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Strategaeth Osteoporosis aAtaliad Torasgwrn i Gymru Strategaeth Gofal Sylfaenol i Fyrddau Iechyd Lleol Cynhyrchwyd gan y Gymdeithas Osteoporosis Genedlaethol Osteoporosis andFracture PreventionStrategy for Wales A Primary Care Strategyfor Local Health Boards National
Osteoporosis
Produced by the National Osteoporosis SocietyJune 2003 “Osteoporosis is a ver y serious disease which results in 12,000 fractures in Waleseach year, causing severe pain and disability to individuals at a heavy cost to theWelsh Health Ser vice. But it is one of the few areas in which early inter vention topromote and maintain bone health can make a real impact on the burden of thedisease.
“I am delighted that the National Osteoporosis Society (NOS) has developed thisprimar y care strategy for osteoporosis and fracture prevention to help inform LocalHealth Boards (LHBs). The Society’s ‘cradle to grave’ strategy, involving manydifferent agencies, is an excellent example of the type of integrated approach thatis likely to be successful in the long-term.” Professor Ruth HallChief Medical Officer Message from the Minister for Health and Social Services “This Osteoporosis and Fracture Prevention Strategy will assist and inform LocalHealth Boards (LHBs) working with the NHS trusts and social ser vices to addressthe rising tide of osteoporotic fractures in par ticular, reducing bed blockage. Thisapproach emphasises the prevention of osteoporotic fractures through thepromotion of a healthy active life and the prevention and treatment of osteoporosis.
The NOS strategy uses an evidence-based approach and links to national priorities,making it a wonder ful example of joined-up thinking.
“By tackling osteoporosis, LHBs have a real oppor tunity to improve the health oftheir patients through adopting a systematic approach within multi-agency teams.” Jane HuttMinister for Health and Social Ser vices Introduction to the Osteoporosis and Fracture Prevention Strategy for Wales An osteoporosis framework – meeting health needs Action plan for population-wide primar y prevention measures Prevention and management of osteoporosis Osteoporosis and Fracture Prevention Strategy 3 Executive summaryKey recommendations are summarised below: Include prevention of osteoporotic fractures in the local Health Improvement Programme (HIP).
Equality of access for diagnosis and treatment of osteoporosis for the people of Wales.
Identify lead clinicians in primar y and secondar y care to develop an osteoporosis programme based on thisstrategy: each Local Health Board (LHB) should have a lead GP for osteoporosis, responsible for monitoring theimplementation of this programme.
each acute Trust should have a lead consultant for osteoporosis, responsible for clinical referrals,super vision of diagnostic ser vices and liaison with primar y care.
Establish a local osteoporosis interest group to facilitate multi-disciplinar y implementation of this framework.
Use a selective case-finding approach to target the treatment of individuals at high risk of osteoporoticfracture. This includes individuals with a histor y of previous fracture, frequent falls, use of oralglucocor ticosteroids or other clinical risk factors.
Provide access to adequate levels of diagnostic and specialist ser vices; thus a LHB ser ving a population of100,000 would require approximately 1,000 hip and spine DXA scans per year.
Promote the use of care pathways and audits to improve standards of care.
Monitor per formance to assess health impact.
Limit prescribing costs by targeting treatment at those for whom it is really necessar y and by identifyingthose treatments inappropriately prescribed.
This strategic document sets clear standards to enable LHBs to offer a high quality osteoporosis ser vice. LHBsmay wish to adopt a stepwise approach to its implementation, identifying which of the high risk groups detailedon pages 15-19 require immediate, medium and long-term action, and targeting resources as appropriate.
Crynodeb GweithredolCrynhoir yr argymhellion allweddol isod.
Cynnwys ataliad toresgyrn osteoporotig yn y Rhaglen Gwelliant Iechyd lleol.
Sicrhau cydraddoldeb hygyrchedd diagnosis a triniaeth osteoporosis i bobl Cymru.
Uniaethu clinigwyr ar weiniol mewn gofal sylfaenol ac eilaidd i ddatblygu rhaglen osteoporosis leol yn seiliedigar y strategaeth hon.
Dylai pob Bwrdd Iechyd Lleol gael Meddyg Teulu ar weiniol dros osteoporosis gyda chyfrifoldeb am gadwgweithrediad y rhaglen hon dan sylw.
Dylai pob Ymddiriedolaeth lem gael Meddyg Ymgynghorol dros osteoporosis gyda chyfrifoldeb amymgynghoriadau clinigol, goruchwyliad gwasanaethau diagnostig a chysylltiad â gofal sylfaenol.
Sefydlu gr wp lleol â diddordeb mewn osteoporosis i hyr wyddo gweithrediad amlddisgyblaethol y fframwaithhwn.
Defnyddio dull dethol o ddarganfod achosion er mwyn anelu triniaeth at unigolion mewn per ygl uchel.
Cynnwys hyn unigolion â hanes o dorasgwrn blaenorol, cwympiau aml neu defnydd steroidiau oral.
Darparu hygyrchedd lefelau digonol o wasanaethau diagnostig ac arbenigol; felly byddai angen oddeutu 1,000o archwiliadau amsugnometreg pelydr-X ynni deuol y flwyddyn ar Fwrdd Iechyd Lleol sy’n gwasanaethupoblogaeth o 100,000.
Hyr wyddo’r defnydd o lwybrau gofal ac archwiliad i wella safonau gofal.
Adolygu cyflawniad er mwyn asesu dylanwad ar iechyd.
Cyfyngu costau rhagnodi tr wy anelu triniaeth at y rhai sydd a’i angen ac uniaethu rheini â dderbyniasentragnodion anaddas.
Mae’r ddogfen strategol hon yn gosod safonau clir i alluogi Byrddau Iechyd Lleol i gynnig gwasanaethosteoporosis o ansawdd uchel. Efallai y bydd Byrddau Iechyd Lleol yn dymuno mabwysiadu dull cynyddol o’igweithredu, gan uniaethu pa fath o gleifion mewn per ygl uchel sydd angen gweithrediad yn y tymor byr, canoligneu hir ac anelu adnoddau fel bo angen.
Osteoporosis and Fracture Prevention Strategy Osteoporosis and FracturePrevention Strategy for Wales In Our Healthier Nation1 the Secretar y of State for Health highlighted the role that osteoporosis plays in an epidemiologically-based needs assessment, causing fractures in older people, noting that, as aresult of this disease, falls are a major cause of death ii) the health impact that action will have on and disability. Osteoporosis prevention was therefore included as one of the measures recommended to achieve a 20% reduction in accidents by 2010.
iv) consideration of the feasibility of implementation.
To facilitate progress at a local level towards achieving Activity stemming from this strategy can be reductions in fracture incidence and implementation of incorporated into LHB programmes for the care of this, the National Osteoporosis Society (NOS) has older people and for accident prevention under the developed this osteoporosis strategy that should be local Health Improvement Programme (HIP).
implemented by Local Health Boards (LHBs). The Standards of ser vice provision identified in this strategy offers practical advice for commissioners and strategy relate to evidence-based clinical guidelines providers to enable them to benchmark their current recommended by the Royal College of Physicians activity on osteoporosis and to identify how to improve (RCP) (Royal College of Physicians, 1999)2, (Royal health by investing in appropriate osteoporosis College of Physicians and Bone and Tooth Society, ser vices for a base population of 100,000.
2000)3 incorporated into LHB programmes for the careof older people and for accident prevention under thelocal HIP.
Osteoporosis and Fracture Prevention Strategy 5 An osteoporosis framework – meeting health needs Implementation of an osteoporosis framework offers an appropriate andeffective means of improving the health and health-related quality of life forolder men and women.
Health Evidence Bulletin in Wales PhysicalDisability and Discomfor t, Osteoporosis November Osteoporotic fractures are a major cause of pain, Royal College of Physicians, Bone and Tooth More than 12,000 osteoporotic fractures occur Society of Great Britain, National Osteoporosis Society. Glucocor ticoid-induced osteoporosis.
There are over 4,200 hip fractures each year in Guidelines for prevention and treatment, 200216.
7% of people suffering hip fracture die in hospitalwithin 30 days5.3, and 25% die within the following Wide variations in clinical recognition of Half of those sur viving hip fracture fail to regain their pre-fracture level of independence7.
Wide variation in access to diagnostic and In Wales5.1 the care of people with hip fractures specialist ser vices and in prescribing patterns.
alone leads to a total cost to Health and Social Range of therapeutic inter ventions now viable but concerns regarding inappropriate prescribing.
Fracture incidence and resulting costs will rise by Limited inter vention among high-risk individuals to over 1% per year, simply as a consequence of the Clear standards of evidence for interventions andservice delivery Identify lead clinicians in primar y and secondar ycare to develop an osteoporosis programme based Depar tment of Health. Repor t: Advisor y Group – each Local Health Board (LHB) should have a Audit Commission. United They Stand. HMSO National Osteoporosis Society. Guidelines for the provision of a clinical bone densitometr y ser vice.
– each acute trust should have a lead consultant for osteoporosis, responsible for clinical Depar tment of Health. Repor t on Health and Social referrals, super vision of diagnostic ser vices and Subjects 49. Nutrition and Bone Health: with par ticular reference to calcium and vitamin D.
Establish a local osteoporosis interest group to facilitate multi-disciplinar y implementation of this Depar tment of Health. Strategy for Osteoporosis.
Health Ser vice Circular 124. 199813.
Use a selective case-finding approach to target the Depar tment of Health. Local Health Action Sheet treatment of individuals at high risk of osteoporotic fracture. This includes individuals with a histor y of Royal College of Physicians. Osteoporosis: clinical previous fracture, frequent falls or use of oral guidelines for prevention and treatment. 19992.
Royal College of Physicians, Bone and Tooth Provide access to adequate levels of diagnostic Society of Great Britain. Osteoporosis: clinical and specialist ser vices; thus a LHB ser ving a guidelines for prevention and treatment. Update on population of 100,000 would require approximately pharmacological inter ventions and an algorithm for 1,000 hip and spine DXA scans per year.
Promote the use of care pathways and audits toimprove standards of care.
Monitor per formance to assess health impact.
Equality of access for diagnosis and treatment ofosteoporosis for the people of Wales. Osteoporosis and Fracture Prevention Strategy Population-wide primar y prevention measures Per formance indicators in this health care area mainly involve health education and are relatively Bone density measurement offers good value for money to ensure appropriate prescribing: costs Rate of discharge to normal place of residence var y, with most falling between £30 and £60, less within 28 days of admission with fractured neck than the cost of three months’ prescription of the Rate of deaths in hospital within 30 days of admission with a hip fracture for patients Approximately 1,000 DXA scans per year would be required for a population of 100,000 (see page Propor tion of older people exhibiting high risk for osteoporotic fracture, but without any injur y Prescribing costs are likely to increase but cost- to their bones, referred for assessment of bone effective inter ventions are available and clinical assessment with bone densitometr y should be used to target treatment at those who will benefit Reducing osteoporotic fractures features in the ‘Oppor tunities and Potentials’ of the FracturedNeck of Femur Collaborative, one of theOr thopaedic Ser vices Collaborative programmesunder the umbrella of the NHS ModernisationAgency: All fracture patients presenting in A&E to beassessed for osteoporosis treatment.
All ambulator y patients residing in residentialhomes to be prescribed calcium and vitamin D.
Table 1 on page 8 illustrates indicators for themanagement of osteoporosis in primar y care.
Osteoporosis and Fracture Prevention Strategy 7 Table 1: Indicators for the management of osteoporosis Age and sex-standardised incidence rates for osteoporosis fracture Referral rates for DXA scans by general practice Audit of prescribing patterns by general practice to appropriate therapeutic inter ventions Rate of discharge within 28 days following hip fracture to good rehabilitation following fractures Rate of re-admission for fur ther fracture Effective deliver y of appropriate health care, ie known to be clinically effective and appropriate Local implementation of RCP clinical guidelines and Waiting times for DXA within 3 monthsPropor tion of older people with risk factors for fracture,or previous fragility fracture, who are referred forassessment of bone mineral density (BMD) and/oroffered appropriate inter ventionsIncidence of fractured neck of femur Cost of DXA scansCost of fracture management per patient Waiting times for referral for diagnostic ser vices orspecialist consultationPropor tion of operations for fracture repair carried out within 24 hours of admission by experienced staff Access to information and advice on prevention and long-term managementRate of discharge to normal place of residence within28 days of admission with a fractured neck of femur for patients aged 65+ Percentage of people in high-risk groups given optimised function and improved quality of life Percentage of people followed up after fracture Percentage of people given information about self-care Percentage of people given information aboutosteoporosis and details of the NOSPercentage of people returned to pre-injur y residenceand level of independence prior to fracturePercentage of people with hip fracture operated onwithin 24 hours of admissionStandardised mor tality rates for hip fractureRate of deaths in hospital within 30 days of admissionwith a hip fracture for patients aged 65+Propor tion of frail or housebound elderly who areassessed for fall risk and given calcium and vitamin Dand/or hip protectors Osteoporosis and Fracture Prevention Strategy Current annual expenditure incurred in managing fractures related to osteoporosis issummarised in Table 2.
Table 2: Estimated annual expenditure on fracturemanagement in a Local Health Board (LHB) of 100,000 patients # Of the 200 patients with x-ray evidence of ver tebral fractures 40 come to clinical attention and are costed.
The oppor tunity cost of not taking action to prevent fractures is clearly considerable. The cost of implementingthis ser vice strategy will var y according to local unit costs for diagnostic ser vices, professional educationrequirements, extent of generic prescribing and whether patient costs are included. An illustration is given onpage 23. From a societal perspective, fracture prevention will yield significant improvements in quality of life,such as the ability to maintain independent living. It will also reduce demand on social ser vices. In addition,reducing the cost of acute care for osteoporotic fractures will save scarce health care resources.
Osteoporosis and Fracture Prevention Strategy 9 Preventive strategies for reducing the incidence of falls and osteoporotic fracturesneed to include measures which target: the whole population – lifestyle inter ventions the individual – selective case-finding Osteoporosis is defined as a progressive systemic individual are still being developed21 and will enable skeletal disease characterised by low bone mass and determination of absolute rather than relative risk and microarchitectural deterioration of bone tissue, with a be related to a time inter val (for example 10 years).
consequent increase in bone fragility and susceptibility Fur thermore, the addition of bone densitometr y to the to fracture18. In Wales this results in over 12,000 identification of these risk factors enhances fracture osteoporotic fractures each year, causing severe pain risk prediction. Current national and international and disability to individual patients and at an annual guidelines therefore propose a number of clinical cost to the Welsh health and social care budget of indicators for bone densitometr y3 in which more than £84 million4. More than one third of adult measurement can aid clinical decision-making and women and 1 in 12 adult men will sustain one or more osteoporotic fractures in their lifetime4,6.
pharmacological inter ventions to arrest bone loss.
Fracture risk depends ultimately on the strength of bone and propensity to trauma. The relative a. previous fragility fracture (forearm fractures contributions of each of these to fracture increase the risk of subsequent hip fractures by pathogenesis varies, even at the three commonest sites at which fractures occur: the hip; wrist and ver tebral fracture have another within a year23) ver tebral body. Thus, almost all wrist fractures areassociated with a fall, while less than 25% of all b. radiographic evidence of ver tebral deformity or ver tebral fractures follow such a fall19. Approaches to prevention include population-based strategies and c. untreated hypogonadism (premature menopause, those targeted to people at the highest risk2. Possible secondar y amenorrhoea, primar y hypogonadism in measures to reduce fracture risk in the general women; primar y or secondar y hypogonadism in population include increasing the level of physical activity under taken at all ages, reducing the d. treatment with oral glucocor ticosteroids (ie prevalence of smoking and increasing dietar y calcium intake. Epidemiological studies have shown, with e. diseases associated with an increased prevalence var ying degrees of cer tainty, that these risk factors are associated with osteoporosis. But there is little sporadic risk factors, such as low body mass index evidence about the effect of these population inter ventions on fracture risk from randomisedcontrolled trials and therefore uncer tainty about the Approaches to the prevention and treatment of falls practical outcome of implementing them on a large and osteoporotic fractures include population-based scale. Among high-risk strategies, there is no clear strategies and those targeted at individuals at highest evidence that population-wide screening using bone densitometr y to identify those at greatest risk iseffective in reducing fracture incidence. The major Prevention and early detection of osteoporosis thrust for prevention should therefore be directedtowards case-finding. 1. Action Plan for primar y prevention measures forosteoporosis (Population-wide approach) Assessment of fracture risk in an individual shouldideally be expressed as absolute rather than relative The Royal College of Physicians guidelines (1999)2 risk and be related to a time inter val (for example 10 repor ts that possible measures to reduce fracture risk years). Bone densitometr y has been shown to predict in the general population include increasing the level absolute fracture risk20, in studies of populations of physical activity under taken at all ages, reducing independently of other risk factors for fracture (most the prevalence of smoking and increasing dietar y impor tantly, age; previous fragility fracture; calcium intake. Epidemiological studies have shown, glucocor ticosteroid use and untreated hypogonadism).
with var ying degrees of cer tainty, that these lifestyle Methods of assessment of fracture risk in an modifications may help reduce osteoporosis. But there Osteoporosis and Fracture Prevention Strategy is little evidence about their effect on fracture risk from randomised controlled trials. The RCP repor t Peak bone mass is under genetic control26. However, a therefore made no recommendations concerning such number of factors, from conception to skeletal maturity, determine the extent to which this genetic The most comprehensive approach to finding patients potential is achieved. These include: hormonal status; at high risk of future fracture would entail population- weight-bearing physical activity; nutritional status and wide screening using an effective investigation and lifestyle attributes such as smoking and alcohol inter vention in those at the highest risk. However, this intake. Many of these factors also influence the rate is not justifiable because there is no trial-based of bone loss in later life. Preventive strategies should evidence that such a programme using bone densitometr y, biochemical markers of bone turnover or LHBs have an oppor tunity to integrate health risk factor profiling is effective in fracture reduction promotion and health care at the individual and nor that such an inter vention is cost-effective. For this population level thanks to their links with other reason, the RCP repor t recommended that the major thrust of prevention should be directed towards cost-effectiveness, it is recommended that lifestyle selective case-finding (the oppor tunistic identification measures* to develop and maintain bone health of high risk patients against predetermined criteria, throughout life are included in health promotion who are then offered bone densitometr y).
activities since there is synergy with messages forprevention of other chronic diseases, while a selective case-finding approach is adopted to target individualsat high absolute risk of fracture.
In the absence of current evidence to suppor t apopulation-wide screening strategy, a selective case- Oppor tunities for population-wide health promotion and finding strategy has been recommended by all national the input required from relevant agencies are identified and international collaborations to examine this issue in the following action plan. Fur ther details regarding (The World Health Organisation24, International case-finding at the individual level are given on pages Osteoporosis Foundation25, the American Society for 15-21. The prevention and treatment of osteoporosis Bone Mineral Research and the Royal College of requires a collaborative approach between primar y, Physicians2). Using the selective case-finding strategy, secondar y and community care and between health patients are identified, measured and treated because and social ser vices. Identifying key contacts within of a fragility fracture or by the presence of strong risk different agencies and involving them in a local osteoporosis interest group will promote inter-sectoralworking and help to ensure a strategic approach to theidentification of local priorities and the development oflocal osteoporosis ser vices. In addition to the work ofhealth and social ser vices, local radio and newspapersmay also act as useful media for promoting bonehealth messages.
*See Table 3 on page 12 for fur ther details Osteoporosis and Fracture Prevention Strategy 11 Table 3:Action plan for primary prevention measures for osteoporosis(This will also benefit other disease areas such as coronary heart disease and diabetes) sunshine exposureAdequate weight-bearing activity Health promotion ser viceLeisure centresSocial ser vicesPrimar y health care team Include regular weight-bearingactivity into school curriculum Information on excessivedieting and nutrition contraceptive carecer vical screeningante-natal care Osteoporosis and Fracture Prevention Strategy Refer for DXA and treat accordingto current glucocor ticosteroidguidelines both men and women on healthyliving and risk of osteoporosis Encourage adherence topharmacological treatment at highest risk of osteoporoticfracture and initiationof appropriate treatment and advise on safe andindependent living in health checks for 75+ Include bone health and accidentprevention messages in healthbehaviour initiatives Ensure patients understand theirmedication and adhere todosage regimes *Including: GPs, Practice Nurses, District Nurses, Health Visitors, Midwives, Physiotherapists, Occupational Therapists and Health Promotion Ser vice The National Osteoporosis Society is a valuable source for patient and professional literature promoting a healthy lifestyle.
Osteoporosis and Fracture Prevention Strategy 13 As with osteoporosis, strategies to reduce the frequency of falls in elderly peoplemay be aimed either at the entire population or at high risk individuals.
Epidemiological studies have clearly identified important risk factors for falls inelderly people27. Intrinsic risk factors include problems with walking (reducedbalance, gait and muscle strength); use of multiple medications (particularly thoseleading to sedation and reduced blood pressure), and impairment of vision ormemory. Extrinsic factors include poor lighting, unsafe stairs, loose rugs, poorlyfitting footwear or clothing, and the lack of safety equipment. The reduction offalls should lead to a reduction in fractures.
The NHS provides an administrative frameworkwhereby general health screening for the identification Population-based preventive strategies are par ticularly of risk factors for falls and systematic inter vention well placed to reduce fall frequency by encouraging with a multi-dimensional series of components could regular weight-bearing physical activity among elderly easily be incorporated in primar y and secondar y care.
people (which also increases bone mineral density Indeed a study from Australia suggested a GP health (BMD) and reduces fractures), encouraging the education programme could significantly improve the identification of impor tant risk factors through general well being of elderly patients in their care30.
health screening, and reducing the prevalence of poly-pharmacy and environmental hazards among the International guidelines have now been developed elderly (especially among the institutionalised jointly by the British and American Geriatrics Societies and the American Society of Or thapaedic Surgeonswhich provide evidence-based strategies31. Multi-faceted inter ventions reduce falls in olderpeople and therefore fractures This strategy for the prevention of falls in those at Assessment and appropriate referral of high risk high risk of falling and fracturing is suppor ted by a prospective randomised controlled trial from theUnited States29. A multi-dimensional assessment and Home assessment of older people at risk of falls inter vention was offered to people identified as being needs to be accompanied by direct inter vention or at risk of falls. This achieved a reduction in annual fall incidence of 12% compared with a control sample.
Comprehensive assessment and modification of Extrapolation from this study suggested that it was risk factors is effective when offered to community relatively cost-effective, but its sample size precluded dwelling older people who have presented to an assessment of health outcomes other than falls (for accident and emergency depar tment after a fall32 example, fracture or all cause mor tality).
The provision of hip protectors to residents ofnursing homes is effective if they have had A randomised controlled trial of multi-dimensional inter ventions to those at the highest risk carried out inthe UK suppor ted these findings. The key components It is essential that clear referral pathways for the of the inter vention in these studies are: assessment and management of osteoporosis areintegral to such ser vices.
It is recommended that an approach is based on collaboration between primar y care teams and A similar integrated approach to the management offalls risk will be crucial if effective fracture preventionstrategies are to be developed in Wales.
Osteoporosis and Fracture Prevention Strategy Prevention and management of osteoporosis Case-finding may occur in both primar y and secondar y Most DXA scanning units provide guidelines on care although long-term management is mainly the appropriate referral that conform to national responsibility of primar y care teams. Referral for bone guidelines. DXA is recommended for individuals with density measurement of hip and spine (DXA) should key clinical risk factors to confirm whether treatment is be considered in those who are at increased risk of required2. Table 4 indicates the groups of people who osteoporosis and therefore of fracture and where the may be considered for diagnostic DXA scan.
result is likely to change clinical management.
Table 4: Referral criteria for bone density measurement ANNUAL ESTIMATED NUMBER OF SCANS PER 100,000 POPULATION* glucocor ticosteroid use(ie. prednisolone for three months or more) family histor y of osteoporosis(especially maternal hip fracture) other clinical risk factors:height loss, kyphosis, low BMI (<19 kg/m2) possible secondar y osteoporosis, primar y hyperparathyroidism,rheumatoid ar thritis, liver disease, alcoholism,primar y hypogonadism untreated oestrogen deficiency(surgical or natural menopause <45 years,secondar y amenorrhoea > 6 months not due to pregnancy,primar y hypogonadism) many centres also utilise DXA scanning to monitor therapeutic response *Data assembled from a national NOS sur vey34 and from Dr N Peel, Osteoporosis Centre, University of Sheffield Osteoporosis and Fracture Prevention Strategy 15 Bone density measurement by hip and spine DXA DXA results are conventionally repor ted according to (DXA) remains the “gold standard” for the diagnosis of the number of standard deviations by which a reading patients with osteoporosis, although the spine may differs from the young adult mean (T score)2.
also be a suitable site for diagnosis in younger people Instruments also provide information on the number of without evidence of osteoar thritis35. If spine and standard deviations by which a reading differs from proximal femur bone density measurements are not the age-specific mean (Z score). Table 5 shows a available, a measurement of forearm or calcaneal simple classification of hip and/or spine DXA scan bone density by DXA can be used but interpretation of results must be evaluated carefully to identify those at recommended. Current guidelines recommend that risk of fracture as diagnostic inter vention thresholds treatment decisions should be based on clinical may differ with these technologies. Quantitative assessment in addition to T scores. Z scores may be ultrasound in common with DXA must have stringent useful in determining management of cer tain patients; quality assurance and can be used in the assessment appropriate guidance should be provided by the local of fracture risk, but not for the diagnosis of bone densitometr y ser vice or lead clinician.
osteoporosis36. This is currently an area of activeresearch and the NOS will continue to update itsposition statements on the use of these peripheralbone density techniques36,37.
Falls preventionOffer treatment if previousfragility or ver tebral fracture:See Table 7 on page 17 Lifestyle adviceFalls prevention and offertreatment as detailed on pages 17–18 *Derived from Royal College of Physicians (1999)2 Several inter ventions are now available which retardbone loss, reduce fracture risk and are licensed forthe prevention and/or treatment of osteoporosis. Lackof comparative data makes it difficult to recommendspecific treatments based on a hierarchy of efficacy orclinical effectiveness.
Evidence suppor ting the use of specific treatment issummarised extensively in the Royal College ofPhysicians update 20003. Tables 6 and 7 on the nextpage are a tabulation of this evidence.
Osteoporosis and Fracture Prevention Strategy Table 6: Effect of interventions on the prevention/reduction of postmenopausal bone loss: grade of recommendations Table 7: Anti-fracture efficacy of interventions in postmenopausal osteoporotic women: grade of recommendations Meta analysis of Randomised Controlled Trials (RCTs) or from at least one RCT From at least one other type of well designed quasi-experimental studyFrom well-designed non-experimental descriptive studies, eg. comparative studies, correlation studies, case-control studies From exper t committee repor ts/opinions and/or clinical experience of authorities Osteoporosis and Fracture Prevention Strategy 17 All patients commencing pharmacological therapy osteoporosis with various inter ventions are listed should also be counselled on lifestyle measures to reduce bone loss including: weight-bearing physicalactivity; nutritional status and lifestyle attributes such Bisphosphonates: Alendronate and risedronate prevent bone loss at all sites vulnerable toosteoporosis and decrease the risk of spine and Advice regarding smoking cessation and safe drinking hip fracture. Cyclical etidronate reduces bone loss should always be given, not only because there is at the spine in women with osteoporosis and good evidence that these behaviours can increase the reduces the risk of ver tebral fracture.
risk of osteoporosis but also because, as with all the Calcium supplements of 1g or more daily decrease modifiable lifestyle factors, there is secondar y gain in bone loss in elderly women but the effects are other areas such as coronar y hear t disease and bisphosphonates. Calcium in combination with The National Osteoporosis Society is a valuable vitamin D has also been shown to reduce the hip source for patient and professional literature fracture rate. It is impor tant to note that calcium and vitamin D were used in addition to therapy inthe bisphosphonate and raloxifene studies, eitherfor all par ticipants, or where dietar y/lifestyle information suggested less than optimal levels.
Patients at risk of osteoporosis may present in both This may have contributed to the beneficial effects primar y and secondar y care, hence the need for a collaborative approach to identify appropriate patients Oestrogen (HRT) prevents bone loss; its effects and to agree subsequent management policies. Table are dose dependent. Ver tebral and hip fracture 8 provides some examples of oppor tunities for frequency decrease while on treatment.
identifying patients at high risk of osteoporosis. Audits Obser vational studies indicate potential protective of computer records to identify such patients offer a effects on distal forearm fractures. Anti-fracture more systematic approach. The National Osteoporosis efficacy will wane on cessation of treatment38.
Society (NOS) holds examples of validated audit Nasal Calcitonin prevents bone loss, reduces protocols which are available on request.
ver tebral fracture frequency but there is no trial-based evidence that it prevents fractures atother sites.
SERMs (selective estrogen receptor modulator):Raloxifene has been shown to increase bonedensity at the spine and hip in women with lowbone density (osteopenia and establishedosteoporosis) and decrease the risk of ver tebral(but not hip) fracture.
Testosterone and anabolic steroids have beenshown to prevent bone loss in men and olderpeople respectively but adequate studies have notbeen per formed to examine their effect againstfracture.
Vitamin D metabolites (calcitriol and alfacacidol)retard bone loss and some studies havedemonstrated an effect against ver tebral fracture;but not hip fracture. There is some evidence thatreplacement of vitamin D insufficiency may reducefalls via an enhancement of neuromuscular and/orpsychomotor per formance.
Osteoporosis and Fracture Prevention Strategy Table 8: Examples of opportunities for selective case-finding Consider need for diagnostic evaluationof osteoporosis and/or referral to falls ser vice glucocor ticosteroid inducedosteoporosis16 Consider falls prevention and use of hip protectors Osteoporosis and Fracture Prevention Strategy 19 Figure 1: Medical management of men and women aged over45 years who have or are at risk of osteoporosis For men aged less than 65 years, specialist referral should be considered.
Recommended daily dose 0.5-1g and 800iu respectively.
Treatments listed in alphabetical order. Calcium and vitamin D aregenerally regarded as adjuncts to treatment. HRT: oestrogen inwomen, testosterone in hypogonadal men.
*** Calcium and vitamin D should be offered as adjunctive therapy Osteoporosis and Fracture Prevention Strategy Below is an explanation of Figure 1 featured on Bone and liver function tests (Ca, P, alk phos, Major risk factors (other than previous fragility fracture – a fracture sustained from a fall from standing height or less) include the following: 1. Untreated hypogonadism (premature menopause, 2º amenorrhoea, 1º hypogonadism in women; 1º 2. Glucocor ticosteroids (prednisolone for 3 months Lateral thoracic and lumbar spine x-rays.
3. Disease associated with increased prevalence of osteoporosis (eg, gastrointestinal disease, chronic Serum FSH if hormonal status unclear (women).
Serum testosterone, LH and SHBG (men).
4. Radiological evidence of ver tebral deformity or Other risk factors in national and international Adequate nutrition especially with calcium and guidelines include family histor y, low body weight, cigarette smoking, height loss or low bone mass asassessed by other techniques.
Avoidance of tobacco use or alcohol abuse.
Defined as a fracture sustained from a fall fromstanding height or less and includes prevalentver tebral deformity. A previous fragility fracture is astrong independent risk factor for fur ther fracture andmay be regarded as an indication for treatmentwithout the need for BMD measurement when theclinical histor y is unequivocal.
Derived from Royal College of Physicians.
Osteoporosis: Clinical guidelines for prevention and treatment update. RCP (2000)3 Osteoporosis and Fracture Prevention Strategy 21 1. Population-wide: bone health promotion There are current health promotion activities in which Prescribing costs can be limited by using clinical osteoporosis bone health messages could be assessment and bone density measurement to included, such as Hear t Health campaigns.
identify individuals at greatest risk of fracture who willderive greatest benefit from treatment and by Patient information leaflets and other educational identifying those who are being treated inappropriately resources are available from the National and whose treatment can be discontinued.
The cost-effectiveness of bone densitometr y dependsupon the costs of treatment, targeted on the basis ofthe results: the more expensive the inter vention, thegreater the cost-effectiveness of bone density referraland measurement. It is not cost effective to measureBMD where treatment costs less than £100 perannum, for example calcium and vitamin D2.
Assessing standards of care for all those with or at The RCP Clinical Guidelines (1999/2000)2,3 provide risk of osteoporosis requires clear process and standards for clinical care. Standards for ser vice outcome indicators as well as effective tools for configuration which will enable such care to be monitoring per formance. The key per formance provided are outlined for secondar y care in Guidelines indicators are summarised on page 7.
for the provision of a clinical bone densitometr yser vice11 and for primar y care in this osteoporosis The major objective is fracture reduction, and it is strategy. Standards for falls prevention and impor tant that LHBs are able to access local fracture management ser vices are given in the joint British and data. Hip fracture data is available through the Patient American Geriatric Societies Guidelines31. The NOS Episode Database for Wales (PEDW) and the All Wales has examples of audit protocols which focus on Injur y Sur veillance System (AWISS). Currently wrist management of high-risk groups such as patients and ver tebral fractures are poorly recorded. LHBs may being prescribed oral glucocor ticosteroids, that can be wish to liaise with their local acute providers to identify used by LHBs to assess their per formance against what local data are available. Ver tebral fractures are commonly under-repor ted but this is in par t becauseonly approximately one-third come to clinical attention.
Benefits in fracture reduction may be seen within oneyear, par ticularly if inter ventions are aimed at thoseaged over 65.
Osteoporosis and Fracture Prevention Strategy LHBs may wish to adopt a stepwise approach to the implementation of anosteoporosis strategy, identifying which of the high-risk groups require immediate,medium or long-term action, and targeting resources appropriately. Initially, as atemporary measure, LHBs may want to adopt a few of the steps below beforeproviding a full osteoporosis service.
The following indicates the annual cost that might be incurred in providing the ser vice framework forosteoporosis as outlined. It is viewed from the perspective of a LHB ser ving a population of 100,000 and willvar y according to local unit costs.
Identification of a lead clinician(s) for osteoporosis in secondar y care and a lead GP for the LHB GP time to par ticipate in local district-wide interest group, implement framework and monitor per formance: 1 GP session per week (£110 plus NI) plus travel expenses (absorbed within ongoing health promotion activity) Referral for hip and spine DXA (approximately 1,000 scans assuming a cost of £50) (The actual cost of DXA scans varies) Access to specialist exper tise on treatment for established osteoporosis 1 par t-time osteoporosis nurse to assist with case finding 16,000 Prescribing costs (500 patients @ average drug cost of £170 per patient with 4 GP consultations per year) This ser vice would cost the same as managing 9 out of the 145 hip fractures which occur in a population of100,000 per year39 (see Table 2 on page 9).
Osteoporosis and Fracture Prevention Strategy 23 For fur ther information on the government’s strategyfor osteoporosis please see: National Osteoporosis Society (NOS) literature: Examples of audit protocols which have been effectively piloted by GP practices targeting: For fur ther information on glucocor ticoid-induced Royal College of Physicians, Bone and Tooth Society ofGreat Britain, National Osteoporosis Society.
Glucocor ticoid-induced osteoporosis. Guidelines for The use of peripheral x-ray absorptiometr y in the The use of quantitative ultrasound in the The NOS has a wide range of literature for the public, Guidelines for the provision of a clinical bone which may be useful for health promotion activity. Its telephone helpline offers confidential advice on the The repor ting of dual-energy x-ray absorptiometr y treatment and prevention of osteoporosis, and membership offers practical and continuing suppor t to Examples of NOS patient information – fur ther leaflets To obtain fur ther information, please contact: Osteoporosis – causes, prevention and treatment Living with osteoporosis – coping after broken The NOS has worked with many LHBs to develop and The National Osteoporosis Society would like to thank implement local osteoporosis strategies – please the International Osteoporosis Foundation for their contact the NOS if you require fur ther information: Angela JordanActing Health Ser vices Liaison ManagerNational Osteoporosis SocietyCamer tonBath BA2 0PJ Professional helpline(staffed by osteoporosis nurses): 0845 450 0230 This document was based on a document producedfor England.
email: hsl@nos.org.ukwebsite: www.nos.org.uk The National Osteoporosis Society (NOS) wishes tothank members of the NOS Scientific Advisor y Groupwho assisted in the production of this document, withpar ticular thanks to Professor David Barlow, Dr PamBrown, Professor Cyrus Cooper, Professor RichardEastell, Professor Graham Russell, Professor CameronSwift and Dr David Torgerson.
Osteoporosis and Fracture Prevention Strategy Depar tment of Health. Saving Lives: Our Healthier Nation. Depar tment of Health 1999.
Royal College of Physicians. Osteoporosis: clinical guidelines for prevention and treatment. RCP 1999.
Royal College of Physicians and Bone and Tooth Society of Great Britain. Osteoporosis: Clinical guidelinesfor prevention and treatment. Update on pharmacological inter ventions and an algorithm for management.
RCP London 2000.
Torgerson DJ, Iglesias CP, Reid DM. The economics of fracture prevention. In The Effective Management ofOsteoporosis; 111-21 2001.
5.1. Johansen A, Evans R, Stone MD, Richmond P, Lo SV, Woodhouse KW. The incidence of fracture in the United Kingdom: a study based on the population of Cardiff. Injur y; 28: 655-660 1997.
5.2. Patient Episode Database for Wales (PEDW) 1997-1999. Health Solutions Wales, 1999.
Welsh Office: Clinical Indicators for the NHS, 1995-1998. Welsh Office, 1999.
Cooper C, Epidemiology of Osteoporosis, Osteoporosis International, Supplement 2, S2-S8. 1999.
Eddy DM, Johnson CC, Cummings SR, Dawson-Hughes B, Lindsay R, Melton LJ, and Slemenda CWOsteoporosis: review of the evidence for prevention, diagnosis, treatment and cost-effectiveness analysis.
Osteoporosis International 8 (Supplement 4). 1998.
Burge RT, Worley D, Johansen A, Bhattachar yya S, Bose U. The Cost Of Osteoporotic Fractures In TheUnited Kingdom: Projections for 2000-2020. J. Medical Economics 2001;4:51-62 Depar tment of Health. Advisor y Group Repor t on Osteoporosis. Depar tment of Health 1994.
Audit Commission. United they stand. HMSO 1995.
National Osteoporosis Society Guidelines for the Provision of a Clinical Bone Densitometr y Ser vice. NOS 2002.
Depar tment of Health. Repor t on Health and Social Subjects 49. Nutrition and Bone Health: with par ticularreference to calcium and vitamin D. HMSO 1998.
Depar tment of Health. Strategy to prevent and tackle osteoporosis. Health Ser vice Circular 124 1998.
Preventing Accidents Caused by Osteoporosis. Local Health Action Sheet. Depar tment of Health 1998.
Health Evidence Bulletin in Wales Physical Disability and Discomfor t, Osteoporosis November 2001.
Royal College of Physicians, Bone and Tooth Society of Great Britain, National Osteoporosis Society.
Glucocor ticoid-induced osteoporosis. Guidelines for prevention and treatment, 2002.
Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis;57(6):378-9 1998.
Consensus Development Conference. Diagnosis, prophylaxis and treatment of osteoporosis. Am J Med; 94 646-50 1993.
Melton III LJ, Cooper C, “Osteoporosis”, (Marcus R, Fetham D, Kelsey J, ed.) 2nd Edition 2001, Chapter21, Volume 1 557-567 Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predictoccurrence of osteoporotic fractures. BMJ; 312(7041): 1254-9 1996.
Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B. Ten year probabilities of osteoporoticfractures according to BMD and diagnostic thresholds. Osteoporosis International; 12(12): 989-95 2001.
Cuddihy MT, Gabriel SE, Crowson CS, O’Fallen WM, Melton LJ III. Forearm fractures as predictors ofsubsequent osteoporotic fractures. Osteoporosis International; 9:469-75 1999 Lindsay R, Silverman SL, Cooper C, Hanley DA, Bar ton I, Broy SB et al. Risk of new ver tebral fracture in theyear following a fracture. JAMA, Jan 17 vol 285, no. 3 2001.
Osteoporosis and Fracture Prevention Strategy 25 WHO. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis;technical repor t series 843. Geneva: WHO, 1994.
Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D. Guidelines for diagnosis and management ofosteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporosis International;7(4):390-406 1997.
Ralston SH. Osteoporosis. BMJ 315, 469-472. 1997.
Masud T, Morris RO. Epidemiology of falls. Age & Ageing 2001; 30 (Suppl 4):3-7. Primar y Care Strategy forOsteoporosis and Falls.
Campbell, AJ et al. Randomised Controlled trial of a general practice programme of home based exerciseto prevent falls in elderly women, BMJ, 315, 1065-1069. 1997.
Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M et al. A multifactorial inter vention toreduce the risk of falling among elderly people living in the community. New England Journal of Medicine.
1994;331(13):821-7.
Kerse NM, Flicker L, Jolley D, Arroll B, Young D. Improving the health behaviours of elderly people:randomised controlled trial of a general practice education programme. [see comments.]. BMJ;319(7211):683-7 1999.
Guideline for the Prevention of Falls in Older Persons. American Geriatrics Society, British Geriatrics Societyand American Academy of Or thopaedic Surgeons Panel on Falls Prevention. JAGS; 49:664-672 2001.
Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET)– a randomised controlled trial. Lancet; 353:93-7 1999.
Lauritzen JB, Petersen MM, Lund B. Effect of external hip protectors on hip fractures. Lancet; 341:11-13 1993 Rowe RE, Cooper C. Osteoporosis ser vices in secondar y care: a UK sur vey. Journal Royal Society ofMedicine; 93: 22-24 2000.
Kanis JA, Gluer CC. An update on the diagnosis and assessment of osteoporosis with densitometr y.
Committee of Scientific Advisors, International Osteoporosis Foundation. Osteoporosis International; 11(3): 192-202 2000.
National Osteoporosis Society. Position statement on the use of quantitative ultrasound in the managementof osteoporosis. NOS 2001.
National Osteoporosis Society. Position statement on the use of peripheral x-ray absorptiometr y in themanagement of osteoporosis. NOS 2001.
Michaëlsson K, Baron JA et al. Variation in Efficiency of HRT in Prevalence of Hip Fracture. Osteoporosis International 8 540-546 1998.
Torgeson DJ, Iglesias CP, Reid DM. The Economics of Fracture Prevention (chapter). In The EffectiveManagement of Osteoporosis. Barlow DH, Francis RM, Miles A (eds) Aesculpius Medical Press, London 2001.
Osteoporosis and Fracture Prevention Strategy Key recommendations are summarised below: Include prevention of osteoporotic fractures in the local HIP Identify lead clinicians in primar y and secondar y care to develop an osteoporosis program based on thisstrategy: each Local Health Board (LHB) should have a lead GP for osteoporosis , responsible for monitoring theimplementation of this program.
each acute trust should have a lead consultant for osteoporosis, responsible for clinical referrals,super vision of diagnostic ser vices and liaison with primar y care.
Establish a local osteoporosis interest group to facilitate multi-disciplinar y implementation of this framework.
Use a selective case-finding approach to target the treatment of individuals at high risk of osteoporoticfracture. This includes individuals with a histor y of previous fracture, frequent falls or use of oralglucocor ticosteroids.
Provide access to adequate levels of diagnostic and specialist ser vices; thus a LHB ser ving a population of100,000 would require approximately 1,000 hip and spine DXA scans per year.
Promote the use of care pathways and audits to improve standards of care.
Monitor per formance to assess health impact.
Equality of access for diagnosis and treatment of osteoporosis for the people of Wales. This strategic document sets clear standards to enable LHBs to offer a high quality osteoporosis. LHBs maywish to adopt a stepwise approach to its implementation, identifying which of the high risk groups detailed onpages 15-19 require immediate, medium and long-term action, and targeting resources as appropriate. The National Osteoporosis Society (NOS) wishes to thankmembers of the NOS Scientific Advisor y Group who assisted National
in the production of this document. Par ticular thanks to : Osteoporosis
Dr Pam BrownDr Antony JohansenDr Phil Jones of the Writing Group of the Welsh Osteoporosis website: www.nos.org.uke-mail: info@nos.org.uk Ms Anne BeamesDr Wil D EvansMs Liz GreenDr Wyn HarrisDr Anthony JamesDr Jim Mar tinMs Julie MorganDr KT RajanDr Priscilla Williams June 2003 National Osteoporosis Society All rights reser ved. No par t of this publication may be reproduced, stored in anyretrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or other wisewithout the prior permission of the copyright owner.
Osteoporosis and Fracture Prevention Strategy 27 Osteoporosis and fracture prevention across the LHB DXA scans provided, the cost of the ser vice, and appropriateness of referrals if data available Fracture data – hip, Colles, ver tebral fracture numbers and costs Drug use and costs (calcium and vitamin D,bisphosphonates) Agree implementation plan and implement the care pathway

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