to axial bone densitometry
Older people
Objective 4: Consistent delivery of public
health messages on preserving physical
activity, healthy lifestyles and reducing
environmental hazards
Maximise cost-
effectiveness by
stepwise delivery
BoneCare 2020: Osteoporosis New Zealand
A systematic approach for New Zealand
http://www.bones.org.nz/
Australian and New Zealand Hip Fracture Registry
A systematic approach to hip fracture care
http://www.anzhfr.org/
ANZ Guideline for Hip Fracture Care
Public Consultation until 13 December 2013
http://www.anzhfr.org/
Australian and New Zealand Hip Fracture Registry
NZ Clinicians want it!
N Z Med J. 2013 Oct 18;126(1384):77-83. De Silva CU et al
„We advocate the
development of a
multicentre audit in NZ
hospitals‟
BoneCare 2020: Osteoporosis New Zealand
Fracture Liaison Services in New Zealand
http://www.national.org.nz/Article.aspx?ArticleId=41324
Another way we can help older people remain independent at home for longer
is by reducing the impact of osteoporosis and fragility fractures. To achieve
this goal, we have made it a priority for district health boards to implement
Fracture Liaison Services as part of their annual planning processes.
Fracture Liaison Services take a proactive approach to treating and
preventing fragility fractures in our older population. Led by nurse
practitioners, the services assess and treat fragility fractures and then,
importantly, carry out interventions to reduce the person‟s risk of future
fractures.
I look forward to seeing how Waikato DHB uses the new facilities and services
here at the Older Persons and Rehabilitation service to successfully
implement a Fracture Liaison Service and help reduce the number and
impact of fragility fractures amongst older people in Waikato.
What happens next?
Peak oil
Peak hip fracture
Peak hip fracture
Objective:
Global peak hip fracture to be attained before the 28th FFN Global Congress
Additional slides
Fracture Liaison Services
A cost-saving intervention
• In May 2011, a formal cost-effectiveness
analysis of the Glasgow FLS was published
• This study concluded that 18 fractures were
prevented, including 11 hip fractures, and
£21,000 was saved per 1,000 patients managed
by the Glasgow FLS versus UK „usual care‟
Osteoporos Int. 2011; 22(7):2083-98 Wolowacz SE et al