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The waiting game

New research is 'final nail in the coffin' for co-proxamol use

Osteoporosis should be in the QOF

Dr Jonathan Bayly argues that including osteoporosis could have a huge impact on public health

Evidence exists on the efficacy and cost-effectiveness for osteoporosis to be included in the next QOF. On efficacy we have randomised controlled trials and meta analysis to show what works, while on costs we have the support of a NICE technology appraisal.

The suggested markers from the National Osteoporosis Society concentrate on three groups:

·Elderly patients in a nursing or residential care home who can gain a substantial reduction in hip fracture risk with calcium and vitamin D31,2

·Patients over 65 years on long-term systemic glucocorticoids who can be effectively helped to reduce the risk of glucocorticoid induced osteoporosis3

·Females over 65 with a history of minimal trauma fracture who should be managed according to NICE4.

The evidence linking interventions to health outcomes for osteoporosis is as robust as indicators in other disease areas. And they don't concentrate on measurements but on delivering effective treatments. In short the markers will reduce fractures.

The cost of non-inclusion

There is a risk that patients will suffer more avoidable ill-health and the nation will have greater health economic burdens if our plea to add osteoporosis to the framework is not heeded.

·One in two women and one in five men will suffer a fracture after the age of 50 and the vast majority of these will be osteoporotic in nature.

·The total burden to the NHS is more than two million bed days per year for fractures in the over-60s. This is more than nearly all other domains within the QOF at any age.

·Half of hip fracture survivors can no longer live independently ­ 64 per cent will need a walking aid and half can no longer move about outside on their own.

·40 per cent of patients sustaining a clinical vertebral fracture will have constant pain and the majority will have difficulties with activities of daily living.

·Treating high-risk osteoporotic patients ultimately decreases GP workload by reducing consultations (as many as 14 in a year) that can follow the occurrence of a fracture.

Osteoporotic fracture is an under-recognised, under-treated risk for which there are national clinical management guidelines and a solid evidence base for the effectiveness of interventions agents (see evidence in our full submission at: when provided for the correct patients. Without these very reasonable indicators within QOF there is a risk that the increasing number of older patients expecting good health in later life will feel that their needs are not being adequately addressed by the new GMS contract.

Jonathan Bayly is an associate lecturer at the University of Derby where he works on the Radiography, Informatics and Osteoporosis programme. He is a former GP in Stroud and sits on the scientific advisory group of the National Osteoporosis Society


1. Chapuy MC, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women.

N Engl J Med 1992; 327 (23):1637-42

2 Lilliu H, et al. Calcium vitamin D3 supplementation is cost-effective in hip fractures prevention. Maturitas 2003;44:299-305

3 Royal College of Physicians (London), the Bone and Tooth Society of Great Britain, and the National Osteoporosis Society (2002). Glucocorticoid-induced osteoporosis.

4 National Institute for Clinical Excellence (2005). Bisphosphonates (alendronate, etidronate, risedronate) selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

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