Evaluation of current practice: compliance with osteoporosis clinical guidelines in an outpatient fracture clinic.

Abstract Better detection and management of osteoporosis will reduce unnecessary health expenditure. A number of high quality guidelines are available to support early detection and best practice management of osteoporosis in hospital settings. However, sustainable implementation of guidelines poses practical issues in terms of structure and processes in hospitals. This paper describes an investigation into guideline compliance in one large tertiary metropolitan hospital and discusses practical elements of guideline implementation. Given the evidence of poor practice across the two audit periods, we recommend that a coordinated clinical pathway be implemented in the fracture clinic, supported by a targeted and discipline-specific training program. Small steps towards improving awareness and management of osteoporosis in patients presenting for the first time with non-trauma wrist fracture may well produce large cost savings by future fracture prevention. Aust Health Rev 2008: 32(1): 34-43 OSTEOPOROSIS CONTRIBUTES significantly to fractures, subsequent disability and premature mortality in Australia.1 It is estimated that the annual cost in Australia of both direct and indirect management of osteoporosis is $7.4 billion. This cost includes the management of osteoporosis and, significantly, the costs of osteoporotic-related fractures.1 In 2004-2005, the direct costs for neck of femur fracture patients in the large Adelaide metropolitan tertiary hospital providing data for this project approximated $6 million, reflecting an average per-patient cost of $13 800. (Flinders Medical Centre. Clinical Epidemiology and Health Outcome Unit Review, 2006; unpublished.) This figure is calculated for an acute inpatient stay only, and does not include rehabilitation, changes to residential status, or financial and social costs to the patient, their family and the community. The costs of osteoporosis prevention are considerably less by comparison. Medication costs per patient range from $19.55-$77.00 per month depending on subsidisation status.2 There are additional relatively low costs of health professionals providing education to patients on osteoporosis and lifestyles issues, and guiding and promoting best clinical practice guidelines to other health professionals (about $59 000 per annum full-time equivalent, based on a full-time registered nurse level 2 salary).3 Osteoporosis fractures, commonly occurring at the hip, vertebrae or wrist, are typically sustained with little or no trauma.4"6 A low-trauma fracture is defined as a fracture occurring spontaneously or from a fall no greater than standing height.6 These fractures are called low-trauma or fragility fractures, and are often associated with considerable morbidity, cost and significant increased risk of further fractures.5,7'8 Low-trauma wrist fractures (commonly occurring at the distal radius ± ulna) have been proposed as a reliable indicator of patients who may have osteoporosis.9,10,11 These fractures can signal the beginning of "fracture cascade" events,1,5,11,12 and reflect patients whose osteoporosis risk may have been undetected, and who are at risk of higher order fractures11 from falls or other trauma. Identifying wrist fractures without trauma would thus appear to offer a practical and sensitive way in which early risk of osteoporosis can be identified, and which allows risk-reduction strategies to be put in place before more major fractures eventuate. The increasing ageing population in Australia, and the high and increasing incidence of osteoporotic fractures as well as the high associated management costs have the potential to spiral out of control if steps are not implemented to address this problem at the early risk-detection stage.13,14 There is a particularly strong co-relationship between the ageing process, osteoporosis and being female.15-19 Other risk factors for osteoporosis and related fractures include inadequate dietary intake of calcium, too little physical exercise or activity, high alcohol intake, smoking, early menopause, inadequate vitamin D intake, family history, comorbid disease states (anorexia, persistent GI disturbances/malabsorption, rheumatoid arthritis problems), and use of certain medications (steroids, anticonvulsants, chemotherapy). …