Management
of osteoporosis
Section
8: Implementation, audit and research
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.