Fracture Liaison Service (FLS) · 2016. 4. 6. · nicheprogram.org • 2016 Annual NI HE onference • are Across the ontinuum 1 Improving Patient Care with Fracture Liaison Service

nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum

1

Improving Patient Care with Fracture Liaison Service (FLS) Program Implementation

Speakers

Anita J. Meehan, MSN, RN-BC, ONC

Clinical Nurse Specialist, Geriatrics/Med-Surg

NICHE program director

Akron General Medical Center

Disclosures: No competing interests to disclose

Susan Randall, MSN, FNP-BC, RN

Senior Director, Science & Education

National Osteoporosis Foundation

Disclosures: No competing interests to disclose

Objectives

1. Briefly describe the epidemiology of

osteoporosis and related fractures

2. Discuss the role of the NICHE GRN in post-

fracture patient care

3. Define 3 key patient benefits of fracture liaison

service (FLS) program

4. Identify resources for patient counseling and

professional education


2

What is Osteoporosis?

“A skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture.”“Bone strength is a

composite of bone density and bone quality”

• Genetics

• Excessive thinness

• Inadequate calcium

intake

• Vitamin D deficiency/

insufficiency

• Smoking

• Co-morbid conditions

Risk Factors for Osteoporosis

• Excessive alcohol

intake

• Lack of physical

activity

• Immobility

• High salt intake

• Treatment for other

health conditions

Osteoporosis is responsible for an estimated 2

million fractures per year, including approximately:

•~297,000 hip fractures

•~547,000 vertebral fractures

•~397,000 wrist fractures

•~135,000 pelvic fractures

•~675,000 fractures at other sites

Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and Economic Burden of Osteoporosis-Related Fractures in the United States 2005-2025. JBMR. 2007; 22:465-475.

Incidence of Osteoporotic Fractures


3

Significance of Osteoporosis

2,050,6951

0

500,000

1,000,000

1,500,000

2,000,000

Osteoporotic

Fractures

795,0002

Stroke

249,2603

Breast Cancer

547,426vertebral

674,919 other sites

396,961 wrist

296,610 hip

An

nu

al

inci

den

ce o

f co

mm

on

dis

ease

s

750,0002

Heart Attack

134,779 pelvic

1Annual fracture incidence age 50+

2Annual estimate new & recurrent MI ages 35+

2Annual estimate new & recurrent stroke all ages

3 2014 new cases in situ & invasive breast cancer all ages

1 Burge, et al. JBMR. 2007. 465-75.

2 American Heart Association. Heart Disease and Stroke

Statistics – 2016 Update.

3 American Cancer Society. Surveillance Research. 2016.

550,000 new

attacks

200,000 recurrent

attacks

610,000

new

strokes

185,000

recurrent

Overwhelming evidence shows that osteoporosis is a massive public health problem nationwide:

• Nearly 65 percent of people in this country who are 65 years old and older have osteoporosis or low bone mass and are at risk for a fracture, according to data from the Centers for Disease Control.

• Currently only 25 percent of patients who suffer a fracture are treated to reduce the risk of future fractures.

• Hip fracture patients’ use of osteoporosis medications following fracture decreased from 40 percent to 21 percent between 2002 and 2011.

A Public Health Emergency

The Care Gap

• Missed opportunities for osteoporosis assessment & treatment

after fracture, even more so in diverse populations and in men

• Fragmented health care system – Fracture patients get “lost”

from hospital to rehab to nursing home to home to primary care

provider

• FLS programs have been proven to work to reduce this gap –

FLS is a system of patient-centered, coordinated care that

follows the patient throughout the care pathway to ensure

adequate assessment and treatment.

Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for

Medicare and Medicaid Services. Enhancing Use of Clinical Preventive Services Among Older Adults. Washington, DC: AARP, 2011.

NCQA. Improving Quality and Patient Experience: The State of Health Care Quality 2013.


4

Care of Older Adults with

Fragility Fracture: A Case Study

Evidence based recommendations

NICHE and NOF

Anita Meehan, MSN, RN-BC, ONC, FNGNA

A break in the bone that occurs spontaneously

or following a minor trauma such as coughing,

sneezing or falling from a standing height.

The major cause of fragility fracture is a

decrease in bone mineral density.

Low bone density occurs more often in older

adults

Fragility Fracture Definition

Why is this important?

• 54 million US citizens have osteoporosis or osteopenia (low bone density)

• Osteoporosis contributes to 2 million fractures including approx. 300,000 hip fractures annually

• Medical costs for fractures estimated at $17 billion in 2005

• Results in pain, disfigurement, loss of self esteem, impaired mobility and loss of independence

Wright, N, et al. The Recent Prevalence of Osteoporosis and Low Bone Mass in the United States Based on Bone Mineral Density at the Femoral Neck or Lumbar Spine. JBMR, Vol. 29, No. 11, November 2014, pp 2520–2526


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Morbidity and Mortality

• Fragility Hip fractures have a reported mortality rate of up to 20-24% in the first year after a hip fracture

• The increased risk for dying may persist for at least 5 years after the fracture.

• Loss of function and independence among survivors is significant; 40% unable to walk independently 60% requiring assistance a year later.

• 33% are totally dependent or in a nursing home in the year following fracture.

Downloaded from October 5, 2014. http://www.iofbonehealth.org/facts-statistics

The Aging Imperative

Increasing proportion of elders in global society (2013) (The World Bank Data)

– Australia & US 14% – Canada 15%– Japan 25%– Sweden 19%– UK 17%

– All % predicted to increase– In 2015 the world population of >65 outnumbered <5.

Are We Ready for the Silver

Tsunami??


6

Global Implications

8.9 MILLION FRACTURES ANNUALLY A FRAGILITY FRACTURE EVERY 3 SECONDS

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

3250

1990 2050

668

400

1990 2050

1990 2050

100

629

378

742

The incidence of spinal & hip fractures in women…

Is greater than the incidence of heart attack, stroke and breast cancer.

COMBINED

The ‘Silent Thief’: No Symptoms then a Fracture

• A prior fracture is associated with an 86% increased risk of a future fracture.

• The majority of those who have had at least one osteoporotic fracture were not evaluated for underlying osteoporosis.


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Risk Factors

Non Modifiable

• Age

• Gender: More common in women. More disability/fatalities with men.

• Ethnicity: Asia, Nordic Europe, Caucasian North & South America, Europe

Potentially Modifiable

• Low BMI

• Inadequate calcium & vitamin D, high intake of acid e.g. cola, caffeine.

• Life Style: Smoking, 3 or more alcoholic drinks/day

Secondary Risk Factors

• Medical conditions/ medications that:

• Impact absorption of calcium and or vitamin D: Chrohn’s, hyperparathyroidism, liver or kidney disease, diabetes

• Limit activity: rheumatoid arthritis or severe pulmonary disease

• Impact sex hormones: early menopause

• Increase body acidity (accelerates osteoclasts)

• Medications: Steroids, Certain chemotherapy agents

Medical conditions and Medications are inter-related

Meet Mrs. Mae Wong

• Frail 82 Year old widow

• Hx of hypertension, arthritis, cataracts, HOH, urge incontinence, mild cognitive impairment

• PSH: Cholecystectomy; hysterectomy, cataract, fx wrist

• Lives in a 1 bedroom apt, 78 year old sister lives in same apt building

• Son and his family live nearby

• Independent in ADL’s family helps with IADLs

• Dentures, cane/glasses/refuses hearing aid

• Difficulty sleeping d/t arthritic pain in her knees


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Case Study

• Awoke during night needing to toilet

• Fell on way to bathroom

• Unable to summon help

• Found by sister next morning

• EMS called

• She arrives at your emergency room

Case Study ~ Cont

• Assessed

• Labs drawn

• IV started

• Pain med admin

• Awaiting arrival of ortho resident

• X-ray

• Fx Prox L Femur

• Admitted for surgical fixation

Time Spent in ED

Varies according to:

• Time of arrival

• Availability of bed

• Availability of staff


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Pre Surgical Care

• OR may be delayed due to an emergency ‘trauma’/full surgery schedule

• Bucks Traction applied to affected leg

• Indwelling urinary catheter

• IV opiates

• NPO after midnight

Post Op Course


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Mrs. Wong’ Care Revisited

• Wrist facture at age 66 was a

‘signal’ fracture

• Dexa Scan ordered

• Osteoporosis/osteopenia Rx

by PCP or FLS

• Possible prevention of future

fracture

Mrs. Wong’s Care Revisited

• Fall occurs

• Transported by EMS

• Care initiated during transport following protocol

• Pain relief provided

• Oxygen & fluids

• Labs Drawn

• EKG

• Information transmitted to ED

Mrs. Wong Revisited

EMS arrives at ER as a priority

Geriatric ER & CNS

PMH obtained from EMR

Transfer immediately to xray

Fracture confirmed

Regional pain block

No skin traction, pillows to off load

heels

Transfer to ortho unit within 2 hours

of arrival


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Potential Complications Identified

• Pain – Acute on Chronic

• Delirium – D/T Cognitive impairment

• Pressure Ulcers

• Rhabdomyolitis?

• DVT

• Infection – Surgical site, PNA, UTI

• Sleep Deprivation

• Constipation

• Functional decline

• Falls

• Depression

Evidence Based Care Strategies

Patient/family is active participant in care

Geriatric Hip Fracture pre and post surgical protocol

Sensory aids in place

Multimodal pain relief initiated

• Regional block: Pre op pain relief

• Scheduled Tylenol for chronic arthritic pain

Screening for cognitive changes

Pressure relieving surfaces, In EMS, ER, OR and Unit

HOB elevated 30%

Surgery within 24-48 hours

Liberalized NPO restrictions

http://www.aaos.org/Research/guidelines/HipFxSummaryofRecommendations.pdf

Which answer best describes fasting pre-op restrictions at your hospital?

A. NPO after midnight

B. Allowed clear liquids 6 hours prior to OR

C. Order for clear high carb drink 2-3 hours prior to OR


12

Pre-op Carbohydrate Loading

• 8 oz clear carbohydrate drink 3

hours prior to surgery

• Reduces loss of muscle strength,

post-op N&V, post-op insulin

resistance, LOS, improves patient

satisfaction

Evidence

American College of Surgeons and many Anesthesia Societies have

recommendations to liberalize NPO prior to surgery; allowing clear liquids up

to 2 hours prior to surgery

The European Society of Parenteral and Enteral Nutrition, ESPEN

recommends a carbohydrate rich drink 2 -3 hours before anesthesia

American College of Surgeons Guidelines 2015

Guidelines on Parenteral Nutrition: surgery. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann

A, Bozzetti F, ESPEN Clin Nutr. 2009 Aug; 28(4):378-86.

Post-op Evidence Based Care Strategies

• Pressure ulcer prevention strategies throughout continuum of

care – ED, OR PACU, Unit

• Early ambulation within 24 hours of surgery ~ starting with

sitting at side of bed DOS

• Nursing mobilizes in conjunction with PT/OT

• High protein oral nutritional supplements in addition to

normal diet

• Encourage/ offer fluids

• Constipation prevention protocol

• Fracture Liaison Nurse Consult prior to discharge


13

NICHE “Need to Know”

Post-op Care Information Hip fractures and Repair

Post-op Course

• Family active in care

• Active participant in PT/OT & self care

• Discharge PO day 4

• Rehab for 2 weeks

• Home with family assisting and home

community support services in place

• Secondary fracture prevention

General Recommendations

• Regular weight bearing exercises

• Muscle strengthening exercises

• Avoid Smoking

• Avoid excessive alcohol consumption

• Ensure a diet that includes adequate amounts of

Calcium and Vitamin D for optimal bone health


14

National Osteoporosis Foundation Recommendations for Vitamin D

Women and Men

Under age 50 400-800 IU per day**

Age 50 and older 800-1,000 IU per day**

Sources of Vitamin D

Sunlight

Food

Supplements

**Some people may need a Vitamin D supplement depending on diet and where

they live; check with your care provider for recommendations

National Osteoporosis Foundation Recommendations for Calcium

Women Men

Age 50 & Younger 1000 mg* daily Age 70 & younger 1,000 mg/day

Age 51 & Older 1200 mg* daily Age 71 & older 1,200 mg/day

*this amount Includes calcium obtained from food and supplements

Optimal source is dietary, supplement if diet does not meet requirements

Non-Pharmacologic Management

Non-pharmacological management of fragility fractures aims at

preventing a future fracture fracture. This includes 2 main

strategies:

• Fall prevention

• Hip protectors

Fall prevention is the most effective of the two interventions


15

Pharmacologic Management

• Non adherence major challenge

• Related to:

– Inadequate patient education

– Lack of understanding of relationship between osteoporosis and

fractures / benefit vs. risk

– Following specific requirement for oral administration

– Adverse effects

– Cost

• No agent or treatment should be taken indefinitely

• Monitoring with Bone Mineral Density (DEXA) testing essential

• Therapy needs to be individualized based on risk/benefits

Bone Mineral Density (BMD)

BMD is one measure of bone strength

Peak BMD occurs at about age 30.

Low BMD occurs when the rate of osteoclasts breaking

down bone exceeds the rate of osteoblast regeneration

of new bone.

Bone Mineral Density Testing

• Women age 65 and older

• Men age 70 and older

• Post menopausal age 50-59 based on risks

• Post menopausal starting at age 50 w/fx history

• BMD 1-2 years after initiating RX

• Q 2 years thereafter


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Standard Measure for BMD:Dual Energy X-ray Absorptiometry (DEXA):

Measures bone mineralization. Detects the amount of X-ray that

passes thru the bone. The lower the bone density, the higher the

amount of ray will pass thru. Measured at the spine, hip and

sometimes wrist. DEXA results reported as a T-Score.

Interpreting DEXA T-Score

T-score compares how far the person’s bone density score

varies from the average population, same gender score at

peak bone health. Low bone density T-score has a minus

sign.

• T-score of -1 to -2.5: Osteopenia

• T-score of -2.5 or lower: Osteoporosis

T-Score

T=0-1-2-2.5

Osteoporosis

Normal distribution of

BMD scoresOsteo-

penia


17

When is Pharmacologic Treatment Recommended?

• NOF National Osteoporosis Foundation guidelines recommend

pharmacological treatment based on the following criteria:

• Hip or vertebral fracture

• T-scores of <= -2.5 at femoral neck, total hip or lumbar spine

• Post menopausal women and men age >50 with T-score between -

1.0 and -2.5

• 10-year fracture probability of >3.0% hip fx probability or >20.0%

major osteoporosis-related fracture probability by FRAX

FDA Approved Pharmacologic Management Options

• Anti-resorptive agents

• Selective Estrogen Receptor Modulators (SERMS)

– Raloxifene (Evista)

• Bisphosphonates

– Alendronate, Risedronate, ibandronate (Fosamax, Actonel, Boniva)

• Calcitonin

– Calcitonin (Miacalcin; Fortical)

• Receptor Activator of Nuclear factor Kappa-B ligand (RANKL)

– Denosumab (Prolia)

– Bone Stimulating Agent - Anabolic

• Teriparatide (Forteo)

Individualize Treatment Plan

When developing a treatment plan it is imperative that the

patient be actively involved in the process

• Consider patients’ expectations, concerns and beliefs

• Set realistic and achievable goals

• Communicate information with regard to medical literacy

• For optimal adherence, be willing to negotiate an

acceptable treatment plan

• Active engagement with care provider


18

Secondary Fracture Prevention

• Optimize function

• Prevent future fracture

• Fracture Liaison Nurse Role

• Management of Bone Health

• DEXA Scan

• Pharmacological intervention

• Follow up and referral as needed

• Fall Prevention and Balance Enhancement

National Committee on Quality Assurance, “The State of Health Care Quality 2014”. 2014.

88%

87%

84%

74%

70%

64%

63%

62%

59%

43%

34%

29%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

RA ANTI-RHEUMATOID THERAPY

CHOLESTEROL MANAGEMENT (CVD …

BETA BLOCKERS (POST-HEART ATTACK)

BREAST CANCER SCREENING

PNEUMOCOCCAL VACCINATIONS (2012)

CONTROLLING HIGH BLOOD PRESSURE

COLORECTAL CANCER SCREENING

FALL RISK INTERVENTION

COMPREHENSIVE DIABETES CARE

COPD SPIROMETRY TESTING

FALL RISK DISCUSSION

TESTING/TREATMENT AFTER A FRACTURE

Osteoporosis Care Lags FAR BEHIND

Other Major Diseases/Conditions

Some Improvement in NCQA

HEDIS Post-Fracture Measure*

* National Committee on Quality Assurance, “The State of Health Care Quality 2014”. 2014: 90-91.

2007-2010: little

change

• HMO +0.3%

• PPO +0.7%

2010-2013:

statistically

significant change

• HMO: +8.5%

• PPO: +3.9%


19

The Nurses’ Role in Osteoporosis

Prevention, Diagnosis and Treatment

• Increase patient awareness

• Identify patients at-risk for

osteoporosis and related fractures

• Counsel individuals on risk reduction

strategies with emphasis on promotion of healthy lifestyle choices. These should begin in the childhood years

• Refer to primary healthcare provider to assess need for BMD

• Promote patient adherence with osteoporosis management through support and education

Patient Teaching Points

• Proper way to take prescription medication

• Side effects to watch for (major vs. minor) and what to do about

them

• Counsel calcium & vitamin D (not a substitute for meds)

• Monitor adherence with meds and lifestyle issues

• Refer to tobacco cessation class if indicated

• Counsel re: alcohol moderation

• Counsel re: exercise, safety considerations & fall prevention

measures / Suggest PT referral as needed

• Instruct on the plan for follow up and periodic assessments / bone

density testing

• Support services

Fracture Liaison Service (FLS)

Model of Care

• A coordinated preventive care model

Supervised by bone health specialists and collaborates with

the patient’s primary care physician

Post-fracture care coordinated by an FLS coordinator (RN,

NP, PA or other healthcare professional)

Ensures fracture patients receive appropriate diagnosis,

treatment and support

• Patients tracked via a population registry

• Processes and timelines for patient assessment and follow-up

• Proven success over the last 15 years

• FLS programs have greatly reduced the number of recurrent

fractures by identifying and appropriately treating post-fracture

patients


20

Key Facts About Secondary

Fractures

• A prior fracture almost doubles a patient’s future

fracture risk

• Half of patients presenting with hip fractures have

suffered a prior fracture

• Despite the risk of future fractures, the majority of

fragility fracture patients are neither assessed, nor

treated to reduce fracture risk.

• To achieve a significant reduction in future fracture

rates and resulting health care costs, healthcare

systems must target those patients who have already

suffered a fracture, as they are the ones at highest risk

for future fractures.

Hip

fracture

patients

Objective 1: Improve outcomes

and efficiency of care after hip

fractures by delivering

professional standards per

established performance and

quality measures

Non-hip fragility

fracture patients

Objective 2: Respond to the first

fracture to prevent the second

through establishment of Fracture

Liaison Services bridging

hospital and primary care services

for fracture patients

Individuals at high risk of

first fragility fracture or

other injurious falls

Objective 3: Health insurers or

primary care providers to stratify

risk for their patients using

fracture risk assessment tools

combined with bone density

testing

Older peopleObjective 4: Consistent delivery

of public health messages on

preserving physical activity,

healthy lifestyles and reducing

environmental hazards

Maximize cost-

effectiveness

by stepwise

delivery

Why Secondary Fracture Prevention?

(Adapted from Falls and fractures: Effective interventions in health and social care)

United States FLS Outcomes

1. Kaiser Permanente

• Reduced the hip fracture rate expected by over 40% (since 1998)

• If implemented nationally, a similar effort could reduce the number of hip fractures by over 100,000 (and save over $5 billion/year)

2. Geisinger Health System

• Achieved $7.8 million

in cost savings from 1996-2000

3. American Orthopaedic AssociationOwn the Bone® Program

• Achieved statistically significant changes in health professional behavior/referral (calcium and vitamin D, exercise, fall prevention, etc.)

• Over 190 sites and 20,000+ patients involved from 46 states and the District of Columbia (since mid-2009)

$0

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

1996 1997 1998 1999 2000

Cu

mu

lati

ve

co

sts

(m

illio

ns

$)

No interventionActual results

Savings

(millions)

$ 7.8

$ 7.2

$ 3.1

-$ 2.4

Age

group

65-75

75+

All

55-65

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/documents/digitalasset/dh_109122.pdf


21

Annual Unadjusted Probability of

Osteoporosis Medication Use Within

12 Months After Discharge

Solomon, et al., “Osteoporosis Medication Use after Hip Fracture in U.S. Patients between 2001 and 2011.” JBMR (September 2014);29(9):

1929-37.

FLS Program Goal

Objective: A post-fracture prevention Fracture Liaison

Service (FLS) program aims to ensure that post-

fracture patients receive appropriate diagnosis,

treatment and follow-up

Expected Outcomes: Improved treatment adherence,

reduction in secondary fractures and cost savings

FLS Care Coordination in Action

FLSCoordinator/

PhysicianChampion

PrimaryCare

MedicalSpecialists

Nursing,physicaltherapy,

nutritionist

Hospital/

Emergency Department

Orthopaedics


22

FLS Effectiveness Based on “5 I’s”Identify/Inform/Initiate Treatment/Investigate/Iterate

1. Ganda K et al. Osteoporosis International 2013 Feb; 24(2): 393-406.

2. Osteoporosis Canada. “Make the FIRST break the LAST with Fracture Liaison Services”.

Resources

Fracture Prevention CENTRAL, an Online FLS Resource: this publicly-accessible website

was launched in March 2013 (available at www.FracturePreventionCENTRAL.org) to help

HCPs and administrators implement a coordinator-based, post-fracture FLS model of care to

reduce secondary fractures and the associated costs while increasing patient outcomes:

• NBHA compiled materials from a number of successful domestic and international

post-fracture care programs

• highlights the work of leading FLS programs including the American Orthopaedic

Association Own the Bone program, Kaiser Permanente and Geisinger Health

System

Fracture Prevention CENTRAL enables sites to implement a FLS in support of NBHA’s

20/20 vision to reduce fractures 20% by the year 2020

www.FracturePreventionCENTRAL.org

More than 3,300

individual users

have signed up

to access

these tools

since March

2013


23

The Impact of Osteoporosis and Bone Breaks

in the United States

“Cast Mountain” represents

just 1 DAY of fractures caused

by osteoporosis in the U.S.

Online Professional Education

The complete ISO course curriculum,

including the FLS Certificate of Completion

Pathway is available on-

demand

Professional Education


24

For More Information

NOF: www.NOF.org (Patient education)

www.NOF-ISO.org (FLS Certificate Program)

(202) 223-2223

www.cme.nof.org (Professional Learning Ctr)

NBHA: www.nbha.org/fpc (FLS resources)

http://www.nbha.org/nof-consult-request(FLS 1-on-1 consults)

Ostonics: www.ostonics.com (QCDR registry)

(202) 721-6364

IOF: www.capturethefracture.org (Program recognition)

Questions?

About NOF

Founded in 1984, the National Osteoporosis

Foundation (NOF) is the leading health

organization dedicated to the prevention of

osteoporosis and broken bones; the promotion

of strong bones for life; and the reduction of

human suffering through programs of public and

clinician awareness, education, advocacy, and

research.

http://www.nof.org/

http://www.nof-iso.org/

http://www.cme.nof.org/

http://www.nbha.org/fpc

http://www.nbha.org/nof-consult-request

http://www.ostonics.com/

http://www.capturethefracture.org/

Documents

Fracture Liaison Service (FLS) · 2016. 4. 6. · nicheprogram.org • 2016 Annual NI HE onference • are Across the ontinuum 1 Improving Patient Care with Fracture Liaison Service