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Fragility Fracture Network - FFN A Global Multidisciplinary Network to Improve Fragility Fracture
Management and Prevention
Ami Hommel
RN, CNS, PhD, Associate Professor Lund University & Skane university hospital, Lund, Sweden Chair International Collaboration of Orthopaedic Nursing Scientific Board member, the Fragility Fracture Network
• Hip fractures – 87% of total cost of all fragility fractures
• Often considerably increased dependency
Hip Fractures Are the Key
50 60 70 80 90 Age
No fractures –
increasing morbidity
due to ageing alone
Age Adapted from Kanis JA, Johnell O; 1999
The fragility fracture ‘career’ - a chronic disease Morbidity
Dependence
The fragility fracture ‘career’ - a chronic disease Morbidity
Dependence
50 60 70 80 90
Colles' fracture
Vertebral fracture
Hip fracture
Age
No fractures –
increasing morbidity
due to ageing alone
Added morbidity from
fractures
Age Adapted from Kanis JA, Johnell O; 1999
• Despite falling age-adjusted incidence, ageing will lead to massive increase in burden over the next 25 years
– Double the number of cases
– Treble the cost
• Unless we do something about it
Adapted from Cooper C et al,
Osteoporosis Int, 1992; 2:285-9
Total number of
hip fractures:
1990 = 1.66 million
2050 = 6.26 million
1990 2050
600
325
0
1990 2050
668
400
1990 2050
1990 2050
10 0
629 378
742
Projected Osteoporotic Hip Fractures Worldwide
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
– Other doctors: geriatricians, osteoporosis doctors etc
– Nurses and allied health professionals
– Scientists
– Industry
• Application for membership via the website – www.ff-network.org - €50
Members by global region
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Europe NorthAmerica
ANZ Asia Middle East LatinAmerica
43%
12% 14% 13% 12%
4%
Members by discipline
0%
10%
20%
30%
40%
50%
1% 3%
31%
11%
44%
6% 5%
• First Global Congress 6-8 Sep 2012 Berlin
• Attended by >350
• Workshops
• First Global Congress 6-8 Sep 2012 Berlin
• Attended by >350
• Workshops
• Second Global Congress 29-31 August 2013 Berlin
• Attended by >400
• Workshops
Progress
• “Blue Book” on fragility fracture care
• National Hip Fracture Database
– Sweden started in 1988
• Fracture Liaison Services
Goals of the NHFD
• To change clinical behaviour – raise standards
• To raise the political profile of fragility fractures
• To provide a platform for clinical research
Four big messages Multidisciplinary approach to the management of fragility fracture patients Reliable secondary prevention Osteoporosis and falls Chronic disease model Quality assurance the NHFD
Six standards for hip fracture care
1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation (2h)
2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, during normal working hours (24h)
3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer
4. 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
5. All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures
6. All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls
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
Package for older people Top priority
Prevent next fracture
• We need to prevent hip fractures as well as treat them well if they happen
– By responding to earlier fractures we could reduce the future incidence by ~25%
– This requires a Fracture Liaison Service model
– Can a FLS-database drive change similarly? 19
Earlier fractures signal the hip fracture Morbidity
Dependence
50 60 70 80 90
Colles' fracture
Vertebral fracture
Hip fracture
Age
No fractures –
increasing morbidity
due to ageing alone
Added morbidity from
fractures
Age Adapted from Kanis JA, Johnell O; 1999
Secondary prevention
• Secondary prevention is more cost-effective than primary prevention
45.3 44.6 45.4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Lyles et al Edwards et al Mclellan et al
Per
cent
age
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.
n=2124 n=632 n=701
Prevalence of prior fractures among patients presenting with hip fracture
National Clinical Audit of Falls and Bone Health (2007) Clinical Effectiveness and Evaluation Unit, RCP, London
0
10
20
30
40
50
60
Osteoporosis assessment
DXA referral (65-74 years)
Supplementation with calcium + D3
Treatment with osteoporosis medication
Per
cent
age
hip (n = 3184)
non-hip (n = 5642)
Target 100% 100% 100% ~70%
Interventions after fragility fracture
Capturing patients reliably
• Employment of a dedicated coordinator in the fracture service is the most effective system
NEW FRACTURE
EDUCATION PROGRAMME
EXERCISE CLASSES
FALLS RISK ASSESSMENT
INPATIENT ORTHO/TRAUMA WARD
OUTPATIENT FRACTURE CLINIC
PRESCRIPTION ISSUED BY GP
Rx FOR FRACTURE 2Y PREVENTION
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
Central role of nurses • Acute care of elderly fracture patients
– Pathways
– Orthogeriatric liaison
– Trauma coordinator
• Secondary prevention – FLNs in fracture units
– FLNs in primary care
– Falls prevention
The FFN needs nurses • Only way to cope with the numbers
• Many parts of the world where nurses not allowed much independent action
• Great opportunity to spread good practice
Next Global Congress in Madrid
4-6th Sep 2014 www.ff-network.org
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