Geraldine Carter describes an NOS pilot project that was set up to identify patients at risk from osteoporosis

In 1998, a county-wide audit in Gloucestershire indicated that patients with osteoporosis were under-identified and under-treated and that there was limited access to DXA scanning.

Osteoporosis is a common condition, affecting one in three women and one in 12 men over 50 years old. The consequences are low trauma fractures, particularly hip fractures, which when combined with an increased tendency to fall leads to preventable morbidity and mortality in the older patient. The associated health and social care costs are estimated at £1.8 billion a year.1-4

The predicted growth rate in the over 65-year age group in Gloucestershire between 1999 and 2005 is roughly double the national average. Hospital admission rates for accidents in the over-75 age group are between 30 and 50% higher in Gloucestershire than in other counties. There are also notably higher rates for fractured neck of femur than in other areas of England and Wales.5-6 These factors will have an impact on the elective hip replacement programme that is 52% greater than national norms.

Setting up a nurse-led osteoporosis clinic

One of the GPs in the practice had an interest in osteoporosis and together we set up a nurse-led osteoporosis clinic in our practice. The aims were to target women aged 30 years and over with risk factors who were registered with the practice, to identify those at risk of osteoporosis or who were already suffering from osteoporosis, as well as those who were at risk of, or who had a history of, falls.

In partnership with the other practices in Stroud and Berkeley Vale PCG, and the Severn NHS Trust, the practice became one of the National Osteoporosis Society pilot sites. We wanted to develop and rigorously test a model of care that could be applied across the PCG.

The roll-out has been costed to reflect the need for a practical approach to translate best practice into embedded practice.

There is a solid evidence base for the cost effectiveness of pharmacological and non-pharmacological interventions in osteoporosis and fracture prevention programmes.7-8

The project leads felt that appropriate assessment for fracture risk could be achieved by using a combination of selection by risk factor and peripheral DXA scanning.

While peripheral forearm DXA is a well-validated technique, there is a potential for discordance, or misclassfication, particularly in early post-menopausal women.9 However, we have found that more general use of the peripheral scanner has led to more judicious referral for hip and spine DXA scanning.

The expected outcomes (Box 1) relate to 'proxies' of care (improving the number of patients that could be identified as suffering from low bone mineral density and the amount of appropriate prescribing, measuring compliance by both clinician and patient) as well as a reduction in the number of incidents of minimal trauma fractures.

Box 1: Expected outcomes
  • Increased identified prevalence of osteoporosis
  • Increased therapeutic interventions
  • Documented compliance with clinical assessment and disease monitoring
  • Reduced incidence of fracture
Box 2: Risk factors for osteoporosis and falls

Major risk factors

  • Family history of osteoporosis, especially maternal fractured neck of femur (osteoporosis)
  • Corticosteroid use (osteoporosis)
  • Early hysterectomy/menopause (osteoporosis)
  • Low BMI (<19) (osteoporosis)
  • History of falls or risk of falls (falls)
  • Previous minimal trauma fracture (osteoporosis/falls)
  • History of kyphosis or loss of >2 inches in height, significant back pain (osteoporosis/falls
  • Medical condition (e.g. coeliac disease, hypogonadism, thyrotoxicosis, malabsorption) (osteoporosis/falls)
Minor risk factors
  • Smoking (osteoporosis)
  • Lack of exercise (osteoporosis/falls)
  • Lack of dietary calcium/vitamin D deficiency (osteoporosis/falls)
  • Excess alcohol intake (osteoporosis/ falls)

Identifying patients

The practice pilot project, which started in October 1998 and was completed by August 2001, became an NOS pilot project in July 2000. Ours is an osteoporotic fracture prevention project that includes falls, but is not merely a falls prevention programme.

Patients were identified by a variety of methods. A selective screening process was used for all women aged 65 years and over registered with the practice who were sent a postal questionnaire. Those whose responses showed that they had one major or two minor risk factors for falls or osteoporosis (see Box 2) were invited to attend the surgery for assessment.

This initiative forms part of the PCG's approach to implementing Standard 6 of the NSF for Older People, the aim of which is 'To reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.'

Women aged between 30 and 65 years with risk factors for osteoporosis were identified through the EMIS clinical system, and invited for assessment. These patients were also asked to complete the questionnaire, which formed a significant component of the assessment process. The criteria for this group are given in Box 3 (below).

Box 3: Criteria for assesment of women aged 30-65 years
  • Hysterectomy but no record of current HRT therapy
  • BMI <19
  • History of long-term corticosteroid use
  • History of minimal trauma fracture
  • Relevant medical condition as above
  • Opportunistically identified

Although our original audit looked at women from 45 to 84 years, we have now extended the programme to include women from 30 years old and there is no upper age limit.

Men at risk of osteoporosis were opportunistically assessed, but the project now acknowledges that a more pro-active approach is called for.

A separate multidisciplinary team will assess patients living in residential and nursing home accommodation. Their remit will include introducing education of care staff, exercise programmes, dietary advice including calcium and vitamin D supplementation, and use of hip protectors.

Patient assessment

The process of assessment involved:

  • a forearm DXA scan
  • review of the questionnaire
  • completing a template on the practice EMIS clinical system to document medical, lifestyle and falls risks that identify the patient as needing intervention
  • appropriate therapeutic and non-therapeutic advice following RCP guidelines10 and good practice. This included lifestyle, safety advice and also, if appropriate, referral to a falls clinic or falls prevention programme run by the PCT-based Falls Prevention Group.

Benefits for patients

It is as yet too early to demonstrate a reduced fracture rate; however, the project, other participating practices and the trust information services are recording the incidence. Table 1 (below) compares the results of the baseline audit with the audit figures for January 2002. Figures 1 and 2 (below) show the other 'proxy' quality markers compared with baseline audit.

Table 1: Women aged 45-84 years with osteoporosis or osteopenia identified by audit
 

1997-98

January 2002

Total patients
Osteoporotic
Osteopenic
Normal
Osteoporosis prevalence
Osteopenia prevalence
Patients taking:
– HRT
– bisphosphonates
– calcium preparations
– SERMS
Fractures recorded

1882
40
0

2.13
0

257
25
8
0
58

1983
151
172
161
7.61

8.67
528
175
193
24
156

 

Figure 1: Women aged 45-84 years with osteoporosis or osteopenia Figure 2: Therapeutic
interventions in women aged
45-84 years

 

Figure 3: Algorithm for selected screening process

Health Promotion Gloucestershire funded the supply of a limited number of hip protectors, and a pilot trial to assess their acceptability has been undertaken as part of the project.

Figure 3 (above) is an algorithm for the screening and assessment process.

Implementing best practice

Induction programmes for partner practices began in July 2001. Each practice receives a diskette and a resource file outlining the clinical processes together with educational material, research papers and patient information leaflets.

A meeting is held initially with the entire primary health care team so that all members of staff are aware of the new initiative.kThe more successful practices involved in the project employ a multidisciplinary, collaborative approach.

A second meeting is held to focus on the practical details with lead staff. Templates for data acquisition devised by the project are up-loaded and advice is given on search strategies. The initial cohort of patients identified are those aged 65 years and over. Clinics are held as soon as questionnaires have been assessed.

Patients for whom DXA scanning may be inappropriate include those who are already receiving treatment and who need advice about taking medication, patients with overt osteoporosis, those who present with a history of falls or who are at risk of falls and those who are housebound.

The clinics are run by practice and district nurses, health visitors and nurses for the elderly. A visiting radiographer performs forearm scanning at each practice. The osteoporosis specialist nurse demonstrates, mentors and supports. Talks and presentations are also given to patient groups.

Twelve practices are committed to the programme, and this will ensure coverage of a population of 60000 by May 2002.

Reference

  1. Cummings SR, Nevitt MC. A hypothesis: the causes of hip fractures. J Gerontol 1989; 44: M107-11.
  2. Grisso JA, Kelsey JL, Strom BL et al. Risk factors for falls as a cause of hip fracture in women. N Engl J Med 1991; 324: 1326-31.
  3. Hedlund R, Lindgren U. Trauma, type, age and gender as determinants of hip fracture. J Orthop Res 1987; 5: 242-6.
  4. Burge RT, Worley D, Johansen A et al. The cost of osteoporotic fractures in the UK: projections for 2000-2020. J Drug Assessment 2001: 4: 71-160.
  5. Gloucestershire Health Authority. Public Health Common Data Set. 2000.
  6. Office for National Statistics
  7. Barlow DH, Francis RM, Miles A. The Effective Management of Osteoporosis. UK Key Advances in Clinical Practice Series. London: Aesculapius Medical Press/The National Osteoporisis Society, 2001.
  8. Torgerson D et al. Rational prescribing in osteoporosis. Osteoporosis International 2000; 11(Suppl. 5): S18
  9. Masud T, Francis RM. The increasing use of peripheral bone densitometry. Br Med J 2000; 321: 396-7.
  10. Royal College of Physicians/Bone and Tooth Society of Great Britain. Osteoporosis: Clinical Guidelines for Prevention and Treatment. Update on pharmacological interventions and an algorithm for management. London: RCP/Bone and Tooth Society of Great Britain, July 2000