Fracture Liaison Services in
Scotland
Dr SJ Gallacher
Consultant Physician
Southern General Hospital; Glasgow
stephen.gallacher@ggc.scot.nhs.uk
Key Points
• The health and social care costs of hip fractures
estimated at £2.3billion per year
• Hip fractures are associated with significant
morbidity and mortality
• After a first fracture the risk of fracturing again is
increased 2-5 fold
Key Points
• Hip fractures account for over 7000 unplanned
admissions per year in Scotland
• Hip fractures account for over 416,000 bed days per
year in Scotland
• Hip fractures cost around £206million annually in
Scotland in direct hospital costs (not counting social
care costs)
• FLS is most effective way to target interventions that
reduce subsequent fracture risk by up to 30-50% in
people with fragility fractures
• Background to Fracture Liaison Services
(FLS)
• Why is FLS an imperative
• Does FLS prevent fractures and is it
cost-effective
• FLS and NHS Scotland
Background to FLS
Terminology & Definitions
• Fracture Liaison Service (FLS)
• Secondary Fracture Prevention Programme
(SFP)
What is a Fracture Liaison Service (FLS)/
Secondary Fracture Prevention Programme (SFP)?
A Fracture Liaison Service (FLS) systematically
identifies, treats and refers to appropriate
services all eligible patients over 50 within a
local population who have suffered fragility
fractures, with the aim of reducing their risk of
subsequent fractures.
Lih et al. Osteoporosis Int 2011;22:849-58
Cooper et al. Osteoporosis Int 2012; 23:97-107
What are the constituent parts of a high
quality FLS?
• 5IQ
• Identify
• Investigate
• Inform
• Intervene
• Integrate
• Quality
FLS Definition
A FLS is a dedicated clinical service that
systematically:
Identifies all patients over the age of 50
years within a local population who have
suffered a fragility fracture
FLS Definition
A FLS is a dedicated clinical service that
systematically:
Investigates to assess bone health and
falls risk
FLS Definition
A FLS is a dedicated clinical service that
systematically:
Informs patients to enable them to
understand future fracture risk and what
can be done to reduce this
FLS Definition
A FLS is a dedicated clinical service that
systematically:
Intervenes to improve bone health and
referring to other specialist services
including falls prevention
FLS Definition
A FLS is a dedicated clinical service that
systematically:
Integrates patient care across primary and
secondary care to ensure long-term
management including making sure that
patients are concordant with their
treatment in order to obtain its benefits
FLS Definition
A FLS is a dedicated clinical service that
delivers the ‘5Is’
Underpinned by high quality clinical care
that is inclusive, responsive and
responsible to individual patients and the
health economy.
Data collection allowing local and national
audits will be core to a FLS, promoting
continual service improvement.
FLS Definition
FLS is therefore an essential component of
a comprehensive and integrated approach
to preventing falls and fractures among
people over the age of 50 years in a local
health system.
Referral to an FLS should be part of the
pathway for all patients with a fragility
fracture.
Ensuring quality in the delivery and
organisation of the FLS is paramount.
Why is FLS an imperative?
Age group (years)
Scotland 1911
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
0-4
300 250 200 150 100 50
0
50 100 150 200 250 300
Age group (years)
Population in age/sex group (thousands)
Scotland 2031
80-84
70-74
60-64
50-54
40-44
30-34
20-24
10-14
0-4
300 250 200 150 100 50
0
50 100 150 200 250 300
Population in age/sex group (thousands)
Males
Females
668
400
742
629
600
378
1990 2050
1990 2050
100
Total number of
hip fractures:
1990 = 1.66 million
2050 = 6.26 million
3250
Why secondary fracture prevention matters
Projected incidence of hip fractures by 2050
1990 2050
1990 2050
Estimated no of hip fractures: (1000s)
Adapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289
Projected to
reach 3.250
million in
Asia by 2050
Hip fracture patients tell us they are coming!
Morbidity
attributable to
ageing alone
Hip fracture is all too often the final destination of a thirty year
journey fuelled by decreasing bone strength and increasing falls risk
J Endocrinol Invest 1999;30:583-588 Kanis JA
Signal fractures amongst patients
presenting with hip fracture
100.0
90.0
80.0
Percentage
70.0
Percentage of patients with hip fracture reporting prior
fragility fracture
n=2124
n=632
n=701
60.0
50.0
45.3
44.6
Lyles et al
Edwards et al
45.4
40.0
30.0
20.0
10.0
0.0
McLellan et al
Lyles KW et al. ASBMR 2006. Abstract SA405
Edwards BJ et al. Clin Orthop Rel Res 2007;461:226-230
McLellan AR. et al. (CEPS 99/03). NHS Quality Improvement Scotland. 2004.
Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland
Does a Fracture Liaison Service
Prevent Fractures?
Does FLS Prevent Fractures?
Main focus of FLS evaluation is around process
Some outcome (fracture) outcome data available
from:
• USA (Kaiser Permanente)
• Glasgow (hip fracture incidence evalaution)
• New South Wales (Australia) – re-fracture incidence
FLS is Associated with Reduction in ReFracture Rates
Re-fractures (4-years follow-up):
4.1% (FLS) vs. 19.7% (controls)
Lih et al. Osteoporosis Int 2011;22:849-58
Kaiser Permanente
FLS Southern California Style
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Kaiser Permanente
FLS Southern California Style
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Kaiser Permanente
FLS Southern California Style
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Kaiser Permanente
FLS Southern California Style
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
Kaiser Permanente
California Dreamin’ ?
"I'd like to dispel the misconception that nothing
can be done to prevent or treat osteoporosis.
It is possible to achieve at least a 25 percent
reduction in the hip fracture rate in the United
States if a more active role is taken by all
orthopedic surgeons in osteoporosis disease
management.
We've seen it; we've done it.”
Rick Dell MD
JBJS 2008;90:S4:188-194 Dell et al PubMed ID 18984730
NHS Greater Glasgow and Clyde
Strategy for Osteoporosis and Falls Prevention 2006-2010
AN EVALUATION
2007-2009
South Glasgow FLS (10 Year Review)
12312
21887 Patients
Patients Identified
identified
1755 Declined (8.0%)
1497 DNA (6.8%)
18635 patients to be assessed
11755 - BMD Measured
(63%)
6409 - Started on Treatment
(35%)
4877 - Treatment Started Without
Scanning
(26%)
2003 - Already on Treatment
Or Previously Assessed
(11%)
5346 – No Treatment Required
(28%)
% of the 21887 patients presenting
Hip fractures in the 65+ age group
(England) (1998-2008)
Admissions for Hip Fractures in England
(ICD S72.0, 72.1 and 72.2)
66,000
Growth 1.8% per year (2005-8)
64,000
62,000
60,000
58,000
56,000
54,000
52,000
50,000
1998-1999
1999-2000
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
Hip fractures (65+) (1998-2008)
Greater Glasgow/ Greater Glasgow & Clyde
Between 1998 and 2008 the number of hip fractures (as assessed by
ISD codes S.72-S.72.2) in Greater Glasgow decreased by 7.3% from
1377 to 1276 fractures.
The equivalent figure for Greater Glasgow & Clyde was 3.6%, 2026
fractures in 1998 to 1953 fractures in 2008 (i.e hip fractures increased
in Clyde).
Emergency Admissions due to Hip Fractures Codes
S.72.0-72.2 (1998-2008) for
2,500
2,000
1,500
1,000
NHS Greater Glasgow &
Clyde
500
NHS Greater Glasgow
0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
FLS: Is it affordable?
(can we afford not to do it?)
1000 patients (Hypothetical Cohort)
686 patients received anti-osteoporosis treatment
£83,598 (for assessments)
£206,554 (for treatments)
18 fractures (including 11 hip fractures) prevented
Overall cost saving - £21,000
Cost of widespread adoption of FLS across UK - £9.7m
McLellan et al. OI 2011;22:2083-2098
Cost-Effectiveness (International Models)
Data from Australia:
Savings of $23,000 AUD in 6 months1
Cost of $20,000-30,000 AUD per QALY gained2
Data from Canada:
Cost saving of $50,000 per annum (minimum 350 hip fractures seen)3
1. Vaile et al. Internal Medical Journal 2007;37:717-720
2. Cooper et al. Osteoporosis Int 2012;23:97-107
3. Sander et al. JBJS 2008;90:1197-1205
FLS in Scotland in 2014
DXA Scanners/
Health Board
1 NHS Ayrshire and Arran
2 NHS Borders
3 NHS Dumfries and Galloway
4 NHS Western Isles
5 NHS Fife
6 NHS Forth Valley
7 NHS Grampian
8 NHS Greater Glasgow and
Clyde
9 NHS Highland
10 NHS Lanarkshire
11 NHS Lothian
12 NHS Orkney
13 NHS Shetland
14 NHS Tayside
NWT Clearing Unit , Jubilee
Irvine
Melrose
Dumfries
Travel to Dingwall/DX
recently installed
Western Isles hospital
Stornoway(Q2Q3 2014
service under
development
Kirkcaldy
Larbert
Aberdeen and Elgin
WIG/GRH//Stobhill/
SGH,RAH,( Paisley),
IRH(Greenock,
Dingwall
Wishaw
Edinburgh
Travel to Aberdeen
Travel to
Aberdeen/mobile scann
project begins Q4
2014/Lerwick
Dundee and Perth
Clydebank
DXA Services – Available Hours of Operation
Radiographers
BOARD
(WTE)
Hours
scanning
A&A
2.76
40
Borders
0.5
D&G
Radiographers
(WTE)
Hours
scanning
Highland
2.0*
30
14
Lanarkshire
1.0
40
1.0
5
Lothian
?
?
Fife
1.0
40
Orkney
0
0
Forth
Valley
0.4
10
Shetland
0
0
Grampian 2.0
?
Tayside
2.0
?
GGC
20-40
Western
Isles
0
0
BOARD
5.0
DXA Services – Available Hours of Operation
Radiographers
BOARD
(WTE)
Hours
scanning
A&A
2.76
40
Borders
0.5
D&G
Radiographers
(WTE)
Hours
scanning
Highland
2.0*
30
14
Lanarkshire
1.0
40
1.0
5
Lothian
?
?
Fife
1.0
40
Orkney
0
0
Forth
Valley
0.4
10
Shetland
0
0
Grampian 2.0
?
Tayside
2.0
?
GGC
20-40
Western
Isles
0
0
BOARD
5.0
Health Boards – FLS Available
BOARD
FLS
DADS
BOARD
FLS
DADS
A&A
Yes
Yes
Highland
Yes
Yes
Borders
Yes
Yes
Lanarkshire
Yes
Yes
D&G
Yes
Yes
Lothian
Yes
Yes
Fife
No
?
Orkney
No
No
Forth
Valley
No
Yes
Shetland
No
No
Grampian
Yes
Yes
Tayside
No
Yes
GGC
Yes
Yes
Western
Isles
No
No
Health Boards – FLS Available
BOARD
FLS
DADS
BOARD
FLS
DADS
A&A
Yes
Yes
Highland
Yes
Yes
Borders
Yes
Yes
Lanarkshire
Yes
Yes
D&G
Yes
Yes
Lothian
Yes
Yes
Fife
No
?
Orkney
No
No
Forth
Valley
No
Yes
Shetland
No
No
Grampian
Yes
Yes
Tayside
No
Yes
GGC
Yes
Yes
Western
Isles
No
No
Osteoporosis/FLS Specialist Nurse
Availability by Health Board
BOARD
Nurses (WTE)
BOARD
Nurses
(WTE)
A&A
0
Highland
0
Borders
1.0
Lanarkshire
2
D&G
1.0
Lothian
2.2
Fife
1.0
Orkney
0
Forth
Valley
0
Shetland
0
Grampian
1.0
Tayside
2.0
GGC
6.8
Western Isles
0
Osteoporosis/FLS Specialist Nurse
Availability by Health Board
BOARD
Nurses (WTE)
BOARD
Nurses
(WTE)
A&A
0
Highland
0
Borders
1.0
Lanarkshire
2
D&G
1.0
Lothian
2.2
Fife
1.0
Orkney
0
Forth
Valley
0
Shetland
0
Grampian
1.0
Tayside
2.0
GGC
6.8
Western Isles
0
The Case for FLS is Robust
• Fractures are a rapidly increasing problem
across the world
• Fractures are associated with significant
morbidity, mortality and cost
• Identifying patients presenting after fracture
identifies a population at high risk of future
fracture
The Case for FLS is Robust
• FLS encourages cost-effective resource
utilisation and integration across primary and
secondary care
• FLS programmes now required through many
national/international guidelines
• Adoption of FLS across NHS Scotland should
be an urgent priority
Whilst we have been talking,
342 people have had a fragility fracture,
60 people have broken their hip
And 30/60 let us know they were coming