How I... improved osteoporosis management through audit
Dr Charles Buckley explains how he used audit to select clear-cut standards for the complicated area of managing osteoporosis
Osteoporotic fractures are a major source of morbidity, misery and death for older patients and the statistics make scary reading – 70,000 hip fractures a year and NHS costs of £1.5-2bn.
As GPs we see the descent into institutionalised care and loss of quality of life and, in the hard-nosed new world of practice-based commissioning, the frightening health, social and financial costs of fractures.
The trouble for me with osteoporotic fractures is that the whole area feels complicated. Guidelines only tackle bits of the problem (until we hear from NICE) and because it's not in QOF it is not easy to concentrate on it when there is so much else to do.
This is where a well-constructed audit helps. We have been able to look at, and select, the clear-cut standards that the evidence shows are important. We can review progress towards meeting those standards and be prepared for NICE guidance (and QOF) when it comes.
Gloucestershire did a major county-wide audit in 1998, which led to the development of a local case-finding service that included my practice. The beauty of having a dynamic and effective audit group locally is that we haven't had to spend hours sorting all the
evidence and data out for ourselves. They have experts in Read Codes and data quality, Miquest search tools and enthusiasts to
review and precis the evidence – this can all be found on the Gloucestershire website (see box, right).
What we did
As a result of the 1998 audit and subsequent local case-finding project we had a headstart in awareness and also systems for looking for, and advising and treating, those at risk. We used the NICE and Royal College of Physicians guidance and protocols for secondary prevention of osteoporosis – mainly those with fragility fractures or on long-term steroids. We started recording falls and fall assessments. We coded all those in nursing and residential homes and those who are housebound so they could be offered advice and calcium and vitamin D3.
We are looking for, and referring for DEXA scanning, all those at high risk of osteoporosis using the known risk factors and awareness enables us to be sensible about levels of referral and investigation. Major risk factors are premature menopause, hypogonadism, steroid therapy (7.5mg/day or more for > six months), associated diseases: liver, parathyroid; GI diseases such as Coeliac and thyrotoxicosis; and radiological osteopenia. Minor risk factors include family history, low weight, sedentary lifestyle, smoking, drug therapy such as anti-epilepsy therapy and height loss. There are scoring systems such as the Fracture Index but we aren't routinely using these as we are not sure how robust the evidence is. NICE guidance in this area will help us enormously.
We are regularly reviewing patients on bisphosphonates and calcium + vitamin D3 for concordance (a known problem).
We noted many patients found the calcium supplements unpalatable and did not take them and that the overall treatment compliance was only 50 per cent without regular review and encouragement. This is a bit like anti-hypertensive treatment – patients need regular review and monitoring.
We still have work to do on data quality
as the basis for diagnosis for many inherited and transferred patients is unclear and here the audit has helped by giving us lists of patients with a diagnosis but no treatment and patients with treatment but no diagnosis.
Areas that have caused us particular difficulty are the falls assessment and management of fallers (because local standards, assessment tools and services are still evolving) and primary prevention and case finding, as the risk assessment tools are controversial and we aren't sure of their cost-effectiveness.
What we achieved
In a small practice like ours it is hard to
produce robust clinical outcome data to prove that our time, effort and prescribing budget has been well spent – the numbers are too small and the confidence intervals too wide – but we are convinced. Fracture numbers are down and patients on treatment and those reviewed are up.
We estimate our reduction in hip fractures may be between 30 and 50 per cent per year since 1998 but we cannot prove this statistically with the small numbers involved.
The real proof will be when all the other practices in the county are involved and we can look at results in a treated population of thousands rather than tens or hundreds.
We feel we are now offering our elderly patients an improved chance of avoiding
the misery and danger of osteoporotic
fractures. There is much more to do on primary prevention and we are keen to pursue that when we have the guidance. Perhaps inclusion in the QOF is the long-term answer.
Charles Buckley is a GP in Frampton-on-Severn, Gloucestershire. He is a PEC and board member at Cotswold and Vale PCT, and he is clinical governance and CHD and cancer lead for the PCT
Competing interests None declared
Osteoporosis care tips
Advice for practices wanting to improve osteoporosis care
1 Make sure you are coding all fragility fractures and identifying patients for secondary prevention
2 Identify and code all patients in residential or nursing home care
3 Find out how your local falls assessment and management services work and liaise with them
4 Look at the www.glospccag.nhs.uk open website (you can see how we are doing and how much more there is to do!)
5 Review your prescribing and concordance checking (there are major cost-effectiveness choices in terms of products with generic bisphosphonates and so on but none is effective unless taken).
How long to continue bisphosphonates is a vexed question with very little evidence to base a decision on – we have decided to continue for seven years and probably indefinitely until more evidence emerges
6 Read the guidance from NICE (TA 87), SIGN (guideline 71), RCP and look at www.nos.org.uk