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(i) Osteoporosis: an overview of the organisation of services to deliver secondary prevention measures to older people with fragility fractures
Current Orthopaedics (2008) 22, 315e321
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journal homepage: www.elsevier.com/locate/cuor
MINI-SYMPOSIUM: OSTEOPOROSIS
(i) Osteoporosis: an overview of the organisation of services to deliver secondary prevention measures to older people with fragility fractures Anne Sutcliffe National Association for the Relief of Paget’s Disease, 323 Manchester Road, Walkden, Worsley, Manchester M28 3HH, United Kingdom
KEYWORDS Fragility fractures; Older People; Secondary prevention; Service Delivery; Multidisciplinary approach
Summary Fragility fractures in older people lead to significant morbidity and mortality. An initial fracture is a clear indicator for further fractures and therefore it is imperative that services should focus on secondary prevention for this vulnerable group of people. Despite shortfalls in current provision it should be possible to focus on effective interventions that will reduce future fracture risk through fracture liaison, specialist orthogeriatric care and falls services. Within Primary Care, case finding and medicines management offer proven opportunities that will contribute and impact on successful service delivery. All aspects need to be founded on the identification of priorities and standards and require a coordinated multidisciplinary approach with clear pathways of communication across the relevant health care system. ª 2008 Elsevier Ltd. All rights reserved.
Introduction Low trauma fractures occurring in older people constitute a major clinical and financial burden to the NHS. Each year approximately 310,000 patients present to hospital with fractures and although some are trauma-related and occur in the younger population, a substantial number are associated with advancing age, increased bone fragility and non-skeletal factors.1 In 2002e2003 there were 78,554 admissions for cases of fractured neck of femur alone and this is expected to rise to 91,500 by 2015 and 101,000 by 2020. McClellan et al have suggested that for every patient E-mail address: [email protected]
admitted with a hip fracture, there will be three patients treated for a low trauma fracture of the wrist, shoulder, ankle, hand or foot, in addition to uncertain numbers sustaining both symptomatic and ‘‘silent’’ fractures of the spine.2 The combined cost of social and hospital care for patients with osteoporotic fractures has been reported to be more than £1.8 billion per year in the UK, with most of these costs being related to hip fracture care in the older person.3 Fractures in over 60-year-olds utilise more than two million bed days and those attributable to hip fracture have been estimated to cost between £5,600 and £12,000 per case.1 After discharge from hospital, the cost of complex home and institutional care for those who make a poor recovery is substantial, averaging at £13,000 in the first two years.
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As demographic change in the UK will result in a substantial and inevitable increase in the incidence of fractures during the following decades, it is imperative that secondary prevention becomes an integral component of osteoporosis and fracture management. It is well recognised that those with a prior fracture have anything from a 1.5 to 9.5 increased risk of future fracture, with the risk potentially greater in men. Future fracture risk is greatest during the first year after initial fracture but the additional risk appears to persist for up to 10 years after the first fracture. Although a number of pharmacological interventions have demonstrated consistent anti-fracture efficacy, achieved during three years of therapy, historically osteoporosis remains under-diagnosed with many post-fracture patients not receiving appropriate assessment and management. In 2007 The Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians published its findings from a national audit on the organisation of services for falls and bone health for older people.4 Data were obtained in the secondary care setting on 8,800 fracture patients, 64% having sustained a non-hip fracture and 36% with hip fracture. Whilst there were marked variations between centres, general findings suggested that osteoporosis assessment and management were not meeting standards set by the National Institute for Clinical Excellence (NICE) technology appraisal 87 (Fig. 1). A minority of non-hip fracture patients (19%) and hip fracture patients (35%) received a clinical osteoporosis assessment, with Dual Energy X-ray Absorpitometry (DXA) measurements being performed in only 18% of the 65 to 74 years age group. After three months, only a fifth of patients were taking appropriate treatment to prevent further fractures and even after recovering from hip fracture surgery less than 50% were on appropriate osteoporosis medication. Patient(50+) with fracture A&E X-Ray
In a primary care setting the QRESEARCH database has been used to conduct the first national evaluation of standards in the management of osteoporosis and falls in older people within primary care. QRESEARCH is one of the largest general practice databases in the world and for the purpose of this study it evaluated standards of care in a population of nearly 3.4 million patients.5 With respect to secondary prevention in the older person, the study demonstrated that almost 75% of females aged 65 to 74 years with a history of fragility fracture and a diagnostic code for osteoporosis had been prescribed a bone-sparing agent. However, in women over the age of 75 years with a prior fracture only a quarter was receiving appropriate treatment. The prevalence of fragility fracture among men aged 65 and older was 6% compared to 14.8% in women, but less than 2% of males had a record of DXA measurements and slightly less than half were receiving treatment.
Practice Points 1 Each year 310,000 patients present with fractures, with 78,554 hospital admissions for fractured neck of femur, predicted to rise to 101,000 by 2020 CEEU audit on organization of Falls and Bone Health Services for the older person suggests that secondary prevention is not meeting NICE technology appraisal guidance. Within primary care only a quarter of females aged over 75 years is receiving therapeutic intervention for secondary prevention, with only a half of males over 65 years receiving appropriate treatment.
Service organisation Fracture liaison service
Orthopaedic/Trauma In Patient
Fracture Clinic Out Patient
Case Finding by Fracture Liaison Service
Case Finding by Fracture Liaison Service
Clinical Assessment Inc FRAX
?DXA Referral to Falls Clinic
?Referral to Bone Clinic
Treatment to prevent further fractures
Communication with Primary Care Team
Figure 1 Recommended pathway for older person presenting with fragility fracture.
Historically, services that have been established for patients at risk of osteoporosis have encouraged referrals of those with classic risk factors, leading to access for patients whose potential fracture risk is intrinsically low by virtue of their relative youth. It is now clear that service delivery should focus on those with a history of prior fracture who should be prioritized, assessed and offered appropriate therapeutic intervention to prevent further fracture. This approach offered through a Fracture Liaison Service (FLS) demonstrates a continuum of care for fracture patients different to the usual model, where care ended with the healing of the fracture (Fig. 2). In the context of an FLS, a fracture event can represent a new start to a pathway of care that has the potential to reduce a patient’s experience of further fractures by 50%. The service should be offered to all patients over 50 years presenting to hospital with a fragility fracture and should be available irrespective of the site of fracture and whether post-fracture care is provided as an in-patient or out-patient. By utilising an FLS it has been suggested that 95 to 97% of patients with
Osteoporosis Assessment Medical history
317 Multidisciplinary Team
Falls History
Multifactorial Intervention Exercise programmes
Medication
Gait/balance
Gait/balance
Medication review
Cardiovascular
Home hazard assessment
Neurological Cardiovascular treatment Vision assessment
Figure 2 Multidisciplinary Falls Risk Assessment. Adapted from the NICE Falls Guidance.
fractures of the radius or ulna or of the hip are offered the opportunity to undergo assessment (or are treated) for fracture secondary prevention.6 This model has been recognized internationally and by the UK Department of Health (DofH) as a model of best practice for implementing reliable assessment and treatment for secondary prevention of fractures. In reality, however, it would appear that commissioning and budgeting processes within the NHS do not incentivise these types of services as they only exist in approximately 30% of NHS hospitals. In establishing an FLS it is essential that it fulfills the criteria for any new development within the NHS and is acceptable to both commissioners and providers. It will require a strong evidence base regarding current provision, for example national data recorded in CEEU audits on falls and bone health. At a local level, audits covering standards such as current levels of identification of fracture patients, referrals for DXA and prescription of treatment for secondary fracture prevention would demonstrate specific shortfalls in service provision. Patient centered service developments that transform outcomes, reduce inequalities in health care, engage with multidisciplinary professionals and cross the primary - secondary care interface are more likely to warrant consideration and funding. For a new service to be justified it will also need to demonstrate that it can deliver cost-effective interventions that comply with NICE Technology appraisals and guidelines and DofH directives, e.g. the National Service Framework (NSF) and the Musculoskeletal Services Framework (MSF). In establishing an FLS it is appropriate to examine any existing services that may offer osteoporosis management and subsequently define clear and effective links. In any one secondary care setting the management of osteoporosis may rest in varied clinical domains e.g. Rheumatology, Endocrinology or Care of the Elderly. Access to DXA may be relatively easy but may be constrained by lack of funding and /or staffing levels. Ideally there should be clear links with Falls and Rehabilitation Services, which may be based within both secondary and primary care. As the majority of fracture patients will be discharged from hospital review it is imperative that there is effective liaison with GPs and other health and social care professionals based in primary care. Central to an FLS is the appointment of at least one dedicated staff member, demonstrating the skills and
expertise of a Fracture Liaison Nurse. A recent study from Chakravarthy and colleagues assessing secondary prevention of fragility fractures by orthopaedic surgeons and the effect of the multidisciplinary approach suggested that in the 60 to 80-year age group the presence of a Fracture Liaison Nurse made a significant difference in the prescription of vitamin D and calcium, providing weightbearing advice, falls risk assessment and DXA scan requests.7 Key components of this role are case-finding, osteoporosis assessment, treatment recommendations, referrals to other services and patient and staff education. Work carried out in Glasgow has suggested that one full time nurse should be able to address the case-finding and subsequent osteoporosis assessment and treatment needs of between 1400 and 1900 new fracture cases per annum.8 Whilst fracture clinics potentially provide the ideal setting for case-finding, this will have to be optimised by regular contact with orthopaedic wards, A&E and Falls Services. If one individual is responsible for providing this service it will be necessary to introduce some type of system that highlights ‘‘missed cases’’ who could then be assessed on a future visit. Although time-consuming, this could include checking of discharge summaries, fracture clinic lists and radiology databases, along with educating other staff about the value of case finding and secondary prevention. Following identification, each patient should be offered a clinical assessment to determine future fracture risk. Clinical assessment involving general and specific history taking may also be helped by the use of specific tools indicating future fracture risk, and the recent introduction of the FRAX WHO Fracture Risk Assessment Tool, accessed at http://www.shef.ac.uk/FRAX, should provide a useful means of fracture risk assessment that could easily be used in the fracture clinic setting. FRAX is accessed as a computer driven tool but it also provides several simplified versions based on risk factors that may be downloaded. It is based on individual patient models developed from studying population based cohorts in Europe, North America and Australia. An individual’s risk factors such as age, gender, weight and height and femoral neck bone density are entered into a simple website tool. Clearly, the femoral neck bone density will not be available in many elderly patients but the programme accounts for this in its calculations. The following risk factors are then added:
Previous fracture history. Parental history of hip fracture. Current smoking history. History of glucocorticoid use. (Either current exposure to oral glucocorticoids or previous exposure for more than 3 months at a dose of at least 5 mg daily.) Rheumatoid arthritis. (Osteoarthritis is not a risk factor.) Secondary osteoporosis, including type 1 diabetes, osteogenesis imperfecta in adults, untreated long standing hyperthyroidism, hypogonadism, premature menopause (<45 years), chronic malnutrition, malabsorption and chronic liver disease. Alcohol intake >3u daily Once the data have been entered, FRAX is then able to calculate a figure indicating a 10-year fracture probability
318 of both hip and other major osteoporotic fracture. The advantage of this specific tool is that it produces an accurate numerical value, presented in percentage terms that can be easily explained to the patient. Following the assessment it is appropriate to offer general advice on bone health, but should the value be low this can provide reassurance to the patient. A high value, however, indicates that a patient requires further investigation and probably treatment to prevent bone loss and future fractures. Although DXA measurements may be considered as part of fracture risk assessment it is currently unusual to find a DXA scanner located directly in a fracture clinic setting, and if considered necessary the Fracture Liaison Nurse may have to request these as a separate investigation. The most recent technology appraisal from NICE regarding secondary prevention suggests that in those women aged 65 to 74 years, DXA measurements are required to aid treatment decisions but are not necessarily required prior to commencing therapy in the older age group. Whilst case-finding and targeting of therapies are critical components in the secondary prevention of fractures, it is also important that patient education becomes part of the overall assessment. Patient education should ideally aim to increase an individual’s knowledge and understanding of a specific condition, leading to greater empowerment and subsequent increase in coping strategies and adaptability. For any educational activity to succeed it is important to be aware of patient education skills with respect to assessment of readiness to learn, timing and sequence of education, clarification and repetition of information and evaluation of learning, when appropriate. In addition, by focusing on twoway communication and individualised information giving it is hoped to emphasise co-operation not compliance. Common areas that have been explored with respect to osteoporosis and patient education include levels of osteoporosis knowledge and prevention, explanation of DXA results and effect on lifestyle, and advice on treatment options leading to adherence. Despite studies showing that osteoporosis treatments are generally well tolerated and associated with significant efficacy benefits, adherence to therapies on a long-term basis remains inconsistent. Treatment adherence and persistence is a complex process influenced by many factors in both the short and long term. Patient adherence is governed by their beliefs about the severity of their illness and relevant treatment. Illnessrelated factors include severity of symptoms, level of disability and rate of progression. Treatment-related factors include complexity and duration of treatment regimen, immediacy of beneficial effects and perceived or actual side-effects. Adherence rates to osteoporosis treatment will also be influenced by other concomitant medications; a particular problem with advancing age when over 50% of people over the age of 70 take three or more prescribed medicines. In the UK the use of specialist nurses within fracture clinic liaison roles appears to have impacted on patient adherence with therapy. Examples from Kent and Glasgow, where the specialist nurse has considerable input at the commencement of therapy, demonstrate approximately 80% adherence with therapy after two to three years.9,10 Objectively measuring the impact of education as part of secondary fracture prevention is not easy as it is
A. Sutcliffe influenced by so many variables. However, it would appear that it is more likely to result in positive rather than negative outcomes and should be an integral part of the Fracture Liaison Nurse’s role.
Practice Points 2 Fracture Liaison represents an ideal model of best practice for delivering secondary prevention to the older person. Only 27% of UK hospitals have a Fracture Liaison Service. A Fracture Liaison Nurse is central to this service, with a role combining case-finding, osteoporosis assessment, treatment recommendations, referrals to appropriate agencies and patient education.
Orthogeriatric services In the absence of a dedicated FLS, secondary prevention of fracture in the older person could be addressed within the orthogeriatric setting. The NSF for Older People states that ‘‘at least one general ward in an acute hospital should be developed as a centre of excellence for orthogeriatric practice’’. Collaboration between orthopaedic and care of the elderly services has developed over the past two decades with various different models of orthogeriatric care in existence. Evidence as to the efficacy and cost effectiveness of these models is complex with the Cochrane review of Coordinated Multidisciplinary Hip Fracture Care suggesting that there is ‘‘no conclusive evidence of coordinated post-surgical care. but a trend towards effectiveness in all main outcomes.’’ The NHS Health Technology Assessment Programme has also performed a systematic review of the evidence in respect of geriatric rehabilitation following fractures in older people. This review is inconclusive about rehabilitation units but does suggest that there is good evidence to support development of collaborative approaches in the acute setting, e.g. the Geriatric Hip Fracture Programme. It also suggests benefits from intermediate care initiatives such as early supported discharge schemes and the use of care pathways to expedite rehabilitation. In the absence of any generic model of service it is important to focus on multidisciplinary working patterns with free communication and sharing of information between health care professionals, the patient and their carers. How and where the concept of secondary prevention and osteoporosis assessment is introduced into the orthogeriatric structure will clearly depend on local provision and type of service model. It may come within the remit of a hip fracture nurse/practitioner who takes responsibility for coordinating initial assessment, pre-and post-operative care, secondary prevention and discharge planning. An additional facet to this individual’s role could be supervision of data collection for the National Hip Fracture Database (NHFD). Based on several large scale UK hip fracture audits the NHFD has been designed to improve
Osteoporosis quality and cost-effectiveness of patient care following hip fracture. It contains a full core dataset covering key elements of case mix, process and outcome. Data collected in field 5.02 shows whether or not antiresorptive therapy has been started whilst an in-patient and continued on discharge. It also questions whether DXA measurements have been performed/requested and if a referral has been made for bone clinic assessment. A later field questions the continuance of antiresorptive therapy one year postfracture.
Practice Points 3 Existing orthogeriatric services may provide a means of offering secondary prevention. A Hip Fracture Nurse/Practitioner may be best placed to incorporate secondary prevention into their role. The inclusion of data on implementation of therapy for secondary prevention and referral for DXA measurements in the National Hip Fracture Database will add to the improvement of quality of care and cost-effectiveness of patient care following hip fracture.
Falls services In the older person there is an inextricable link between falls and fractures with approximately 95% of fractures occurring after a fall. Falls are common and increase with age, occurring in approximately 30% of those aged over 65 years living in the community, rising to 45% of those aged 80 and above. Recurrent falls are associated with increased mortality, increased rates of hospitalisation and institutionalisation and curtailment of daily living. In addition, falls can lead to loss of confidence, anxiety and a marked fear of future falling. Whilst there is limited evidence to prove that interventions to reduce the rate of falls significantly impact on fracture incidence the general consensus from the British Orthopaedic Association (BOA), British Geriatric Society (BGS) and National Service Framework (NSF) for Older People suggests that those who fracture should be offered a falls assessment. The year 2001 saw the publication of the NSF for Older People. Standard 6 set out a standard of care for older people at high risk of falling and recognized that the detection, assessment and care of people with, or at high risk of osteoporosis was integral to this standard. This standard also suggested that all patients presenting with a fragility fracture should be offered multidisciplinary assessment and intervention to prevent future falls, as also acknowledged in NICE clinical guideline11 (Table 1). A key feature of Standard 6 was the recommendation that integrated services for falls and osteoporosis should be developed and be in place in all local healthcare and social care systems by April 2005. The CEEU audit of organisation
319 Table 1 NICE Technology Appraisal 87: Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the prevention of osteoporotic fragility fractures in postmenopausal women NICE, 2005 Alendronate, etidronate, risedronate recommended for women >75 years without the need for DXA 65e75 years, if osteoporosis is confirmed by DXA, T score 2.5, <65 years, if there is evidence of a very low BMD T score 3.0 Raloxifene recommended if Bisphosphonates contraindicated or not tolerated Teriparatide recommended for women >65 years, if there is evidence of a very low BMD, T score 4 Unsatisfactory response to bisphosphonates Intolerance of bisphosphonates
of falls services published in 2005 showed that although 74% of Trusts had multi-disciplinary fall services there was inadequate involvement in the critical components of the hospital services where patients presented with fracture. More than half of A&E departments had no mechanism for involving specialist falls services, with many falls services having limited involvement in developing protocols with A&E for patients with osteoporotic hip fracture. In fracture clinics only 15% of older people are screened for risk of falling and 18% for a history of falling. With respect to inpatient care, only half of the Trusts report having one ward developed as a centre for excellence of orthogeriatric practice. The findings from the CEEU audit in 2007 demonstrated a marked variation between centres with respect to secondary falls prevention, with a quarter of centres scoring less than 20% for non-hip fracture patients and less than 40% for hip fracture patients. NICE guidance has recommended four key components of a multifactorial falls assessment: strength and balance training, home hazard assessment and intervention, vision assessment and referral and medication review and modification. 12 weeks following fracture, 22% of non-hip and 44% of hip fracture patients were offered any form of exercise training, with strength and balance exercises being the most commonly offered. Approximately 80% of all fracture patients were given a home hazard assessment and in the majority of cases interventions were made. Vision assessment was performed in 10% of non-hip fracture patients and 19% of hip fracture patients, with less than a half being offered further intervention. Medicine review was performed in a third and a half of non-hip and hip fracture patients respectively. The percentage of those receiving psychotropic drugs and/or night sedation was low and this did not decrease further following fracture.4 According to findings from the QRESEARCH study there is no widespread recording in general practice of falls, disorders of balance or risk of future falls in older people. Though about three quarters of NHS acute trusts reported the presence of an integrated Falls Service, the number of
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patients assessed per week was only 1.7 per 100,000 population.5 These two audits would therefore suggest that the reality of Falls Services offering secondary prevention measures to older people with fragility fractures is not being met on a universal basis. To address these issues falls co-ordinators have been employed both within secondary and primary care, with the aim of integrating existing services, identifying shortfalls in provision and initiating comprehensive strategies that focus on both primary and secondary prevention.
Practice Points 4 There is an inextricable link between falls and fractures in the older person. The CEEU national audit and QRESEARCH findings suggest that Falls Services exist but that there remains a lack of integration between departments within secondary care and between secondary and primary Care Falls coordinators may be crucial to this aspect of service delivery, encouraging multi-agency working with primary and secondary prevention strategies.
Primary care Chronic disease management has become firmly rooted in the primary care sector and if one accepts that fragility fractures are an acute exacerbation of the chronic underlying condition of osteoporosis, it is likely that both postacute care and secondary prevention following fracture will increase in this setting. It has been estimated that 80% of the population will visit their GP practice at least once in a three-year period, and because of the increased health needs of the older person it is likely the age group at greatest need to prevent further fractures are seen more often. With respect to secondary prevention, primary care has a role to play in identifying those with a past history of fracture who are currently not being treated and also encouraging adherence to therapy if this has already been instigated. Although there are fragmented examples of osteoporosis services operating in primary care, current staffing structures and lack of financial incentives fail to support the potential contribution of the primary care team in the management of osteoporosis and fragility fractures in the older person. Identification of those with previous fractures is not straightforward as there are known shortfalls in the coding systems on GP computers with respect to fractures and osteoporosis. There is currently no single concept code for a fragility fracture and it would in any event probably not be well used. In particular, as only about 8% of vertebral fractures come to clinical attention in the UK, most estimates of fracture prevalence will underestimate and
vertebral fractures will rarely be recorded on GP databases. On a more positive note, self-reported prior fracture estimates derived from patient recall are estimated to be accurate with a study in Lanarkshire finding a prevalence of self-reported prior fragility fracture in over 65-year-old women of 24.3%.12 Despite a paucity of resources in primary care, the work of Bayly and Carter in 2000 to 2003 demonstrated that it is feasible to offer a case finding service within the primary care setting.13 They piloted a generic model that identified ‘‘at risk’’ female patients aged 65 þyears by questionnairedriven case-finding, with a percentage of these patients having already fractured. After identification and appropriate intervention, the fracture rate at the initial pilot practice was followed and between1 and 3 years there was a 55% reduction in fracture incidence in women over 65 years. In 2006 three years after the project’s close Gloucestershire’s Primary and Community Care audit group used database queries to evaluate electronically documented standards of care for falls and bone health in 560,000 patients.14 Standards in some of the chosen indicators remained higher in the practices which had originally participated in the project despite lack of specific input in the previous three years. In the project practices, women aged over 75 years with a history of previous fracture were at least four times more likely to have received assessment in the last three years or treatment in the last six months. With respect to referral for DXA measurements for females aged 65 to 74 years with a previous fracture there was an achievement rate of 45% in the project practices compared to 12% in others. In an attempt to progress this type of service delivery within primary care, representation was made for the inclusion of osteoporosis and falls in the Quality Outcomes Framework (QOF) of the GP contract, which in turn would have attracted universal funding and subsequent service development. Unfortunately, osteoporosis has not been included in QOF but there has at least been some recognition by the DofH that it is an area warranting funding and attention and has been designated as a Directed Enhanced Service (DES), which will therefore attract some extra funding. Although medication for secondary prevention may be prescribed following fracture, it will only be effective if taken regularly and on a long term, probably lifelong basis. Akin to other chronic diseases, adherence to osteoporosis treatments is generally poor. 77% of patients taking a once daily bisphosphonate stop treatment within a year, with almost two thirds of patients taking a once weekly preparation also failing to adhere. As previously noted, treatment adherence and persistence is a complex process that requires both immediate and sustained action. To improve adherence it is important that the prescriber presents the patient with clear information on mode of administration, possible side-effects and the need to continue therapy even though there may be no immediate perceivable benefits. As treatment will generally be necessary for at least five years and possibly indefinitely medication reviews are an essential part of management. Within primary care, the prescription and review of medications is the responsibility of GPs, practice nurses and increasingly community pharmacists. An example of service
Osteoporosis development has evolved from the Community Pharmacy Contract of 2005 that offers opportunities for improving the care of patients with osteoporosis because it increases the range and quality of the services that are provided. As part of essential services of this contract, pharmacists can use dispensing as an opportunity to discuss potential sideeffects of or interactions with other medications. They can also provide practical solutions to some of the physical barriers that prevent patients from taking their medications e.g. large print labels for those with poor visual acuity and dosing boxes. Pharmacists may also offer repeat dispensing, eliminating the need to collect prescriptions for regular medication from the GP. Although not included in the national contract, many pharmacists now offer collection and delivery services where the pharmacy will deliver medication to the patient’s own home. The Advanced Services, Medicines Use Review (MUR) is a concordance centred review of the patient’s medication, and with permission from the PCT can be conducted in the patient’s own home. Through this review pharmacists can discuss patients’ attitudes towards their medications as well as offering them practical advice about how to organise their medicine taking to minimise interactions and side effects. This is of particular relevance to bisphosphonate therapy, which must be administered in the correct manner for effectiveness. To address local priorities, PCTs can recommend that MURs are targeted at certain patient groups. Local guidelines for secondary prevention in Dorset and Somerset have recommended that all patients started on oral bisphosphonates are referred to the pharmacist for an MUR. By introducing individual or combined service initiatives through community pharmacy it is envisaged that there will be a positive impact on long term adherence to osteoporosis medication, particularly with respect to the frailer, older person.
Practice Points 5 As part of a chronic disease management model, secondary prevention services need to be expanded in primary care despite non-inclusion in the Quality Outcomes Framework of the GP contract. Case-finding based on improved coding systems will begin to impact on secondary prevention. Multi-disciplinary working between GPs, nurses and community pharmacists should aim to determine treatment needs and offer solutions to longterm persistence with therapy to prevent further fractures.
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Conclusion Osteoporosis and fractures have a substantial influence on health and quality of life and are associated with significant social costs. While no age group is spared, the prevalence of fractures rises with age and with an ageing population there will be an increase in demand for services offering secondary prevention in the future years. Set against a background of technological advances, an expanding population of older people and increased public expectations, existing and new services will face increasing challenges. Critical to service delivery of effective secondary prevention measures to older people is the identification of priorities and standards with clear concise pathways linking secondary and primary care.
References 1. Torgerson DJ, Iglesias CP, Reid DM. The economics of fracture prevention. In: Barlow DH, Francis RM, Miles A, editors. The effective management of osteoporosis. Aesculapius Medical Press; 2001. p. 111e21. 2. McLellan A, Fraser M. Fracture liaison services. In: Lanham-New S, O’Neill T, Morriss R, Skelton D, Sutcliffe A, editors. Managing osteoporosis. Atlas Medical Publishing; 2007. p. 219e34. 3. Burge RT, Worley D, Johansen A, Bhattacharya S, Bose U. The cost of osteoporotic fractures in the UK. J Med Econ 2001;4:51e62. 4. Royal College of Physicians. The clinical effectiveness and evaluation unit. London: National Clinical Audit of Falls and Bone Health in Older People; 2007. 5. Hippsley-Cox J, Bayly J, Potter J, Fenty J, Parker C. Evaluation for standards of care for osteoporosis and falls in primary care. The Information Centre for health and social care; 2007. 6. McLellan AR, Reid DM, Forbes K, et al. Effectiveness of strategies for the secondary prevention of osteoporotic fractures in Scotland. Edinburgh, Scotland: NHS Scotland; 2005. 7. Chakravarthy J, Ali A, Iyengar S, Porter K. Secondary prevention of fragility fractures by orthopaedic teams in the UK: a national survey. Int J Clin Pract 2008 Mar;62(3):382e7. 8. Fraser M, McLellan AR. A fracture liaison service for patients with osteoporotic fractures. Prof Nurse 2004;19:286e90. 9. McLellan AR, Gallacher SJ, Fraser M. The fracture liaison service: success of a programme for the evaluation and management of patients with osteoporotic fracture. Osteopor Int 2003;14:1028e34. 10. Barton J, Worcester G, Ryan PJ. Long term adherence from a fracture liaison clinic. Osteopor Int 2004;14(Suppl. 4):S12. 11. National Institute for Health and Clinical Excellence. Falls: the assessment and prevention of falls in older people. Clinical guideline 21. London; 2004. 12. Brankin E, Caroline M, Munro R. Closing the osteoporosis management in primary care: a secondary prevention of fracture programme. Curr Med Res Opin 2005;21:425e82. 13. Bayly J, Carter G. A primary care approach to managing patients at risk of osteoporotic fracture. Osteopor Rev 2004; 12(2):7e11. 14. Bayly J. Changing practice in primary care. Osteopor Rev 2008; 16(1):9e12.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/cuor
MINI-SYMPOSIUM: OSTEOPOROSIS
(i) Osteoporosis: an overview of the organisation of services to deliver secondary prevention measures to older people with fragility fractures Anne Sutcliffe National Association for the Relief of Paget’s Disease, 323 Manchester Road, Walkden, Worsley, Manchester M28 3HH, United Kingdom
KEYWORDS Fragility fractures; Older People; Secondary prevention; Service Delivery; Multidisciplinary approach
Summary Fragility fractures in older people lead to significant morbidity and mortality. An initial fracture is a clear indicator for further fractures and therefore it is imperative that services should focus on secondary prevention for this vulnerable group of people. Despite shortfalls in current provision it should be possible to focus on effective interventions that will reduce future fracture risk through fracture liaison, specialist orthogeriatric care and falls services. Within Primary Care, case finding and medicines management offer proven opportunities that will contribute and impact on successful service delivery. All aspects need to be founded on the identification of priorities and standards and require a coordinated multidisciplinary approach with clear pathways of communication across the relevant health care system. ª 2008 Elsevier Ltd. All rights reserved.
Introduction Low trauma fractures occurring in older people constitute a major clinical and financial burden to the NHS. Each year approximately 310,000 patients present to hospital with fractures and although some are trauma-related and occur in the younger population, a substantial number are associated with advancing age, increased bone fragility and non-skeletal factors.1 In 2002e2003 there were 78,554 admissions for cases of fractured neck of femur alone and this is expected to rise to 91,500 by 2015 and 101,000 by 2020. McClellan et al have suggested that for every patient E-mail address: [email protected]
admitted with a hip fracture, there will be three patients treated for a low trauma fracture of the wrist, shoulder, ankle, hand or foot, in addition to uncertain numbers sustaining both symptomatic and ‘‘silent’’ fractures of the spine.2 The combined cost of social and hospital care for patients with osteoporotic fractures has been reported to be more than £1.8 billion per year in the UK, with most of these costs being related to hip fracture care in the older person.3 Fractures in over 60-year-olds utilise more than two million bed days and those attributable to hip fracture have been estimated to cost between £5,600 and £12,000 per case.1 After discharge from hospital, the cost of complex home and institutional care for those who make a poor recovery is substantial, averaging at £13,000 in the first two years.
0268-0890/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.cuor.2008.10.008
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As demographic change in the UK will result in a substantial and inevitable increase in the incidence of fractures during the following decades, it is imperative that secondary prevention becomes an integral component of osteoporosis and fracture management. It is well recognised that those with a prior fracture have anything from a 1.5 to 9.5 increased risk of future fracture, with the risk potentially greater in men. Future fracture risk is greatest during the first year after initial fracture but the additional risk appears to persist for up to 10 years after the first fracture. Although a number of pharmacological interventions have demonstrated consistent anti-fracture efficacy, achieved during three years of therapy, historically osteoporosis remains under-diagnosed with many post-fracture patients not receiving appropriate assessment and management. In 2007 The Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians published its findings from a national audit on the organisation of services for falls and bone health for older people.4 Data were obtained in the secondary care setting on 8,800 fracture patients, 64% having sustained a non-hip fracture and 36% with hip fracture. Whilst there were marked variations between centres, general findings suggested that osteoporosis assessment and management were not meeting standards set by the National Institute for Clinical Excellence (NICE) technology appraisal 87 (Fig. 1). A minority of non-hip fracture patients (19%) and hip fracture patients (35%) received a clinical osteoporosis assessment, with Dual Energy X-ray Absorpitometry (DXA) measurements being performed in only 18% of the 65 to 74 years age group. After three months, only a fifth of patients were taking appropriate treatment to prevent further fractures and even after recovering from hip fracture surgery less than 50% were on appropriate osteoporosis medication. Patient(50+) with fracture A&E X-Ray
In a primary care setting the QRESEARCH database has been used to conduct the first national evaluation of standards in the management of osteoporosis and falls in older people within primary care. QRESEARCH is one of the largest general practice databases in the world and for the purpose of this study it evaluated standards of care in a population of nearly 3.4 million patients.5 With respect to secondary prevention in the older person, the study demonstrated that almost 75% of females aged 65 to 74 years with a history of fragility fracture and a diagnostic code for osteoporosis had been prescribed a bone-sparing agent. However, in women over the age of 75 years with a prior fracture only a quarter was receiving appropriate treatment. The prevalence of fragility fracture among men aged 65 and older was 6% compared to 14.8% in women, but less than 2% of males had a record of DXA measurements and slightly less than half were receiving treatment.
Practice Points 1 Each year 310,000 patients present with fractures, with 78,554 hospital admissions for fractured neck of femur, predicted to rise to 101,000 by 2020 CEEU audit on organization of Falls and Bone Health Services for the older person suggests that secondary prevention is not meeting NICE technology appraisal guidance. Within primary care only a quarter of females aged over 75 years is receiving therapeutic intervention for secondary prevention, with only a half of males over 65 years receiving appropriate treatment.
Service organisation Fracture liaison service
Orthopaedic/Trauma In Patient
Fracture Clinic Out Patient
Case Finding by Fracture Liaison Service
Case Finding by Fracture Liaison Service
Clinical Assessment Inc FRAX
?DXA Referral to Falls Clinic
?Referral to Bone Clinic
Treatment to prevent further fractures
Communication with Primary Care Team
Figure 1 Recommended pathway for older person presenting with fragility fracture.
Historically, services that have been established for patients at risk of osteoporosis have encouraged referrals of those with classic risk factors, leading to access for patients whose potential fracture risk is intrinsically low by virtue of their relative youth. It is now clear that service delivery should focus on those with a history of prior fracture who should be prioritized, assessed and offered appropriate therapeutic intervention to prevent further fracture. This approach offered through a Fracture Liaison Service (FLS) demonstrates a continuum of care for fracture patients different to the usual model, where care ended with the healing of the fracture (Fig. 2). In the context of an FLS, a fracture event can represent a new start to a pathway of care that has the potential to reduce a patient’s experience of further fractures by 50%. The service should be offered to all patients over 50 years presenting to hospital with a fragility fracture and should be available irrespective of the site of fracture and whether post-fracture care is provided as an in-patient or out-patient. By utilising an FLS it has been suggested that 95 to 97% of patients with
Osteoporosis Assessment Medical history
317 Multidisciplinary Team
Falls History
Multifactorial Intervention Exercise programmes
Medication
Gait/balance
Gait/balance
Medication review
Cardiovascular
Home hazard assessment
Neurological Cardiovascular treatment Vision assessment
Figure 2 Multidisciplinary Falls Risk Assessment. Adapted from the NICE Falls Guidance.
fractures of the radius or ulna or of the hip are offered the opportunity to undergo assessment (or are treated) for fracture secondary prevention.6 This model has been recognized internationally and by the UK Department of Health (DofH) as a model of best practice for implementing reliable assessment and treatment for secondary prevention of fractures. In reality, however, it would appear that commissioning and budgeting processes within the NHS do not incentivise these types of services as they only exist in approximately 30% of NHS hospitals. In establishing an FLS it is essential that it fulfills the criteria for any new development within the NHS and is acceptable to both commissioners and providers. It will require a strong evidence base regarding current provision, for example national data recorded in CEEU audits on falls and bone health. At a local level, audits covering standards such as current levels of identification of fracture patients, referrals for DXA and prescription of treatment for secondary fracture prevention would demonstrate specific shortfalls in service provision. Patient centered service developments that transform outcomes, reduce inequalities in health care, engage with multidisciplinary professionals and cross the primary - secondary care interface are more likely to warrant consideration and funding. For a new service to be justified it will also need to demonstrate that it can deliver cost-effective interventions that comply with NICE Technology appraisals and guidelines and DofH directives, e.g. the National Service Framework (NSF) and the Musculoskeletal Services Framework (MSF). In establishing an FLS it is appropriate to examine any existing services that may offer osteoporosis management and subsequently define clear and effective links. In any one secondary care setting the management of osteoporosis may rest in varied clinical domains e.g. Rheumatology, Endocrinology or Care of the Elderly. Access to DXA may be relatively easy but may be constrained by lack of funding and /or staffing levels. Ideally there should be clear links with Falls and Rehabilitation Services, which may be based within both secondary and primary care. As the majority of fracture patients will be discharged from hospital review it is imperative that there is effective liaison with GPs and other health and social care professionals based in primary care. Central to an FLS is the appointment of at least one dedicated staff member, demonstrating the skills and
expertise of a Fracture Liaison Nurse. A recent study from Chakravarthy and colleagues assessing secondary prevention of fragility fractures by orthopaedic surgeons and the effect of the multidisciplinary approach suggested that in the 60 to 80-year age group the presence of a Fracture Liaison Nurse made a significant difference in the prescription of vitamin D and calcium, providing weightbearing advice, falls risk assessment and DXA scan requests.7 Key components of this role are case-finding, osteoporosis assessment, treatment recommendations, referrals to other services and patient and staff education. Work carried out in Glasgow has suggested that one full time nurse should be able to address the case-finding and subsequent osteoporosis assessment and treatment needs of between 1400 and 1900 new fracture cases per annum.8 Whilst fracture clinics potentially provide the ideal setting for case-finding, this will have to be optimised by regular contact with orthopaedic wards, A&E and Falls Services. If one individual is responsible for providing this service it will be necessary to introduce some type of system that highlights ‘‘missed cases’’ who could then be assessed on a future visit. Although time-consuming, this could include checking of discharge summaries, fracture clinic lists and radiology databases, along with educating other staff about the value of case finding and secondary prevention. Following identification, each patient should be offered a clinical assessment to determine future fracture risk. Clinical assessment involving general and specific history taking may also be helped by the use of specific tools indicating future fracture risk, and the recent introduction of the FRAX WHO Fracture Risk Assessment Tool, accessed at http://www.shef.ac.uk/FRAX, should provide a useful means of fracture risk assessment that could easily be used in the fracture clinic setting. FRAX is accessed as a computer driven tool but it also provides several simplified versions based on risk factors that may be downloaded. It is based on individual patient models developed from studying population based cohorts in Europe, North America and Australia. An individual’s risk factors such as age, gender, weight and height and femoral neck bone density are entered into a simple website tool. Clearly, the femoral neck bone density will not be available in many elderly patients but the programme accounts for this in its calculations. The following risk factors are then added:
Previous fracture history. Parental history of hip fracture. Current smoking history. History of glucocorticoid use. (Either current exposure to oral glucocorticoids or previous exposure for more than 3 months at a dose of at least 5 mg daily.) Rheumatoid arthritis. (Osteoarthritis is not a risk factor.) Secondary osteoporosis, including type 1 diabetes, osteogenesis imperfecta in adults, untreated long standing hyperthyroidism, hypogonadism, premature menopause (<45 years), chronic malnutrition, malabsorption and chronic liver disease. Alcohol intake >3u daily Once the data have been entered, FRAX is then able to calculate a figure indicating a 10-year fracture probability
318 of both hip and other major osteoporotic fracture. The advantage of this specific tool is that it produces an accurate numerical value, presented in percentage terms that can be easily explained to the patient. Following the assessment it is appropriate to offer general advice on bone health, but should the value be low this can provide reassurance to the patient. A high value, however, indicates that a patient requires further investigation and probably treatment to prevent bone loss and future fractures. Although DXA measurements may be considered as part of fracture risk assessment it is currently unusual to find a DXA scanner located directly in a fracture clinic setting, and if considered necessary the Fracture Liaison Nurse may have to request these as a separate investigation. The most recent technology appraisal from NICE regarding secondary prevention suggests that in those women aged 65 to 74 years, DXA measurements are required to aid treatment decisions but are not necessarily required prior to commencing therapy in the older age group. Whilst case-finding and targeting of therapies are critical components in the secondary prevention of fractures, it is also important that patient education becomes part of the overall assessment. Patient education should ideally aim to increase an individual’s knowledge and understanding of a specific condition, leading to greater empowerment and subsequent increase in coping strategies and adaptability. For any educational activity to succeed it is important to be aware of patient education skills with respect to assessment of readiness to learn, timing and sequence of education, clarification and repetition of information and evaluation of learning, when appropriate. In addition, by focusing on twoway communication and individualised information giving it is hoped to emphasise co-operation not compliance. Common areas that have been explored with respect to osteoporosis and patient education include levels of osteoporosis knowledge and prevention, explanation of DXA results and effect on lifestyle, and advice on treatment options leading to adherence. Despite studies showing that osteoporosis treatments are generally well tolerated and associated with significant efficacy benefits, adherence to therapies on a long-term basis remains inconsistent. Treatment adherence and persistence is a complex process influenced by many factors in both the short and long term. Patient adherence is governed by their beliefs about the severity of their illness and relevant treatment. Illnessrelated factors include severity of symptoms, level of disability and rate of progression. Treatment-related factors include complexity and duration of treatment regimen, immediacy of beneficial effects and perceived or actual side-effects. Adherence rates to osteoporosis treatment will also be influenced by other concomitant medications; a particular problem with advancing age when over 50% of people over the age of 70 take three or more prescribed medicines. In the UK the use of specialist nurses within fracture clinic liaison roles appears to have impacted on patient adherence with therapy. Examples from Kent and Glasgow, where the specialist nurse has considerable input at the commencement of therapy, demonstrate approximately 80% adherence with therapy after two to three years.9,10 Objectively measuring the impact of education as part of secondary fracture prevention is not easy as it is
A. Sutcliffe influenced by so many variables. However, it would appear that it is more likely to result in positive rather than negative outcomes and should be an integral part of the Fracture Liaison Nurse’s role.
Practice Points 2 Fracture Liaison represents an ideal model of best practice for delivering secondary prevention to the older person. Only 27% of UK hospitals have a Fracture Liaison Service. A Fracture Liaison Nurse is central to this service, with a role combining case-finding, osteoporosis assessment, treatment recommendations, referrals to appropriate agencies and patient education.
Orthogeriatric services In the absence of a dedicated FLS, secondary prevention of fracture in the older person could be addressed within the orthogeriatric setting. The NSF for Older People states that ‘‘at least one general ward in an acute hospital should be developed as a centre of excellence for orthogeriatric practice’’. Collaboration between orthopaedic and care of the elderly services has developed over the past two decades with various different models of orthogeriatric care in existence. Evidence as to the efficacy and cost effectiveness of these models is complex with the Cochrane review of Coordinated Multidisciplinary Hip Fracture Care suggesting that there is ‘‘no conclusive evidence of coordinated post-surgical care. but a trend towards effectiveness in all main outcomes.’’ The NHS Health Technology Assessment Programme has also performed a systematic review of the evidence in respect of geriatric rehabilitation following fractures in older people. This review is inconclusive about rehabilitation units but does suggest that there is good evidence to support development of collaborative approaches in the acute setting, e.g. the Geriatric Hip Fracture Programme. It also suggests benefits from intermediate care initiatives such as early supported discharge schemes and the use of care pathways to expedite rehabilitation. In the absence of any generic model of service it is important to focus on multidisciplinary working patterns with free communication and sharing of information between health care professionals, the patient and their carers. How and where the concept of secondary prevention and osteoporosis assessment is introduced into the orthogeriatric structure will clearly depend on local provision and type of service model. It may come within the remit of a hip fracture nurse/practitioner who takes responsibility for coordinating initial assessment, pre-and post-operative care, secondary prevention and discharge planning. An additional facet to this individual’s role could be supervision of data collection for the National Hip Fracture Database (NHFD). Based on several large scale UK hip fracture audits the NHFD has been designed to improve
Osteoporosis quality and cost-effectiveness of patient care following hip fracture. It contains a full core dataset covering key elements of case mix, process and outcome. Data collected in field 5.02 shows whether or not antiresorptive therapy has been started whilst an in-patient and continued on discharge. It also questions whether DXA measurements have been performed/requested and if a referral has been made for bone clinic assessment. A later field questions the continuance of antiresorptive therapy one year postfracture.
Practice Points 3 Existing orthogeriatric services may provide a means of offering secondary prevention. A Hip Fracture Nurse/Practitioner may be best placed to incorporate secondary prevention into their role. The inclusion of data on implementation of therapy for secondary prevention and referral for DXA measurements in the National Hip Fracture Database will add to the improvement of quality of care and cost-effectiveness of patient care following hip fracture.
Falls services In the older person there is an inextricable link between falls and fractures with approximately 95% of fractures occurring after a fall. Falls are common and increase with age, occurring in approximately 30% of those aged over 65 years living in the community, rising to 45% of those aged 80 and above. Recurrent falls are associated with increased mortality, increased rates of hospitalisation and institutionalisation and curtailment of daily living. In addition, falls can lead to loss of confidence, anxiety and a marked fear of future falling. Whilst there is limited evidence to prove that interventions to reduce the rate of falls significantly impact on fracture incidence the general consensus from the British Orthopaedic Association (BOA), British Geriatric Society (BGS) and National Service Framework (NSF) for Older People suggests that those who fracture should be offered a falls assessment. The year 2001 saw the publication of the NSF for Older People. Standard 6 set out a standard of care for older people at high risk of falling and recognized that the detection, assessment and care of people with, or at high risk of osteoporosis was integral to this standard. This standard also suggested that all patients presenting with a fragility fracture should be offered multidisciplinary assessment and intervention to prevent future falls, as also acknowledged in NICE clinical guideline11 (Table 1). A key feature of Standard 6 was the recommendation that integrated services for falls and osteoporosis should be developed and be in place in all local healthcare and social care systems by April 2005. The CEEU audit of organisation
319 Table 1 NICE Technology Appraisal 87: Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the prevention of osteoporotic fragility fractures in postmenopausal women NICE, 2005 Alendronate, etidronate, risedronate recommended for women >75 years without the need for DXA 65e75 years, if osteoporosis is confirmed by DXA, T score 2.5, <65 years, if there is evidence of a very low BMD T score 3.0 Raloxifene recommended if Bisphosphonates contraindicated or not tolerated Teriparatide recommended for women >65 years, if there is evidence of a very low BMD, T score 4 Unsatisfactory response to bisphosphonates Intolerance of bisphosphonates
of falls services published in 2005 showed that although 74% of Trusts had multi-disciplinary fall services there was inadequate involvement in the critical components of the hospital services where patients presented with fracture. More than half of A&E departments had no mechanism for involving specialist falls services, with many falls services having limited involvement in developing protocols with A&E for patients with osteoporotic hip fracture. In fracture clinics only 15% of older people are screened for risk of falling and 18% for a history of falling. With respect to inpatient care, only half of the Trusts report having one ward developed as a centre for excellence of orthogeriatric practice. The findings from the CEEU audit in 2007 demonstrated a marked variation between centres with respect to secondary falls prevention, with a quarter of centres scoring less than 20% for non-hip fracture patients and less than 40% for hip fracture patients. NICE guidance has recommended four key components of a multifactorial falls assessment: strength and balance training, home hazard assessment and intervention, vision assessment and referral and medication review and modification. 12 weeks following fracture, 22% of non-hip and 44% of hip fracture patients were offered any form of exercise training, with strength and balance exercises being the most commonly offered. Approximately 80% of all fracture patients were given a home hazard assessment and in the majority of cases interventions were made. Vision assessment was performed in 10% of non-hip fracture patients and 19% of hip fracture patients, with less than a half being offered further intervention. Medicine review was performed in a third and a half of non-hip and hip fracture patients respectively. The percentage of those receiving psychotropic drugs and/or night sedation was low and this did not decrease further following fracture.4 According to findings from the QRESEARCH study there is no widespread recording in general practice of falls, disorders of balance or risk of future falls in older people. Though about three quarters of NHS acute trusts reported the presence of an integrated Falls Service, the number of
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patients assessed per week was only 1.7 per 100,000 population.5 These two audits would therefore suggest that the reality of Falls Services offering secondary prevention measures to older people with fragility fractures is not being met on a universal basis. To address these issues falls co-ordinators have been employed both within secondary and primary care, with the aim of integrating existing services, identifying shortfalls in provision and initiating comprehensive strategies that focus on both primary and secondary prevention.
Practice Points 4 There is an inextricable link between falls and fractures in the older person. The CEEU national audit and QRESEARCH findings suggest that Falls Services exist but that there remains a lack of integration between departments within secondary care and between secondary and primary Care Falls coordinators may be crucial to this aspect of service delivery, encouraging multi-agency working with primary and secondary prevention strategies.
Primary care Chronic disease management has become firmly rooted in the primary care sector and if one accepts that fragility fractures are an acute exacerbation of the chronic underlying condition of osteoporosis, it is likely that both postacute care and secondary prevention following fracture will increase in this setting. It has been estimated that 80% of the population will visit their GP practice at least once in a three-year period, and because of the increased health needs of the older person it is likely the age group at greatest need to prevent further fractures are seen more often. With respect to secondary prevention, primary care has a role to play in identifying those with a past history of fracture who are currently not being treated and also encouraging adherence to therapy if this has already been instigated. Although there are fragmented examples of osteoporosis services operating in primary care, current staffing structures and lack of financial incentives fail to support the potential contribution of the primary care team in the management of osteoporosis and fragility fractures in the older person. Identification of those with previous fractures is not straightforward as there are known shortfalls in the coding systems on GP computers with respect to fractures and osteoporosis. There is currently no single concept code for a fragility fracture and it would in any event probably not be well used. In particular, as only about 8% of vertebral fractures come to clinical attention in the UK, most estimates of fracture prevalence will underestimate and
vertebral fractures will rarely be recorded on GP databases. On a more positive note, self-reported prior fracture estimates derived from patient recall are estimated to be accurate with a study in Lanarkshire finding a prevalence of self-reported prior fragility fracture in over 65-year-old women of 24.3%.12 Despite a paucity of resources in primary care, the work of Bayly and Carter in 2000 to 2003 demonstrated that it is feasible to offer a case finding service within the primary care setting.13 They piloted a generic model that identified ‘‘at risk’’ female patients aged 65 þyears by questionnairedriven case-finding, with a percentage of these patients having already fractured. After identification and appropriate intervention, the fracture rate at the initial pilot practice was followed and between1 and 3 years there was a 55% reduction in fracture incidence in women over 65 years. In 2006 three years after the project’s close Gloucestershire’s Primary and Community Care audit group used database queries to evaluate electronically documented standards of care for falls and bone health in 560,000 patients.14 Standards in some of the chosen indicators remained higher in the practices which had originally participated in the project despite lack of specific input in the previous three years. In the project practices, women aged over 75 years with a history of previous fracture were at least four times more likely to have received assessment in the last three years or treatment in the last six months. With respect to referral for DXA measurements for females aged 65 to 74 years with a previous fracture there was an achievement rate of 45% in the project practices compared to 12% in others. In an attempt to progress this type of service delivery within primary care, representation was made for the inclusion of osteoporosis and falls in the Quality Outcomes Framework (QOF) of the GP contract, which in turn would have attracted universal funding and subsequent service development. Unfortunately, osteoporosis has not been included in QOF but there has at least been some recognition by the DofH that it is an area warranting funding and attention and has been designated as a Directed Enhanced Service (DES), which will therefore attract some extra funding. Although medication for secondary prevention may be prescribed following fracture, it will only be effective if taken regularly and on a long term, probably lifelong basis. Akin to other chronic diseases, adherence to osteoporosis treatments is generally poor. 77% of patients taking a once daily bisphosphonate stop treatment within a year, with almost two thirds of patients taking a once weekly preparation also failing to adhere. As previously noted, treatment adherence and persistence is a complex process that requires both immediate and sustained action. To improve adherence it is important that the prescriber presents the patient with clear information on mode of administration, possible side-effects and the need to continue therapy even though there may be no immediate perceivable benefits. As treatment will generally be necessary for at least five years and possibly indefinitely medication reviews are an essential part of management. Within primary care, the prescription and review of medications is the responsibility of GPs, practice nurses and increasingly community pharmacists. An example of service
Osteoporosis development has evolved from the Community Pharmacy Contract of 2005 that offers opportunities for improving the care of patients with osteoporosis because it increases the range and quality of the services that are provided. As part of essential services of this contract, pharmacists can use dispensing as an opportunity to discuss potential sideeffects of or interactions with other medications. They can also provide practical solutions to some of the physical barriers that prevent patients from taking their medications e.g. large print labels for those with poor visual acuity and dosing boxes. Pharmacists may also offer repeat dispensing, eliminating the need to collect prescriptions for regular medication from the GP. Although not included in the national contract, many pharmacists now offer collection and delivery services where the pharmacy will deliver medication to the patient’s own home. The Advanced Services, Medicines Use Review (MUR) is a concordance centred review of the patient’s medication, and with permission from the PCT can be conducted in the patient’s own home. Through this review pharmacists can discuss patients’ attitudes towards their medications as well as offering them practical advice about how to organise their medicine taking to minimise interactions and side effects. This is of particular relevance to bisphosphonate therapy, which must be administered in the correct manner for effectiveness. To address local priorities, PCTs can recommend that MURs are targeted at certain patient groups. Local guidelines for secondary prevention in Dorset and Somerset have recommended that all patients started on oral bisphosphonates are referred to the pharmacist for an MUR. By introducing individual or combined service initiatives through community pharmacy it is envisaged that there will be a positive impact on long term adherence to osteoporosis medication, particularly with respect to the frailer, older person.
Practice Points 5 As part of a chronic disease management model, secondary prevention services need to be expanded in primary care despite non-inclusion in the Quality Outcomes Framework of the GP contract. Case-finding based on improved coding systems will begin to impact on secondary prevention. Multi-disciplinary working between GPs, nurses and community pharmacists should aim to determine treatment needs and offer solutions to longterm persistence with therapy to prevent further fractures.
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Conclusion Osteoporosis and fractures have a substantial influence on health and quality of life and are associated with significant social costs. While no age group is spared, the prevalence of fractures rises with age and with an ageing population there will be an increase in demand for services offering secondary prevention in the future years. Set against a background of technological advances, an expanding population of older people and increased public expectations, existing and new services will face increasing challenges. Critical to service delivery of effective secondary prevention measures to older people is the identification of priorities and standards with clear concise pathways linking secondary and primary care.
References 1. Torgerson DJ, Iglesias CP, Reid DM. The economics of fracture prevention. In: Barlow DH, Francis RM, Miles A, editors. The effective management of osteoporosis. Aesculapius Medical Press; 2001. p. 111e21. 2. McLellan A, Fraser M. Fracture liaison services. In: Lanham-New S, O’Neill T, Morriss R, Skelton D, Sutcliffe A, editors. Managing osteoporosis. Atlas Medical Publishing; 2007. p. 219e34. 3. Burge RT, Worley D, Johansen A, Bhattacharya S, Bose U. The cost of osteoporotic fractures in the UK. J Med Econ 2001;4:51e62. 4. Royal College of Physicians. The clinical effectiveness and evaluation unit. London: National Clinical Audit of Falls and Bone Health in Older People; 2007. 5. Hippsley-Cox J, Bayly J, Potter J, Fenty J, Parker C. Evaluation for standards of care for osteoporosis and falls in primary care. The Information Centre for health and social care; 2007. 6. McLellan AR, Reid DM, Forbes K, et al. Effectiveness of strategies for the secondary prevention of osteoporotic fractures in Scotland. Edinburgh, Scotland: NHS Scotland; 2005. 7. Chakravarthy J, Ali A, Iyengar S, Porter K. Secondary prevention of fragility fractures by orthopaedic teams in the UK: a national survey. Int J Clin Pract 2008 Mar;62(3):382e7. 8. Fraser M, McLellan AR. A fracture liaison service for patients with osteoporotic fractures. Prof Nurse 2004;19:286e90. 9. McLellan AR, Gallacher SJ, Fraser M. The fracture liaison service: success of a programme for the evaluation and management of patients with osteoporotic fracture. Osteopor Int 2003;14:1028e34. 10. Barton J, Worcester G, Ryan PJ. Long term adherence from a fracture liaison clinic. Osteopor Int 2004;14(Suppl. 4):S12. 11. National Institute for Health and Clinical Excellence. Falls: the assessment and prevention of falls in older people. Clinical guideline 21. London; 2004. 12. Brankin E, Caroline M, Munro R. Closing the osteoporosis management in primary care: a secondary prevention of fracture programme. Curr Med Res Opin 2005;21:425e82. 13. Bayly J, Carter G. A primary care approach to managing patients at risk of osteoporotic fracture. Osteopor Rev 2004; 12(2):7e11. 14. Bayly J. Changing practice in primary care. Osteopor Rev 2008; 16(1):9e12.