Fracture Liaison Service - The British Society for Rheumatology
Fracture Liaison Service - The British Society for Rheumatology
Fracture Liaison Service - The British Society for Rheumatology
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Secondary <strong>Fracture</strong> Prevention:<br />
<strong>Fracture</strong> <strong>Liaison</strong> <strong>Service</strong><br />
Margaret French<br />
Osteoporosis Nurse Specialist<br />
Western Infirmary<br />
Glasgow
Hip<br />
fracture<br />
patients<br />
Non-hip fragility<br />
fracture patients<br />
Individuals at high risk of<br />
1 st fragility fracture or<br />
other injurious falls<br />
BUT!<br />
only ~30% acute trusts<br />
have a FLS<br />
RCP-CEEU national organisational audit 2009<br />
Older people<br />
DoH Prevention Package <strong>for</strong> Older People<br />
endorses FLS
Background to <strong>Fracture</strong> <strong>Liaison</strong> <strong>Service</strong><br />
• <strong>Fracture</strong> leads to fracture<br />
• Morbidity & mortality – osteoporotic fractures<br />
• Treating osteoporosis reduces fracture risk<br />
• Most orthopaedic units ignore osteoporosis<br />
• Audit showed fracture secondary prevention NOT<br />
happening
<strong>Fracture</strong> Patient Pathway (prior to 1999)<br />
PATIENT WITH<br />
NEW FRACTURE<br />
IP TRAUMA WARD<br />
OP FRACTURE CLINIC<br />
GP<br />
PRIMARY CARE<br />
DIRECT ACCESS DXA<br />
SERVICE<br />
NO ASSESSMENT<br />
BONE METABOLISM<br />
CLINIC
SECONDARY PREVENTION AUDIT<br />
(PRIOR TO 1999)<br />
• Hip fractures<br />
– 12% underwent DXA<br />
– 44% were given treatment<br />
• Wrist fractures<br />
– 3% underwent DXA<br />
– 32% were given treatment
1999: West Glasgow FLS<br />
Patient population 250K:<br />
1600 new fractures/yr<br />
2002: East Glasgow FLS<br />
Patient population 350K:<br />
2500 new fractures/yr
NEW<br />
CLINICAL<br />
FRACTURE<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
(RADIOLOGY REPORT)<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA
What happens at a<br />
FLS Nurse Led Clinic?
What happens at a<br />
FLS Nurse Led Clinic?<br />
• Patient brings completed self history questionnaire<br />
• Patient – height & weight measurements<br />
• Patient undergoes DXA scan - radiographer<br />
• Bloods (as per protocols)<br />
• Patient meets with osteoporosis nurse specialist<br />
– Medical case records<br />
– Questionnaire<br />
– DXA scan result
What happens at a<br />
FLS Nurse Led Clinic?<br />
• Discuss risk factors <strong>for</strong> falls and fracture<br />
• Discuss results of DXA scan<br />
• Discuss treatment if required as per protocols & FRAX<br />
• Provide lifestyle advice<br />
• Provide literature<br />
– Drug treatments<br />
– Lifestyle<br />
– Fall prevention<br />
– NOS<br />
• Refer <strong>for</strong> physiotherapy (if required)<br />
• Refer to Community Falls Prevention Programme (if necessary)<br />
• Refer onto Bone Metabolism Clinic (if necessary) as per protocols<br />
• Input data into GISMO- letter to GP – result & treatment<br />
recommendations
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
(RADIOLOGY REPORT)<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
(RADIOLOGY REPORT)<br />
PREVIOUS<br />
FRACTURE<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
‘CASE-FINDING’ BY<br />
GP<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
(RADIOLOGY REPORT)<br />
PREVIOUS<br />
FRACTURE<br />
NON-FRACTURE<br />
HIGH RISK<br />
GROUPS<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
‘CASE-FINDING’ BY<br />
GP<br />
‘CASE-FINDING’ BY<br />
GP & SEC CARE<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME
FLS Outcomes<br />
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
30622 fractures<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
26365 patients<br />
19529 F<br />
74%<br />
ALIVE<br />
81%<br />
6836 M<br />
26%<br />
DEAD<br />
19%<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR<br />
FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME
%<br />
30622 fractures in 26365 patients in first 10yr of NG FLS
WHO Criteria<br />
• Normal BMD<br />
• Osteopenia<br />
• Osteoporosis<br />
• Severe<br />
Osteoporosis<br />
T score > -1<br />
T score –1 to –2.5<br />
T score < -2.5<br />
T score < -2.5 plus a<br />
fracture
How prevalent is osteoporosis in<br />
patients with fractures?
%<br />
Female
%<br />
Male
Protocols<br />
and treatments
FLS treatment protocols<br />
Lowest T-score (at femoral neck / total<br />
hip / total spine)<br />
Site<br />
of fracture<br />
Age 50-59 Age 60+<br />
Non-vertebral ≤-3.0 ≤-2.5<br />
Vertebral ≤ –2.5 ≤-2.5<br />
First choice treatment: alendronic acid 70mg/w & 1g calcium carbonate + 800IU vit D/d.<br />
Second line: options include IV zoledronic acid, SC denosumab
Treatments<br />
• Bisphosphonates<br />
– Alendronic Acid (Fosamax)<br />
– Risedronate (Actonel)<br />
– IV Zoledronic Acid (Aclasta)<br />
• Denosumab (Prolia)<br />
• Strontium Ranelate (Protelos)<br />
• Calcium & vitamin D
30622 NEW FRACTURES<br />
IN 26365 PATIENTS<br />
INPATIENTS<br />
48%<br />
OUTPATIENTS<br />
52%<br />
~100% IDENTIFIED BY FLS<br />
& OFFERED ASSESSMENT<br />
79% ASSESSED BY FLS<br />
52% OF ALL PATIENTS - DXA<br />
21% NOT ASSESSED<br />
TOO ILL / REFUSED / DNA<br />
34%<br />
BISPHOSPHONATE<br />
+ Ca/VIT D<br />
2%<br />
OTHER e.g.<br />
STRONTIUM / HRT<br />
+ Ca/VIT D<br />
20%<br />
Ca/VIT D<br />
44%<br />
NO TREATMENT
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
(RADIOLOGY REPORT)<br />
PREVIOUS<br />
FRACTURE<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
‘CASE-FINDING’ BY<br />
GP<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME
Hospital-based Exercise Classes<br />
• Assessed first by a physiotherapist<br />
• 12 week introductory programme<br />
run by a specialist physiotherapist<br />
• Venues<br />
– Gartnavel General Hospital<br />
– Glasgow Royal Infirmary<br />
– Southern General Hospital<br />
– Stobhill Hospital<br />
• Includes:<br />
– In<strong>for</strong>mation sessions<br />
– Visit<br />
• Osteoporosis Nurse Specialists<br />
• Glasgow NOS support group
Vitality Classes<br />
Glasgow leisure centre<br />
exercise classes
Stage 1<br />
General education (1:1)<br />
Linking their fracture with need <strong>for</strong><br />
assessment <strong>for</strong> osteoporosis<br />
Stage 2<br />
Specific education (1:1)<br />
Personalising education, with<br />
interpretation of DXA, fracture risk<br />
& need <strong>for</strong> treatment<br />
Stage 3<br />
Empowerment (Group)<br />
2.5hr interactive education<br />
programme 6-12mo after starting Rx
14.00 Welcome<br />
14.05 Treatment options<br />
14.30 Pharmacy review<br />
14.45 Fall prevention<br />
15.00 Osteoporosis exercise classes<br />
15.15 Pain management<br />
15.30 National Osteoporosis <strong>Society</strong><br />
15.45 Q & As
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
(RADIOLOGY REPORT)<br />
PREVIOUS<br />
FRACTURE<br />
NON-FRACTURE<br />
HIGH RISK<br />
GROUPS<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
‘CASE-FINDING’ BY<br />
GP<br />
‘CASE-FINDING’ BY<br />
GP & SEC CARE<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME<br />
PRESCRIPTION ISSUED BY GP
Does an FLS prevent all<br />
further fractures?
No!<br />
Despite early intervention by FLS<br />
at 6-8 weeks - refractures do occur.
13.3% of fractures assessed by FLS were secondary fractures<br />
during up to 10yr of follow-up<br />
86.7%<br />
0.5%<br />
1.9%<br />
10.9%<br />
1 fracture 2 fractures 3 fractures 4+ fractures
10.9% of fractures managed by the FLS<br />
were 2nd fractures: when did these occur?<br />
%<br />
~21% secondary fractures had occurred by 6months<br />
Timing to secondary fracture after index fracture (months)
Hip fractures (65+)<br />
• Hip fractures decreased by 3.6% from 2026 in 1998<br />
to 1953 in 2008 in GGC<br />
– Skelton DA, Neil F. Evaluation of GGC Osteoporosis & Falls<br />
Strategy 2009<br />
• Hip fractures increased by 1.8% per year in England<br />
– Bayly J. HES data England 1998-2008
FLS<br />
Conclusions<br />
NEW<br />
CLINICAL<br />
FRACTURE<br />
NEW<br />
VERTEBRAL<br />
FRACTURE<br />
PREVIOUS<br />
FRACTURE<br />
NON #<br />
HIGH RISK<br />
GROUPS<br />
Sustainable over 10yr<br />
ORTHO<br />
IP<br />
OP Fx<br />
CLINIC<br />
‘CASE-FINDING’ BY FLS<br />
FLS<br />
RISK ASSESSMENT<br />
ONE-STOP CLINIC<br />
WITH DXA<br />
‘CASE-FINDING’ BY<br />
GP<br />
‘CASE-FINDING’ BY<br />
GP & SEC CARE<br />
Achieves unrivalled rates<br />
of post-fracture<br />
assessment<br />
FALLS RISK<br />
ASSESSMENT<br />
EXERCISE<br />
CLASSES<br />
Rx FOR<br />
FRACTURE<br />
2 Y PREVENTION<br />
EDUCATION<br />
PROGRAMME<br />
Secondary fractures<br />
occurred rapidly
Osteoporosis Guidelines
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