8.1 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance. It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including patient-specific reminders, continuing education and training, and clinical audit.

The National Osteoporosis Society has produced an Osteoporosis Framework⁸¹ setting out standards for osteoporosis services in Scotland. This framework has been endorsed by the Chief Medical Officer.

The key recommendations from the NOS framework document are:

• Include prevention of osteoporotic fractures in the local Health Improvement Plan (HIP)
• Identify lead clinicians in primary and secondary care to develop a local osteoporosis programme based on this framework. Each Local Health Cooperative, Primary Care, and Acute Trust should have a lead clinician for osteoporosis.
• Each Health Board should have a consultant in Public Health to assist in coordinating this osteoporosis strategy between primary and secondary care.
• Establish a local osteoporosis advisory group to facilitate multidisciplinary implementation of this framework.
• Use a selective case-finding approach to target treatment at individuals at high risk.
• Provide access to adequate levels of diagnostic and specialist services – eg a Local Health Care Co-operative serving a population of 50,000 would require approximately 500 DXA scans per year.
• Promote the use of care pathways and audit to improve standards of care.
• Monitor performance to assess health impact.

8.2 Key points for audit

Diagnosis

• Risk profile of those referred for investigation
• Proportion of low impact fractures in orthopaedic wards referred for investigation of osteoporosis
• Proportion of patients who are referred following identification of severe osteopaenia on plain X-ray
• Proportion of those sent for a DXA scan that are subsequently diagnosed with osteoporosis

Treatment

• Proportion of patients diagnosed with osteoporosis that are subsequently offered treatment.
• Proportion of patients referred for high-intensity strength training and low impact weight bearing exercise.
• Proportion of post-menopausal women achieving a dietary intake of 1000mg calcium per day

Follow-up

• Number of osteoporosis patients followed-up two years after first referral
• Extent of compliance with treatment.
• Increase in BMD following treatment.

Audit criteria for osteoporosis are expected to be developed by Scottish Programme for Improving Clinical Effectiveness in Primary Care (SPICEpc) based on this guideline.

8.3 Recommendations for research

The following list of research topics represents the key areas where the guideline development group were unable to identify good existing evidence, and where there is a need for such evidence.

• Development of a validated risk scoring method that would allow primary care workers to prioritise patients for scanning or treatment.
• The role of DXA in monitoring the effectiveness of treatment over time.
• Identification of the most appropriate biochemical markers for monitoring the effectiveness of treatment, and the preferred strategy for their use.
• Investigation of the possible role of such techniques as vertebroplasty and kyphoplasty in the management of acute vertebral fracture and the associated pain.