The National Audit of Falls and Bone Health in Older People

1. The National Audit ofFalls and Bone Healthin Older People [insert name] Strategic health Authority [date], [venue] [Speaker’s name and designation] On behalf of the Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London Funded by Healthcare Quality Improvement Partnership

2. Commissioning: A Systematic approach to falls & bone health Four key objectives Stepwise implementation Objective 1: Improve outcomes and efficiency of care after hip fractures – by following the 6 “Blue Book” standards Hip fracture patients Objective 2: Respond to the 1st fracture, prevent the 2nd – 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

3. “We can only be sure to improve what we can actually measure” Lord Darzi, High Quality Care for All, June 2008 How do we know how we are doing?

4. Clinical audit evaluation Evidence based standards National Hip Fracture Database BOA/BGS Blue Book High quality hip fracture care Hip fracture patients Blue Book, NSF, NICE Fracture Liaison Service Falls Clinic National Audit of Falls and Bone Health Non-hip fragility fracture patients NSF, NICE Exercise programmes Falls clinics Bisphosphonates Individuals at high risk of 1st fragility fracture or other injurious falls NSF Health promotion Older people Where audit fits in this model

5. Hip fracture management • Pre-operative management was generally good for pain relief, fluids, routine observations • only 46% pressure risk assessments, 54% mattresses • Surgery within 24h - 35%, 48h - 69% • Organisational delay was responsible for 29% • Low rates of routine medical review • Lack of acute orthogeriatric services • Only 39% had multidisciplinary team review within 1st week Hip fracture

6. Secondary prevention - Bone health Hip fracture v Non-hip fragility fracture Hip fracture 50% osteoporotic Non-hip

7. Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre.

8. Secondary prevention - Falls risk assessment Hip fracture v Non-hip fragility fracture Individuals at high risk

9. Aspects of integrated falls care in patients 75 and over (n = 270,028) n = 1,076 / 251,049 n = 1,335 n = 15 n = 10 n = 319 Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre.

10. Secondary prevention • Most patients receive inadequate secondary prevention so are at unnecessarily greater risk of further harm • Non-hip fragility fracture patients receive less attention than hip fracture patients

11. The Second National Audit of the Organisation of Services for Falls and Bone Health in Older People (2008)

12. Acute trusts 100% (158/158) Primary Care Organisations 88% (150/171) Health & Social Care Trusts 88% (7/8) Mental Healthcare Trusts 76% (44/58) Care homes 73 homes (sample drawn from 2 national providers) Participation

13. Key Results

14. Commissioning for falls and bone health TAG 87 = National Institute for Health and Clinical Excellence, Technology Appraisal Guidance, Number 87

15. Acute trusts - case finding

16. Secondary prevention of falls

17. Key Messages

18. Services fail to achieve evidence based standards Services are variable in quality and many lack key evidence based components Lack of integration between falls services and fracture services Significant gaps along patient journey for falls and fractures Inadequate levels of secondary prevention for both falls and bone health Secondary prevention for non-hip fragility fracture is less good than for hip fracture

19. Opportunities to prevent recurrent falls and fractures are being missed Risk assessments in A&E departments and Fracture services are inadequate Services with Falls Coordinators and Fracture Liaison Nurses have better case finding systems in place to identify high risk fallers Many trusts do not provide these important posts Many of the exercise programmes being provided are not evidence based Services for bone health appear less well developed than services of falls prevention

20. Commissioning for falls and bone health is weak Only 64% (110/171) of commissioning bodies have a written strategy on falls prevention Only 23% (38/171) have a strategy for bone health Important public health information on fracture rates is inadequate or not collated Only 39% (67/171) of commissioning trusts report having a mechanism to assess local compliance with national guidelines on osteoporosis treatment

21. Thank You Non-hip fragility fracture patients Individuals at high risk of 1st fragility fracture or other injurious falls Older people

22. Falls risk assessment