Fracture prevention: a population-based intervention delivered in primary care

Abstract

Background: Osteoporosis is common, increasing as the population ages and has significant consequences including fracture. Effective treatments are available.

Aim: To support proactive fracture risk assessment (FRAX) and optimizing treatment for high-risk patients in primary care.

Design: Clinical cohort.

Setting: November 2017 to November 2018, support was provided to 71 practices comprising 69 of 90 practices within two National Health Service Clinical Commissioning Groups areas. Total population 579 508 (207 263 aged over 50 years).

Participants: FRAX (National Institute for Care and Clinical Excellence, NICE CG146) in (i) males aged 75 years and over, (ii) females aged 65 years and over, (iii) females aged under 65 years and males aged under 75 years with risk factors and (iv) under 50 years with major risk factors.

Results: A total of 158 946 met NICE CG146, 11 961 were coded with an osteoporosis diagnosis (7.5%), of those, 42% were prescribed treatment with a bone sparing agent (BSA). In total, 6942 were assessed to initiate BSA. Thirty percent of untreated osteoporosis diagnosis patients had never been prescribed BSA. Even when prescribed, 1700 people (35%) were for less than minimum recommended duration. Of the total 9784 patients within the FRAX recommended to treat threshold, 3197 (33%) were currently treated with BSA and 3684 (37%) had no history of ever receiving BSA. From untreated patients, expected incidence of 875 fractures over a 3-year period (approximately £3.4 million). Treatment would prevent 274 fractures (cost reduction: £1 274 045, with prescribing costs: saving £805 145 after 3 years of treatment).

Conclusion: Underdiagnosis and suboptimal treatment of osteoporosis was identified. Results suggest that implementing NICE guidance and optimizing treatment options in practice is possible and could prevent significant fractures.

Figure 1.

FRAX assessment of area population mapped with osteoporosis and hip fracture prevalence.

Figure 2.

(a) Consort diagram of total population in blue boxes with interventions delivered in yellow boxes and fragility fractures in grey boxes. (b) Previous bone sparing agent usage in currently untreated osteoporosis diagnosed patients. (c) Combined duration of treatment of all previously tried bone sparing agent treatments in patients with osteoporosis but no current therapy.

Figure 3.

(a) Duration of treatment with current bone sparing agent therapy. (b) Bone sparing agent prescribing across all reviewed practices.

Figure 4.

(a) Analysis of bone sparing agent treatment in patients with osteoporosis diagnosis or history of major osteoporotic fracture. (b) Proportion of patients aged over 50 sustaining a fragility type fracture since April 2012 with a coded fragility fracture.