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Please note that the citations in this document have active EndNote links that have been created with the Thomson Reuters EndNote version X6 software. If you have this software, Reference Manager or other bibliographic software, you could export the Travelling Library into your software package. The output style has been set to Archives of Internal Medicine format.
[Insert name of local healthcare economy]
Executive Summary
Fracture Liaison Services improve quality and reduce costs through a reduction in unscheduled emergency admissions for hip and other fragility fractures
XXX patients from [Insert District Health Board] present with hip fracture to [Insert hospital] incurring an annual cost of NZ$YYY,YYY
Half of hip fracture patients suffer a fragility fracture of the wrist, shoulder, humerus, hip or other skeletal sites prior to breaking their hip HYPERLINK \l "_ENREF_1" \o "Edwards, 2007 #1" ADDIN EN.CITE ADDIN EN.CITE.DATA 1-4
Osteoporosis treatments subsidised by the Ministry of Health HYPERLINK \l "_ENREF_5" \o "New Zealand Government, 2012 #5" ADDIN EN.CITE ADDIN EN.CITE.DATA 5-8 have the potential to halve secondary hip fracture incidence if initiated when patients present to hospital with their first fragility fracture HYPERLINK \l "_ENREF_9" \o "Black, 1996 #9" ADDIN EN.CITE ADDIN EN.CITE.DATA 9-17
Fracture Liaison Services (FLS) have been recognised by many policymakers throughout the world HYPERLINK \l "_ENREF_18" \o "Department of Health, 2009 #21" ADDIN EN.CITE ADDIN EN.CITE.DATA 18-28, professional organisations HYPERLINK \l "_ENREF_29" \o "British Orthopaedic Association, 2007 #28" ADDIN EN.CITE ADDIN EN.CITE.DATA 29-33 and patient societies HYPERLINK \l "_ENREF_34" \o "Marsh, 2011 #32" ADDIN EN.CITE ADDIN EN.CITE.DATA 34-39 as the optimal model of care to reliably deliver secondary preventive care for fragility fracture patients
Successful FLS have been established in Australia HYPERLINK \l "_ENREF_40" \o "Giles, 2011 #35" ADDIN EN.CITE ADDIN EN.CITE.DATA 40-44, Canada HYPERLINK \l "_ENREF_45" \o "Bogoch, 2006 #40" ADDIN EN.CITE ADDIN EN.CITE.DATA 45-48, Europe HYPERLINK \l "_ENREF_49" \o "Clunie, 2008 #44" ADDIN EN.CITE ADDIN EN.CITE.DATA 49-58, Singapore ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_59" \o "Chandran, 2013 #139" 59, HYPERLINK \l "_ENREF_60" \o "Chandran, 2013 #140" 60 and the United States HYPERLINK \l "_ENREF_61" \o "Dell, 2009 #54" ADDIN EN.CITE ADDIN EN.CITE.DATA 61-63
The results of audits of secondary preventive care conducted in New Zealand ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_30" \o "Dreinhofer, 2004 #29" 30, HYPERLINK \l "_ENREF_64" \o "Bloomfield, 2011 #57" 64-67 concur with findings from numerous similar reports from elsewhere HYPERLINK \l "_ENREF_68" \o "Teede, 2007 #61" ADDIN EN.CITE ADDIN EN.CITE.DATA 68 HYPERLINK \l "_ENREF_69" \o "Chen, 2009 #62" ADDIN EN.CITE ADDIN EN.CITE.DATA ADDIN EN.CITE.DATA ADDIN EN.CITE.DATA ADDIN EN.CITE.DATA 69-114; in the absence of an FLS, fragility fracture patients are neither assessed nor treated for osteoporosis
FLS have been demonstrated to be highly cost-effective in health economic evaluations from Australia HYPERLINK \l "_ENREF_115" \o "Cooper, 2012 #108" ADDIN EN.CITE Cooper201210810810817Cooper, M. S.Palmer, A. J.Seibel, M. J.University of Birmingham, Birmingham, UK. m.s.cooper@bham.ac.ukCost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention studyOsteoporos IntOsteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USAOsteoporos Int97-1072312011/09/292012Jan1433-2965 (Electronic)
0937-941X (Linking)21953475Research Support, Non-U.S. Gov'thttp://www.ncbi.nlm.nih.gov/pubmed/2195347510.1007/s00198-011-1802-zeng115, Canada HYPERLINK \l "_ENREF_116" \o "Sander, 2008 #109" ADDIN EN.CITE ADDIN EN.CITE.DATA 116, the UK ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_19" \o "Department of Health, 2009 #22" 19, HYPERLINK \l "_ENREF_117" \o "McLellan, 2011 #110" 117 HYPERLINK \l "_ENREF_104" \o "McLellan, 2011 #134" and the United States HYPERLINK \l "_ENREF_118" \o "Dell, 2008 #111" ADDIN EN.CITE Dell200811111111117Dell, R.Greene, D.Schelkun, S. R.Williams, K.Richard.M.Dell@kp.orgOsteoporosis disease management: the role of the orthopaedic surgeonJ Bone Joint Surg AmThe Journal of bone and joint surgery. American volumeJ Bone Joint Surg Am188-9490 Suppl 42008/11/15AgedAged, 80 and overFemaleFractures, Spontaneous/prevention & controlHip Fractures/diagnosis/*prevention & controlHumansMaleMiddle AgedOrthopedicsOsteoporosis/*complicationsPatient Education as TopicProspective StudiesRole2008Nov1535-1386 (Electronic)18984730Research Support, Non-U.S. Gov'thttp://www.ncbi.nlm.nih.gov/pubmed/1898473010.2106/JBJS.H.00628eng118
[Insert name of local healthcare economy] does not have a Fracture Liaison Service as of [DD-MM-YYYY]
The Ministry of Health requires all DHBs to operate a FLS in 2014-15 HYPERLINK \l "_ENREF_26" \o "Ministry of Health, 2014 #138" ADDIN EN.CITE Ministry of Health201413813813846Ministry of Health,2014/15 ANNUAL PLAN Guidelines (Including Planning Priorities) WITH STATEMENT OF INTENT and STATEMENT OF PERFORMANCE EXPECTATIONS2014Wellington.26.
This business plan makes the case for urgent commissioning of a Fracture Liaison Service, structured in accordance with successful models from elsewhere, to reduce the incidence of hip fracture amongst our older people
The need for a Fracture Liaison Service in [Insert name of local healthcare economy]
Hip fractures are costly to patients and the New Zealand health care system
The incidence of hip fracture in New Zealand was estimated to be 3,803 cases per year in 2007, at a cost of NZ$105 million HYPERLINK \l "_ENREF_119" \o "Brown, 2011 #112" ADDIN EN.CITE ADDIN EN.CITE.DATA 119. Given that hip fractures represent up to 20% of all fragility fractures that come to clinical attention HYPERLINK \l "_ENREF_120" \o "Kanis, 2012 #113" ADDIN EN.CITE Kanis201211311311317Kanis, J. A.Oden, A.McCloskey, E. V.Johansson, H.Wahl, D. A.Cooper, C.on behalf of the, I. O. F. Working Group on EpidemiologyQuality of, LifeWHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK, w.j.pontefract@sheffield.ac.uk.A systematic review of hip fracture incidence and probability of fracture worldwideOsteoporos IntOsteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USAOsteoporos Int2012/03/162012Mar 151433-2965 (Electronic)
0937-941X (Linking)22419370http://www.ncbi.nlm.nih.gov/pubmed/2241937010.1007/s00198-012-1964-3Eng120, approximately 19,000 fragility fracture presentations to urgent care services occur in New Zealand every year. The annual incidence of hip fractures in women aged 60 years and over in 1991 was 1,830 HYPERLINK \l "_ENREF_121" \o "Lane, 1996 #114" ADDIN EN.CITE Lane199611411411417Lane, A.Independent Research Economist, Auckland, New Zealand.Direct costs of osteoporosis for New Zealand womenPharmacoeconomicsPharmacoEconomicsPharmacoeconomicsPharmacoEconomicsPharmacoeconomicsPharmacoEconomics231-45931996/02/07*Cost of IllnessFemaleFractures, Bone/economicsHealth Care CostsHip Fractures/economics/epidemiologyHumansMaleNew Zealand/epidemiologyOsteoporosis/drug therapy/*economics/epidemiology1996Mar1170-7690 (Print)
1170-7690 (Linking)10160099Research Support, Non-U.S. Gov'thttp://www.ncbi.nlm.nih.gov/pubmed/10160099eng121 which had risen to 2,639 by 2007 HYPERLINK \l "_ENREF_119" \o "Brown, 2011 #112" ADDIN EN.CITE ADDIN EN.CITE.DATA 119, an increase of 44%. In 2007, the total direct cost of osteoporosis in New Zealand was estimated to be NZ$330 million per year ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_119" \o "Brown, 2011 #112" 119, HYPERLINK \l "_ENREF_122" \o "Brown P, 2007 #115" 122. As New Zealands 1 million baby boomers began to retire in 2011 HYPERLINK \l "_ENREF_123" \o "Cleaver, 2000 #116" ADDIN EN.CITE Cleaver200011611611617Cleaver, M.Green, B.C.Muller, T.E.Using consumer behaviour research to understand the baby boomer touristJournal of Hospitality & Tourism ResearchJournal of Hospitality & Tourism Research274-2872422000123, hip fractures will continue to exert a tremendous burden on older New Zealanders and the New Zealand healthcare system.
Half of hip fracture patients give advance notice
Studies from Australia HYPERLINK \l "_ENREF_4" \o "Port, 2003 #4" ADDIN EN.CITE ADDIN EN.CITE.DATA 4, the UK HYPERLINK \l "_ENREF_3" \o "McLellan, 2004 #3" ADDIN EN.CITE McLellan200433327McLellan, ARReid, DMForbes, K Reid, RCampbell, CGregori, ARaby, NSimpson, AEffectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03)2004NHS Quality Improvement Scotlandhttp://www.nhshealthquality.org/nhsqis/files/99_03FullReportFINAL_040705.pdf3 and the USA ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_1" \o "Edwards, 2007 #1" 1, HYPERLINK \l "_ENREF_2" \o "Gallagher, 1980 #2" 2 have demonstrated that approximately half of hip fracture patients suffer a fragility fracture at another skeletal site prior to breaking their hip. Amongst women aged over 50 years, approximately one sixth of the population has a history of fragility fracture ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_34" \o "Marsh, 2011 #32" 34, HYPERLINK \l "_ENREF_124" \o "Mitchell, 2011 #117" 124. Based on policy developed by the Department of Health in England HYPERLINK \l "_ENREF_18" \o "Department of Health, 2009 #21" ADDIN EN.CITE Department of Health200921212146Department of Health,Department of Health,Falls and fractures: Effective interventions in health and social care.2009http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_10314621-07-201118, an estimate of number of post-menopausal women that would require secondary preventive assessment can be made for a District Health Board population:
Implementation of guidelines HYPERLINK \l "_ENREF_125" \o "Mak, 2011 #118" ADDIN EN.CITE ADDIN EN.CITE.DATA 125-127 regarding secondary prevention of fracture has the potential to halve subsequent hip fracture incidence for patients that have suffered a fragility fracture at any skeletal site.
Fracture Liaison Services: clinically and cost-effective care
Definition of a Fracture Liaison Service: A Fracture Liaison Service (FLS) is a system to ensure fracture risk assessment, and treatment where appropriate, is delivered to all patients with fragility fractures. An FLS is usually comprised of a dedicated case worker, often a clinical nurse specialist, who works to pre-agreed protocols to case-find and assess fracture patients. An FLS is usually based in hospital and requires support from a medically qualified practitioner. The structure of a hospital-based FLS is indicated in the diagram below which was adapted from the UK Blue Book on the care of patients with fragility fracture HYPERLINK \l "_ENREF_29" \o "British Orthopaedic Association, 2007 #28" ADDIN EN.CITE British Orthopaedic Association200728282827British Orthopaedic Association,British Geriatrics Society,The care of patients with fragility fracture2nd2007http://www.fractures.com/pdf/BOA-BGS-Blue-Book.pdf21-07-201129.
Figure 1. The structure of the Glasgow Fracture Liaison Service adapted from The care of patients with fragility fracture HYPERLINK \l "_ENREF_29" \o "British Orthopaedic Association, 2007 #28" ADDIN EN.CITE British Orthopaedic Association200728282827British Orthopaedic Association,British Geriatrics Society,The care of patients with fragility fracture2nd2007http://www.fractures.com/pdf/BOA-BGS-Blue-Book.pdf21-07-201129
* Older patients, where appropriate, are identified and referred for falls assessment
FLS is clinically and cost-effective: The business plan authors may choose to insert one or more of the case studies on successful FLS described in section 4.2 of this Fracture Liaison Service Resource Pack e.g. the Minimal Trauma Fracture Liaison (MTFL) service HYPERLINK \l "_ENREF_42" \o "Lih, 2011 #37" ADDIN EN.CITE Lih201137373717Lih, A.Nandapalan, H.Kim, M.Yap, C.Lee, P.Ganda, K.Seibel, M. J.Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, and Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord, Sydney NSW 2139, Australia.Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled studyOsteoporos IntOsteoporos Int849-582232010/11/262011Mar1433-2965 (Electronic)
0937-941X (Linking)21107534http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2110753410.1007/s00198-010-1477-xeng42 at Concord Repatriation General Hospital, Sydney. Also please note that a case study on the first FLS to be established in New Zealand, the Waitemata DHB FLS HYPERLINK \l "_ENREF_128" \o "Waitemata District Health Board, 2013 #146" ADDIN EN.CITE Waitemata District Health Board201314614614613Waitemata District Health Board,Board Meeting Agenda201312 December 2013http://www.waitematadhb.govt.nz/LinkClick.aspx?fileticket=Kc7MDO8jttE%3D&tabid=76128, is available from the Osteoporosis New Zealand website at HYPERLINK "http://osteoporosis.org.nz/resources/health-professionals/fracture-liaison-services/" http://osteoporosis.org.nz/resources/health-professionals/fracture-liaison-services/.
Service structure: The Minimal Trauma Fracture Liaison (MTFL) service HYPERLINK \l "_ENREF_42" \o "Lih, 2011 #37" ADDIN EN.CITE Lih201137373717Lih, A.Nandapalan, H.Kim, M.Yap, C.Lee, P.Ganda, K.Seibel, M. J.Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, and Bone Research Program, ANZAC Research Institute, The University of Sydney at Concord, Sydney NSW 2139, Australia.Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled studyOsteoporos IntOsteoporos Int849-582232010/11/262011Mar1433-2965 (Electronic)
0937-941X (Linking)21107534http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2110753410.1007/s00198-010-1477-xeng42 was established in 2005 at this large tertiary referral centre in Sydney. The MTFL service provides a good illustration of effective collaboration between a physician-led FLS and the hospitals Orthogeriatrics Service; the MTFL provides care for non-frail patients with fragility fractures whilst the Orthogeriatrics Service HYPERLINK \l "_ENREF_27" \o "NSW Government Health, 2010 #121" ADDIN EN.CITE NSW Government Health201012112112146NSW Government Health,New South Wales Agency for Clinical Innovation,The Orthogeriatric Model of Care: Summary of Evidence 20102010North Rydehttp://www.health.nsw.gov.au/resources/gmct/agedcare/pdf/aci_orthogeriatrics_summary_of_evidence.pdf24 February 201227 focuses on frail patients, including the majority of hip fractures. The MTFL is delivered by an advanced trainee (i.e. a physician in his/her 4th-6th year of post-graduate training) which required a 0.4-0.5 FTE appointment.
Service outcomes: The impact of the MTFL service was evaluated after 4 years. Fracture patients who chose to decline the consultation freely offered by the service, in favour of follow-up with their primary care physician, were considered as a control group for statistical comparison. Refracture incidence for those patients managed by the MTFL service was 80% lower than the control group.
A recently published cost-effectiveness analysis HYPERLINK \l "_ENREF_115" \o "Cooper, 2012 #108" ADDIN EN.CITE Cooper201210810810817Cooper, M. S.Palmer, A. J.Seibel, M. J.University of Birmingham, Birmingham, UK. m.s.cooper@bham.ac.ukCost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention studyOsteoporos IntOsteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USAOsteoporos Int97-1072312011/09/292012Jan1433-2965 (Electronic)
0937-941X (Linking)21953475Research Support, Non-U.S. Gov'thttp://www.ncbi.nlm.nih.gov/pubmed/2195347510.1007/s00198-011-1802-zeng115 of the MTFL service reported:
A mean improvement in discounted quality-adjusted life expectancy per patient of 0.089 QALY gained
Partial offset of the higher costs of the MTFL service by a decrease in subsequent fractures, which lead to an overall discounted cost increase of AU$1,486 per patient over the 10-year simulation period
The incremental costs per QALY gained (incremental cost-effectiveness ratio - ICER) were AU$17,291, which is well below the Australian accepted maximum willingness to pay for one QALY gained of AU$50,000
Endorsement of FLS: A growing number of professional organisations HYPERLINK \l "_ENREF_29" \o "British Orthopaedic Association, 2007 #28" ADDIN EN.CITE ADDIN EN.CITE.DATA 29-33, patient societies HYPERLINK \l "_ENREF_34" \o "Marsh, 2011 #32" ADDIN EN.CITE ADDIN EN.CITE.DATA 34-39 and policymakers HYPERLINK \l "_ENREF_18" \o "Department of Health, 2009 #21" ADDIN EN.CITE ADDIN EN.CITE.DATA 18-28 throughout the world have recognised the need for systematic approaches to secondary fracture prevention. A number of expressions have been adopted to describe exemplar service models, including Fracture Liaison Services in Europe HYPERLINK \l "_ENREF_49" \o "Clunie, 2008 #44" ADDIN EN.CITE ADDIN EN.CITE.DATA 49-58, Australia HYPERLINK \l "_ENREF_40" \o "Giles, 2011 #35" ADDIN EN.CITE ADDIN EN.CITE.DATA 40-44 and Asia ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_59" \o "Chandran, 2013 #139" 59, HYPERLINK \l "_ENREF_60" \o "Chandran, 2013 #140" 60, Co-ordinator Programs in Canada HYPERLINK \l "_ENREF_45" \o "Bogoch, 2006 #40" ADDIN EN.CITE ADDIN EN.CITE.DATA 45-48 and Care Manager Programs in the United States HYPERLINK \l "_ENREF_61" \o "Dell, 2009 #54" ADDIN EN.CITE ADDIN EN.CITE.DATA 61-63. Regardless of the terminology, all of these service models deliver high quality secondary preventive care through identification, investigation and intervention for fragility fracture sufferers, with the aim of preventing future fractures.
[Insert name of local healthcare economy] does not have an FLS as of [DD-MM-YYYY].
A Fracture Liaison Service for [Insert name of local healthcare economy]
This business plan makes the case for urgent commissioning of a Fracture Liaison Service in [Insert name of local healthcare economy], structured in accordance with successful models from elsewhere, to reduce the incidence of hip fracture amongst our older people.
The Ministry of Health requires all DHBs to operate a FLS in 2014-15 HYPERLINK \l "_ENREF_26" \o "Ministry of Health, 2014 #138" ADDIN EN.CITE Ministry of Health201413813813846Ministry of Health,2014/15 ANNUAL PLAN Guidelines (Including Planning Priorities) WITH STATEMENT OF INTENT and STATEMENT OF PERFORMANCE EXPECTATIONS2014Wellington.26.
Aim: The aim of the proposed Fracture Liaison Service is to ensure that all patients aged 50 years and over presenting to urgent care services with fragility fractures receive assessment and treatment, where appropriate, for osteoporosis and referral to local falls prevention services to reduce their risk of subsequent fractures.
Current provision: An assessment of current service provision sets a context for funders to consider the merits of the business plan.
Service model: The Fracture Liaison Service will be structured in accordance with successful models from elsewhere. The author(s) of the business plan is/are referred to international publications below to inform the description of the proposed FLS model in their business plan including:
Seibel MJ, Lih A, Nandapalan H et al. Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporosis International. 2011 Mar;22(3):849-858. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/21107534" PubMed ID 21107534
Bogoch ER, Elliot-Gibson V, Beaton DE et al. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. Journal of Bone and Joint Surgery (Am). 2006 Jan;88(1):25-34. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/16391246" PubMed ID 16391246
McLellan A, Gallacher S, Fraser M et al. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporosis International. 2003;14(12):1028-1034. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/14600804"PubMed ID 14600804
Greene D, Dell RM. Outcomes of an osteoporosis disease-management program managed by nurse practitioners. Journal of the American Academy of Nurse Practitioners. 2010 Jun;22(6):326-329. HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/20536631" PubMed ID 20536631
Budgetary impact of an FLS for [Insert name of local healthcare economy]
The recurrent cost of the proposed Fracture Liaison Service of [NZ$XXX,XXX] per year is less than/comparable to the cost of [H] hip fractures to the District Health Board service budget. If the service prevents [P%] of hip fractures overall, this would save [NZ$YYY,YYY] in terms of averted fractures.
Number of hip fractures per year at this facility (H)
Number of fragility fractures at all skeletal sites at this facility (A)
Estimated cost of hip fracture (NZ$ C)
Total Cost of hip fracture per year at this facility (NZ$HxC)
Estimated average reduction in hip fracture readmission costs e.g. [P%] of (NZ$HxC) = (S)
Cost of liaison service (NZ$185xA) HYPERLINK \l "_ENREF_115" \o "Cooper, 2012 #108" ADDIN EN.CITE Cooper201210810810817Cooper, M. S.Palmer, A. J.Seibel, M. J.University of Birmingham, Birmingham, UK. m.s.cooper@bham.ac.ukCost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention studyOsteoporos IntOsteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USAOsteoporos Int97-1072312011/09/292012Jan1433-2965 (Electronic)
0937-941X (Linking)21953475Research Support, Non-U.S. Gov'thttp://www.ncbi.nlm.nih.gov/pubmed/2195347510.1007/s00198-011-1802-zeng115 = (L)
Cost saving per year (S)-(L)
Assumptions
Based on Australian experience, the cost of liaison services average of NZ$1,850 over ten years HYPERLINK \l "_ENREF_115" \o "Cooper, 2012 #108" ADDIN EN.CITE Cooper201210810810817Cooper, M. S.Palmer, A. J.Seibel, M. J.University of Birmingham, Birmingham, UK. m.s.cooper@bham.ac.ukCost-effectiveness of the Concord Minimal Trauma Fracture Liaison service, a prospective, controlled fracture prevention studyOsteoporos IntOsteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USAOsteoporos Int97-1072312011/09/292012Jan1433-2965 (Electronic)
0937-941X (Linking)21953475Research Support, Non-U.S. Gov'thttp://www.ncbi.nlm.nih.gov/pubmed/2195347510.1007/s00198-011-1802-zeng115
Only hip fractures are averted (about 20% of osteoporotic fractures are hip)
Service models and hence success rates and costs vary between facilities
Proviso: This estimate is simplistic and contains many assumptions, not including the impact of approximately 20% to 30% one year mortality after hip fracture = 25% x (H).
Insert local data on the total number of hip fracture admissions and non-hip fragility fracture patients managed as in-patients and out-patients respectively. Consider producing a table as indicated below:
Provide local costs associated with hospital, primary care and Local Authority funded social care related to these fractures.
Projected Costs and Income
Capital Expenses NZ$XX,XXX
Recurrent Expenses
1 Full time equivalent, band (X) Fracture Liaison Nurse NZ$XX,XXX
Clerical support as required NZ$X,XXX
Acquisition of database and support package NZ$XXX
Production and postage of reports and questionnaires NZ$X,XXX
Support literature NZ$XXX
DXA equipment service contract NZ$X,XXX
DXA equipment depreciation/replacement costs NZ$X,XXX
Room charges NZ$XXX
Other NZ$X,XXX
Total Recurrent Costs NZ$XX,XXX
Revenue
Additional DXA scans NZ$XX,XXX
Additional outpatient appointments NZ$XX,XXX
Additional procedures e.g. i.v. therapy NZ$X,XXX
Total Additional Revenue NZ$XX,XXX
Revenue Surplus Generated (revenue-costs) NZ$XX,XXX
Summary
Hip fractures exert a substantial toll on our local older people and the healthcare budgets. Half of hip fracture patients give us considerable advance notice that one day they will present to the local orthopaedic unit. Half of hip fracture patients suffer prior fragility fractures that could and should serve as a trigger for secondary preventive care.
Implementation of a Fracture Liaison Service in [Insert name of local healthcare economy] will close the secondary fracture prevention gap in our area. The Fracture Liaison Service will improve the quality of care we give and reduce costs associated with preventable fragility fractures. This business plan recommends commissioning of this service as a matter of urgency, in accordance with Ministry of Health requirements for 2014-15 HYPERLINK \l "_ENREF_26" \o "Ministry of Health, 2014 #138" ADDIN EN.CITE Ministry of Health201413813813846Ministry of Health,2014/15 ANNUAL PLAN Guidelines (Including Planning Priorities) WITH STATEMENT OF INTENT and STATEMENT OF PERFORMANCE EXPECTATIONS2014Wellington.26.
References
ADDIN EN.REFLIST 1. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res. Aug 2007;461:226-230.
2. Gallagher JC, Melton LJ, Riggs BL, Bergstrath E. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop Relat Res. Jul-Aug 1980(150):163-171.
3. McLellan A, Reid D, Forbes K, et al. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03): NHS Quality Improvement Scotland; 2004.
4. Port L, Center J, Briffa NK, Nguyen T, Cumming R, Eisman J. Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int. Sep 2003;14(9):780-784.
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8. New Zealand Government. Form SA1187 Application for subsidy by special authority: Zoledronic acid. In: Health Mo, ed. Wanganui; 2012.
9. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. Dec 7 1996;348(9041):1535-1541.
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In a District Health Board population of 300,000, there are likely to be:
55,000 post-menopausal women
17,400 post-menopausal women with osteoporosis
6,900 post-menopausal women with a previous fracture of any kind
900 post-menopausal women with a new fracture each year
The last two groups above constitute just 16% of the local population. But it is among this 16% that half of the hip fractures occur. Targeting these groups in primary care and through Fracture Liaison case-finding Services in hospital provides ready access to those at greatest risk of hip fractures.
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