How Many Individuals at High Fracture Risk Are on the Average GP’s List?

One in two women and one in five men over the age of 50 will have a fracture. Using national data, a GP with an average list size of 1,779 patients will have between 50 and 60 patients with a previously recorded fracture and six patients per GP will sustain a new osteoporosis-related fracture each year. This illustrates that delivery of secondary fracture preventive care is very achievable. Estimates of patients at high risk of fragility fracture compared with those currently on treatment are provided below to put management strategies into context.

GP's average list size 1,779
Postmenopausal women 326
Patients with osteoporosis 100
Patients with a history of fragility fracture(s) >50 years of age 50-60
Patients currently taking bisphosphonates 20-30
Patients with a new fragility fracture at any skeletal site each year 5-6
Patients with a new hip fracture each year 2

Taking Part In QOF

To optimise QOF points, all men and women aged 50 and over suffering a fragility fracture from 1 April 2014 must be added to a register (i.e. their fracture must be coded in such a way that they can be identified). Practices may want to use a template to ensure that they capture data using the correct codes. Incorrect codes: no money.

At this stage, it is useful to pilot your system for identifying and coding new fractures (and those prevalent fractures identified opportunistically that will not count for QOF but still should identify people to assess and treat) and begin ensuring that appropriate patients with fractures are initiated on bone-sparing therapy.

A fragility fracture is a fracture occurring in a person over the age of 50 years that results from a fall from standing height or less, or a vertebral fracture caused by minor trauma (e.g. bending to pick up a shopping bag, coughing or turning over in bed).

Primary-care teams must identify these incident (i.e. new) fractures from A&E and fracture clinic letters or orthopaedic ward discharge summaries, unless your CCG has an overarching Fracture Prevention Service (FPS), or Fracture Liaison Service (FLS), that does this for you (e.g. Oxfordshire CCGs). It may not be clear whether a fracture is a fragility fracture or was caused by high-impact trauma (e.g. a motor vehicle accident). It may be necessary to clarify this with a telephone call to the patient before coding. Although you may wish to code the exact fracture, including its site and type, you should also use the N331N fragility fracture code, or another code requested by the QOF rules. This will ensure that every patient is included in the register and will allow you to search for all fragility fractures and ensure that they have been referred for DXA and have received treatment where appropriate.

Some locations will have an FLS in place that may already have referred your patient for a DXA scan. This should be documented in the clinic letter or discharge summary. If it is not clear, and your patient has not been told that they have been referred, you need to make the referral yourself using the preferred referral form. Clearly document the fragility fracture and any other reasons for the scan request.

In patients over age 75, a DXA scan may not be required by the QOF indicators. In many cases, it is clinically appropriate and feasible to send a patient over the age of 75 for a scan, although NICE guidance allows for a diagnosis to be assumed in this age group if a scan is not undertaken. Some patients aged over 75 years, however, really want to know if they have osteoporosis or not before they will accept treatment. Under the change of wording of the 2014 QOF this now allows these people to obtain a DXA, which previously in a lot of localities was not commissioned.

Referral for DXA should be coded (8HQ8) when the referral is sent, and it is vital that the appropriate DXA result code is added when the result is received:

•Hip DXA osteoporotic: 58EG

•Lumbar spine DXA osteoporotic: 58EM

Code only the site with the lowest score to avoid confusion (i.e. if the lumbar spine is osteopenic and the femoral neck is osteoporotic, code as hip DXA osteoporosis). You may also want to add the T-scores in free text for each site, but this is not required for QOF.

It is good practice to check compliance and tolerability of treatment 2 to 3 months after initiation, and this can be carried out by telephone for some patients. If the patient is intolerant of any bone-sparing medication, add that code to the record when initiating new medication (e.g. intolerant of bisphosphonates). This will prevent accidentally restarting or switching to a treatment to which the patient has already been found to be intolerant. Since more than 50% of patients will stop therapy within 1 year, it will be important to check for compliance and persistence with therapy 1 to 2 months before the end of the QOF year so that those who have defaulted can be encouraged to restart. Those not receiving treatment at the end of the year will not be included in targets.

Duration of Treatment

Drug-induced osteoporosis

Corticosteroids, aromatase inhibitors and androgen deprivation therapy (in men) represent the principal causes of drug-induced osteoporosis. Assessment of fracture risk and the need for prophylaxis with bone-sparing agents amongst patients treated with these agents should be a priority for GPs.

There are European Oncology Guidelines for bone health in breast cancer and prostate cancer, as well as NICE prostate cancer guidelines that should have been assimilated into algorithms by your local oncology services to specifically manage these patients.

Residential care and nursing homes

Hip fractures are 3.3 times more common in residential-home populations than in community-dwelling older people; therefore, this is an important target group. Those who have had prior fragility fractures require bone-sparing therapy and high-dose calcium and vitamin D, as recommended by NICE and NOGG. Often previous fractures will not have been coded so a review of case records may be needed if a reliable history is not available from the patient or family.

For institutionalised elderly people without prior fragility fractures, high-dose calcium and vitamin D supplements (1200 mg/800 IU per day) used alone can reduce hip fracture risk by 43% within 18 months, and improve falls risk. Giving a choice between preparations that can be swallowed, chewed or dissolved may improve adherence.

Bisphosphonates and strontium ranelate need to be taken correctly to optimise absorption, so dosing instructions need to be discussed in detail with those responsible for drug administration in care homes and filtered down to all staff. Giving once-weekly or monthly bisphosphonates all on the same day may improve dosing accuracy. High staff turnover means frequent reminders are important.

Lapsed users

Every practice will have patients who need bone-sparing therapy and who have lapsed. Many more will fail to continue calcium and vitamin D supplements. Reasons for lapse include:

• Not being aware of the need to continue or that long-term therapy is required

• Being intolerant of the therapy

• Difficulties remembering to take the therapy

• Difficulties complying with dosing instructions

• Accidentally discontinuing on admission/discharge

Comparing those taking each drug one year previously with a list of current users will identify recent lapsers, who can be reviewed first. Searching backwards will identify preceding cohorts of lapsers. Identifying lapsed patients can be combined with reviewing the appropriateness of the therapy and co-prescribing calcium and vitamin D.

Alerts can be added to notes/prescribing screens for opportunistic discussion in surgery or when ordering prescriptions, or patients can be written to and invited to discuss restarting therapy with an appropriate drug with a doctor or nurse.

Unnecessary users

Every practice will have patients on bone-sparing therapies who do not need them. As many as 50% of patients in receipt of bone-remodelling agents have no record of a diagnosis of osteoporosis. These may be people who were started inappropriately, those using adjuvant therapies during steroids that have been stopped or those who have been on therapy long term and no longer have osteoporosis.

To find these patients:

• Search for those taking bisphosphonates, raloxifene and strontium ranelate on acute and repeat prescriptions.

• Agree which guidance or guidelines you will follow (e.g. NICE or SIGN guidelines for postmenopausal women, NOGG for men, Royal College of Physician corticosteroid-induced osteoporosis guidelines for those on corticosteroids). If using NICE guidance, decide how rigidly you will interpret it.

• Work your way through the list of patients, identifying when and why therapy was initiated and judge if it is still appropriate. Make notes initially on your search sheets.

• While reviewing each record, check that the drugs are prescribed generically, that the patient is persisting with therapy, that adjuvant calcium and vitamin D are prescribed and whether coding is accurate.  A data collection table can be downloaded.

You are likely to identify:

• Patients being treated appropriately: continue treatment.

• Lapsed patients: phone to discuss therapy; many will be intolerant and need a therapy change.

• Patients where it is not clear why therapy was started or continues: discuss these in a clinical meeting as colleagues may be able to clarify; many may be able to discontinue treatment.

Keep notes of patients in each category. Repeat the process after 6 months.

Patients without co-prescriptions

About half of patients on bisphosphonates may not have been prescribed calcium and D3. Start with your list of patients on bone-sparing therapies. Assess dietary calcium intake and whether the patient is taking over-the-counter preparations. In light of your findings, check whether each patient has been appropriately co-prescribed a calcium (1000-1200 mg/day) and vitamin D (800 IU/day) preparation. See the list of treatments within the Initiation section. Ensure that all are prescribed generically but that generic 'calcium and vitamin D tablets BPC' are not used as these contain very little calcium. Review compliance/adherence with therapy.

You may want to check that those not receiving adjuvant therapy do not have hypercalcaemia or other contraindications. These supplements are not contraindicated in stone-formers.

Review interactions, contra indications and precautions according to Summary of Product Characteristics and British National Formulary. Patients taking strontium ranelate need to ensure their second dose of calcium and vitamin D is taken at least 2 hours before their strontium ranelate; it may be easier to use a once-daily preparation taken in the morning.  Strontium ranelate should be suspended during treatment with oral tetracycline or quinolone antibiotics, or if the patient develops cardiovascular risk factors. Patients taking strontium ranelate need to be re-assessed every 6 months. Thyroxine affects the absorption of both strontium and calcium and should be given separately.

How should GPs Assess Falls Risk?

'How long should I prescribe osteoporosis treatments for?' is a difficult and controversial question to answer. Bisphosphonates have a long half-life in bone and probably continue to be effective for some time after they are withdrawn. Because of potential concerns about the safety of long-term treatment with bisphosphonates, a drug holiday may be considered in some patients following a period of treatment. Calcium and vitamin D supplements should be continued during this time.

In patients receiving oral bisphosphonates (alendronate, ibandronate, risedronate), treatment is usually given for 5 years in the first instance. If bone mineral density (BMD) remains the same or has improved from baseline, the post-treatment T-score is > −2.5 and no fractures have occurred during treatment, it may be reasonable to withdraw bisphosphonate treatment for 2 to 3 years with reassessment of fracture risk at the end of that time and re-continuation of treatment if indicated. Because the effects of intravenous zoledronic acid last for longer than oral bisphosphonates, a drug holiday should be considered after 3 rather than 5 years of treatment.

The rationale for giving bisphosphonate holidays is that there is an association between two rare conditions, namely atypical femoral fractures and osteonecrosis of the jaw, and prolonged bisphosphonate therapy. However, a direct causal relationship has not been established and these conditions can occur in people who have never received bisphosphonates. Patients with severe osteoporosis (e.g. multiple vertebral fractures) need to continue bisphosphonates as the benefits of osteoporotic fracture prevention outweigh the potential risks of continuing treatment. Similarly, if fractures have occurred during treatment and/or BMD remains low, bisphosphonate therapy should be continued.

Atypical fractures usually occur in the subtrochanteric region of the femur or the femoral shaft. They are associated with minimal trauma, are usually transverse or oblique, heal poorly and are bilateral in nearly 50% of cases. They are often preceded by prodromal pain in the groin or thigh and X-ray or MRI imaging should be considered in patients with these symptoms. Osteonecrosis of the jaw is characterised by exposed bone in the maxillofacial region for at least eight weeks in the absence of previous radiation. Both conditions are very rare.

The effects of other anti-osteoporosis treatments (denosumab, raloxifene, strontium ranelate, teriparatide) wear off more rapidly when treatment is stopped and there is no clear case for drug holidays in patients receiving these drugs. In the case of strontium ranelate there is evidence for continued efficacy for up to at least 10 years of treatment. Withdrawal of denosumab is followed by rapid bone loss, and if it is stopped treatment with another anti resorptive drug should be considered. Teriparatide is approved for a maximum of 24 months and its beneficial effects may be maintained by subsequent treatment with an anti resorptive drug.

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