Bone health is an often overlooked condition that affects millions of people across the UK with high rates of morbidity and mortality associated with fractures in the elderly population. The aim of the programme is to improve the health outcomes for patients at risk of sustaining a fragility fracture and to promote improvements in bone health through patient education, targeted case finding and review, effective treatment and medication compliance. The programme is underpinned by national guidance and local regional treatment pathways.
Targeted proactive risk assessment is undertaken as recommended by NICE CG146 with NICE TA160 and TA161 providing clear and structured direction in relation to the use of bone sparing therapies in primary and secondary prevention. Quality Statements 1,2,3 and 4 taken from NICE QS149 provide the overarching backdrop to the programme, supporting clinicians to identify opportunities to improve the standard of care provided to those at risk of fracture.
- Falls in older people: assessing risk and prevention (CG161)
- Osteoporosis: assessing the risk of fragility fracture (CG146)
- Osteoporosis (QS149)
- Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (TA161)
- Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women (TA160)
Aims and objectives
This innovative and unique programme supports primary care in identifying patients at risk of fragility fracture and/or osteoporosis, enhancing the reputation of the region by leading innovation in targeting proactive fracture risk assessment. The Academic Health Science Network for the North East and North Cumbria (AHSN NENC) aims to deliver this programme on a National footprint through the AHSN Network.
The aims of the programme are to support primary care in achieving the key long term goals of osteoporosis management such as prevention of fragility fractures and to support GP practices in the identification and management of patients at risk of fracture.
The objectives of the review include:
- Performance of a fracture risk assessment for patients with a history of fragility fracture or with high-risk factors for fragility fracture and osteoporosis
- Reducing fracture risk for patients with or without osteoporosis through the identification and prioritisation of defined patient cohorts
- Supporting the optimisation of treatment for patients being prescribed bone-sparing agents (BSA) including assessment of duration of treatment, adherence and adverse effects or clinical risks associated with current treatment
- Identification of those patients at risk of calcium and vitamin D deficiency who may benefit from the addition of a calcium and vitamin D supplement
- Establishing a process and educational legacy to support sustained quality improvement in the management of patients with osteoporosis
- Appropriately increase the number of patients receiving bone sparing agents
- Adoption of local bone metabolic pathway(s) and facilitating patient access to treatment options.
Reasons for implementing your project
The AHSN NENC has an service level agreement (SLA) with The North East Quality Observatory Service (NEQOS) to produce strategically and operationally important insights into the health status of the region and the healthcare system. The region covers an overall population of 3.2m. The report provided an overarching picture of falls and fractures and a quantitative baseline against which the impact of programme could be measured.
- In 2014/15 there were 12,654 emergency admissions for falls in NENC, costing an estimated £84,973,249 to the Region. The number of people aged 65-79 who fall (as measured by emergency admissions due to injuries from a fall) is significantly higher than the England average.
- For all age groups, 65 and above, the North East and North Cumbria has a high rate of emergency admissions for hip fracture - significantly above the England average and higher than any other region in the country.
- The quality of care received in hospital appears to be good, with the region performing better than the England average for many of the indicators examined.Building upon this initial programme, the Sheffield University FRAX multi-patient assessment tool for fracture risk assessment was made available within the programme. This tool enabled key components of the NICE CG146 guidelines, namely proactive fracture risk assessment; to be undertaken at scale and tested across 20 GP practices covering a total patient population of 160,000. This model was subsequently expanded to other areas. The cost saving model (based on a Cochrane Review 2008) conservatively indicates that treatment of 1500 patients with bone sparing drugs could support the avoidance of 59 hip fractures, giving a saving of £960,000 over 4 years (against a cost of bone sparing treatment for four years of £60,900). This figure relates purely to the direct costs of hip fractures and does not include social care costs or the avoidance of other low trauma fractures.
- The programme has evolved and grown over a period of 3 years. Commencing in 2014, support was provided to 13 GP practices in West Northumberland covering a total population of ~80,000 patients. Following successful delivery, this support was then replicated in other GP practices across the region. The programme identified a lack of clarity in relation to bone health for primary care and a significant primary care training gap in relation to the osteoporosis Quality and Outcomes Framework (QOF) indicators leading to vastly underreported prevalence rates.
How did you implement the project
A successful falls and fracture pathway can integrate a wide multidisciplinary team and reach across healthcare boundaries; often including non-medical providers such as the fire service. Although this programme of support is most visible within primary care, the impact is augmented by assisting clinicians and patients to direct and navigate the pathway in the most appropriate manner. As the programme has evolved, The North East and North Cumbria AHSN engaged initially with its members, Clinical Commissioning Groups, to form falls and fracture groups with their providers and Interface Clinical Service (ICS) to understand and indeed shape falls and fracture pathways which enable a fracture prevention initiative to succeed.
At GP practice level, the ICS pharmacist worked with the authorising clinician(s) within primary care to determine the criteria for inclusion and exclusion within the project. By choosing the criteria to be included, the GP determined the patient cohorts to be clinically assessed. The pharmacist then used the GP electronic patient records to collate data for presentation. Collation involved using the clinical system search functionality to create searches that extract data in order to give current baseline at "risk populations" and opportunities to improve their treatment.
This process was augmented through utilisation of the Sheffield University FRAX tool and ICS ‘Attend2 Fracture Prevention’ toolkit. Upon receiving authorisation to review patient cohorts the pharmacist then carried out a detailed medical record review for individual patients. Interventions were then implemented by the pharmacist in accordance with the authorising clinicians’ specification. All interventions were then communicated to patients.
Within the cohorts, patients identified as meeting the criteria of the QOF clinical indicator target groups for Osteoporosis, were highlighted to the practice authority along with any appropriate intervention recommendation as necessary to meet the current QOF target.
Applying the guidelines taken from NICE CG146 to a population of 258,000, identified 110,643 patients requiring a fracture risk assessment. Utilising the Attend2 Fracture tool a FRAX score was calculated for each of these patients and a greater than 20%, 10-year probability of a major osteoporotic fracture identified in 7.3% of patients (8044 patients).
As per local pathways, the NOGG interpretation graph was utilised to further stratify patients based upon calculated FRAX risk. In this manner, 2,890 patients were identified as requiring treatment with only 23% of these patients receiving bone sparing therapy at the baseline assessment. Additional cohorts of patients were prioritized for further clinical assessment and/or bone densitometry.
Within the treatment cohort of 2890 patients approximately 50% of patients were untreated and/or had no previous evidence of bone health assessment. Within this untreated cohort alone, using the FRAX 10 year probability of hip fracture we would expect 140 hip fractures at a direct hospital cost of almost £2.3million. With effective treatment, a reduction in hip fracture incidence of circa 40% could be achieved (Cochrane 2008) delivering a net saving of circa £0.9million and avoiding 56 hip fractures as well as innumerable low trauma fractures.
Further subset analysis of 1337 patients receiving bone sparing therapy identified:
- 520 patients with greater than 5 years on treatment - NOGG guidelines and guidelines from the All Wales Medicines Strategy Group were utilised to identify patients suitable for discontinuation of treatment or treatment holidays
- 318 patients with compliance <80% during the last 12 months – Educational materials, compliance reminder letters and/or direct patient consultations were scheduled to better understand the drivers behind this and where appropriate alternative therapies considered.
- 194 patients with possible fracture(s) whilst on treatment – further analysis of this cohort was undertaken and where appropriate patients referred for specialist assessment as per local pathway.
- 16 patients with reduced renal function (GFR<35) – patients were invited for review with the clinician and where significant risk of fracture was found, patients were referred for specialist assessment in relation to their bone health and concurrent renal function.
Key learning points
- Improvements in bone health can be achieved through a range of non-medical and medical interventions. These might include diet and lifestyle modifications, exercise and mobilisation, bone sparing therapy, calcium and vitamin D supplementation etc. Clinical decisions should be shaped around and with individual patient requirements.
- There has been limited adoption of national guidelines and the QOF parameters relating to Osteoporosis have not been fully understood or wholly implemented within primary care.
- Adoption of national guidelines around bone health can be achieved at scale; however, the rate of adoption needs to be commensurate with clinical capacity in both primary and secondary care – this would ideally involve consultation with all stakeholders ahead of implementation through round table discussions with Clinical Commissioning Groups/Task Groups (involving members from Community, Primary and Secondary Care), GP Educational Events (time-out sessions).
- Adoption of NICE CG146 guidelines requires collaborative working between stakeholders to deliver optimal outcomes.
- Screening of large populations utilising ‘risk’ tools depends largely upon the quality of the source data. Whilst tools can be immensely powerful where data is accurate, it is important to ensure the validity of this data before making a treatment / intervention decision.
Commenced in 2014 with funding from The AHSN-NENC and Kyowa Kirin and delivered by Interface Clinical Service (ICS). It now operates under a Joint Working Agreement with AHSN NENC and Amgen Ltd delivered by ICS.