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The National Audit ofFalls and Bone Health
in Older People
[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
[insert name] Strategic health Authority
[date], [venue]
Commissioning:A Systematic approach to falls & bone health Four
key objectives
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
Older peopleObjective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards
Stepwise implementation
“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?How do we know how we are doing?
National Hip Fracture Database
National Audit of Falls and Bone Health
Evidence based standards
Where audit fits in this model
Hip fracture patients
Non-hip fragility fracture patients
Individuals at high risk of 1st fragility fracture or other injurious falls
Older people
Clinical auditevaluation
NSF
Health promotion
NSF, NICE
Exercise programmes
Falls clinics
Bisphosphonates
Blue Book, NSF, NICE
Fracture Liaison Service
Falls Clinic
BOA/BGS Blue Book
High quality hip fracture care
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
Interventions following low trauma fracture Oct-Dec 2006 England, Wales and NI (n=8826)
0
10
20
30
40
50
60
Osteoporosisassessment
DXA referral (65-74years)
Supplementation withcalcium + D3
Treatment withosteoporosismedication
Per
cent
age
hip (n = 3184)
non-hip (n = 5642)
50% osteoporotic
Non-hip
Hip fracture
Secondary prevention - Bone health Hip fracture v Non-hip fragility fracture
43.6
4.8
1.8
73.0
17.0
9.8
25.3
0 20 40 60 80 100
Males > 65 + prior # + OP on Rx
Males > 65 + prior # + OP
Males > 65 + prior # + DXA
Females 65-74 + prior # + OP on Rx
Females 65-74 + prior # + OP
Females 65-74 + prior # + DXA
Females ≥ 75 + prior # on treatment
Percentage
Secondary prevention following fragility fracture in British primary care (n= 3.4 million)
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.
n = 7860/31094
n = 1476/15025
n = 2551/15025
n = 1862/2551
n = 261/14651
n = 700/14651
n = 305/700
Secondary prevention - Falls risk assessment Hip fracture v Non-hip fragility fracture
0102030405060708090
100
Secondary prevention of falls
Hip fracture Non-hip fracture
Individuals at high risk
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Documented enquiry about no.
falls
High risk fallers High risk fallers with documented
referral
High risk fallers assessed for osteoporosis
Fragility fracture patients
assessed for falls
Percentage
n = 1,076 / 251,049 n = 1,335 n = 15 n = 10 n = 319
Aspects of integrated falls care in patients Aspects of integrated falls care in patients 75 and over (n = 270,028)75 and over (n = 270,028)
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.
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
The Second National Audit of the The Second National Audit of the Organisation of Services for Falls Organisation of Services for Falls and Bone Health in Older People and Bone Health in Older People
(2008)(2008)
Acute trustsAcute trusts 100% (158/158)100% (158/158)
Primary Care OrganisationsPrimary Care Organisations 88% (150/171)88% (150/171)
Health & Social Care TrustsHealth & Social Care Trusts 88% (7/8)88% (7/8)
Mental Healthcare TrustsMental Healthcare Trusts 76% (44/58)76% (44/58)
Care homesCare homes 73 homes73 homes(sample drawn from 2 national providers)(sample drawn from 2 national providers)
ParticipationParticipation
Key ResultsKey Results
TAG 87 = National Institute for Health and Clinical Excellence, Technology Appraisal Guidance, Number 87
Commissioning for falls and bone health
Acute trusts - case finding
Secondary prevention of falls
Key MessagesKey Messages
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 Lack of integration between falls services and fracture
servicesservices
Significant gaps along patient journey for falls and Significant gaps along patient journey for falls and
fracturesfractures
Inadequate levels of secondary prevention for both falls Inadequate levels of secondary prevention for both falls
and bone healthand bone health
Secondary prevention for non-hip fragility fracture is less Secondary prevention for non-hip fragility fracture is less
good than for hip fracturegood than for hip fracture
Risk assessments in A&E departments and Risk assessments in A&E departments and Fracture services are inadequateFracture services are inadequate
Services with Falls Coordinators and Fracture Services with Falls Coordinators and Fracture Liaison Nurses have better case finding systems Liaison Nurses have better case finding systems in place to identify high risk fallersin place to identify high risk fallers
Many trusts do not provide these important postsMany trusts do not provide these important posts Many of the exercise programmes being provided Many of the exercise programmes being provided
are not evidence basedare not evidence based Services for bone health appear less well Services for bone health appear less well
developed than services of falls preventiondeveloped than services of falls prevention
Opportunities to prevent recurrent Opportunities to prevent recurrent falls and fractures are being falls and fractures are being missedmissed
Only 64% (110/171) of commissioning bodies have Only 64% (110/171) of commissioning bodies have a a written strategy on falls preventionwritten strategy on falls prevention
Only 23% (38/171) have a strategy for bone healthOnly 23% (38/171) have a strategy for bone health
Important public health information on fracture rates Important public health information on fracture rates is inadequate or not collatedis inadequate or not collated
Only 39% (67/171) of commissioning trusts report Only 39% (67/171) of commissioning trusts report having a mechanism to assess local compliance having a mechanism to assess local compliance with national guidelines on osteoporosis treatmentwith national guidelines on osteoporosis treatment
Commissioning for falls and bone Commissioning for falls and bone health is weakhealth is weak
Non-hip fragility fracture patients
Thank You
Individuals at high risk of 1st fragility fracture or other injurious falls
Older people
Falls history
Syncope considered
Medication reviewed
CVS examination
Vision assessment
Vision impaired
Gait & balance assessed
Exercise programme
Home hazard assessed
Non-Hip (%)
25
17
31
40
1038 (most treated)
28
22
14
Hip (%)
452244
89
1940 (most treated)
68
44
51
Falls risk assessment