My phone rang as I walked out of the hospital past the pregnant, dressing-gowned smokers. I was five minutes late for my next appointment with a Dr Miranda Scotland, who had described herself as a ‘GP, breast and bone physician’ in her email to me, whatever that was.
Dr Smith greeted me like a long lost friend, as indeed we were I now realised, she and I had shared a one-in-two paediatric rota in 19xx and there is nobody closer than somebody with whom you split a working week.
Miranda, currently working for two neighbouring trusts, had a proposition. She had set up a fracture prevention service in the North-east and wondered if we would be interested in one in North Cumbria.
Now, dear reader, your first task is one I have just done in my own practice: run a search for all of your patients who are on long-term corticosteroids and cross reference it against bone protection treatment such as bisphosphonates and the like.
You will expect all such patients to be protected and I am too embarrassed to tell you how many of mine were not. So, let’s move on to the other groups at high risk of fractures after reminding ourselves that the silent epidemic of osteoporosis and its nadir of #NOF (or fractured neck of femur, the common or garden hip fracture), which puts more people in residential care than dementia, and at least a quarter of affected patients, are dead within a year.
Secondary prevention anyone? Obviously anyone who has had one fracture due to fragile bones is more at risk of another and they need to be protected.
Next we know that our breast cancer patients on aromatase inhibitors all get bone density scans through their oncologists but what about your prostate cancer patients on anti-androgen treatment? You knew about your hyperthyroid patients and your coeliacs but what about your other malabsorbers, your inflammatory bowel sufferers or post-bariatric surgery patients?
By the time you’ve thought about your underweight patients, rheumatoids, transplants, smokers and those drinking more than three units of alcohol a week (sic!) you may wonder if there is anyone who shouldn’t be assessed by a fracture prevention service. Of course a lot of this is already done by a GP - as you will have done. You will have thought about all of the above, processed them through FRAX or other decision support tools, appropriately referred to your local bone densitometry service (forty miles away) and managed the result accordingly.
Miranda worked with GP practices and, using the data you already hold, screened over a hundred thousand patients. A similar service in Scotland reduced the fracture rate by 7% while the rest of the UK’s fracture rate increased by 17%.
Fracture prevention service anyone?
Dr Peter Weaving is the GP-clinical director for North Cumbria University Hospitals Trust and a GP partner in Carlisle. @PeterWeaving.