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