Approximately 300,000 fragility fractures occur each year in the UK. The number of patients presenting with hip fractures is set to double by 2050.1 Patients who have experienced one fracture have at least double the chance of sustaining another in the future. Between one-half and two-thirds of hip fracture patients have experienced a prior fracture, which should have triggered assessment for osteoporosis and falls risk and might have prevented a further incident. Fragility fractures cause pain, suffering, morbidity, and mortality. Drug treatments are effective and reduce fracture risk by approximately 50% over 3 years, yet osteoporosis remains underdiagnosed and undertreated, denying patients these treatment benefits.1
The 2007 British Orthopaedic Association and British Geriatrics Society (BOA-BGS) guideline on The Care of Patients with Fragility Fracture—the ‘BOA-BGS Blue Book’1— is a collaborative effort, with input from other groups, including the primary and secondary care forums of the National Osteoporosis Society. It summarises best practice in the care and secondary prevention of fragility fractures. The Blue Book highlights the crucial primary care role in initiating and ensuring compliance with medication and assessing falls risk. It also introduces an important new concept—osteoporosis as a chronic disease, with fracture as the acute exacerbation.1
Focus of the BOA-BGS Blue Book
The BOA-BGS Blue Book focuses on three key elements that are required to optimise patient care. These are:1
- high quality fracture care, with prompt pre-operative assessment and stabilisation, and surgery carried out during working hours by experienced surgeons/anaesthetists
- high quality secondary prevention, focusing on both drug therapy for bone protection and falls assessment and prevention
- high quality information management—using evidence-based standards, audit, and feedback through the recently launched National Hip Fracture Database (NHFD, www.nhfd.co.uk) to improve fracture care and secondary prevention.
This article deals with the role of primary care as outlined in the 2007 Blue Book.1
Setting standards for care
The standards for hip fracture care as shown in Table 1, form part of the audit criteria in the NHFD, with Standards 5 and 6 being of relevance to primary care.1
The most cost-effective way to achieve Standard 5 is by use of a fracture liaison service, which assesses inpatients and outpatients attending fracture clinics. Several different models of fracture liaison service are available throughout the UK. If these are unavailable, it is vital that assessment and management are undertaken in primary care, triggered by prompt notification of the fracture.
The burden on individual practices is small, with only six cases of new fragility fractures in postmenopausal women presenting annually per average GP list of 1700 patients.1 In addition, each GP list would be expected to deal with approximately 40 other postmenopausal women with previous fragility fracture,1 and these can be assessed opportunistically or using audit techniques based on Read Code recording, as discussed later.
The NICE guideline on assessment and prevention of falls,2 published in 2004, offers succinct guidance for primary care on how to meet Standard 6 (see Table 1). An initial assessment of gait and balance involves performing a ‘Get up and go’ test—the patient is observed standing up from an upright chair without using their arms, walking a few metres, turning around, and returning. If a disorder of gait and balance is identified, or if the patient has had recurrent previous falls (with or without fractures), then referral to the falls clinic for assessment and multidisciplinary intervention is appropriate. Balance exercise classes are available in some areas.
Current structures and incentives do not encourage primary care management of osteoporosis in the same way as for the management of other chronic diseases. Some strategies proposed in the BOA-BGS Blue Book,1 which may help optimise primary care management, are shown in Box 1.
Table 1: Standards for hip fracture care from The BOA-BGS Blue Book 20071
|1||All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation|
|2||All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours|
|3||All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer|
|4||All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission|
|5||All patients presenting with fragility fracture should be assessed to determine their need for antiresorptive therapy to prevent future osteoporotic fractures|
|6||All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls|
|Reproduced from the BOA-BGS Blue Book by permission of the British Orthopaedic Association|
Box 1: Recommendations to improve fragility fracture management in
|Reproduced from the BOA-BGS Blue Book by permission of the British Orthopaedic Association|
Table 2: Examples of Read codes for osteoporosis, falls, and fractures
|8HQ8||Referral for DXA|
|58EG||Hip DXA osteoporotic|
|58EM||Lumbar spine DXA osteoporotic|
|14G6||H/O fragility fracture|
|14G8||H/O vertebral fracture|
|140C||At risk of falls|
|90g3||Primary healthcare team falls assessment|
|66aF||Referral for falls assessment|
|3988||Get up and go test abnormal|
|817E||Bisphosphonate not tolerated|
|817H||Strontium ranelate not tolerated|
|817F||Calcium and vitamin D not tolerated|
|DXA=dual energy X-ray absorptiometry; H/O=history of|
Improving osteoporosis and fracture prevention care
Primary care teams excel at chronic disease management, as demonstrated by achievements in the quality and outcomes framework of the GMS contract. The BOA-BGS Blue Book proposes that fractures should be regarded as the acute exacerbation of the chronic underlying disease of osteoporosis. An analogy with cardiovascular disease (CVD) care is useful to explain this. When patients suffer a myocardial infarction, acute care is provided by secondary care, with long-term management of the underlying hypertension, hyperlipidaemia, heart failure, and angina undertaken by primary care to help reduce the risk of future events.1 Yet, following a fracture, it remains acceptable to forego management of osteoporosis in an affected patient, even though future consequences can be as serious and costly as those resulting from ignoring underlying CVD.
Recent research using the QRESEARCH database of 487 practices across England and Wales, serving a population of 3.4 million people, showed that only 25% of women over 75 years with a previous fragility fracture (representing approximately one in two of expected prevalence) were receiving bone-sparing therapy.3 Although 73% of women aged 65–74 years with both prior fragility fracture and a Read code of osteoporosis were receiving bone-sparing therapy, less than 1 in 10 women of this age with a fragility fracture had evidence of a dual energy X-ray absorptiometry (DXA) scan,3 a prerequisite according to NICE for treatment decisions in this age group.4
The research also showed that only 44% of men aged over 65 years with a fragility fracture and osteoporosis were being treated with alendronate3 but less than 2% of men with a fracture had a DXA scan coded.3
Of men and women receiving bone-sparing therapy, 46% were not receiving adjuvant calcium and vitamin D as recommended by NICE technology appraisal 87.3,4 The 1.8% overall prevalence of osteoporosis in this database is likely to be an underestimate, because only 51% of those receiving bone-sparing therapy had been diagnosed as having osteoporosis.3 There was virtually no evidence of primary care falls case-finding or its integration with osteoporosis, as recommended in the National Service Framework for older people.5
This research demonstrates issues with both quality of data and of care. Consistent use of key Read codes (Table 2) can help practices to identify patients with fragility fractures and audit care. In a similar way, the National Hip Fracture Database (www.nhfd.co.uk) will facilitate web-based collection and reporting of a dataset, including key elements of casemix, process, and outcome relating to hip fracture care.
Compliance with treatment
Management of post-menopausal women following fragility fractures is governed by the recommendations of NICE technology appraisal 87, with a new version of this guidance in preparation. This recommends treatment with bisphosphonates as first-line therapy, with adjuvant treatment with high dose calcium and vitamin D unless the patient is known to have sufficient calcium intake and is vitamin D replete.4
The BOA-BGS Blue Book highlights compliance as an area where primary care, with its frequent patient contact and computerised prescribing systems, can make a huge impact. For a bisphosphonate to be effective it depends on:1
- the patient taking it correctly—for example, after an overnight fast, washing it down with water, and allowing a delay (of 30–60 minutes) before food, drinks or other medication are taken
- adherence—taking it regularly
- persistence—taking it for long enough.
All of these are a particular challenge for elderly patients taking osteoporosis therapies, but compliance is vital to optimise fracture prevention. The General Practice Research Database has been used to study adherence to therapy, as measured by the medication possession ratio (MPR), a measure of how many days patients have medication in their possession.6 For bisphosphonates, MPR is around 74%, with women on weekly regimens having higher possession rates, 76% versus 64% for daily regimens. Overall mean persistence with bisphosphonate therapy is only 243 days, again with women on weekly regimens persisting longer—249 days versus 208 days.6 It may be possible to improve persistence further by extending the dosing interval to monthly combined with patient support.7
Computerised prescribing systems allow opportunistic checking that patients remain compliant and are persisting with therapy. Many fragility fracture patients are elderly, with multiple pathologies, and, therefore, consult their GP regularly, further facilitating this process.
Other high-risk groups
In addition to patients presenting with new fragility fractures, the BOA-BGS Blue Book recommends that primary care teams identify three other high-risk groups to reduce the possibility of future fractures. These are:1
- those with previous fragility fracture (fracture due to fall from standing height or less in those aged over 50 years)
- patients of any age committed to 3 months or longer treatment with oral steroids—manage according to Royal College of Physicians 2002 guidance8
- patients who are housebound, frail, and elderly, especially those in care homes—treat with calcium and vitamin D if no fracture is present, or as described above if there is evidence of previous fracture.
The BOA-BGS Blue Book encourages GPs to look at osteoporosis as a chronic disease, with fracture as the acute exacerbation, and to undertake important primary care roles in ensuring that patients receive optimal falls and fracture prevention care.
If GPs were to manage patients with fragility fractures as aggressively as they manage those with CVD, then potentially thousands of hip fractures could be avoided within the next few years.
- 50–66% of hip fractures occur in people who have already had a fracture
- Effective drug prophylaxis reduces fracture risk by 50% over 3 years
- Only 10% of women aged 65–74 years with prior fragility fractures have had a DXA scan as recommended
- Each GP has approximately 40 patients who would benefit from osteoporosis prophylaxis, with five new cases presenting each year
- Costs of prophylaxis:
- sodium alendronate monthly ~ £4.70 per month (70 mg weekly dose)
- calcium and vitamin D ~ £4 per month
- Tariff prices:1
- fractured neck of femur = £5997
- DXA scan = no separate tariff (can be negotiated locally, which is ideal for PBC schemes)
- British Orthopaedic Society, British Geriatrics Society. The care of patients with fragility fracture. London: British Orthopaedic Association, British Geriatrics Society, 2007.
- National Institute for Clinical Excellence. Falls: the assessment and prevention of falls in older people. Clinical guideline 21. London: NICE, 2004. https://www.nice.org.uk/pdf/CG021NICEguideline.pdf
- Hippisley-Cox J, Bayly J, Potter J et al. Evaluation of standards of care for osteoporosis and falls in primary care. London: QRESEARCH, The Information Centre for Health and Social Care, 2007.
- National Institute for Health and Care Excellence. Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology appraisal 87. London: NICE, 2005.
- Department of Health. National Service Framework for older people. London: DH, 2001.
- Cramer J, Amonkar M, Hebborn A, Altman R. Compliance and persistence with bisphosphonate dosing regimens among women with postmenopausal osteoporosis. Curr Med Res Opin 2005; 21 (9): 1453–1460.
- Cooper A, Drake J, Brankin E et al. Treatment persistence with once-monthly ibandronate and patient support vs once-weekly alendronate: results from the PERSIST study. Int J Clin Pract 2006; 60: 896–905.
- Bone and Tooth Society, National Osteoporosis Society, Royal College of Physicians. Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment. London: RCP, 2002.G