OSTEOPOROSIS IN PRIMARY CARE – ARE WE MISSING A TRICK?
1Luton and Dunstable University Hospital, Rheumatology, Luton, United Kingdom
2Woodland Avenue Practice, Primary car, Luton, United Kingdom
3Bell House Medical centre, Primary care, Luton, United Kingdom
Background: Globally various incentive schemes have been employed in primary care to improve early diagnosis and management of several rheumatic conditions. In the UK, the Primary Care Quality and Outcomes Framework (QOF) rewards general practices for the provision of ‘quality care’ and helps to fund further improvements in the delivery of clinical care. Currently, there is one quality indicator in place for secondary prevention of osteoporosis. In order to help establish an integrated care pathway encompassing the whole patient journey between primary and secondary care, we undertook a detailed survey of two GP practices.
Objectives: The aims of the exercise were to identify the utility of quality indicator and any gaps in the model of care for the high-risk osteoporosis patients.
Methods: An independent service evaluation tool was employed to interrogate the IT system used in the GP surgeries. All patients over the age of 65 were extracted from the database and FRAX analysis was undertaken. Those with medium to high FRAX score (i.e. ten-year risk of >20% for major osteoporotic fracture and/or >5% for hip fracture) were captured to explore whether they were offered further evaluation and bone-sparing therapy as necessary.
Results: Of 18,248 patients registered in the multi-cultural urban practices, 6796 were >65 years old. 793 had pre-defined moderate-high FRAX score. 300 (37%) had a confirmed diagnosis of osteoporosis. Median age was 78 (range 65-103 years). 249 (83%) were women. 88.5% were White and remaining of other ethnicities.
20/300 (6.6%) had been coded to have ever sustained a fragility fracture. 178 (59.3%) were prescribed bone-sparing therapy with five people taking it for over five years. 91% were prescribed oral therapy (78% alendronic acid, 10% risedronic acid and 3% others) and remaining had parenteral therapies. Of the 27 patients not receiving any treatment, 11 (30%) were incorrectly coded. The remainder’s reasons for lack of treatment include intolerance, poor adherence and comorbidities.
Conclusion: This study highlights the inadequacy of quality indicators in the overall management of osteoporosis burden in primary care. It relies heavily on active identification process for high-risk individuals and correct coding of fragility fracture. However the vast majority of patients with moderate-high risk, based on case finding strategy advised by international bodies e.g. FRAX, remain hidden. Less than 10% of patients with confirmed osteoporosis fulfil the quality outcome in this survey. The QOF hence fails to reflect the nature of disease burden in the primary care thereby risking the management strategies skewed towards too small a cohort and missing the big picture. It is clear that quality indicators for osteoporosis need to be aligned to risk stratification model. This will allow better identification of at-risk individuals and improved care pathway for patients requiring bone active therapies.
Disclosure of Interests: Sultana Parvin: None declared, Manraj Barhey: None declared, Talib Abubacker: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Novartis, Celgene, Mallinckrodt, UCB and Lilly, Consultant for: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Novartis, Celgene, Mallinckrodt, UCB and Lilly, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Novartis, Celgene, Mallinckrodt, UCB and Lilly
Citation: Ann Rheum Dis, volume 78, supplement 2, year 2019, page A943