Developing effective services for falls and fracture patients
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Developing effective services for falls and fracture patients. Presented by member of Older People & Dementia Branch, Department of Health. Why are we here today?. 68,000 fell and fractured hip in England in 2008/9 largest occupier of trauma bed days high mortality, morbidity, and cost

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Developing effective services for falls and fracture patients

Developing effective services for falls and fracture patients

Presented by member of

Older People & Dementia Branch,

Department of Health


Developing effective services for falls and fracture patients

Why are we here today?

  • 68,000 fell and fractured hip in England in 2008/9

    • largest occupier of trauma bed days

    • high mortality, morbidity, and cost

  • 200,000 + other fragility fractures: wrist, pelvis, shoulder

  • Total costs of fragility fracture care is < £2 billion yearly

  • Falls affect 30% of people over 65 and 50% over 80yrs

    • - major reason for hospital attendance and admission

    • - ambulance call out and admission to long term care

  • We have guidelines and standards, but…………

  • The NHS is NOT delivering adequate care

  • Care and outcomes show massive variation


Developing effective services for falls and fracture patients

Oxfordshire PCT Commissioning 2008/9


This morning s messages

Falls and Fractures – the growing epidemic of our ageing population

Why we need to get it right for older people

Why we need to get it right for the NHS and Social Care

Understanding fragility fractures as a long-term condition

How are we doing against standards and guidance

Doing it better is possible and cost-effective

The 4 key aims - why and how to achieve them

Objective 1: Improve outcomes and efficiency of hip fracture care

Objective 2: Respond to the first fracture, prevent the second

Objective 3: Early intervention to restore independence after falls

Objective 4: Prevent frailty, preserve bone health, reduce accidents

What will be done nationally to support this

What PCTs and councils and providers need to do locally

This morning’s messages


Developing effective services for falls and fracture patients

What about your other priorities ?

IssueStrokes/TIAsHeart attacksFragility Fractures

Incidence/year 110,000275,000310,000

Current trend Falling Falling Rising

NHS bed days*1.85 million1.15million1.57 million (hips)

Annual costs £2.8 Billion£ 1.7 Billion£ 1.7 Billion

Thanks to Jonathan Bayly for bar chart


Developing effective services for falls and fracture patients

> 15,000 will fall each year, >6000 twice or more

Most will not call for help

>70/week will attend A&E or the MIU

A similar number will call the ambulance service

350 hip fractures/year

~1000 other fragility fractures

Average PCT & council costs on falls are £50m per annum

Ageing demography means this will increase 50% by 2020

For a typical 300K PCT :


Understanding falls and fragility fractures as long term conditions

Understanding falls and fragility fractures as long-term conditions

Genetics and maternal factors

Lifestyle etc

Events and illnesses and chance

Well woman with first fracture, usually wrist

Age 50-70s

Postural instability and falls

Osteopenia

and osteoporosis

First fracture in frail person

Age 70-80s

Fall, injury, loss of confidence

 strength, balance, vision or judgment

50%

Second fracture, usually more serious,

often hip - average age 82 y

Reduced activity

The vicious cycle into dependency


Fragility fracture through the life span 1 osteoporosis falls fragility fractures

Fragility fracture through the life span1Osteoporosis + falls = fragility fractures

Additional morbidity from fragility fractures

Morbidity from other causes

“Hip fracture is all too often the final destination of a 30 year journey fuelled by decreasing bone strength and increasing falls risk”2

1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell

2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ


Efforts to tackle the problem with policy and guidance etc

Efforts to tackle the problem with policy and guidance etc

NSFNICE NICE

falls 20 prevention

RCP audit ------------------------------------I

NHFD ------------------------I

Toolkit

PbR best practice

increasing incidence of fragility fractures

20012011

?


Rcp national audits 2005 to 2011

RCP national audits 2005 to 2011

Clinical Audit 2006/7

  • Individual patient level data

  • Fragility fractures rather than falls because

    • simple to define

    • good evidence base for benefit (NICE)

  • Patients attending Emergency Departments with

    • Non-hip fractures (40) - radius, ulna, humerus, pelvis or vertebra

    • Hip fractures (20)

  • Total scores calculated from all domains of acute care and secondary prevention of falls and fractures


Total audit scores showed variation

Total audit scores showed variation ++

non-hip fractureship fractures

Best practice


No sha has got it sorted non hips

No SHA has got it sorted - non hips


Developing effective services for falls and fracture patients

Not even in centres of excellence

  • QJM 2009 e-pub 28 Oct Premaor M.O. Et al

  • http://news.bbc.co.uk/1/hi/health/8333834.stm


Dh systematic approach to falls and fracture care prevention four key objectives

DH Systematic approach to falls and fracture care & prevention: four key objectives

Stepwise implementation

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 1st 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

20 September 2014


Dh systematic approach to falls and fracture care prevention four key objectives1

DH Systematic approach to falls and fracture care & prevention: four key objectives

Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards

NSF, TA161, CG21, Blue Book & NHFD

Hip fracture patients

Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care

NSF, TA161, CG21 & Blue Book

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

NSF, TA160

& CG21

Individuals at high risk of 1st 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

NSF, LTC programmes

Social care

Older people

20 September 2014


Developing effective services for falls and fracture patients

Fracture Liaison Services

Case finding in A&E, MIUs and hospital fracture services

Apply NICE guidance care pathways

Link straight to falls services

Monitor and maintain medication adherence

Case find for those with previous fractures

Agree who needs specialist investigations and services from local Osteoporosis experts

Objective 2: Respond to the first fracture,

Prevent the second

How is this achieved?

What do the NHS and local councils need to do?

  • Commission a Fracture Liaison Service from the acute hospital

  • Appoint an Osteoporosis champion in primary care

  • Implement the DES for Osteoporosis

  • Broker the local service level agreements


Consider a pct population of 300 000

Consider a PCT population of 300,000

Post-menopausal women with new fracture each year

Fracture Liaison: Acute-care based

900

Post-menopausal women with priorfracture history

Fracture Liaison: Primary-care based

6,900

Post-menopausal women with osteoporosis

17,400

GP case-finding

stratified by risk

+ Direct Access DXA Services

Post-menopausal women

55,000

1. http://www.statistics.gov.uk/pdfdir/popest0808.pdf

2. (Adapted from) Curr Med Res Opin 2005;21:4:475-482 Brankin E et al


It improves care as shown by the fls in uk europe and n america

It improves care ------- as shown by the FLS in UK, Europe and N America

Kaiser Permanente Southern CaliforniaSurgeon Led Fracture Prevention Program

1. JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730


Kaiser permanente southern california surgeon led fracture prevention program

Kaiser Permanente Southern CaliforniaSurgeon Led Fracture Prevention Program

And it reduces incidence of hip fractures

1. JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730


Developing effective services for falls and fracture patients

Fallers who are unsteady need a falls risk assessment

medical conditions, gait & balance, vision, medication review

Fear of falling and restricting activity leads to further falls

re-enablement and rehabilitation

Increase opportunities for social participation

Successful programmes are multidisciplinary BUT coordinated

Exercise to improving strength and balance is the most powerful

Objective 3: Early intervention

To restore independence

How is this achieved?

What do the NHS and local councils need to do?

  • Review the local falls pathway with the community and acute providers

  • Agree who does what? Who attends specialist clinics?

  • Build falls prevention into mainstream services and intermediate care

  • Commission effective exercise programmes

  • Consider using the leisure services and voluntary sector


Developing effective services for falls and fracture patients

Promote healthy ageing and preserve bone health

Physical activity (as per the NHS physical activity strategy) 30minutes x 5 per week

Maintain optimal weight

Quit smoking

Alcohol only in moderation

Targeted home assessments and Telecare

Medications reviews

Safe environments for promoting social participation

Objective 4: Prevent frailty, preserve bone health, reduce accidents

How is this achieved?

What do the NHS and local councils need to do?

  • Use JSNA and develop local strategies

  • Involve the local population


What is in the dh falls fractures commissioning toolkit 2009

What is in the DH falls & fractures commissioning toolkit 2009

Overview guide and narrative slide set

Economic evaluation

Joint Strategic Needs Assessment advice note

Web based care pathways

for acute care of fragility fractures from presentation to secondary prevention

for primary care and community services based on long term conditions model

Business planning tool for Fracture Liaison

Good practice examples

Exercise for fall and fractures: advice note


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