Introduction

This article is written to help GP practices set up appropriate protocols for the assessment of patients with possible osteoporosis, and to facilitate keeping up-to-date records. See related separate article on Osteoporosis.

Requirements

Ideally, the practice should be able to identify:

• All patients with confirmed osteoporosis.
• All patients (at least those over 65 years of age) with fragility fractures (due to a low-energy event, e.g. a fall from standing height or less; rib fracture due to sneezing or coughing),¹ particularly fractures of the femur/pelvis, humerus, wrist (Colles' or Smith's) and vertebral wedge fractures.
• All patients who have had an osteoporosis risk assessment (either opportunistically, by case finding, e.g. fragility fracture, or as part of other chronic disease management).
• Any patients who have had a dual-energy X-ray absorptiometry (DEXA) scan (and those patients with osteoporosis who have had such a scan confirming osteoporosis).
• Patients who are on appropriate pharmacological secondary prevention of osteoporosis (by searching patient repeat medications).

Implementation

1. All patients who have (or have had) a fracture of the hip/femur/pelvis, wrist, humerus and a wedge fracture of the spine - need both the fracture and whether it was a fragility fracture to be coded, either at the time of data entry or when notes are summarised (code both using the date the fracture was sustained).
2. All patients who have an osteoporosis risk assessment are coded with "Osteoporosis risk assessment done" (9OdA.), refused (9Odb.), or defaulted (9OdC.).
   This risk assessment involves considering the individual patient's risk of subsequent fractures following either the NICE guideline (where the risk is not explicitly stated), FRAX or QFracture® calculations.
   If the FRAX® score is used, the 10-year risk can be appended (using 38DB. FRAX 10-year hip fracture probability score and/or 38DC. FRAX osteoporotic fracture probability score).²
   The QFracture score is an externally validated risk score which may be more appropriate in the UK, Read codes not yet available.³
3. All requests for DEXA scans, and the results of such scans, need to be coded (assigning the patient with the diagnosis of osteoporosis when appropriate).
4. All patients with confirmed osteoporosis, or "at risk of osteoporosis" need to be offered appropriate pharmacological secondary prevention of osteoporosis (record the discussion, and ideally whether it was declined or accepted).

Possible usable Read Codes

Whenever a fracture is recorded (e.g. fractured neck of femur), also code "Fragility fracture" (N331N) using the same date as the fracture, or "History of fragility fracture" (14G6.) during the consultation where the information is elicited.

Risk factor recording:

• When patients are considered to have an independent clinical risk factor for fracture code "At risk of osteoporotic fracture" (14OD.). Such factors are parental history of hip fracture, alcohol intake of 4 or more units per day, and rheumatoid arthritis.
• When patients are considered to have indicators of low BMD - code "At risk of osteoporosis" (14O9.). Such indicators are low BMI (defined as less than 22 kg/m²), long-term corticosteroid use, medical conditions such as ankylosing spondylitis, Crohn's disease, rheumatoid arthritis, or conditions that result in prolonged immobility, and untreated premature menopause (before age 40).

When osteoporosis is assumed (fragility fracture without DEXA scan in a patient aged over 75) use "N331M Fragility fracture due to unspecified osteoporosis".

When osteoporosis is diagnosed by DEXA scan, etc., add diagnostic Read Code "N330. Osteoporosis" to the record, (or one of its more detailed children: "N3301 Senile Osteoporosis"; "N3302 Postmenopausal Osteoporosis"; "N3303 Idiopathic Osteoporosis"; "N330D Osteoporosis due to corticosteroids"), using the date of diagnosis.

As well as using the diagnostic codes above, add the following codes as appropriate (use the date of the scan):

• Hip DEXA scan result osteoporotic (58EG.).
• Hip DEXA scan result osteopenic (58EB.).
• Hip DEXA scan result normal (58EF.).
• Hip DEXA scan T score (58EE.) record actual value.
• Lumbar DEXA scan result osteoporotic (58EM.).
• Lumbar DEXA scan result osteopenic (58EH.).
• Lumbar DEXA scan result normal (58EL.).
• Lumbar DEXA scan T score (58EK.) record actual value.

Other codes are available for heel and forearm scans if required.

When osteoporosis is discussed with the patient, add code "Health Education - osteoporosis" (679F.). The following administration codes may be helpful in a template: "Osteoporosis treatment started" (66a2.), "Osteoporosis treatment stopped" (66a3.) and "Osteoporosis treatment changed" (66a4.).

Audit

The GP osteoporosis directed enhanced service (DES) requires the following:⁴

• Proportion of women aged 65-74 with history of fragility fracture in previous 12 months who have had diagnosis of osteoporosis confirmed with a DEXA scan (target standard initially 50%, rising to 60% in 2009/10).
• Proportion of these woman (aged 65-74) who are receiving treatment with a bone-sparing agent (target standard 90%).
• Proportion of women aged 75 or over with fragility fracture in the previous 12 months on a bone-sparing agent (target standard 90%).

If the National Institute for Health and Clinical Excellence (NICE) audit is proposed:⁵

• Criterion 1: the percentage of patients offered evidence-based written information about their illness or condition and the treatment and care they are going to receive (standard 100%) - use code "Health Education - osteoporosis" (679F.), and record which information leaflet given in the consultation record.
• Criterion 2: women prescribed alendronate for the primary prevention of osteoporotic fragility fractures must fit into one of the following three groups:
  • Women aged 70 years or older who are confirmed to have osteoporosis and have either an independent clinical risk factor for fracture or an indicator of low BMD.
  • Women aged 65-69 years with an independent clinical risk factor for fracture and confirmed osteoporosis.
  • Postmenopausal women younger than 65 years who have an independent clinical risk factor for fracture and an additional indicator of low BMD and confirmed osteoporosis.

Additional criteria on choice of bone-sparing agent are described in the NICE document.⁵

Background

This article was written to conform to the specification for the directed enhanced service (DES) for osteoporosis in England (2008-2010). It has been based on the current NICE guidance, and osteoporosis "Map of Medicine"⁶ and the national guidelines.

Document references

1. Management of osteoporosis, Scottish Intercollegiate Guidelines Network (SIGN), 2004
2. WHO Fracture Risk Assessment Tool (FRAX®), World Health Organization Collaborating Centre for Metabolic Bone Diseases
3. QFracture® - risk calculator for hip fracture or osteoporotic fracture (hip, vertebral, or distal radius fracture) over the next 10 years
4. Clinical directed enhanced services (DES) guidance for GMS contract 2008/09
5. Osteoporosis - primary prevention: audit support, NICE (Sep 2008)
6. Osteoporosis, Map of Medicine (Endocrinology)

Internet and further reading

• Osteoporosis - primary prevention, NICE Technology Appraisal Guideline (January 2011); Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women
• Osteoporosis - secondary prevention including strontium ranelate, NICE Technology Appraisal Guideline (January 2011); Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

Acknowledgements