The new Primary Care Rheumatology Society guidelines should ensure that osteoporosis achieves a central place in primary care, explains Dr John Dickson

The National Osteoporosis Society (NOS) can be proud of its work in promoting research into osteoporosis and its prevention. By making osteoporosis a high profile condition, the Society has focused the attention of healthcare professionals on the importance of proper management.

We now have accurate ways of diagnosing osteoporosis (dual energy X-ray absorptiometry, or DXA) and an increasing array of measures, both pharmacological and non-pharmacological, for prevention and treatment.

Over the past 18 months there has been a proliferation of guidelines on osteoporosis treatment, including a booklet and summary sheet from the DoH, guidelines on corticosteroid-induced osteoporosis from the NOS, and most recently new guidelines for the prevention and treatment of osteoporosis from the Royal College of Physicians (see News, and Personal View ).

The Primary Care Rheumatology (PCR) Society has a long history of producing guidelines for primary care, having produced the first osteoporosis guidelines in 1992.

One of the strengths of the PCR Society is helping GPs with their education and perceiving future needs. The Labour Government's package of healthcare reforms has resulted in the advent of PCGs and the requirement to appoint an officer in charge of clinical governance.

With these changes in mind, the PCR Society met to consider how best to help working GPs and their primary care teams cope with the new demands imposed on the management of osteoporosis by today's changing health economy – especially its growing time and cost constraints.

Around 20 members of the Society met in York for a two-day meeting in March last year. Participants included GPs with a long-standing interest in osteoporosis and newer members who were undertaking the Primary Care Rheumatology Diploma (by distance learning) with the University of Bath.

All attendees had received a circular containing the most recent articles and guidelines on osteoporosis. These included peer review journals as well as GP journals. The last review included was Eastell's 'Treatment of ostmenopausal osteoporosis' (N Engl J Med 1998; 338: 736-46).

The format for the two days was a mixture of tutorials, discussions and workshops. Each tutorial was on a specific topic led by a GP expert in osteoporosis, the exception being the health economics tutorial led by Dr David Torgerson from the Centre for Health Economics and Department of Health Studies, University of York.

The overall conclusion was that there was a large knowledge gap for many GPs in the fields of:

  • Diagnosis
  • Investigation
  • Management
  • Economics.

It was felt that this knowledge gap was unlikely to be filled by the current guidelines. It was also considered that, for the guidelines to be of practical use, all general practices would need to have a lead practitioner who would be required to remain up to date on most aspects of osteoporosis.

But it was also recognised that this goal was unobtainable. Another meeting was therefore arranged, at which the tutors and workshop leaders would meet and consider what minimum criteria all GPs should be able to aspire to achieve.

At this second meeting, minimum standard guidelines were drawn up (see below).

PCR Society Minimum Standard Guidelines on the treatment of osteoporosis
pcrs guidelines page 1
pcrs guidelines p2

It was considered essential to:

1. Close the knowledge gap: This required discussions to consider:

  • Which groups of patient should be offered treatment
  • Whether practice computers and diagnostic registers could be used in the prevention of osteoporosis.

2. Document the advice given to or discussed with patients: This is an area of growing importance in our changing world of negligence and litigation, and one that will become an essential element of GPs' requirement to show that they are offering a 'quality' service under the Government's healthcare reforms: as yet, this is an implication that is not widely recognised.

The majority of GPs have databases, so it was felt that three major groups of patients could be identified:

  • Corticosteroid users
  • Early menopause patients
  • Patients with previous osteoporotic fractures

Corticosteroid users: There is good evidence that patients on 7.5mg or more of prednisolone daily will develop osteoporosis or be osteoporotic. GPs have many ways of identifying these patients. It is unlikely that practices will have many patients in this category, so the costs involved will be acceptable, and certainly will be condoned by any pharmacist or adviser appointed by their PCG or PCG equivalent.

There is as yet no evidence available to support osteoporosis prophylaxis with inhaled steroids. This evidence is awaited.

Early menopause: It is hoped that there will be few practices that have not offered HRT to all their patients aged 45 or younger who have had a total hysterectomy with bilateral oophorectomy. Thus the only question regarding these patients is 'Have the notes documented any patients who have not accepted treatment?'

Another question is 'Should we be checking FSH/LH in patients who are 45 and younger, and who have had a hysterectomy with conservation of the ovaries?' Most will have ovarian failure within 2 years of operation. GPs are advised to adopt a pragmatic approach, and offer HRT to all such patients within 2 years of hysterectomy, and assess the FSH/LH levels of patients who are reluctant to believe that their ovaries are ceasing to function and who request evidence of this.

Previous osteoporotic fracture: This group is potentially the most difficult to identify in primary care. Our patients are normally treated in casualty or orthopaedic wards, leaving us to receive discharge letters and reports – but invariably we don't see our patients afterwards.

It would seem sensible to collect data on these patients, certainly once a year and possibly twice a year, in large practices. We are not dealing with a large number of fractures per year. The fractures involved are usually hips, colles and vertebral.

It was considered that the medical records of patients who had had a fracture would need to be checked. This is because a large proportion of osteoporotic fractures result from road traffic accidents or other major traumas. Remember that elderly and frail patients require treatment but rarely require a DXA.

Most doctors are happy to start patients on HRT, but not all will wish to start bisphosphonates without advice from secondary care. This is the rationale for including a space for the telephone number and name of the local specialist or specialist nurse. It is based on the concept that we should be positive in asking our colleagues for advice when we are unsure.

There is good quality evidence that osteoporosis responds to HRT and bisphosphonates. There is some evidence, but less, that osteoporosis responds to calcitriol treatment.

Calcitriol has few problems associated with its use, e.g. it does not need to be taken sitting upright, or 2 hours before food. It may therefore have a place in the treatment of patients withsother disabilities and medical conditions such as inflammatory diseases and coexisting gastrointestinal problems. These patients are commonly on routine drug monitoring, so that checking their calcium every 6 months is not an added burden. If doctors are concerned about its efficacy, then a repeat DXA should be carried out.

General information is given on the reverse side of these minimum standard guidelines. All decisions must be made in partnership with our patients. Included here are the basic facts pertinent to patients, which also remind us that we probably have lots more information in our surgeries that we could or can give to patients.

Apart from facts for patients, we ourselves require information so that we can answer questions during the consultation. The most common facts are included in the guidelines, e.g. risk factors, and information on deep vein thrombosis, breast cancer and when to ask or refer for a DXA.

Importantly, there is a reminder about which investigations may be required for particular patients, and that we should be referring male patients with suspected osteoporosis to our local expert.

These are minimum standard guidelines. They are based on the strongest possible evidence used to produce the current NOS and DoH standard guidelines. The Society has endeavoured to produce the minimum guidance that is practical for ensuring the correct treatment of osteoporosis in any general practice. These guidelines also include facts that patients and doctors usually request at seminars.

Most guidelines are long and impractical for the busy, hardworking GP. The PCR Society guidelines are about attainable goals in real-life situations and being able to counsel patients in a general practice consultation. It is hoped that they will improve patient care by increasing the confidence of both the patient and the GP. This will naturally lead to better compliance with the overall consultation plan of action.

The minimum standard guidelines include prevention, not just for the elderly and daughters of identified cases (see 'Other information'), but also, by the use of collected information (on computers or a disease register), for all patients at risk of osteoporosis. This brings all of the primary healthcare team into the circle of osteoporosis management. Hence the learning and educational opportunities will continue for all staff, and so improve (and continue to improve) the care of the practice's patients.

Minimum standard guidelines are about attainable goals in today's economic climate. These standards do not need to be imposed, nor should they be. But they will be able to help all types of PCGs and their practices to get to grips with osteoporosis.

The guidelines should take the mystique out of the condition, and allow health professionals in primary care to diagnose, investigate, advise and treat patients with osteoporosis. By this means, it is hoped that osteoporosis will achieve a central place in primary care for the overall good of patients.

  • The Minimum Standard Guidelines are available from the PCR Society, PO Box 42, Northallerton, North Yorkshire DL7 8YG. Telephone/Fax: (01609) 774794.

Guidelines in Practice, April 1999, Volume 2
© 1999 MGP Ltd
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