Evaluation of Standards of Care for Osteoporosis and Falls in Primary Care
In 2007, The Information Centre for health and social care commissioned the first national evaluation of standards of care for osteoporosis and falls in primary care, using the QRESEARCH general practice database. This document reports the findings of the evaluation. The main aims of the project were:
To conduct the first national evaluation of standards of care in the primary care setting for older people at risk of falls and osteoporotic fractures.
To scope the feasibility and implications of including osteoporosis and falls within the Quality Outcome Framework (QOF) in the new GP contract.
To advise on the feasibility of extending this evaluation to additional practices in the UK and providing feedback to practices aimed at improving clinical care (ie undertake a full audit cycle).
Gradual reductions in bone mass and strength are part of the normal ageing process, but for some individuals the resulting bone fragility (osteoporosis) brings a substantial increase in risk of fragility fractures, particularly in association with a number of well described skeletal and extra-skeletal risk factors. The clinical importance of osteoporosis lies in the resultant fractures most commonly experienced at the hip, wrist and spine.
The combined costs of social and hospital care for patients with osteoporotic fractures has been reported as more than £1.8 billion per year in the UK, and are most likely to occur in an older person with osteoporosis who suffers a fall.
Fractures in over-60 year olds involve more than two million bed days in England alone, and another two million are taken up by frailty related falls in patients over the age of 75. Half of people suffering an osteoporotic hip fracture can no longer live independently as a result of the injury. Effective medications and lifestyle measures are now available for people with osteoporosis, or at high risk of developing the condition or having a fall.
The increasing number of people aged 65 and over will result in a marked increase in prevalence of these conditions. There is new evidence however that people at even the highest risk are unlikely receive optimal care.
This new study built on guidance from a number of national bodies, including the Department of Health, NICE and the Royal College of Physicians, aims to determine the best clinical care for osteoporosis and falls within general practice. A set of indicators was developed, similar to those which already exist in the Quality Outcomes Framework for conditions such as coronary heart disease and diabetes. The QRESEARCH database, which collects anonymous electronic medical records from patients in 525 UK general practices, was used to investigate the extent to which:
information relevant to osteoporosis and falls is currently held in the electronic medical record
best practice care for osteoporosis and falls is currently being provided, as shown by the proposed indicators
The project has been completed in collaboration with the following:
University of Nottingham
University of Derby
Clinical Effectiveness and Evaluation Unit, Royal College of Physicians
Gloucestershire Primary and Community Care Audit Group
Nottinghamshire County Teaching PCT
The project has been discussed with and endorsed by the National Osteoporosis Society and its Primary Care Forum as well as the multi-professional Steering Group for the National Audit of Falls and Bone Health hosted by the Clinical Effectiveness and Evaluation Unit of the Royal College of Physicians. The Health Care Commission and NICE are aware of this project so that it can inform related developments as appropriate.
Current achievement of best practice appears highest in prescribing appropriate drugs to people with diagnosed osteoporosis, for example
- almost three quarters of older women with diagnosed osteoporosis and a previous fragility fracture receive appropriate drugs.
For other aspects of care, current achievement appears low, for example:
- only one in ten older women with a previous fragility fracture has a referral for bone density assessment in her electronic medical record
- for older men this proportion is even lower, at one in fifty
- less than one in fifty older people recorded as having a high risk of falling has a recorded referral to a falls service or exercise programme
- low levels of achievement arise in part from practices not entering on the electronic medical record the assessments or referrals that have been carried out
- a computer search to identify those eligible for care is likely to under-estimate numbers, given the low level of recording osteoporosis diagnoses, falls history and care home residence in the electronic record
- incorporating an appropriate set of codes in the QOF could rapidly improve both provision of care and recording of relevant information, as has been seen in other clinical areas
- the workload of falls services would increase substantially if all older people at high risk were identified and referred to them.