Fracture Liaison Service in Alberta Dr. Michael Mulholland, FLS Physician Beverly Bowles, FLS Nurse Clinician
Disclosure Dr. Michael Mulholland and Beverly Bowles are paid by the Bone & Joint Health SCN which is funded through Alberta Health Services Dr. Mulholland has no pharmaceutical interests and no conflicts of interest 2 2
Outline • The Problem • The Alberta Context • Creation of the Fracture Liaison Service (FLS) • FLS Processes • Current Status of FLS in AB • Challenges 3 3
The Problem Osteoporosis Canada, 2015 4 4
Key Facts • At least 1 in 3 women, and 1 in 5 men, will break a bone due to osteoporosis in their lifetime • 1 in 3 hip fracture patients will re-fracture within 1 year, and over 1 in 2 will suffer another fracture within 5 years without treatment • Typically >80% of patients who have suffered a fracture are neither assessed nor treated • Annual cost to Canadian Healthcare from osteoporosis and fractures in 2010 was > $2.3 billion https://osteoporosis.ca/about-the-disease/fast-facts/ 5 5
The Alberta Context Red Deer specific • There are close to 3,000 hip fractures in Alberta yearly • To date 846 patients have been enrolled in Red Deer FLS (293 last year) • Of those patients we enrolled – 143 have died – 1/3 are on treatment 6 6
Acute Care Catch a Break Secondary Provincially prevention scaled evidence- program to based best reduce Bone and practices for subsequent inpatient hip Joint Health fractures fracture care SCN Fracture Liaison Restorative Services Care Post-acute care, Dedicated post- emphasizing optimal acute team function level, quality proactively treats of life and underlying reintegration into osteoporosis and community prevents future falls
Catch a Break EVALUAT ALERT INFORM IDENTIFY patients family E program fragility at risk physician fractures annually FOLLOW SCREEN EDUCAT patients for for E 12 months osteoporosis patients avg. cost to fractures $25 14 treat one hip avoided k fracture Acute avg. CAB hip Care 4 $44 cost/patient fractures Fracture Liaison Restorative avoided Services Care
Acute Care Provincial Clinical Pathway + Order Sets STANDARDIZED PROVINCIAL CARE Developing Alberta BEST PRACTICE GUIDELINES for hip fracture care PROVINCIAL and SITE-SPECIFIC PERFORMANCE INDICATORS Early Time to EXAMPLES Surgery ≤ 36 Mobilization 30 Day Readmission Hours Catch a Break Length of Stay Return to Previous Re-fracture < 1 Year Living Environment Fracture Liaison Restorative Services Care
Fracture Liaison Services Provincial ‘3i’ model: identify investigate initiate ASSIGN TRANSFER DISCHARG dedicated to family E from FLS team physician at 1 hospital year TREATMEN FOLLOW- T PLAN UP 3, 6, 9 Months Adherence and persistence to first line osteoporosis treatment - specialist referrals - falls prevention fractures avg. FLS Acute Care Catch a Break $1360 37 avoided cost/patient hip fractures Can be cost- Restorativ e Care 12 avoided savings with some changes
Restorative Care Provincial Restorative Transition to Pathways COMMUNIT STANDARDIZED Y CARE PROVINCIAL CARE Pathways for: 1) Up to post-operative day 7 2) From post-operative day 8 to 28 Home +/- home care Long-term care Includes: Rural acute sites Catch a Break Acute Care Supportive Living Rehab/subacute/ transition Fracture Liaison Services
What is an FLS? • A specific systems-based model of care for secondary fracture prevention • Closes the care gap between orthopaedic care post- fracture / patient’s underlying osteoporosis and return to primary care • 3i program: Identification (1i) Investigation (2i) Initiation (3i) 12 12
Identification (1i) Inpatient Orthopaedic Unit Exclusions: • < 50 years old • out of province/country • pathological fracture • acetabular/pelvic fracture • distal femur or high impact Patient Care Census hip/femur fracture Hip Fracture Diagnosis • peri-prosthetic fracture from elective hip replacement • palliative patients • those with < 1 year life expectancy Patient ≥ 50 years old with identified fragility hip fracture 13 13
Investigation (2i) FLS Patient Checklist Fracture and fixation Medical history Renal function Osteoporosis risks/history Nurse / Physician Fall risks/history patient review Supports Develop plan of care 14 14
Initiation (3i) On First Line Rx Yes Must consider: No CrCl Swallowing issues Adherence Preference < Year > Year Coverage Complexity Defer till 3 months Continue Consider Start first and switching line Rx reinforce medication adherence 15 15
FLS Algorithm 16 16
Calcium and Vitamin D 17 17
Patient Education • Osteoporosis, • Future fracture risk • Medications • Diet (calcium, vitamin D) • Exercise • Home safety & fall prevention 18 18
Patient Education 19 19
Patient Education 20 20
Patient Education 21 21
Q 3 Month Follow-up • Follow-up calls done with patient/family/caregiver at 3, 6, 9, and 12 months Mobility, falls, fractures Medication adherence if on OP treatment Investigations (BMD, vitamin D testing as appropriate) Referrals • Letter faxed to GP after each follow-up call if there is relevant information to pass on to them 22 22
Secondary Fracture Prevention • We haven’t prevented the hip fracture, but the goal of FLS is to prevent further fractures by focusing on: – The reason for the fall and trying to reduce the risk for falling again – falling is not a normal part of aging! – Their bone health and treatment for osteoporosis – if they are osteoporotic and having falls, they will fracture 23 23
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