Consultant orthogeriatrician (OG) Other orthogeriatric support Fracture liaison nurse (FLN) Orthopaedic/ specialist nurse Lead clinician 1 0 0.5 WTE 2.3:1000 patients 1 WTE 4.5:1000 patients 0 1 (rheumatologist) 2 1.0 WTE 2:1000 patients 1 WTE 2:1000 patients 0 0 1 (orthogeriatrician) 3 0.1 WTE 0.3:1000 patients 1 WTE 3:1000 patients 0 0 0 4 0.5 WTE 1.3:1000 patient 0.2 WTE 0.5:1000 patients 0.5 WTE 1.3:1000 patients 0 1 (rheumatologist) 5 0.33 WTE 1.5:1000 patients 0.6 WTE (trust grade orthogeriatrician) 3.7:1000 patients 0 0 0 6 0.5 WTE 2.1:1000 people 0 0 1 WTE 4:1000 patients 1 (rheumatologist) 7 0.7 WTE 1:1000 patients 0.75 WTE 1:1000 patients 0 1.8 WTE 2.6:1000 patients 1 (rheumatologist) 8 1 WTE (1.6:1000 patients) 5 WTE 8:1000 patients 0 0 1 (orthogeriatrician) 9 0 0.25 WTE 1:1000 patents 0 2 WTE 8:1000 patients 2 (specialist nurse-outpatient, orthopaedic 10 0.9 WTE 2:1000 patients 1 WTE 2:1000 patients 1.6 WTE 3:1000 patients 2.2 WTE 4.6:1000 patients 1 (rheumatologist) 11 0.4 WTE 2.3:1000 patients 1 WTE 5.7:1000 patients 0.2 WTE 1:1000 patients 0 1 (orthogeriatrician) Table 1 provides the WTEs and proportion of specialist staff per 1000 hip fracture patients at each hospital, including orthogeriatricians, fracture liaison nurses, falls nurses, lead clinicians or ‘osteoporosis champions’. This highlights the differences in staffing levels across hospitals. For
5 Sept 2009 Trust grade orthogeriatrician appointed 6 Nov 2005 2011 Orthogeriatrician appointed Trauma speciality nurse appointed 7 July 2004 June 2007 Oct 2007 Geriatrician appointed, hip fracture ward opened A second trauma speciality nurse appointed Specialty doctor in geriatrics appointed 8 March 2009 Clinical lead orthogeriatrician appointed 9 Nov 2003 April 2005 2009 Orthopaedic nurse specialist appointed Osteoporosis nurse specialist appointed Staff grade orthogeriatrician 10 Dec 2004 May 2006 May 2008 Nov 2009 Nov 2011 FLN appointed FLNs and consultant lead appointed, Comprehensive trauma FLNs appointed Consultant orthogeriatrician appointed New monitoring pathway and two geriatricians appointed 11 Feb 2011 Nov 2011 Consultant geriatrician appointed FLN appointed Looking specifically at how WTE of specialist staff changed between 2003 and 2103 (Table 6), we see a general increase in the number of consultant orthogeriatricians and specialist nurses across most hospitals in the region, reflecting new guidelines for both optimal recovery after hip fracture and secondary fracture prevention introduced during this period.
Table 8 Participant characteristics (aggregated to ensure anonymity) Professional group Number of participants Years spent working in current roles (range) Years spent working at the hospital (range) Number of these participants who had experience of making business cases for a FLS Fracture Prevention Nurses 8 1-15 1-27 5 Orthogeriatricians 4 4-13 4-16 4 Geriatricians 4 3-21 2-6 4 GP Osteoporosis Specialists 2 10-43 10-20 2 Consultant Trauma Orthopaedic Surgeons 5 <1-32 2-19 3 Rheumatology Consultants 8 5-25 5-25 6 Additional nursing staff (Orthopaedic Nurses, Trauma Matrons, Matrons for Hip Fracture Units) 4 3-14 3-25 3 Falls 1 1 20 0 Falls Nurses 1 23 23 0 Bone Densitometry Specialists 1 11 12 1 Service Managers 5 2-6 <1-5 5
Table 29 Risk equations estimating the probability of events and all-cause mortality Event 2nd hip 30-day after first hip fracture 30-day after second hip fracture All-cause post 30 days 59740 60557 32989 2197 62907 Patients 29888 29888 32989 2197 29888 No of events 2206 1464 3101 173 13008 Functional form Logistic Logistic Mean SE Mean SE Mean SE Mean SE Mean SE Constant -6.951 -6.867 -8.705 -6.264 -7.471 ρ 1.099 1.259 γ 0.012 Female 0.117 0.481 -0.505 -0.623 -0.436 Age at 1st hip fracture 0.042 0.028 0.075 0.072 Age at 2nd hip fracture 0.048 Care home 0.451 0.236 0.360 2.092 0.18 0.14 0.17 0.05 0.02 0.05 0.21
fracture Table 34 Hospital care cost equations (2) Hospitalisation costs if major fracture occurs (subsequent years to 1st hip fracture) Probability of hospitalisation given death Hospitalisation costs if death occurs (conditional on hospitalisation) Patient-years 968 9,282 5,404 No. of patients 899 9,282 5,404 Distributional form Gamma Logistic Gamma Link function Identity Identity Parameters Mean SE Mean SE Mean SE Constant 11582 1057 3.970 0.269 19401 1489 Living in care home 2001 606 -0.209 0.043 896 235 Current age -0.038 0.003 -144 17 Female -2953 1096 -0.251 0.053
After combining costs and outcomes in an incremental cost-effectiveness analysis, and at a £30,000 per QALY threshold, the most cost-effective model of care was introducing an orthogeriatrician (Table 39). The probability of adding an OG being the most cost-effective option at £30,000/QALY was estimated to about 70% across both sexes. Table 39 Cost-effectiveness of the differing models of secondary prevention care of hip fractures Male cohort Difference in costs Difference in LYs Difference in QALYs ICER (£/LY) ICER (£/QALY) Prob that is the most at £30,000/ QALY Usual care - - - - - 0% Fracture liaison nurse vs. usual care to 2592) 0.157 (0.096 to 0.215) 0.097 (0.057 to 0.133) £12,492 £20,302 30% Orthogeriatrician vs. fracture liaison nurse £646 (-132 to 1503) 0.044 (-0.026 to 0.125) 0.028 (-0.016 to 0.078) £14,640 £23,271 70% Female cohort Usual care - - - - - 0% Fracture liaison nurse vs. usual care £1,899 (1272 to 2515) 0.148 (0.092 to 0.204) 0.091 (0.056 to 0.127) £12,871 £20,794 30% Orthogeriatrician vs. fracture liaison nurse £632 (-125 to 1443) 0.043 (-0.026 to 0.119) 0.027 (-0.017 to 0.075) £14,683 £23,189 70% Figure 31 reports the CEAC and EVPI per female patient associated with the different models of care. The population EVPI over 5 years was estimated to be £23 million at the £30,000 per QALY gained threshold. This suggests that undertaking additional major commissioned research work to further reduce decision uncertainty is likely to be of significant benefit.
vs. usual care fracture liaison nurse Base case £20,794 £23,189 Primary and hospital care costs only (excluding care home costs) £9,046 £13,039 Relative effectiveness estimates (where comparator is no OG or FLN rather than pooled estimate) Dominated £21,798* Relative effectiveness for 30-day mortality also applying to second hip fracture £20,754 £23,140 Effectiveness over mortality beyond 1st year post hip fracture into lifetime £16,944 £18,052 Effectiveness over second hip fracture extending into lifetime Extendedly dominated £20,036* Effectiveness over major non-hip fractures requiring hospitalisation (OG: HR 1.14, FLN: HR 0.94, Chapter 5) £20,439 £26,559 Orthogeriatrician and FLN costs without qualification costs (£300 and £177 per patient, respectively) Extendedly dominated £20,230* Orthogeriatrician at 1 WTE (£560 per patient) £20,794 £28,418 FLN at 0.25 WTE (£50 per patient) £19,066 £28,798 FLN at 0.60 WTE (£120 per patient) £19,817 £26,172 220 hip fracture patients per year seen by OG or FLN (intervention costs at £859 and £409 per patient, respectively) £22,922 £31,784 690 hip fracture patients per year seen by OG or FLN (intervention costs at £274 and £131 per £19,929 £20,307