EU Fallsfest Bologna February 2016 Professor Finbarr Martin Geriatrician, Guys and St Thomas’ NHS Trust and King’s College London, UK Developing a comprehensive national approach for falls and fragility fractures reduction: obstacles, alliances and opportunities
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EU Fallsfest Bologna February 2016
Professor Finbarr Martin Geriatrician, Guys and St Thomas’ NHS Trust
and King’s College London, UK
Developing a comprehensive national approach for falls and fragility fractures reduction: obstacles, alliances and opportunities
Declarations
I am speaking in personal capacity, but am also • Clinical lead for the England national falls and
fragility fracture audit programme • Non-executive director of NICE (both funded by the England Dept of Health) • No commercial conflicts of interest
Summary
• this is a story of events the facts are true but the explanations are just opinions the are many actors
Policy and guidance
National Service Framework for Older People (Dept Health 2001)
Standard 6 (of 8) “By 2005, all local health systems should have established an integrated service for the prevention of falls and fractures” “ The aim of this standard is to reduce the number of falls resulting in serious injury and ensure effective treatment and rehabilitation for those who have fallen”
NICE Falls Guidelines 2004 – (updated 2012)
Recurrent falls Single fall No intervention
No falls
Periodic case finding in Primary Care: Ask all patients about falls in past year
Gait/balance problems ? No problems
Patient presents to
medical facility after a
fall
Assessment History and Medications Vision Gait and balance Lower limbs Neurological Cardiovascular Osteoporosis Risk
There was a 90% return rate. Median overall score for the National Audit was 63 Trusts could participate as one whole Trust if services were similar or where there was disparity they could participate as more than one site per Trust. Key Message: Great variation around the country in the provision of services for falls and bone health The National report was divided into six domains (Scores were allocated to each section to enable benchmarking) Commissioning Case finding and referral Specialist Falls Service Specialist falls management Links with key service settings Training and audit
Main results
At 16 weeks post # Calcium/ Vitamin D Bisphosphonate (or other) Some form of exercise training Evidence based
5642 non-hip fragility #
23% 20%
22% 8%
3184 hip fractures
52% 43%
44% 22%
Responses
• Professional • Stakeholders • National policy
Create inter-professional collaboration describing best practice and six standards
The Blue Book and the NHFD
1. Admission to orthopaedic ward within 4 hours
2. Surgery within 36 hours by senior surgeon and anaesthetist in dedicated list
3. Pain relief, pressure area prevention
4. Preoperative assessment by trained orthogeriatrician
2014 audit data arranged around key questions that focus groups have identified
2015: Run chart showing change over time in key performance variables in each service
What about secondary falls and fractures prevention?
IN CONTRAST Incentive in GP Contract 2012
• All patients with fragility fracture on a register • All over 75 with fragility fracture on secondary
prevention treatment and Calcium/Vit D unless justifiable exemption
• Under 75s with previous fracture or at risk of osteoporosis to have investigation and assessment of bone fragility
• With appropriate treatment commenced if osteoporosis proven
ineffective
RCP Falls and Bone Health Audit 2011 (compared to 2008)
2014 – fracture liaison services database
• ~ 35% hospitals participated • large variation in staffing and scope • indicators of what works • funding to continue till 2018
2015 data
Supported by a Falls and Fractures Alliance and Implementation Champions
What about community falls work?
• We have no reliable data on process or outcomes • We have 4000 postural stability instructors trained • We have large variation in service approaches
Why so difficult?
•The NICE guidance is not easy to operationalise in a quantitative way • Ownership is diffuse • Regard for evidence is variable
Possible ways forward
• Focus on community frailty interventions • Promote all types of physical activity and exercise programmes – (don’t mention falls!)
In hospital falls
•2015 National audit programme: 100% participation • Now built into regulator assessments of acute hospitals (CQC) MD falls group 85% Discuss falls rates/1000 OBDs 79% Vision assessment within 3days 43% Ax for Orthostatic hypotension 16% Delirium assessment 36% Mobility aids nearby 68%
But what should be done to improve things?
• RCT evidence for inpatient falls reduction is mixed, despite some definite successes • Implementation is contextual • Quality improvement approaches incorporating falls and other issues may be more effective than refining a universal package
What has helped promote change?
• Evidence helps • Policy and top down pressure alone cannot do it • Inter-specialty collaboration and peer pressure • Reliable clinical performance data • Stakeholder pressure and assistance • Financial incentives don’t work alone
Acknowledgements
• Rikshoft – the original Sweden hip audit • BGS and BOA as partners • Dave Marsh as founder leader of NHFD • Blue Book Authorship Group • NOS and AgeUK –stakeholder partners • DH – for policy • FFFAP programme Board and advisory groups • Royal College of Physicians of London – for managing