Background: Osteoporosis is a significant cause of morbidity and disability through an increase in bone fragility and susceptibility to fracture. In March 2001 guidelines were produced by The Clinical Resource Efficiency Support Team (CREST) on the Prevention and Treatment of Osteoporosis, which were distributed throughout the primary and secondary care groups.

Aim: The aim of this audit was to analyse the use of the CREST guidelines within the secondary care sector.

Methods: The audit was conducted from January 2002 until March 2003. The sample group was identified retrospectively from September 2001 to February 2002 from patients over 45 years of age with diagnosis of osteoporosis / osteopenia and an osteoporotic fracture. All patients sampled were admitted to the secondary care sector, and data was collected using the CREST audit tool data collection form, utilising the information on the central fracture database located at the Royal Victoria Hospital Belfast.

Results: 213 patients studied (165 female). Mean age 73 yrs (Range 41 to 100yrs). 5% had a risk factor for osteoporosis. 30 patients had previous fragility fracture, 9 male and 21 female, 21 of which were either wrist, hip or spine. Of these 30 patients, 4 (13%) had a diagnosis of osteoporosis considered. Regarding most recent fracture; in males (n=46); 24 (52% hip, 15 (33%) vertebra and 7 (15%) colles, in females (n=156); 66 (42%) hip, 62 (40%) colles, 18 (12%) and 10 (6%) hip and colles. 28 patients (13%) received lifestyle advice concerning osteoporosis. Pharmacological intervention; in males 1 (2%) calcium and vitamin D and 47 (98%) no treatment, in females 10 (6%) calcium, 18 (11%) calcium and vitamin D, 5 (3%) bisphosphonate, 4 (2%) SERM, 3 (2%) HRT and 125 (76%) no treatment. 91 patients underwent operation for hip fracture, 33% of operations were completed within 24 hour period, and 74% completed with 72 hour period. Grade of anaesthetist supervising operations: 80% Consultant, 12% Specialist Registrar, 7% Senior House Officer and 1% Staff Grade. 93% of patients received both prophylactic antibiotics and anti-coagulation prior to surgery. 83% of patients were identified at risk of falling, but only 17% had documented evidence that fall prevention advice had been given.

Summary: Only 5% of patients were identified as having a risk factor for osteoporosis; 14% of patients had a previous low trauma fracture – a strong independent risk factor – however in only 13% of these 30 patients had osteoporosis been considered at time of fracture; only 13% of patients received any form of lifestyle advice; only 17% had advice given regarding fall prevention. These low figures could be due to improper recording, or simply that advice was not given. The vast majority of patients received no form of pharmacological intervention. In regards to surgery; time to operation, grade of anaesthetist and prophylactic treatments were appropriate in the vast majority of cases.

Conclusion: The current cost of hip fractures in Northern Ireland is £21 million per year and with 90% of these fractures related to osteoporosis it is important that steps are taken to ensure early diagnosis, and that appropriate action is taken in the prevention and treatment. As can be seen, the CREST Guidelines are being adhered to in parts, however patients at risk are not being identified and appropriate pharmacological treatment and lifestyle advice is not being given.

Introduction: Bone mineral density (BMD) is currently the gold standard in predicting osteoporotic fracture, but evidence suggests that over one third of such fractures occur in those with osteopenia or even normal BMD. The level of bone turnover may affect bone quality in these patients independently of BMD. Bone markers have evolved as tools in monitoring anti-resorptive treatment in osteoporosis.

Aims: The aim of this study was to investigate if levels of bone markers in postmenopausal women could be used as an adjunct to BMD measurements in the assessment of fragility fracture risk.

Patients and Methods: 60 postmenopausal women (30 osteoporotic, 30 with normal BDM) were studied. A single BMD measurement by dual energy x-ray absorptiometry (DEXA) enabled categorisation. Serum bone formation markers (bone specific alkaline phosphatase (BSAP) and osteocalcin (OC)), and resorption marker (C-telopetide of type 1 collagen (CTX)), were measured. History of low trauma fracture was documented for each woman.

Results: 36% of the osteoporotic group had experienced at least one fragility fracture. However, the femoral neck and combined spinal BMD in these women was not significantly different from the 64% of osteoporotic women who had no prior fracture. There was also no significant difference in the age of women in both subgroups. Serum bone markers were significantly increased in the osteoporotic fracture subgroup when compared to the non-fracture subgroup and also to the non-osteoporotic controls. The largest increases were seen in the levels of CTX. Smaller increases in all markers were seen when the non-fracture subgroup was compared to the non-osteoporotic control group but these increases did not reach statistical significance.

Conclusions: Bone turnover is significantly increased in postmenopausal osteoporotic women with previous fracture compared to both osteoporotic non-fracture counterparts and non-osteoporotic controls. This suggests higher bone turnover will increase fracture risk in osteoporotic women. It is possible that combining 2 or 3 markers to produce an “index of bone turnover” would be a useful tool when used in addition to BMD to identify those at greatest fracture risk.

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:

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.

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):

- Normal (0 to −1 SD) 16.6%

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.