Fracture Liaison Service

Melanie Fox

University Hospital Waterford

Epidemiology - why we need to act2010 data (Arch Osteoporosis (2013)

8:137 )18,000 new fragility fractures

3,200 hip fractures, 2,700 vertebral fractures, 3,000 forearm fractures and 9,200 other fractures (i.e pelvis, rib,

humerus, tibia, fibula, clavicle, scapula…Economic burden € 223 million

Incident fractures 56 % of this cost, long-term fracture care 28 % pharmacological prevention 16 %.

Epidemiology – why we need to actDemographic projections for 2025

expected increase of over 9 000, to 28,000 incident fractures Hip, +1800clinical vertebral (spine) +1400 forearm +1400other fractures +4,900

The burden of fractures will increase by 44 % to

€ 320 million.

The evidence for FLSA proven solution to close the secondary

prevention care gap [4]prevent an estimated 18 fractures per 1,000

patients (over 8 yrs) [13]40% overall reduction in hip fractures [14]80% reduction in the risk of hip re-fracture [15]only 2% of patients diagnosed and treated for

osteoporosis through the FLS suffered a subsequent clinical fracture,

88% remained adherent to anti-osteoporosis therapy after 12 months [16]

Who do we assess? A Fracture Liaison Service (FLS) systematically

identifies, treats and refers to appropriate services all low trauma fracture patients aged over 50 years, with the aim of reducing their

risk of subsequent fractures.

How does an FLS work?Identification. Assessment.Information. Intervention. Integration

Identification.

H.I.P.E (Spinal, radius, humerus, ankle, femur).

Radiology (vert). out patient (humerus, radius).

Assessment.Mechanism of fracture.

Frequency of falls.

Risk factors inc, Age/ smoking / alcohol consumption/ FaHx/ paternal hip fracture/Steroid use/ BMI/ Coeliac or Crohn’s/ dairy intake/ exercise/ RA/ age of menopause.

Bloods. DXA

Information

Educating patients about their fracture risk.

BMD results.

FRAX . 10 year prediction of fracture risk.

Benefits and risks of treatment.

InterventionDrug treatments.

Non-pharmacological options for sustaining a reduction in secondary fracture risk and falls,

ie. Lifestyle advice re. smoking / alcohol/ exercise/ dairy intake.

Falls assessment.

Sharing patient-specific management plans with patients GP and Orthopaedic services.

Integration

Who is needed to establish FLS?

Falls Assess

Bone Dr

RadiologyOrthoG

er

Admin

CNSp

Vital Roles – the co-ordinatorEvery successful FLS needs a coordinator

to initiate and organise day-to-day running of the service

Finding and referring patients with fragility fracture

Ensuring osteoporosis assessment (DXA scan) and follow-up

Communicating the care plan

… use your local solution

One stop shop works!Patients assessment and advised 2013-14

contacted 9 months after assessment

treatment started continued

Vit D / calcium 85% of total 79% of starters

Anti-resorptive 70% of total 85% of starters

Reported understanding

85%

Systems we’re getting right

Hip Fracture Care Pathway

HIPE data as source of referral

Radiology reporting

Shared decision-making and compliance

National FLS group.Discussion with Health Care Pricing Office

(HCPO) re. HIPE Portal and Audit.

Discussion with Riomed / Cellma re data export to HIPE

Data audit.

Capture the fracture

These are the 16 trauma Orthopaedic centres

Not all have a FLS or OG input

Site FLS OG DXA CAPTURE

TALLAGHT Y N Y YSt Marys, Park N N Y NMMUH In progress Y Y NSJH Y Y Y NOLL N N N NGalway Y Y Y YCUH & SIVUH N Y Y NUHW Y Y Y YSt Vincents Y Y Y NBlanchardstown Connolly

N N N N

Midlands Tullamore

N Y N N

Letterkenny Y In discussion Y NMayo GeneralSligo General YUHLBeaumont

The “Capture the Fracture” initiativeInternational Osteoporosis Foundation

Mapping FLS worldwide

Recognition of achievement

Stimulus to improve

13-point assessment “Best Practice Framework”

SummaryFLS does what it says on the tin – get the

right people working together to get the right people on treatment

Capture earlyComplete assessmentClear communication

References 2. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of

osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am. 2000;82A:1063–70.

4. Akesson K, Marsh D, Mitchell PJ, et al. Capture the Fracture: a Best Practice Framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013;24:2135–52

13. McLellan AR, Wolowacz SE, Zimovetz EA, et al. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: A cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int. 2011;22:2083–98.

14. D ell R. Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int. 2011;22 Suppl 3:457–60.

15. L ih A, Nandapalan H, Kim M, et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: A 4-year prospective controlled study. Osteoporos Int. 2011;22(3):849–58.

16. Eekman DA, van Helden SH, Huisman AM, et al. Optimizing fracture prevention: the fracture liaison service, an observational study. Osteoporos Int. 2014;25:701–9