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Fast Track Fracture Prevention · 'Bone Up'

0:00
Hello and welcome to Bone Up, the podcast all about bones.
0:06
How we make them, why we break them and if we fully understand them.
0:10
I'm David Armstrong.
0:11
Hi, and I'm Richie Abel and over this series we're going to be exploring osteoporosis,
0:17
bones, what we know and what we yet to discover and we hope you will join us on the journey.
0:24
So for anyone keen to learn more about our infrastructure of calcified collagen, this
0:29
is Bone Up.
0:55
Hi David, how are you doing this week?
0:57
I'm doing well.
0:58
Thanks Richie and yourself?
1:01
Not bad, not bad.
1:02
I heard that you won an award this week.
1:05
Well on World Osteoporosis Day I was privileged to receive a prestigious award from a patient
1:12
who turned up to receive one of her infusions and she presented me with a golden skeleton
1:19
to which she had sellotaped a best bone doc on it.
1:23
And that was very nice, that's the best sort of award to get.
1:26
As it happened I put a photograph of me with my award on Twitter and I think some people
1:31
thought it was actually a serious award I had received.
1:34
So that was quite funny and it was a nice way to mark World Osteoporosis Day and actually
1:40
to see a lot of traction for World Osteoporosis Day on social media.
1:45
Wow, World Osteoporosis Day no less, that's fantastic.
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It must be really rewarding to be treating patients and for them to be doing well and
1:54
for them to say thank you, that's amazing.
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It is and it's nice when people actually go out of their way to mark it in some way so
2:03
it is.
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If the patient's listening thanks very much for my golden skeleton.
2:10
And if you're a young medic listening maybe endocrinology or rheumatology is the way forward.
2:17
Maybe indeed.
2:18
We've been getting a lot of good feedback on Twitter and Facebook for the podcast but
2:25
I think there's a bit of a gap in the content that we've covered so far.
2:30
Our guests that we've had have explained the clinical pathways for bone health screening
2:35
and for fracture risk assessments but one important point that we haven't covered yet
2:41
is how do you as clinicians actually decide which people to screen?
2:49
Well we can't screen everyone and the goal ultimately of screening is to identify people
2:56
who are most likely to have osteoporosis or high fracture risk or ultimately who are likely
3:02
to benefit from treatment.
3:05
And we know that the best predictor of having a fracture this year is if you've had a fracture
3:12
last year and therefore the best chance of those, the best chance of finding those who
3:18
need treatment is to assess people who have recently had a fracture.
3:23
And we know you are at a particularly high risk of having fracture shortly after you've
3:28
had a previous fracture.
3:31
So the idea of going out and doing assessments on people who have recently fractured is really
3:36
the concept behind a fracture liaison service.
3:42
Okay so that makes sense.
3:43
So people who've already had a fracture are most at risk of having another fracture and
3:50
you mentioned there a fracture liaison service.
3:52
What's a fracture liaison service?
3:55
Well a fracture liaison service it varies from place to place but most basically it
4:01
involves screening people in your area who have recently fractured.
4:07
It usually involves having an interview with a nurse specialist or a radiographer or specialist
4:13
radiographer to discuss risk factors and past history and medication.
4:19
It usually involves having a bone density assessment or a DEXA scan and it usually involves
4:25
or indeed it should involve having a calculation of a frac score.
4:29
And it means that everyone in your area who has recently had a fracture gets a specific
4:35
and personalised assessment and prediction of their risk of further fracture.
4:42
Some fracture liaison services have other aspects, some for example do blood tests,
4:46
some offer immediate consultations with doctors and it varies from place to place and indeed
4:52
one of the questions we ask sometimes is what constitutes a good fracture liaison service
4:57
and what should we have as part of our fracture liaison service.
5:02
FLS started over 20 years ago.
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The first FLS in the world was in Glasgow, Scotland.
5:10
It was started by Alistair McClellan and my friend Stephen Gallacher.
5:16
The first fracture liaison nurse in the world as far as I know was Maireen Fraser and Maireen
5:21
is known both you and me as someone who still works for the Royal Osteoporosis Society.
5:28
The fracture liaison concept was one of Scotland's many gifts to the world.
5:34
That's brilliant, along with whiskey and golf.
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And iron brew of course.
5:42
I do really like pineapple iron brew but I've only ever found it once.
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Maireen has been a really great supporter on Twitter so probably a good spot to say thank you Maireen.
5:52
And also thanks to all the other people who've been supporting us on Twitter and Facebook.
5:56
It's really nice to get all of your feedback.
5:59
So David, the process you were describing at FLS there sounds very holistic.
6:03
Asking the patient about their lives, their lifestyles, collecting x-ray data, perhaps
6:09
collecting bloods etc.
6:11
It seems like a lot of information to collect so I suppose you'll get a lot of information
6:16
about the patient.
6:18
Once you have that information, how do you use it?
6:23
Well I suppose what we do next depends on the outcome from each individual assessment.
6:30
For some people we will discover that their bone quality seems good, that their bone density
6:35
is good, that their risk of fracture seems small.
6:37
And for those patients there's not necessarily a lot to do, they can be reassured.
6:43
There's a large group of people in the middle who we find have moderate osteoporosis, a
6:49
moderately increased risk of fracture.
6:51
And those are patients for whom we usually communicate with their GP and advise that
6:56
they should be treated with perhaps a calcium and vitamin D supplement or a bisphosphonate
7:01
or of appropriate HRT.
7:04
And they don't necessarily need to come back to a specialist clinic in hospital.
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It is worth remembering that the majority of osteoporosis care does happen in general
7:13
practice and we depend very much on our GP colleagues for that support.
7:18
There are a smaller number of patients who are complex cases who perhaps have very low
7:23
bone density or who cannot take bisphosphonates, who have kidney disease, who are on cancer
7:29
treatment, who have had organ transplants and many other complex cases.
7:35
And those patients are usually invited to see me at a clinic so that we can discuss
7:39
the use of more unusual drugs or the use of other means to maximise their bone health.
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And of course the better we get at identifying and assessing patients, we turn up sometimes
7:51
people who we know have very, very high risk of fracture and who we would really like to
7:56
see quite quickly to get them started on some of these new anabolic treatments.
8:02
And most osteoporosis services over the years haven't really been set up with an urgent
8:08
channel or an urgent clinic.
8:10
And that's something we're thinking about more, how we deal with these very high risk
8:14
patients and how we can get to see them urgently and get them on some of these new anabolic
8:20
drugs urgently.
8:22
If I'm understanding this correctly then what you're saying is that you can use the
8:25
FLS data collected perhaps by the nurses to stratify the risk of the patients.
8:34
Maybe there's no risk, so they're fine.
8:37
Maybe there's low risk, so you're using some sort of diet or lifestyle intervention.
8:43
Maybe they're high risk, so you might be treating them with some sort of anti-resorptive.
8:47
And it also seems like you're identifying another group of patients, the very, very
8:51
high risk patients.
8:52
You might need some sort of anabolic, that is to say, bone building treatments.
8:57
Are these the patients that you're most worried about?
9:01
They are the patients that we're most worried about.
9:03
We know that if you have, for example, a vertebral fracture and you have very low bone density,
9:09
then your chances of further fracture within even the next six months are extremely high.
9:14
For a long time there wasn't a lot we could do for those patients, but in recent years
9:19
there's some new exciting drugs that can really make a difference to bone density and fracture
9:23
risk in the short term.
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So yes, those are patients we nowadays like to see as quickly as possible to get started
9:31
on the best treatment.
9:34
So now then might be a good time to bring in today's guest.
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And we have been able to get somebody who can help us dig down into this connection
9:44
between FLS, very high fracture risk, and urgent treatments.
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Our guest today is from Oxford University, a consultant in metabolic medicine, consultant
9:57
rheumatologist, and expert in osteoporosis and bone metabolic disease.
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A warm welcome to our guest today, Dr. Karsem Javed.
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How are you today?
10:07
Oh, very well, Richard.
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Good to see you.
10:10
Oh, fantastic.
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It's really great to talk to you today.
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You're one of the people that we wanted to talk to at the very start of the podcast when
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we began this series.
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So we're both very excited.
10:21
And hopefully we're going to pick your brain today so we can explore some of the connections
10:25
between imminent fractures and FLS.
10:28
But I suppose speaking from my own point of view as a non-clinician, one thing that strikes
10:33
me as a bit odd is why do fracture liaison services only screen people over 50 years
10:38
of age?
10:39
Thanks, Richard.
10:40
That's a really good comment.
10:43
So I mean, the aim of a fracture liaison service is to make sure that you're capturing people
10:48
after fracture who could have osteoporosis.
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And when you look at the epidemiology, the risk of osteoporosis really starts going up
10:56
after the age of 50.
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It doesn't mean that people who break a bone below 50 won't have osteoporosis.
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It's just that the risk is much lower.
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And for the best return on investment, it's better to look at people aged over 50.
11:09
Hi, Karsem.
11:10
Hi, Cass, it's great to have you on the podcast.
11:14
Richie and I were talking earlier about how fracture liaison services were set up and
11:21
how some were designed differently from others.
11:23
Some, for example, took bloods at the assessment.
11:28
What from your point of view makes an effective fracture liaison service and how should we
11:33
be designing our services?
11:38
Great question, David.
11:39
If you look back, it was really Alison McClellan and Stephen Gallagher who launched fracture
11:43
liaison service in the late 90s independently.
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That was a real game changer because osteoporosis clinics at that time were really around postmenopausal
11:53
women and no one really thought to go into the trauma wards.
11:57
And at that stage, it was really a one stop shop.
11:59
You saw the patient, assessed them, did the dexer, and in one go, you had them off and
12:05
recommended GPs.
12:07
We've now shifted in measuring effectiveness in terms of how many people you can get on
12:12
treatment early and stay on treatment for at least a year because we know from the pharmacological
12:18
evidence that actually it's early treatment initiation and sustained adherence that produces
12:23
the greatest reduction fracture risk.
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So if you work backwards from that, the good fracture liaison service finds all of the
12:32
medium and high risk patients, assesses them rapidly, recommends treatments that addresses
12:39
their fracture risk, and then makes sure they start and stay on treatment.
12:47
And we've enshrined those within two metrics.
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One is the organizational audit, which is called the best practice framework within
12:56
the International Osteoporosis Foundation.
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And the other one are the key performance indicators, which is also through the IOF,
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but also the Fragility Fracture Network and the National Osteoporosis Foundation in the
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US.
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So we see effectiveness much more on the patient level in getting the right patient quickly
13:15
onto treatment and staying on treatment to reduce their fracture risk.
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But does it mean we ignore the other stuff, the other key points, so falls risk assessment,
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adequate calcium, vitamin D nutrition, and very importantly, patient education?
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Because unless they understand what's happening, they won't engage with your pathway and you
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won't achieve those metrics.
13:40
We can almost be a victim of our own success in that we will identify some people at very
13:46
high fracture risk or what I think we're now calling imminent fracture risk.
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Could you talk to us just a little bit about this concept of imminent fracture and really
13:56
what we should be doing with those patients once we identify them?
14:01
Yeah, that's a really important concept that's drifting into the FLS field.
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So imminent fracture risk is relatively new concept.
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It was only Breo who described it about four years ago.
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But since then, it's become into the common osteoporosis thinking because of epidemiology.
14:19
We've realized that fracture risk is not linear.
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There are some risk factors that cause a spike in short term fracture risk.
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And we define imminent fracture risk as the risk of a fracture in the next two years.
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That's a fragility fracture.
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And that changes what you do because it changes how you assess patients.
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So if patients have got a major osteoporotic fracture such as humerus, spine, or vertebra,
14:46
sorry, humerus, vertebra, or hip, we know that their risk of another fracture in two
14:52
years is extremely high, maybe even 20%.
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And remember, we normally start treating people who have a 10 year risk of around 20%.
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And we're now seeing that at two years.
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And the problem we've had in the past is we've never been able to quantify the imminent fracture
15:08
risk.
15:09
But the team at FRACS have now worked on this.
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And the new FRACS development team will include an imminent fracture risk.
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So if you think about it, then the patient's completely different.
15:21
They're not looking at their 10 year risk, which for some patients is a little bit comforting.
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In the next 10 years, who knows where we're going to be.
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If you start saying in the next two years, you've got a one in five chance of a fracture
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that could be life changing, that engages a patient.
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But it also means a clinician has to act quickly.
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We have to screen the patient, make sure there's no secondary causes, make sure they're eligible
15:43
for treatment, and get them on treatment as soon as possible.
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And then put whatever you can do, whatever you can throw at them, to keep them on treatment
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for at least one to two years.
15:55
And you know, David, when we were growing up, we had HRT, elendronate was a big thing,
16:00
residrinate versus elendronate.
16:03
It's completely different now.
16:04
We have injectables.
16:05
We have zilendronate, dinosumab.
16:08
We have PTH analogs.
16:11
Some of us will soon have access or already have access to antisclerostin inhibitors.
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And this is important because it means based on evidence of head to head trials, we can
16:22
really select the right drug for the right patient and target the treatment more effectively.
16:29
So people at very high imminent fracture risk probably isn't worthwhile giving them an oral
16:34
bisphosphonate.
16:35
When we model it, 80% of refractures will still happen even if you give them an oral
16:41
elendronate because of slow onset of therapeutic benefit, really bad adherence.
16:47
When you go to injectables, you can bring that right down to 50%, even less than 50%.
16:52
And that's really exciting.
16:54
We now almost see our fast track patient who can rapidly be assessed, get on treatment.
17:01
And one day maybe even within the trauma visit, be started on very potent treatments.
17:10
This is interesting.
17:11
And I didn't realize the numbers were so high.
17:14
So if I understand this right, then you're saying that somebody at risk of an imminent
17:18
fracture might have a risk as high as one in five for a fracture in two years, which
17:23
obviously is not very good.
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But at the same time with the FLS, you can get somebody diagnosed and treated on the
17:34
same day.
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And then you have a very powerful range of medicines that you can give the patients to
17:40
try and reduce the fracture as quickly.
17:42
I suppose that leads to the next question, which is how effective are the fracture liaison
17:47
services at preventing the fractures, especially given that the risk is so high?
17:53
So that is the $64,000 question because it's really hard to prove because to do that in
17:59
a traditional scientific way is a randomized controlled trial.
18:03
You give some patients an FLS and some patients not an FLS.
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We don't have equipoise.
18:08
We can't do that.
18:10
And the other issue is FLS is at present, there are very few that deliver to that performance.
18:14
There are very few FLSs that can process patients that quickly and get them on to treatment
18:21
that rapidly because of structural and organizational issues and the lack of investment because
18:27
it's been underappreciated.
18:29
It's always the last man in the queue is the MSK.
18:34
Heart disease, cancer, diabetes, mental illness get really high priority, but osteoporosis
18:40
is still lagging behind.
18:42
So we've done is we've created a mathematical model.
18:45
The team at Oxford with Rafael Bonet of El Nuevo is developing a calculator that uses
18:51
clinical trial evidence and looks at things like how many people do you find?
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How many months do you take or weeks do you take or days do you take to start them on
19:01
treatment and how long do they stay on?
19:04
And the fracture benefits are significant.
19:07
It depends on fracture site, age and sex because mortality is the other problem, but they're
19:12
big.
19:13
And I think it's getting the message across that these are avoidable fractures.
19:18
And if you have a fracture, that's often a permanent loss of independence, either in
19:23
a limb or in your whole mobility.
19:26
And the treatments are extremely effective.
19:29
If you look at the effect of statins and heart attack, you're looking at like 20%, 30% reduction.
19:35
If you're looking at these drugs, they're like 70% reduction spine fractures, 50% reduction
19:40
hip fractures.
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They're way more potent.
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And we just haven't been very good at promoting our specialty that we've got effective treatments.
19:48
We know who the patients are.
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We just need to join the dots and get them, get the right patient, the right treatment.
19:56
So how do we go about moving our specialty up the league table then, if you want to put
20:01
it like that?
20:02
I know this is something we discussed briefly on another forum.
20:07
I mean...
20:08
Some sort of podcast maybe?
20:09
Maybe it was a podcast.
20:14
Funding for the health service is very front loaded.
20:16
It's very emergency loaded.
20:18
And if you take another condition, for example, like stroke care that you talked about, you
20:23
and I growing up, stroke care was something really about aftercare, about rehabilitation.
20:29
And now with the availability of lysis for stroke, stroke has suddenly become an emergency
20:33
occurrence.
20:35
What do you think behind sort of calling imminent fracture an emergency in terms of osteoporosis?
20:43
Are there some other term we should use to really draw attention to the fact that these
20:49
are urgent cases and need to be treated with very powerful drugs urgently?
20:56
I think we just have to bring all the dates together in a way the policymakers and decision
21:00
makers understand and then compare it with other conditions.
21:04
I mean, very simple example.
21:06
Coming with a heart attack, you've got 8% risk of another heart attack in the next two
21:11
years.
21:12
Next year, is it one year or two years?
21:15
I think it's two years.
21:16
I'll have to check on my facts.
21:17
But it's exactly the same after a hip fracture.
21:20
You know, our reaction to a hip fracture is very rehab recovery, just like we did with
21:24
stroke.
21:25
And look what we've managed to do with stroke.
21:27
We transformed it.
21:29
We can now offer same hour CT scans.
21:34
We were struggling to get them the same two week or the same few days.
21:37
So I think that is an important concept.
21:40
And then we take the approach of say, you know, a TIA leading to stroke.
21:44
You know, there are some fracture sites, the humerus and the spine.
21:47
Well, there's a very high imminent fracture risk.
21:49
And we can almost say, look, these are red flag patients need fast tracking because the
21:55
gatekeeper for the very effective treatments will be usually in secondary care.
22:00
But most of the activities in trauma in a different department.
22:04
So you have to get the patient from the trauma clinic into that secondary care anabolic space
22:09
as quickly as possible so they can start treatment.
22:12
And I think it's culture.
22:13
We have to be a lot more advocates, a lot better advocates for our patient groups.
22:20
We have to be really pushing the agenda because great example, I got approached by my CCG
22:27
because they looked at what they were spending money on in older people.
22:30
It was CPD and fractures.
22:33
And then they came to me and said, what can you do about fractures?
22:35
And I said, I've been asking for a better FLS for about five years.
22:39
I know what to do.
22:40
But that's what's going to happen, David.
22:41
People are going to look at their health care system and say, we haven't got any money to
22:44
do everything.
22:45
COVID has made everything very complicated.
22:48
Where are the easy wins we can get to reduce secondary care activity, improve patient outcomes
22:55
that's evidence based?
22:56
And whenever we go, we have the same like open door policy.
23:02
But the problem is that no one owns osteoporosis.
23:06
It's not endocrinology.
23:07
It's not rheumatology.
23:08
It's not geriatrics, not trauma.
23:11
And because we don't have a specialty lead, that's really hard for us.
23:15
It's us.
23:16
We want to do it.
23:17
But they say, well, the money saving is not where the activity is.
23:21
That's something I keep saying to Richie.
23:22
That's what we need.
23:23
We need bone health and osteoporosis as a specialty rather than just something which
23:28
a rheumatologist does a little of or an endocrinologist does a little of.
23:32
But that's probably a topic for another podcast.
23:38
When I first started out as a researcher in osteoporosis, I didn't really know who to
23:42
go and talk to.
23:44
It's really confusing.
23:47
Let's just assume for a minute that we did have a speciality for osteoporosis and there
23:52
was a group of doctors who would be the right advocate.
23:58
Whose door would we have to kick in in order to get more money and more attention, more
24:05
care for your patients?
24:07
Well, there's two doors.
24:09
There's a top down door and the bottom up door.
24:11
So bottom up is easy.
24:13
It's your hospital, your local health system to say, look, this is the local need.
24:19
This is the local delivery and these are the avoided fractures that are messing up your
24:23
local health care system.
24:25
But the local decision maker will always look at the top and say, what is the government
24:29
telling me on my health care priorities?
24:31
What's in the long term care plan?
24:33
What's in the COVID recovery plan?
24:35
You know, great example, Chris Wickey did this thing about coastal deprivation and long
24:40
term conditions.
24:42
Fractures are barn door, higher with deprivation.
24:46
If you're deprived, you're more likely to do badly, longer length of stay.
24:49
It wasn't even mentioned that osteoporosis fractures were an example of coastal deprivation.
24:55
So we really have to work on a sort of whole system approach.
24:59
And there's great advocates to the Royal Osteoporosis Society.
25:02
They've got their all parliamentary osteoporosis group.
25:06
We've got the Society of Endocrinology, the British Society of Rheumatology, the British
25:10
Geriatric Society, the BOA, Royal College of Physicians.
25:14
We've got audits.
25:15
We have all the right ingredients and we just need to capitalise on that to get that step
25:22
change.
25:23
The FLS is not a luxury.
25:26
It's a basic delivery of NHS care.
25:29
I mean, if you went into hospital with an MI and no one checked you for diabetes or
25:34
cholesterol or hypertension, you'd think, what sort of hospital is this?
25:38
And their secondary prevention rates are 95%.
25:43
And for a fracture, which causes chaos because you have to go in operations or you're off
25:48
work, you know, we're at 20%.
25:53
It should be a normal thing for a hospital to have a fracture liaison service and indeed
25:57
to have a fast track service as well.
26:00
And in the way that all hospitals would expect to have a fast track service for breast cancer
26:04
or for stroke prevention.
26:07
And all hospitals really should have a fast track service for imminent fracture.
26:14
And it also feels to me like maybe perhaps all of the FLS should be doing the same thing
26:19
or a similar thing when assessing the patients, meeting the patients, speaking to the patients.
26:24
It sounds like there's quite a lot of variation around the country in the way the patients
26:30
are managed.
26:31
Yeah, you're right, Richard.
26:35
We looked at treatment recommendations across all the FLSs that participate in our audit.
26:41
And some people get some treatments, some people don't get treated, and some people
26:46
get other treatments.
26:47
We looked at treatment, yes or no, and then type of treatment.
26:50
We couldn't work out why some people weren't getting treated.
26:54
We looked at age, fracture site, you know, the variable.
26:58
Okay, some won't have osteoporosis by dexam, but you know, we could, there was a lot of
27:02
variability and there are some differences in clinical pathways.
27:06
But I think those are marginal gains.
27:09
I think the biggest gain is that most services aren't funded very well.
27:14
They'll say, I want an FLS, and you'll get it.
27:16
Fine, I'll give you a nurse and I'll give you half an administrator.
27:20
They won't say, well, how many patients do you have to see?
27:23
Three and a half thousand.
27:24
Okay, that's going to take about four nurses, two administrators, and maybe a lead nurse
27:28
as well.
27:29
They don't think like that.
27:30
They say, let's just tick the box.
27:32
And I think the beauty of the FLSDB is it's showing where there are service gaps because
27:37
of resourcing issues.
27:40
And then, you know, we'll work with them with quality improvement to align their guidelines.
27:46
But I think it's more resourcing than pathways differences.
27:50
Does that make sense, Rishi?
27:55
It does, yes.
27:56
And this is really interesting.
27:58
One of the courses I teach at Imperial is research skills.
28:02
And I teach the medics.
28:04
And what I try to teach them is that as a medic, they need research skills because they
28:09
are going to have to be able to fight for resources when they are doctors.
28:14
And the way that they will do that is by collecting data on their services to show that they need
28:19
more resources and what the kickback would be if they had those extra resources, especially
28:25
things like staffing levels.
28:26
So I'm going to clip this out and put it into the online teaching that the students at Imperial
28:32
get.
28:33
Or maybe I should just put the link in and we can push up the downloads a bit here.
28:38
Before we finish, I have one last question for you.
28:41
Something that has cropped up in this podcast again and again and again and again is that
28:46
maybe osteoporosis is underrepresented, underestimated in the wider world.
28:53
I have, since I've been working on osteoporosis, Karsem, you are somebody who's come up again
28:59
and again and again and again as one of the key advocates for our field.
29:04
I've seen you deliver webinars.
29:06
I've seen you deliver conference talks.
29:08
You recently had a stint as the president of the British Orthopaedic Research Society.
29:14
And I'm always impressed, including today, by your enthusiasm and your energy and your
29:20
drive.
29:22
And we need more people like you in our field.
29:25
Where does your enthusiasm and drive come from?
29:28
How do you manage to fit more than 24 hours a day into 24 hours a day?
29:34
So if you work for me, you know I don't.
29:37
I'm behind on my emails.
29:38
But I suppose it's a very simple, it's actually a simple ask.
29:44
I had a great mentor, Cyrus Cooper, who said, what do you want to be known for?
29:49
And he said, you're going to be known for research or clinical.
29:52
And you know, I don't really, I think it goes beyond that.
29:58
For me, it's like a very simple problem, FLS.
30:03
I can explain to my four year old that if you break a bone and you might have another
30:07
one, you should get checked to see how strong your bones are.
30:10
You know, it's not a very difficult concept.
30:13
And yet, it takes inordinate skill to bring together all of the levers so they're aligned.
30:21
Get that alignment with policy, with the research, with the data, with the clinicians, with quality
30:27
improvement.
30:28
And it's so satisfying.
30:31
Because for me, there is no doubt that every hospital will have an FLS.
30:34
I have no doubt.
30:35
It's inevitable.
30:37
My only question is, can I get there in three years, five years, or 10 years?
30:42
And I'm working as hard as I can.
30:44
And you know, I seem to have lots of energy, but I have a fantastic team around me to support
30:49
me, push me, challenge me.
30:53
And I have great patients who do the same.
30:56
They push me, challenge me.
30:58
And I'm lucky because I can cross both bridges.
31:01
I've done epidemiology.
31:02
I was lucky enough to have a PhD.
31:05
I understand data.
31:06
I understand statistics.
31:09
And I understand clinical.
31:11
And I work clinically as well.
31:13
And it's that beautiful place of being a job that you enjoy, that's never boring, that
31:19
is always challenging.
31:21
And we're doing something that just feels right.
31:25
And Richard, when you're in a field that feels right, there is no limit.
31:30
You don't ask yourself, is this too much?
31:31
You just do whatever it takes to get the job done.
31:34
And it's been very satisfying.
31:36
So I haven't given you a very good answer.
31:38
I'm not being asked that sort of question, but that's why I do it, because the benefit,
31:44
I mean, Cyrus taught me from epidemiology, you can do a lot as a doctor, but if you can
31:50
change a guideline or change a world system, the amount of patients you help is insane.
31:57
And that tantalizing vision that one day, David and I will chuckle that you could go
32:04
into hospital with a fracture and no one thought osteoporosis, that will be gone.
32:11
That will be like, oh, God, they didn't do that anymore.
32:13
Wow, they just paid for all those operations.
32:16
I complete believe that will be gone.
32:19
It's just when.
32:20
I know it's our challenge for this generation and next generation of medics to get us to
32:24
that place, because once we get there, we won't go back.
32:27
It's not like I have to keep telling people that once you had a heart attack, check for
32:32
diabetes.
32:33
It's just in the system.
32:34
And just like David said, we just have to normalize it, because once it's normalized,
32:39
job done, I can start doing more rare disease stuff.
32:42
You know, that's a really good answer.
32:44
It's something we've talked about.
32:45
There are parts of the world, as you know, that are entirely covered by fractal liaison
32:50
service.
32:51
So Scotland is entirely covered by a fractal liaison service.
32:54
Northern Ireland is now, I think New Zealand is.
32:59
There are several other countries.
33:00
And I think once you reach that complete coverage, once you reach the point where if you fracture
33:06
a bone, you will not be able to avoid some nurse tracking you down and demanding that
33:11
you come for your assessment and DEXA scan.
33:14
Once you reach that point, it's very hard to go back.
33:17
It's a logical and ridiculous to go back.
33:19
But we just have to strain every sinew to get to that point.
33:25
But only once.
33:26
But only once.
33:27
Absolutely.
33:28
And it's worth it.
33:29
I mean, I'm going to be 50 next year.
33:32
So I think I've got enough time to see.
33:35
I want to see the other end.
33:37
I want to teach the medical students that, you know, it's just 101.
33:41
Oh, yeah.
33:42
So we'll be going to much better things.
33:45
But that's the enthusiasm because I know it's achievable.
33:48
Yeah.
33:49
And maybe we need to get together and establish osteoporosis as a specialty by itself where
33:54
you can come in and you can train as a registrar right the way through your osteoporosis.
33:59
Because I think, as you were saying, there's so many more drugs.
34:03
There's just a complete paradigm shift in how we think about it.
34:07
And yeah, I think we need our own specialty now.
34:11
And if you look at it in the current specialties, and you may want to edit this out, so rheumatology
34:18
and endocrinology, we kind of look down upon by our colleagues, you know, the real rheumatologists
34:25
have got the really sick patients with vasculitis, rheumatoid arthritis.
34:30
The osteoporosis just sits in the corner and does its own thing.
34:32
And, you know, now we've got biologics that are a little bit more expensive.
34:36
That's a good thing.
34:37
But, you know, if I go to most hospitals with mixed clinics, if I compared their knowledge
34:44
of osteoporosis with rheumatoid arthritis, there would be a disparity.
34:48
I mean, look at frequency.
34:50
It's the other way around.
34:52
Osteoporosis is way more common than rheumatoid or lupus.
34:57
To see if the knowledge rich is going to edit this out, I will agree wholeheartedly with
35:02
you about rheumatology and rheumatologists in general and their attitude to osteoporosis.
35:08
Yeah.
35:09
We're definitely keeping this in.
35:12
This is important.
35:14
This is the whole point of the podcast, you know, to make people know and understand and
35:19
worry more about these things so that we can make change in the world.
35:23
And I would say to trainees, if there is a trainee listening to this, osteoporosis is
35:26
one of the best specialties to go into because nearly every other multi-system disease, either
35:32
because of the disease or how their specialty treats them, gives them osteoporosis.
35:36
So you will see more neurology, gastroenterology, renal, respiratory disease than anywhere else.
35:44
There are some really unusual rare bone diseases that can come in osteoporosis.
35:48
And we know practically nothing about those.
35:51
And only two or three do we have any drugs for them.
35:54
So that's like new discovery.
35:56
And then all of the FLS stuff we're doing now isn't randomized controlled trials.
36:01
It's implementation science and equality improvement, which is growing as a clinical and research
36:06
specialty.
36:07
So if you want an area which has got clinical trials, epidemiology, basic science, implementation,
36:13
rare stuff, common stuff, health policy, health economics, you couldn't go further than from
36:20
osteoporosis.
36:21
But everybody who comes to my clinic says, wow, this is really interesting because pregnancy
36:27
associated osteoporosis, it's a fascinating condition.
36:30
We know nothing about it.
36:32
That's right.
36:34
Students leave my clinic and say, I can't believe osteoporosis was so interesting.
36:38
Yeah.
36:39
The reason why they're disguising their surprise that it was so interesting.
36:43
I have that from senior registrars who come in from endocrinology and rheumatology and
36:49
say, I didn't realize it was that complicated.
36:53
The basics are basic, but you can very quickly get very good.
36:56
But we have GP trainees and they just love the clinic because they're always asking questions.
37:02
And they will know we're on the edge.
37:05
Renal disease, commonest thing we have, kidney failure in older people.
37:11
He's shooting in the dark for treatments.
37:13
Absolutely.
37:14
Yeah.
37:15
And we haven't even touched on the mental health aspects of osteoporosis either, pain
37:20
from vertebral fractures and hip fractures and fear of falling and lack of mobility.
37:24
And that's a whole other area that again is...
37:29
And I'd love to sort of interrupt you there.
37:30
I'd love to see that come part of the FLS.
37:32
Oh, I would as well, very much.
37:35
Yeah.
37:36
Let's get every FLS patient having a depression screen.
37:39
Very simple.
37:40
Let's just get it done.
37:42
But it's not part of the...
37:44
We do it in Oxford a little bit, but we don't do it systematically.
37:47
Unless measures the success of an FLS by having depression screens they've done.
37:52
Unfortunately, we can't even get them on the drugs.
37:55
So I don't want to push it too far.
37:56
But once everyone's on the drugs, let's now try and get the rest of it right.
38:01
Because the two...
38:02
I mean, Zoe Paskin has done some great work.
38:04
You've got to get the engagement.
38:07
And if you ignore the mental health, you can do whatever you want.
38:10
You're not going to take the drugs.
38:11
Absolutely.
38:12
I hope, Richie, you're writing down all these ideas because this is liquid gold.
38:16
Honestly, I just transcribed these directly into a Word document as soon as I finish.
38:22
And we had Zoe Paskin's on a couple of months ago and she was so articulate, as you would
38:27
expect from somebody who researches communication.
38:30
So I'd highly recommend anybody who hasn't listened to that one goes back and listen
38:34
to it.
38:35
It's really fabulous.
38:36
Today, I was very careful.
38:37
I said one in five when we were talking about the risk, not 20%, which is what Zoe told
38:42
us.
38:43
I'm an epidemiologist.
38:44
So for me, one in five is 20%.
38:47
But you're quite right for the listener-lider audience.
38:51
Okay.
38:53
We could go on.
38:54
And every time that we do a podcast, we come up with at least two or three more topics
38:59
for podcasts.
39:00
Dr. Karsem Javade, I would love to have you back on the podcast again.
39:04
I'm sure David will as well.
39:07
Thank you for your time today.
39:08
Not at all.
39:09
It's been a pleasure talking to both of you.
39:10
And this is a really great enterprise and I wish you all the best.
39:13
Thank you.
39:14
It's been a real pleasure having you on.
39:15
Karsem, bye bye.
39:16
Bye bye.
39:17
Take care, everyone.
39:18
David, what a wonderful interview we had with Karsem.
39:26
What were your takeaways?
39:29
I think Karsem's enthusiasm for what he does.
39:33
It really comes across very strongly.
39:35
And that's infectious and is actually really good as someone who works in osteoporosis
39:41
to talk to other people who are so optimistic about it and so enthusiastic about what can
39:49
be done.
39:50
And it's true what he said.
39:52
You can treat one patient and you can make that patient better or you can change a guideline
39:58
and you can influence the health of hundreds of thousands or millions of patients for years
40:04
to come.
40:05
And that's certainly one take home message from this change of guideline and you can
40:11
do so much good.
40:15
And I think that leads on to the idea of establishing a fractured liaison service.
40:20
You can put a lot of money into new and exciting and effective drugs.
40:25
And we are very keen that people do that and that pharma companies and universities do
40:32
continue with that research.
40:35
But unless you have the structures in place to find and identify and treat and follow
40:40
up the patients, then it doesn't matter how effective a drug you have unless you're able
40:46
to get it to the patient.
40:50
And I think that then leads on and you heard as we sort of as the discussion flowed later
40:54
on how it's not just a question of establishing a fractured liaison service to identify the
41:01
need and quantify the need.
41:03
That has to be followed up with what you might call an osteoporosis service.
41:08
You have to follow that up with access to clinics to get these new drugs.
41:14
It's not just a question of identifying the problem.
41:16
It's a question of effectively treating the problem and how we really need to completely
41:22
change how we think about osteoporosis.
41:25
We have talked in earlier episodes of the podcast how this is a lifelong challenge.
41:32
It's changing your lifestyle.
41:34
It's a marathon and not a sprint.
41:35
These are drugs you have to take for years.
41:38
And that's all very true.
41:40
It is a very long term holistic disease.
41:43
But we have to have that fast track element to it.
41:47
We have to have that urgent clinic, that even emergency concept in osteoporosis because
41:53
we have now some very effective anabolic drugs and anti sclerostomy drugs which can make
42:00
a huge difference to the risk of fracture in that relatively small window after the
42:06
first fracture when patients are at such high risk of breaking a bone again.
42:13
And then you just heard Cass and I getting into the whole area of how we view osteoporosis
42:19
as doctors and as specialists and working within the hospital.
42:24
And it has traditionally been something which is done a little by rheumatologists, a little
42:30
by endocrinologists, a little by care of the elderly physicians.
42:34
And I think increasingly as we have more drugs and more ways of assessing patients and more
42:41
complex understanding of how these drugs and diseases work, there's a bigger argument
42:47
really for people training specifically in osteoporosis and developing it as a specialty.
42:54
Not just for the interest and enthusiasm of people like Cass and me and other consultants
43:01
who work in the hospital, but ultimately for the benefit of patients so they get to see
43:05
someone who has the knowledge and experience and enthusiasm to treat them best, to reduce
43:11
the risk of fracture and to allow them to live as long and as happy and as mobile and
43:18
as pain free lives as possible.
43:23
I know today talking about fracture liaison services, that seems a very clinical and organisational
43:30
thing from the point of view as a scientist and as a research scientist.
43:35
What sort of things did you take away from our interview today?
43:41
I suppose the main thing that I took away is even though there is a very strong evidence
43:46
base for FLS, for the powerful treatments that are given out after people have attended
43:57
FLS to prevent fractures, given the huge body of evidence, I'm really surprised that more
44:04
isn't being done to set up FLS all over the country and even all over the world.
44:11
I'm also surprised that the FLS that we do have are not really very standardised, that
44:17
maybe they're managing patients in different ways.
44:21
Again, if there's evidence, if there's data that's been collected that shows how FLS should
44:28
work then probably everybody should be following that.
44:31
And I guess it all comes back to this problem that we talked about today of not having people
44:38
who are specialists in osteoporosis.
44:42
I find that very, very surprising given that it is such an important condition, given that
44:49
it affects so many people's lives.
44:52
The patients living with osteoporosis and their families and given that it affects people's
44:57
lives so severely, I think Carson was talking earlier on about the devastating effects that
45:02
fractures have on people's lives.
45:07
It annoys me and makes me sad that more is not being done.
45:14
As a scientist it must seem strange that you have the data there.
45:19
We know that it works, it's easy to implement, it has great outcomes and yet there are still,
45:26
as you know, large parts of England which are not covered by fractural liaison services.
45:32
Yeah, why is England so far behind Scotland and the rest of the UK?
45:40
It seems silly that that is the case.
45:42
Why is there not a more joined up approach to providing care to patients nationwide?
45:48
If it's been demonstrated to work in some parts of the country, why is it not then being
45:53
rolled out in other parts of the country?
45:55
Now, as a scientist, I do often see that data is ignored or data is misused.
46:01
You know, it's not always used properly to make the right decisions, to make objective
46:07
decisions.
46:08
But like you say, this should be so easy to implement because it is organisational and
46:17
the data and evidence is there.
46:19
It seems like an easy win.
46:25
This is a no-brainer.
46:28
And I think Carlson was talking earlier on as well about how the secondary care of osteoporosis
46:35
patients costs so much money if we could prevent these fractures with some investment of money
46:41
and time and effort and organisation now.
46:45
You know, the benefit, the yield later would be enormous, not only in terms of people's
46:49
quality of life, but in terms of the savings to the NHS and the other care providers as
46:55
well.
46:57
These are questions which involve politics and society and all sorts of things.
47:03
I think in some ways there's that argument you spend money now and you save money in
47:08
10 or 20 years' time.
47:10
But even though that's to the advantage of the patient and the patient's health, if you're
47:15
the health minister spending the money, then it's not you personally or your department
47:19
or maybe even your party who gets the advantage of that.
47:23
And that's why I think we need the all-party parliamentary group that the ROS have supported.
47:29
We need more politicians and more commissioners and more opinion formers really onside here
47:36
because it really is an open goal, the Fracture Liaison Service.
47:41
We really should be seeing complete coverage across the UK.
47:47
The other thing that Carlson mentioned was that the problem of osteoporosis is an incredibly
47:53
difficult one.
47:55
It's incredibly complicated.
47:56
It takes into account anatomy, physiology, ageing, disease, hormonal physiology, bone
48:03
cell physiology, somebody's exercise, diet, lifestyle, smoking.
48:08
All of these things can affect bone health.
48:11
And as a researcher, I do find it very hard to try and design research projects for bone
48:18
that bite off manageable chunks of the subject.
48:22
When you're trying to study such a complex thing as bone ageing or bone disease, it's
48:28
hard to study all of these changing factors at the same time.
48:35
And not all of them you can measure.
48:38
So it's always very difficult to try and articulate in a grant proposal or research paper what
48:44
impact we're going to have, what we're going to learn about bone ageing and bone disease
48:48
because it is such a complicated problem.
48:51
And I always, always struggle to explain osteoporosis in grant proposals.
48:57
And I really like having these interviews with our guests because it helps me to understand
49:02
and learn how to explain better.
49:07
I think we're both getting a lot from this and learning a lot from this.
49:10
And I hope our listeners are too.
49:13
And we'd love to hear your feedback on anything we've talked about, but particularly anything
49:18
that you heard today.
49:20
And indeed, if you're a commissioner and you're keen to commission a fractal liaison service,
49:24
then please do let us know when we'd be keen to point you in the right direction.
49:30
Okay.
49:31
Bye everyone.
49:32
Bye now.