Abstract
The burden of non vertebral fractures on the National Health Service is enormous. Osteoporotic fractures have an associated morbidity and mortality and as a consequent incur heavy financial burden with a current cost to the National Health Service of some £1.7 billion per year, hip fractures accounting for the greater part.
We know from our own local experience in the North of Ireland that this previous service had failed to target these fracture patients for secondary prevention of osteoporosis (Northern Ireland Colles Fracture Study). Although hip fractures account for only 7% of all fractures they result in the utilisation of 25% of acute orthopaedic beds. The silent nature of osteoporosis makes a diagnosis prior to fracture difficult and attendance at a fracture clinic may be the first opportunity to diagnose this condition and to intervene with anti-resportive treatment.
An osteoporosis service commenced in Greenpark Health Care Trust in 1996. In 2001, guidelines (Crest guidelines) for the prevention and treatment of osteoporosis were established and in April 2003 a pilot study for the fracture liaison service commenced with the appointment of a Fracture Liaison Nursing Sister. The responsibility of this Nurse included:
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Liaison and attendance at Out-Patient Fracture Clinic to ensure that all patients presenting with a low trauma fragility fracture were assessed and referred appropriately for bone densitometry.
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An education and awareness role for patients regarding osteoporosis and fall prevention.
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To conduct additional nurse led osteoporosis clinic at Green Park Healthcare Trust for patients referred from the Out-Patient Fracture Service at the Royal Victoria Hospital.
Current activity levels include 18 fracture clinics per week at the Royal Victoria Hospital site with approximately 35 patients per clinic. To date, the Fracture Liaison Nurse has been able to attend 54% of these clinics. The patients were identified by Fracture Clinic chart reviews to identify those greater than fifty years of age with a low trauma fracture and approximately 115 charts were reviewed weekly.
At risk patients were interviewed with approximately 35 interviews carried out weekly. Patients were then recruited first for assessment and dexa scanning, measurements were made at both lumbar spine L1-L4 and at the femoral neck with approximately 22 patients weekly recruited. An assessment of osteoporosis risk was made, a plain bed dexa scanner (lunar prodigy scanner) and treatment options were decided depending on the patients T score and according to the CREST Guidelines. The patients were given bone health advice at their scanning visit. Clinic activity was recorded on a database (Gismo) and a computer generated letter to the GP was produced.
Provisional outcomes included arrangements to rescan after 24 months, referral to falls assessment and referral to a Consultant Specialist Osteoporosis Clinic.
Results: To date, 198 patients have been scanned. 28 were male and 170 were female. BMD results were as follows (T score at hip or spine):
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- Normal (0 to −1 SD) 16.6%
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- Osteopenic (−1 to −2.5 SD) 46.7%
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- Osteoporotic (> −2.5 SD) 36.7%
The mean age for those scanned was 66 years and 3 months.
Osteoporotic risk factors identified include a previous fracture (18%).
Early menopause (19%), fall history (12%), Back pain and height loss (18%), smokers (11%), family history of osteoporosis (13%), alcohol excess (5%).
Outcome – no treatment recommended 26%, 13% were already on treatment, 17% were prescribed treatment, 43% were prescribed Calcium and Vitamin D, 27% a Bisphosphonate, 20% a Bisphosphonate and Calcium and Vitamin D and 12% Evista (serm).
Patient follow-up outcome included a follow-up of dexa scan at 24 months 20%, no hospital review planned 74%, 7% referred to a Specialist Osteoporosis Clinic and 6% were referred for a FALLS assessment.
Conclusion: This service has highlighted the high prevalence of osteoporosis in patients attending a Fracture Clinic. An osteoporosis fracture increases significantly the risk of future fracture. Our current programme for evaluation and managing a patient with osteoporosis fractures is currently being audited to measure quality of service, treatment outcome and trends.
The abstracts were prepared by Emer Agnew. Correspondence should be addressed to Irish Orthopaedic Association, Secretariat, c/o Cappagh National Orthopaedic Hospital, Finglas, Dublin 11, Ireland.
