Dr Alun Cooper describes how his practice strategy for identifying patients at high risk of osteoporosis is aiding implementation of the NSF for Older People

Standard 6 of the National Service Framework (NSF) for Older People has as a key intervention the prevention and treatment of osteoporosis (see Box 1, below).

Box 1: Osteoporosis – key facts
  • Osteoporosis affects 1 in 3 women and 1 in 12 men over the age of 50 in the UK. This results in 230 000 fractures per year.1
  • The life-time risk of a 50 year old sustaining an osteoporotic fracture is 40% for women and 13% for men. These fractures are predicted to double in the next 50 years.
  • A fifth of orthopaedic beds are occupied by patients with hip fractures. These fractures result in lack of mobility, social isolation, deterioration in quality of life and premature death. Only 50% of patients sustaining a hip fracture regain full independence and 20% need residential care.
  • The excess mortality, depending on how this is measured, is between 12 and 37%. More people die from hip fractures (14 000 per year) than the total dying from carcinoma of the ovary, cervix and uterus combined.
  • The cost implications are enormous, amounting to £1.7 billion per year.

National evidence-based guidelines produced by the Royal College of Physicians in collaboration with the Bone and Tooth Society of Great Britain,2 and guidelines from the Primary Care Rheumatology Society,3 advocate a case-finding strategy with referral of patients at high risk of osteoporosis for dual-energy X-ray absorptiometry (DEXA).

In addition, the National Osteoporosis Society (NOS) has published a strategy for prevention of accidents, falls, fractures and osteoporosis for primary care groups and local health groups.4 This is soon to be superseded by a framework for health improvement programmes to help primary care organisations (PCOs) implement the NSF recommendations, and hence deliver the NSF standards for falls and osteoporosis.5

The NHS Executive, endorsed by the Royal College of Physicians, recommends that 'health authorities should purchase bone density measurements by means of DEXA'.

In Crawley, West Sussex, where I work, we have access to a DTX200 forearm Dexa scanner, but not hip or spine Dexa. Does this matter?

Bone densitometry of the forearm is a well-validated technique.6 Nelson and colleagues concluded from their study data that 'with few exceptions, the same clinical decision would be made, no matter which skeletal site is selected for measurement.'7

We are a practice of 12 doctors looking after 21 400 patients from three surgery sites. Our interest in osteoporosis began in 1997, when we adopted a case-finding strategy to identify patients over 20 years of age with a fragility fracture or risk factors for osteoporosis (see Table 1, below).

Table 1: Risk factors for osteoporosis
  • Oestrogen deficiency
  • Steroid use
  • Previous fracture of the wrist
  • Previous fracture of the hip
  • Previous fracture of the spine
  • Anorexia nervosa
  • BMI <19
  • Malabsorption, including coeliac disease
  • Crohn's disease
  • Ulcerative colitis
  • Rheumatoid arthritis
  • Hyperthyroidism
  • Hyperparathyroidism
  • Transplantation
  • Family history of osteoporosis and/or hip fracture
  • Male hypogonadism

Patients were identified by computer search and then invited by post to attend for a DEXA scan. The response rate was 85%, which was higher than expected.

The results of the DEXA scans are shown in Table 2 (below). The category 'Oestrogen deficiency' includes women who have undergone premature menopause (before the age of 45), those who have had a period of prolonged amenorrhoea of more than 6 months, and those who have had a hysterectomy with or without oophorectomy before 45 years of age.

Table 2: Results of the DEXA scans
Indication for scan Males Females Total % with osteoporosis
Oestrogen deficiency 476 476 9%
Steroid use 39 81 120 18%
Previous fracture of the wrist 15 78 93 30%
Previous fracture of the hip 3 7 10 50%
Previous fracture of the spine 0 0 0 0
Anorexia nervosa or BMI <19 0 8 0 0

Malabsorption including coeliac disease

4 16 20 30%
Crohn's disease 12 15 27 15%
Ulcerative colitis 22 22 44 21%
Rheumatoid arthritis 27 54 81 40%
Hyperthyroidism 8 54 62 31%
Hyperparathyroidism 0 3 3 33%
Transplantation 2 4 6 20%
Family history of osteoporosis and/or hip fracture 0 12 12 25%

Male hypogonadism

3 0 3 33%

Although the rate of loss of bone mineral density is known to be highest in the first 3 months of steroid use, patients were recalled if they had been taking steroids in a dose of 7.5mg per day for more than 6 months or the cumulative dose was >1g.

From our results it became apparent that the quality of our recorded data was poor:

  • Only one third of vertebral fractures are detected clinically, but even these were not recorded
  • Neither family history of osteoporosis nor a maternal hip fracture were recorded
  • Only half of those patients who had an osteoporotic fracture of the hip were identified as osteoporotic by DEXA scan.

This last finding highlights the poor sensitivity of DEXA scanning. It is, however, highly selective. The use of DEXA scanning as a predictor of hip fracture is still approximately as accurate as using hypertension as a risk factor for stroke, and more accurate than using cholesterol as a risk factor for myocardial infarction.

We found that Read codes were not available to describe all the terms used in the management of osteoporosis. The shortcomings are now being addressed by the NOS.

All patients diagnosed as having osteoporosis had the following routine blood tests performed, as recommended, for example, by the Primary Care Rheumatology Society (PCRS):

  • Full blood count for malabsorption
  • Erythrocyte sedimentation rate – for myeloma
  • Urea and electrolytes for kidney disease
  • Liver function tests for liver disease
  • Thyroid function tests for hyperthyroidism
  • Calcium, phosphates for hyperparathyroidism
  • Testosterone in men for gonadal failure.

However, very few of these results were abnormal, indicating that more research in primary care needs to be done to validate the PCRS's advice regarding blood testing.

In an average primary care organisation (PCO) of 100 000 patients, there will be 120 hip fractures, 120 wrist fractures, 40 clinically diagnosed vertebral fractures and 100 other osteoporotic fractures per year.

The total cost of fracture management per PCO is £2 652 240, inclusive of social care, long-stay hospital costs, follow-up costs and drugs.

The NOS estimates that the average PCO would require approximately 1000 DEXA scans per year to implement a case-finding strategy. The annual cost of providing a suggested service framework is £175 023 – the same as the cost of managing eight of the 120 hip fractures that occur in the typical PCG per year.

Crawley PCG has decided to implement our case-finding strategy in the light of our practice experience. Practices will be invited to audit their patients at high risk of osteoporosis by a stepwise approach, starting with those patients with oestrogen deficiency, steroid use or past history of low impact fracture.

This can be done by a practice nurse in-house or by an independent audit nurse. Support for this will be provided in the form of background education for the medical teams, a new National Osteoporosis Patient Support Group, which has been established in our locality, and a professional support group.

We also hope to be involved in the NOS Osteoporosis Nurse Initiative (see Figure 1, below), which is part of a national audit programme. An NOS nurse will be available, free of charge, to any GP practice in England, Scotland or Wales that wants to audit its management of osteoporosis in women over 75 years of age.

When identified, these patients will be sent a brief questionnaire to assess their potential risk of osteoporosis. This is based on an assessment tool for predicting fracture risk.8 Those at high risk will be invited to see the nurse and will be offered detailed lifestyle advice and supporting NOS literature.

The GPs will receive advice on the treatment options available for the patient. Patients at high risk will be invited back after 6 months to reassess lifestyle and compliance with medication, and to document any fractures.

We feel that these initiatives represent a systematic commitment to improving the healthcare of our ageing population in Crawley.

Figure 1: Screenshot from the National Osteoporosis Society website: Osteoporosis Nurse Initiative
Screenshot from National Osteoporosis Society website

  1. Adapted from Compston JE, Rosen CJ. Fast Facts: Osteoporosis. 2nd edn. Oxford: Health Press, 1999.
  2. Royal College of Physicians and Bone & Tooth Society of Great Britain. Osteoporosis: Clinical Guidelines for Prevention and Treatment. Update on pharmacological interventions and an algorithm for management. July 2000.
  3. Primary Care Rheumatology Society. Osteoporosis: Minimum Standard Guidelines. February 1999.
  4. National Osteoporosis Society. Accidents, Falls, Fractures and Osteoporosis. January 2000.
  5. National Osteoporosis Society. Primary Care Strategy for Falls and Osteoporosis. July 2001.
  6. Blake GM, Patel R, Fogelman I. Peripheral or axial bone density measurements. J Clin Densitometry 1998; 1(1): 55-63.
  7. Nelson DA, Molloy R, Kleerehoper M. Prevalence of osteoporosis in women referred for bone density testing. J Clin Densitometry 1998; 1(1): 5-11.
  8. Black DM, Steinbuch M, Palermo L et al. An assessment tool for predicting fracture risk in post-menopausal women. Osteoporosis International 2001; 12(7): 519-28.

Guidelines in Practice, December 2001, Volume 4(12)
© 2001 MGP Ltd
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