What Should our Priorities be in Primary Care?

The Department of Health in England has produced commissioning guidance for the NHS in the Falls and fractures section of the Prevention Package for Older People. The key objectives illustrated in the pyramid below provide GPs and service commissioners with a stepwise implementation plan, based on the size of the impact, from a clinical and cost-effectiveness standpoint.

pyramid showing gps priorities regarding identification of osteoporosis

Hip fracture patients: Require effective acute care and a bone health assessment whilst an inpatient with possible subsequent outpatient DXA follow up, falls interventions on discharge, or as soon as is practical thereafter, as described in the British Orthopaedic Association's The Care of Patients with Fragility Fracture (also known as the 'Blue Book') and NICE hip fracture clinical guidelines. The Blue Book and the Department of Health Prevention Package guidance was written with expert input from UK general practice.

Non-hip fragility fracture patients: Half of hip fracture patients suffer a prior fragility fracture before breaking their hip. By routinely managing osteoporosis and falls risk in these patients, in accordance with appropriate national guidance, future hip fracture incidence could be halved amongst these patients. The primary fracture sites include wrist, hip and humerus, in addition to vertebral compression fractures.

Individuals at high risk of first fragility fracture: As UK general practice has done so effectively in cardiovascular disease management, once the secondary preventive actions described for hip and non-hip fragility fracture patients are completed, the issue of primary fracture prevention can be addressed. NICE has published& guidance on the primary prevention of osteoporotic fractures that provides more information about groups to target for primary fracture prevention. Those patients who are experiencing recurrent falls but have not fractured yet represent a high-risk group to be targeted for falls prevention measures and bone health assessment. A fracture risk assessment tool such as FRAX or QFracture can be used to assess future fracture risk for all older people.

Resources to support GPs to implement this strategy are provided in the implementation section of this website.

What are the Risk Factors for Fragility Fracture?

The most important risk factors for fragility fracture are:

Age: Incidence of fragility fractures increases with age and peak incidence occurs between the ages of 60 and 75 years, with vertebral fractures peaking in the over 70s and hip fractures peaking in the over 80s.

Gender: Fragility fractures are twice as common in women as in men.

Low bone mineral density (BMD): Risk of fracture increases progressively with reduction in BMD. Every 1 standard deviation reduction in BMD equates approximately to a doubling of the relative risk of fracture. The majority of fragility fractures occur in those with a BMD T-score above the osteoporosis threshold of 2.5 or less (i.e. within the osteopenic range) rather than those with osteoporosis (i.e. with a T-score of ≤ −2.5). This is attributable to the population of patients with osteopenia being more numerous than those with osteoporosis and the osteopenic range covering a broad spectrum of fracture risk.

Prior fragility fracture: Good evidence exists to support GPs investigating patients with a low-trauma fracture, particularly those of the wrist, spine, humerus and hip. Patients who have sustained a recent fracture are at increased risk of sustaining another fracture irrespective of site and such fractures can often indicate the beginning of a cascade of fractures culminating in hip fracture, with all its implications. For individuals sustaining a new incident fracture, risk of further fracture increases five-fold in the first year, during which nearly a quarter of the re-fractures occur. Just over half of re-fractures will occur over the 5 years following the presenting fracture and risk persists for 15 years.

Parental history of hip fracture: Maternal and paternal history of hip fracture is the most reliable indicator of genetic risk of fragility fracture.

Low body mass index (BMI): BMI of ≤ 19 kg/mis associated with an increase in the risk of hip fracture (and probably other fractures) in both women and men.

Hormones: Premature menopause (in women under the age of 45) - whether natural or induced by surgery, chemotherapy, radiotherapy or endocrine therapy - increases risk. Risk is increased in men who have had orchidectomy or androgen deprivation therapy.

Medical conditions associated with bone loss: These include rheumatoid arthritis, inflammatory bowel disease (e.g. Crohn's disease, ulcerative colitis), malabsorption (e.g. coeliac disease, pancreatic insufficiency), cystic fibrosis, hyperthyroidism, hyperparathyroidism, vitamin D insufficiency, immobilisation (e.g. resulting from CVA or Parkinson's disease), chronic obstructive pulmonary disease, diabetes mellitus type 1 and chronic renal and hepatic disease.

Drug treatments associated with bone loss: These include oral corticosteroids, aromatase inhibitors, androgen deprivation therapy, some anti-epileptic medications and glitazones.

Lifestyle factors: Smoking and alcohol intake ≥ 3 units per day increase fracture risk.

Falls: Non-vertebral fragility fractures usually result from a fall in an individual with compromised bone strength; thus, the risk factors for falls should be routinely considered in older patients, as advocated by NICE guidance.

What is the role of a Fracture Liaison Service (FLS)?

A Fracture Liaison Service (FLS) is a system aiming to ensure that fracture risk assessment, and treatment where appropriate, is delivered to all patients with fragility fractures. An FLS usually comprises a dedicated case worker (often a Clinical Nurse Specialist) who works to pre-agreed protocols to case-find and assess fracture patients. An FLS can be based in primary or secondary care and requires support from a medically qualified practitioner, be they a GP with specialist interest or a hospital doctor with expertise in fragility fracture prevention. In 2010, 37% of localities in England, Wales and Northern Ireland had an FLS whilst Scotland has almost universal access.

Where an FLS is established at the local hospital, this service can ensure that patients presenting with new fragility fractures receive the assessment they need immediately post-fracture. In some localities, a primary-care-based FLS has been established that operates by the nurse specialist providing a peripatetic service to local general practices to case-find prior fragility fracture patients and those at high risk of first fracture. Both approaches have been shown to close the care gap routinely evident in localities lacking an FLS. The National Audit of Falls and Bone Health in Older People 2010 provides information regarding access to FLSs by area.

Where an FLS is already in place, this service will help to support practices to achieve the quality of care required to meet osteoporosis Quality and Outcomes Framework indicators.

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