Draft specifications

							Specifications for an audit of osteoporosis and falls (updated March 2006)

  Overall view

  The criteria map to guidance in established policy documents such as the NSF for
  Older People, SIGN Guidelines, NICE HTA on treatments for secondary prevention
  and NICE Guidance on Falls.

  Additionally it incorporate features that relate to a potential QOF domain for falls and
  osteoporosis. A number of exemption codes have been added to the Read set last
  year. Though this audit will go beyond any potential QOF indicators a sub set of the
  searches and analysis tool would be readily adaptable to any new GMS domain which
  may be adopted from April 2007 on.

  A number of these indicators are likely to be incorporated in to a further round of
  national audit that is likely to commence in April 2007

  Data quality is known to be poor in this clinical area and a stated aim of the audit is to
  allow PHCTs to improve recording and assessment of patients at risk of osteoporotic
  fracture. For this reason we will need to extract and report back on anonymised
  individual patient data. The scope is wide but we will be concentrating on some of
  the simpler criteria in the first instance and reporting only at a county or PCT level
  where data quality is poor.

  1) Data quality: patients with a diagnosis but no treatment/treatment but no diagnosis

  Rationale:

  Patients with a diagnosis of osteoporosis do not all need treatment as that will
  depend upon absolute fracture risk and that will depend on a number of independent
  and semi-independent risk factors, especially age. However patients with a diagnosis
  and no current treatment warrant review as their risk of fracture may have increased
  since diagnosis, they may never have been assessed for falls risk or they may have
  been unable to persevere with treatment or have concordance issues. Patients on
  treatment but without a diagnosis may just have a data gap, but may not have been
  inadequately assessed or may be inappropriately treated

  2) Prescribing quality issues
        a. Prescription of bisphosphonates to under 65s
        b. Co-prescription of calcium or calcium D3 preparations to patients on
            bisphosphonates/strontium
        c. Prescription of etidronate in over 70 year olds

  Rationale:
a) Patients under the age of 65 usually have a low absolute risk of fracture and it
   may not be cost effective to treat them. They may require review, for this reason.
   Recent NICE guidance has suggested patients in this age group with a h/o
   fragility fracture should only be treated if they have either a BMD < -3.0 or
   additional risk factors. This would apply even more to patients in this age group
   without a h/o fragility fracture
b) All the RCTs demonstrating the efficacy of bone re-modelling agents involved the
   use of calcium or calcium/D3 preparations in both treatment and placebo arms.
   NICE guidance is that the clinician should ensure treated patients are calcium
   and D3 replete. Without a dietary assessment detailed dietary assessment and
   serum calcium and PTH assessment this is not practically achievable. It is likely
   therefore, that unless there is a good reason not to do so, patients receiving
   treatment will be co-prescribed calcium or calcium/D3 preparations.
c) Etidronate has not been shown in RCTs to be effective against hip fracture while
   there are now newer preparations that are. Until recently etidronate was the
   most commonly prescribed bisphosphonate even though other preparations may
   be more effective. This ‘therapeutic drag’ may be still be affecting some patients
   who at the age of 70 will be now be inadequately protected against the risk of the
   more devastating effects of a hip fracture.

3) NICE HTA on secondary prevention of osteoporotic fractures
      a. Females over 75 with previous fracture should be considered for treatment
      b. Females 65-74 with previous fracture + osteoporosis should be considered
         for treatment
      c. Females <65 with previous fracture and BMD < -3.0 or additional risk
         factors should be considered for treatment

Rationale

a) See NICE guidance: ‘fracture’ is used as a proxy for fragility fracture, i.e. a
   fracture occurring over the age of 45 resulting from the force experienced in a
   fall from a standing height or less.
b) Ditto
c) This is practically difficult to achieve because of data quality. The numbers will
   be small. I propose that this audit identifies a cohort of female patients in this
   age group who might reasonably be subject to a notes review to see if further
   assessment of their medical/family history or of their BMD is warranted.

4) RCP Guidelines on the prevention of glucocorticoid induced osteoporosis
     a. Patients > 65 with a commitment or exposure to systemic glucocorticoids
        for more than 3/12 should be considered for treatment
     b. Patients < 65 with a commitment or exposure to systemic glucocorticoids
        for more than 3/12 should be considered for treatment if there is a h/o
        fracture or BMD is < -1.5
Rationale

a) Lifted from RCP guidelines
b) Data quality may be poor here and I suggest that the audit should output a list of
   patients under 65 who are on long term steroids but who are not on
   bisphosphonates and that a record review should determine those that need
   further assessment. Appropriate assessment would be indicated by the entry of an
   osteoporosis monitoring code which could be searched for subsequently

5) RNCH patients over 75: should be on a calcium and D3 prescription

Rationale

Lifted from RCP guidelines, SIGN guidelines and RCT evidence for effectiveness in
this population only

6) Fallers

       a) Number of patients at risk of falls
       b) Number of patients over 75 who have a record of an assessment of the
       number of falls in the previous 15/12
       c) Number of patients with a history of fall who have a record of an
       assessment of gait and balance
       d) Number of patients at risk of falls who have been referred to the falls
       service
       e) Patients over 75 with osteoporosis or h/o minimal trauma fracture assessed
       for falls risk

Rationale

a-d) Lifted from NICE guidance on falls
e) NSF for Older People and evidence from observational studies that a
combination of skeletal and extra-skeletal risk factors rapidly increase the absolute
fracture risk


7) Primary Prevention of osteoporotic fractures

       a) Patients over 75 with h/o falls but no h/o fracture with evidence of
       assessment for osteoporosis
       b) Patients over 75 without h/o fracture but with a diagnosis of osteoporosis:
       evidence of assessment for falls risk
       c) Evidence of assessment for osteoporosis in females over 65 with recorded
       ‘strong’ risk factors (Maternal history of hip fracture, BMI < 19kg/m2, early
       menopause, inflammatory bowel disease, celiac disease, rheumatoid arthritis,
       hyperthyroidism, prolonged immobility)
Rationale

a) NSF for Older People and evidence from observational studies that a combination
of skeletal and extra-skeletal risk factors rapidly increase the absolute fracture risk
b) Ditto
c) I would expect this to be incorporated in NICE guidelines and HTA for
preparations for the prevention and treatment of osteoporosis. It follows RCP and
SIGN guidelines.

8) Male osteoporosis

   Male patients > 65 years with a h/o fragility fracture should have evidence of
   assessment for osteoporosis

Rationale

1 in 12 men will develop an osteoporotic fracture after the age of 50 and 35% all hip
fractures occur in men. Many observational studies indicate higher morbidity,
dependency and mortality in men who suffer vertebral or hip fracture. Despite this
male osteoporosis is largely ignored.