National audit findings

• National audit of falls and bone health in older people: The Royal College of Physicians Clinical Effectiveness and Evaluation Unit (RCP-CEEU) has audited the organisation of services and standards of clinical care for fragility fracture care and prevention since 2005. In May 2011, the most recent round of this audit was published. Key findings include:
  • The majority of high-risk patients miss the best or only opportunity for their falls and fracture risk to be identified in the majority of hospitals and most primary care organisations lack adequate services for secondary falls and fracture prevention
  • 37% of local health services provide any kind of Fracture Liaison Service (FLS) and not all of these can demonstrate reliable assessment of all fracture patients
  • 32% of non-hip fracture and 67% of hip fracture patients had a clinical assessment for osteoporosis and/or fracture risk
  • 33% of non-hip fracture and 60% of hip fracture patients received appropriate management for bone health

  Key recommendations from the national audit include:

  • All localities should commission a Fracture Liaison Service following the best-evidenced models either for acute-based services (e.g. Glasgow) or primary care-based services (e.g. West Sussex)
  • The Osteoporosis Directed Enhanced Service (DES) should cease immediately and the findings from the DES data be made public. Instead, a Quality and Outcomes Framework (QOF) for Osteoporosis should be introduced at the earliest opportunity
  • All acute care providers should introduce routine screening of older people, presenting to EDs or minor injury units (MIUs), for falls and fractures and that this is audited at least annually
• National Hip Fracture Database: The National Hip Fracture Database (NHFD) is a joint venture of the British Geriatrics Society and the British Orthopaedic Association, and is designed to facilitate improvements in the quality and cost effectiveness of hip fracture care. The NHFD enables benchmarking of the quality of hip fracture care provided by all hospitals in England, Wales and Northern Ireland. The 2010 NHFD Report presented data on adherence to the 6 clinical standards advocated by the BOA-BGS Blue Book:
  • 57% of patients admitted to an orthopaedic ward within 4 hours
  • 80% receive surgery within 48 hours
  • 6% are reported as having developed pressure ulcers
  • 31% are assessed preoperatively by an ortho-geriatrician, with an additional 32% having other forms of medical assessment
  • 57% are discharged on bone protection medication, with another 7% awaiting a bone scan or bone clinic appointment. A further 11% were assessed but no bone protection medication was needed or appropriate
  • 60% receive a falls assessment by the time they are discharged, with a further 3% awaiting a falls clinic appointment

Notably, 10% of hip fracture patients were receiving osteoporosis treatment on admission to hospital with hip fracture. At a national level this observation is consistent with the sub-optimal standards of secondary preventive care reported in the Royal College of Physicians national audit of falls and bone health; drug therapy is not systematically targeted to those at high risk of hip fracture. However, the fact that 75% of hip fracture patients are in the process of having osteoporosis assessed on discharge suggests that NHFD is driving significant progress.

• Evaluation of standards of care for osteoporosis and falls in primary care: In 2007, QRESEARCH in collaboration with The NHS Information Centre for health and social care published the first UK evaluation of osteoporosis and falls care in primary care. The key findings were:
  • Only 25% of females aged over 75 years with a recorded prior fragility fracture had evidence of treatment for osteoporosis
  • The recorded prevalence of fragility fracture amongst females aged over 65 years was about 15%
  • About 10% of females aged 65-74 years with a prior fragility fracture had evidence of bone densitometry in their medical record
  • 73% of 65-74 year olds with a recorded prior fragility fracture, who also had a diagnosis of osteoporosis, received treatment
  • About 2% of males aged over 65 years with a recorded prior fragility fracture had evidence of bone densitometry
  • 44% of males aged over 65 years with a recorded fragility fracture and diagnosis of osteoporosis were on treatment

Accordingly, the national picture in primary care corresponds to data from the Royal College of Physicians national audit of falls and bone health in secondary care. Patients at the highest risk of suffering fragility fractures in general, and hip fractures in particular, are not receiving the standards of care recommended by NICE Technology Appraisals or Clinical Guidelines.

The Breaking Point Report provided a snapshot of the current situation for women with osteoporosis in the UK.

Breaking Point described the practical steps that must be taken by healthcare professionals, policy makers and commissioners, as well as the public to prevent avoidable suffering and cost of osteoporotic fractures.