ECOOG 2012

of the Bone and Joint Decade

The Global Challenge of Fragility Fractures

David Marsh Emeritus Professor of Clinical Orthopaedics, University College London Royal National Orthopaedic Hospital, Stanmore International Ambassador for the Bone and Joint Decade President of the Fragility Fracture Network

1990 2050

1990 2050

100

600
1990 2050

Total number of hip fractures: 1990 = 1.66 million 2050 = 6.26 million

742

378

629

1990 2050

Adapted from Cooper C et al, Osteoporosis Int, 1992; 2:285-9

400

668

3250

Projected Osteoporotic Hip Fractures Worldwide

The number of hip fractures depends on two things

Age-specific incidence
Secular change

Age structure of the population

Demographic change

 General increase in age-adjusted incidence in the last century Mixed picture since then
Some plateau, some fall, some continue to rise

Rochester MN

Japan

Assuming 0.43% annual secular fall

Summary of the challenge

Despite falling age-adjusted incidence, ageing will lead to massive increase over next 25 years In Europe:
Double the number of cases Treble the cost

In Asia and Latin America 6-fold increase Unless we do something about it

The

Fragility Fracture Network

of the Bone and Joint Decade
Mission: To promote globally the optimal multidisciplinary management of the patient with a fragility fracture, including secondary prevention

Aims
to disseminate globally the best multidisciplinary practice in preventing and managing fragility fractures to promote research aimed at better treatments for osteoporosis, sarcopenia and fracture to drive policy change that will raise fragility fractures higher up the healthcare agenda in all countries

Membership
Open to professionals in any field relevant to fragility fractures, eg:
Orthopaedic surgeons Geriatricians Osteoporosis doctors Nurses and allied health professionals Industry

Outline
The nature of fragility fractures The opportunity for secondary prevention Integrated care of the acute episode Changing policy, changing behaviour

The nature of fragility fractures

A chronic disease Modifiable risk factors
The potential for prevention

Challenges of treatment
The need for multidisciplinary care

Morbidity
Dependence

The fragility fracture career - a chronic disease

No fractures increasing morbidity due to ageing alone

50 60 70 80 90 Age
Adapted from Kanis JA, Johnell O; 1999

Age

Morbidity
Dependence

The fragility fracture career - a chronic disease

Hip fracture

Vertebral fracture

Added morbidity from fractures

Colles' fracture

No fractures increasing morbidity due to ageing alone

50 60 70 80 90 Age
Adapted from Kanis JA, Johnell O; 1999

Age

Why Hip Fractures are the key

Hip fractures 87% of total cost of all fragility fractures (2.0 billion in UK) 1.2 million bed days per year in UK Often considerably increased dependency

Comparison with other priorities

Issues: Strokes Heart Fragility & TIAs attacks fractures ----------------------------------------------------------------------------------------Incidence/year 110,000 275,000 310,000 Current trend Falling Falling Rising

NHS bed days*

1.85m

1.15m

1.2m (hips)
2bn

Annual costs

2.8bn

1.7bn

UK figures from the Department of Health

Risk of fragility fracture

Bone Density Postural Instability

Bone Strength

Falls Risk

Bone Turnover

Slow Responses

Bone Architecture

Frailty

Skeletal Geometry

Environment

Mineralisation

Lack of Padding

Osteoporosis treatment

Strength and balance training

Sarcopenia

Traditionally defined as the loss of muscle mass with age

Extended to include loss of strength or performance

SARCOPENIA

FRAILTY

SARCOPENIA

FRAGILITY
OSTEOPOROSIS

Sarcopenia, frailty, rehabilitation

Falls really are as important as osteoporosis Rehabilitation after fracture is inadequate Drug companies are more excited about antisarcopenic drugs than anti-osteoporotic
Except bone anabolics

Muscle-building effects of exercise work in the elderly

Earlier fractures signal the hip fracture

Morbidity
Dependence Hip fracture

Vertebral fracture

Added morbidity from fractures

Colles' fracture

No fractures increasing morbidity due to ageing alone

50 60 70 80 90 Age
Adapted from Kanis JA, Johnell O; 1999

Age

Secondary prevention
Secondary prevention is more cost-effective than primary prevention

Prevalence of prior fractures among patients presenting with hip fracture

n=2124
100.0 90.0 80.0 70.0

n=632

n=701

Percentage

60.0 50.0 40.0 30.0 20.0 10.0 0.0

45.3

44.6

45.4

Lyles et al

Edwards et al

Mclellan et al

Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006 Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230 McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.

16% of women over 50 have had at least one low trauma fracture
Post-menopausal women with new fracture each year 0.2 million Post-menopausal women with prior fracture history Post-menopausal women with osteoporosis Post-menopausal women

50% of hip fractures from 16% of the population

1.8 million

3.4 million

11.1 million

50% of hip fractures from 84% of the population

UK figures

Interventions after low trauma fracture

Target 100% 100% 100% ~70%

60 50
Percentage

40
hip (n = 3184)

30 20 10 0 Osteoporosis assessment DXA ref erral (65- Supplementation Treatment with 74 years) with calcium + D3 osteoporosis medication

non-hip (n = 5642)

National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London

Secondary prevention
Secondary prevention is more effective than primary prevention A systems approach is needed, where capture of patients is automatic

Capturing patients reliably

Employment of a dedicated coordinator in the fracture service is the most effective system

NEW FRACTURE

INPATIENT ORTHO/TRAUMA WARD

OUTPATIENT FRACTURE CLINIC

FALLS RISK ASSESSMENT

EXERCISE CLASSES

Rx FOR FRACTURE 2Y PREVENTION

EDUCATION PROGRAMME

PRESCRIPTION ISSUED BY GP

McLellan et al OI 2003, 14:1028-1034.

Secondary prevention
Secondary prevention is more effective than primary prevention A systems approach is needed, where capture of patients is automatic When it is done vigorously, it is cost-saving

Cost-saving

Per 1000 fragility fracture patients, 18 fractures (11 hip) prevented net saving 21,000

 38% reduction in expected hip fracture incidence

Secondary prevention
If universally applied, coordinator-based systems in fracture units could
Prevent ~25% of the burden of disease from hip fractures Save money

Treatment of the acute episode

A multidisciplinary approach is needed
Senior input from physicians Good surgery Coordinated rehabilitation and discharge

Treating fragility fractures well is cheaper than treating them badly

Mortality after hip fracture

140 120

100

80

60

40

Royal Victoria Hospital, Belfast 1999-2003

20 0

1003 deaths by one year in 5553 patients

0 10

0 20

0 30

days from injury to death

Complexity of elderly patients

Mean age hip fracture = 80 yrs Comorbidities (median ASA 3)
Cardiac murmurs Renal - Dialysis COPD - home O2 Diabetes Delirium / dementia Pseudo-obstruction Alcohol abuse

Impaired metabolic response to injury

Hyponatraemia

Management problems
Consent Theatre scheduling Discharge planning

Polypharmacy
Warfarin Plavix Neurotropics

Acute medical management

Difficult judgement balance between medical optimisation and prompt surgery Inexperienced surgical trainees not the best people to look after such people and prepare them for surgery Ideal solution is close supervision by senior physicians having expertise with elderly patients
pre- and peri-operatively, not just for rehabilitation

Senior medical backup

Can come from different specialists, depending on health care system
Anaesthesia Internal medicine Geriatrics

Orthogeriatrics a key role in UK, Spain and several other countries

 Compared four types of model Integrated care on an orthopaedic ward gave the best
Mortality rate Length of stay Time to surgery

J Am Geriatric Soc 2008

Geriatric Fracture Center in Rochester, USA Comparison with other fracture services in locality In-hospital mortality 1.5% vs 3.2% Readmission 9.7% vs 19.4% Length of stay 4.6 vs 5.2 days

Orthogeriatric co-management of the acute episode

Gives the patient a better quality of care with better outcomes Saves money by enabling
more efficient use of resources fewer readmissions

Four big messages

Multidisciplinary approach to the management of fragility fracture patients Reliable secondary prevention osteoporosis falls Chronic disease model Quality assurance the NHFD

BOA-BGS Blue Book six standards for hip fracture care

1. 2. 3. 4. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to orthogeriatric medical support from the time of admission All patients presenting with fragility fracture should be assessed to determine their need for bone-protective therapy to prevent future osteoporotic fractures All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls

5.
6.

UK National Hip Fracture Database (NHFD) Project - jointly led by BOA and BGS
Measures compliance with Blue Book standards A web-based national database, now including every fracture unit in England, Wales and N. Ireland Feed back to units their performance compared to national A professional steering group to manage analysis of, and access to the data Extensile for research Adopted by government as a national clinical audit

Smart commissioning
Alliance between multidisciplinary providers and healthcare commissioners can tackle fragility fractures and drive change
Prioritisation Incentivisation

UK DoH package for older people

Top priority
Hip fracture patients
Objective 1: Improve outcomes and improve efficiency of care after hip fractures by following the 6 Blue

Book standards
Objective 2: Respond to the first fracture, prevent the second through

Non-hip fragility fracture patients Individuals at high risk of 1st fragility fracture or other injurious falls

Fracture Liaison Services in acute and primary care

Objective 3: Early intervention to restore independence through falls care

pathway linking acute and urgent care services to secondary falls prevention
Objective 4: Prevent frailty, preserve bone health, reduce accidents

Older people

through preserving physical activity, healthy lifestyles and reducing environmental hazards

Best Practice Tariff (BPT) From April 2010

Reimbursement to Hospitals for each case of hip fracture will vary according to the quality of care Two criteria will be used
Time to theatre less than 36 hours Involvement of orthogeriatrics in the acute phase

Compliance for each case will be determined from the record in the National Hip Fracture Database

Now the hospital CEO gives a damn

PAYMENT PER CASE

National average cost

~500 BPT supplement

before

April 2010

UK National Hip Fracture Database Annual Report 2010-2011

Eligible hospitals Qtr 1 162 Hospitals achieving BPT 92 (57%) Number of Number of pts pts submitted achieving BPT 9455 2303 (24%)

Qtr 2 Qtr 3
Qtr 4

165 163
167

105 (64%) 111 (68%)

118 (71%)

11839 13136
12680

3328 (28%) 4502 (34%)

4671 (37%)

Incentivisation
Next year the BPT differential will double to 900 But the base tariff will be reduced More carrot but also more stick Extra drive to introduce modern multidisciplinary services will benefit our patients

Projected Hip Fractures Worldwide

3250
1990 2050 1990 2050

100

600
1990 2050

Total number of hip fractures: 1990 = 1.66 million 2050 = 6.26 million

742

378

629

1990 2050

Adapted from Cooper C et al, Osteoporosis Int, 1992; 2:285-9

400

668

Launch meeting Berlin, 8-9 Sep 2011

Discipline Orthopaedic surgeons Geriatricians Osteoporosis doctors Nurses Scientists Industry partners Total No 54 20 6 3 6 12 101

Countries represented
Australia Austria Belgium Brazil Canada China Denmark Finland France Germany Hong Kong Ireland Italy 3 1 1 2 1 2 1 1 2 16 3 1 23 Japan Lebanon Netherlands New Zealand Norway Philippines Slovenia Spain Sweden Switzerland Thailand Turkey UK USA 4 1 3 1 3 1 1 6 3 5 1 1 9 6

Global Regions
Europe N America S America Middle East Asia-Pacific 75 7 2 2 15

Middle East Forum of the Bone and Joint Decade

Ghassan Maalouf FFN Board member Vice-chair of the Scientific Committee Coordinator for the Middle East North Africa region

Aims
to disseminate globally the best multidisciplinary practice in preventing and managing fragility fractures to promote research aimed at better treatments for osteoporosis, sarcopenia and fracture to drive policy change that will raise fragility fractures higher up the healthcare agenda in all countries

Global dissemination of best practice

Obviously, conditions differ between countries But there is much in common and all countries can learn from each other There is no time to rediscover the wheel a hundred times This is the philosophy of the Bone and Joint Decade

Two main issues

Multidisciplinary care of the acute fracture episode
Particularly hip fractures

Secondary prevention - reduce risk of another fracture in a patient who has already had one, by addressing
Osteoporosis Falls risk

 First Global Congress 6-8 Sep 2012 Berlin Please come and share your experience

The first FFN Global Congress Berlin 6-8 Sep 2012

International speakers giving state of the art on all relevant aspects Workshops on practical ways forward Submitted abstracts on research and audit of different service models

To register for the Global Congress and submit abstracts online, please go to
www.ffn-congress.com

If you want to get involved:

Go to www.ff-network.org
Download newsletter Link to congress Join FFN (50)

Contact me at d.marsh@ucl.ac.uk or Ghassan Maalouf at gmaalouf@bmchcs.com

Summary
Fragility fractures will present an unmanageable problem all over the world unless we act now Secondary prevention and multidisciplinary management are the keys to success The international forum for exchanging ideas and stimulating action is the Fragility Fracture Network of the Bone and Joint Decade
d.marsh@ucl.ac.uk

www.ff-network.org

gmaalouf@bmchcs.com