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How to chip away at the osteoporosis iceberg

Tim Melville
BSc(Tech)(Hons)
Health Service Liaison Manager
National Osteoporosis Society
Camerton
Bath
E:t.melville@nos.org.uk

Tackling osteoporosis can be daunting when the evidence shows that one in three women and one in 12 men will suffer its debilitating effects in their lifetime.(1,2)
How can a busy GP surgery even contemplate tackling osteoporosis with so many other competing priorities and disease area targets? But should primary care ignore such a prevalent disease? The time osteoporosis takes up in secondary care is well documented, with hip fractures alone accounting for 800,000 bed days - that is more than for myocardial infarctions.(3) On the other hand, less is known about the time taken up in primary care by osteoporosis.

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In the UK there are 120,000 vertebral fractures each year, which take up 14 GP consultations for each fracture that is clinically diagnosed,(5,6) and for the 70,000 wrist fractures four GP consultations are taken up for each fracture.(1,5) Of the 70,000 patients who suffer a hip fracture, 20% will die within six months(1,7) and 87% will not be able to walk over half a mile.(8) Fifty per cent are no longer able to live independently(9) and so are a greater drain on scarce GP time and healthcare and social care resources. 
Yet those at highest risk of osteoporotic fracture are easy to identify and treat. Those at highest risk include people:

  • Who have had a previous fragility fracture.
  • Who are aged 75 or over.
  • Who are on long-term corticosteroid use.

Ninety per cent of patients after suffering an osteoporotic fracture are not on treatment to prevent further fractures.(10) If this were coronary heart disease, cancer or any other life-threatening and debilitating disease, the situation would not be tolerated. If a patient has a heart attack they leave hospital on medication to reduce the risk of further myocardial infarctions. 
Fewer than 10% of patients with fractures caused by osteoporosis are assessed or put on treatment. Such statistics cry out for primary care to work with secondary care colleagues to identify those at future risk of osteoporotic fractures and reduce orthopaedic waiting lists by freeing up some of the 800,000 bed-days taken up by patients with osteoporotic hip fractures.(3)
The over-75s in nursing and residential homes are a very high-risk group for hip fractures, and it is cost-effective to put these patients on calcium with vitamin D, thus reducing the osteoporotic hip fracture risk by 30%. 
The National Osteoporosis Society (NOS) provides nurses free of charge to practices and primary care organisations to audit those patients over 75 and advise which are at high, medium and low risk of osteoporosis, with recommendations, where appropriate, by treatment class. For further information please contact Barbara Vines, Osteoporosis Nurse Initiative Project Coordinator at the NOS. 
The treatment of choice for those on long-term corticosteroid use is bisphosphonates, licensed for the prevention of corticosteroid-induced osteoporosis.
Any health promotion programme should include positive messages about prevention by ensuring a calcium-rich balanced diet, regular weightbearing exercise, avoidance of smoking and excessive alcohol - measures already recommended in health promotion activities to reduce the risk of other chronic diseases.
All this information linking osteoporosis HIMP to the National Service Framework for Older People is included in the NOS's Primary care strategy for osteoporosis and falls, available free to health professionals from the NOS.

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References

  1. Van Staa TP, et al. Epidemiology of fractures in England and Wales.Bone 2001;29:517-22.
  2. Cooper C. Epidemiology of ­osteoporosis. Osteoporosis Int 1999;Suppl 2:S2-8.
  3. Department of Health. Hospital episode statistics, England 1998/9. London: Department of Health; 2000.
  4. Royal College of Physicians. Osteoporosis: Clinical guidelines for prevention and treatment. Available from URL: www.rcplondon.ac.uk/
    pubs/wp_osteo_update.htm
  5. Incidence of vertebral fracture in Europe: results from the European prospective osteoporosis study (EPOS). J Bone Miner Res 2002;17(4):716.
  6. Dolan P, Torgerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporosis Int 1998;8:611-7.
  7. Cooper C, et al. Population-based study of survival after osteoporotic fractures. Am J Epidemiol 1993;137:1001-5.
  8. Cooney LM, Marottoli RA. Functional decline following hipfracture. Proceedings of the Fourth International Symposium on Osteoporosis, Hong Kong. 1993. p. 480-1.
  9. Eddy DM, Johnson CC, Cummings SR, et al. Osteoporosis: review of the evidence for prevention, diagnosis, treatment and cost-effectiveness analysis. Osteoporosis Int 1998;8 Suppl 4:S7-80.
  10. Torgerson DJ, Dolan P. Prescribing by general practitioners after an ­osteoporotic fracture. Ann Rheum Dis 1998;57(6):378-9.

Resources
National Osteoporosis Society
W:www.nos.org.uk
To get a copy of Primary care ­strategy for ­osteoporosis
and falls
E:hsl@nos.org.uk
W:www.nos.org.uk/healthprof.asp
Royal College of Physicians Clinical guidelines on osteoporosis W:www.rcplondon.ac.uk/pubs/wp_osteo_update.htm