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Osteoporosis: the case for enhanced services

Dr Peter Stott offers simple steps on how to apply for funding from your PCT

Directly enhanced services in the new GMS2 contract enable practices in areas of special need to provide innovative services outside essential or the normal category of enhanced services and to be paid for doing so. The concept is analogous to a PMS Plus service under the PMS contract.

To succeed in a bid for this category of services it is important to present the service as something that is not usually provided by the average practice. While caring for osteoporosis is decidedly essential, screening for osteoporosis and providing additional educational services for patients are not.

Osteoporosis is largely a problem of the ageing population. The major cost is fracture. So if your practice is in an area with a large population of elderly patients, your PCT is likely to view fractured wrists, spines and hips as a major public health concern. But osteoporosis is prevalent everywhere and is a problem every PCT should consider.

If you consider osteoporosis is a problem for your practice you should consider approaching the PCT and suggesting a structure for an enhanced obesity service. Your application should be modelled on the current quality initiative framework and should include:

la needs analysis for your practice (basic epidemiology and morbidity)

lthe evidence base for the intervention you choose to adopt

lthe outcome measures that will demonstrate success

la business plan.

Needs analysis

Osteoporosis is very common, threatening both life and quality of life. One in three women and one in 12 men over the age of 50 will have an osteoporotic fracture at some time1.

One in five patients with a fractured hip will die of complications. Half will not live independently again2.

Compared with fractured hips, fractures of the spine are more insidious, gradually leading to a shortened spine, and compression of the lungs and abdominal viscera. Conditions such as breathlessness and reflux will worsen and the consequent immobility can seriously impair quality of life and mental well-being. PCTs know they have a responsibility to take osteoporosis seriously.

You will need to perform some kind of needs analysis to demonstrate your population is particularly at risk. This might be compared with the numbers of patients currently being treated.

It is a great bonus to be able to link your proposal to a Government initiative as it is more likely to receive financial support.

Osteoporosis is directly linked to the national service framework for older people and the falls initiative. So funds to tackle osteoporosis may already have been allocated by your PCT and are just waiting there, ready for you to apply.

There are three groups at particular risk of osteoporosis3:

lpatients with a family history of osteoporosis

lpatients who have suffered a previous fragility fracture

lpatients who have taken steroids (more than 5.0-7.5mg prednisolone/day for more than six months).

Others include:

lthose with a poor dietary history

lpossible secondary osteoporosis ­ primary hyperparathyroidism, poorly controlled thyrotoxicosis, malabsorption

lrheumatoid arthritis, liver disease, alcoholism

loestrogen deficiency (menopause or hysterectomy under 45 years old)

lsecondary amenorrhoea for more than six months, primary hypogonadism.

Interventions

There is an excellent evidence base for interventions to both prevent and treat osteoporosis (see boxes) and your programme should include elements of these which are not normally available to patients under the category of 'essential services'.

Screening, DEXA assessment, risk assessment, plus a physical exercise or

stop-smoking programme might be acceptable.

So might an educational programme, dietary advice or the provision of hip protectors to women in nursing and residential homes. A full domiciliary falls assessment could be useful. Once up and running, this could be offered on a larger scale to other practices.

Nurses and other ancillary staff might be employed to carry out the majority of the screening and risk assessment.

Outcome measures

It is notoriously difficult to produce long-term outcome figures that will demonstrate the benefits of managing osteoporosis effectively. You will probably resort to surrogate outcomes like numbers of patents treated, compliance, DEXA measurements and costs.

In an otherwise progressive condition like osteoporosis, no deterioration in

DEXA measurement or quality of life is probably the most optimistic outcome one might expect.

You should audit the whole process, since future funding will be dependent upon your showing the progress of the scheme.

Business plan

In your application to the PCT you will need to include estimates of the cost of providing the service and the potential benefits that will accrue. These should include personnel, facilities, staff salaries, auditing, use of investigations and therapies. It is common for PMS Plus schemes initially to be funded from non-recurring sources, but if you can demonstrate effectiveness then funding is likely to be extended.

Anti-fracture efficacy of interventions in postmenopausal osteoporotic women:

grade of recommendations1

Spine Non-vertebral Hip

Alendronate A A A

Calcitonin A B B

Calcitriol A A nd

Calcium A B B

Calcium and vitamin D nd A A

Cyclic etidronate A B B

Hip protectors - - A

HRT A A B

Physical exercise nd B B

Raloxifene A nd nd

Risedronate A A A

Tibolone nd nd nd

Vitamin D nd B B

Evidence from A meta-analysis of one or more RCTs or from at least one well-designed controlled study without randomisation; B at least one well-designed quasi-experimental study or well-designed descriptive study; C an expert committee or clinical experience; nd not demonstrated

Effect of interventions on the prevention/

reduction of postmenopausal bone loss:

grade of recommendations1

Intervention Level of evidence

Alendronate A

Calcitonin A

Calcitriol A

Calcium A

Cessation of smoking B

Cyclic etidronate A

HRT A

Physical exercise A

Raloxifene A

Reduced alcohol consumption C

Risedronate A

Tibolone A

Vitamin D plus calcium A

Evidence from A meta-analysis of one or more RCTs or from at least one well-designed controlled study without randomisation; B at least one well-designed quasi-experimental study, or

well-designed descriptive study; C expert committee

or clinical experience

References

1 Royal College of Physicians, Bone and Tooth Society of Great Britain. Osteoporosis. Clinical guidelines for prevention and treatment. London: RCP, BTSGB, 2000

2 National Osteoporosis Society. Priorities for prevention. Bath: National Osteoporosis Society, 1994

3 Department of Health. Quick reference primary care guide on the prevention and treatment of osteoporosis. London: Department of Health, 1998

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