Quality standard
Quality statement 2: Starting drug treatment
Quality statement 2: Starting drug treatment
Quality statement
Adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Rationale
Fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life and sometimes to decreased life expectancy. Taking drug treatment to improve bone density reduces the chance of future fractures and related problems.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local protocols. The Fracture Liaison Service Database (FLS-DB) collects data on which interventions can be recommended or started by the fracture liaison service.
Process
Proportion of adults at high risk of fragility fracture receiving drug treatment to reduce fracture risk.
Numerator – the number in the denominator who receive drug treatment to reduce fracture risk.
Denominator – the number of adults at high risk of fragility fracture.
Data source: Local data collection, for example, local audit of patient records. The NHS Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis, who are currently treated with an appropriate bone-sparing agent. The Royal College of Physicians' Fracture Liaison Service Database collects data on people aged 50 years and over who have had a fragility fracture, and records if drug treatment to reduce fracture risk is recommended and, if so, which treatment.
Outcomes
a) Incidence of fragility fractures.
Data source: Local data collection, for example, local audit of patient records. The Royal College of Physicians' Fracture Liaison Service Database collects data on people aged 50 years and over who have had a fragility fracture.
b) Hospital admission rates for fragility fractures.
Data source: Local data collection, for example, NHS Digital's Hospital episode statistics.
What the quality statement means for different audiences
Service providers (general practices and secondary care services) ensure that systems are in place for adults at high risk of fragility fracture to be offered drug treatment to reduce fracture risk.
Healthcare professionals (GPs, specialists and specialist nurses) are aware of when to prescribe drug treatments to reduce fracture risk, and offer them to adults at high risk of fragility fracture.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Adults with a high chance of fragility fracture are offered medicine to help strengthen their bones and prevent fractures.
Source guidance
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Clinical guideline for the prevention and treatment of osteoporosis. National Osteoporosis Guideline Group (2017), section 6 and section 11, recommendation 7
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Osteoporosis – prevention of fragility fractures. NICE clinical knowledge summary (2021)
Definitions of terms used in this quality statement
At high risk of fragility fracture
Women with a prior fragility fracture (particularly hip or vertebral fracture) and men and women with a 10-year probability of a major osteoporotic fracture derived from FRAX, above the upper assessment threshold, should be considered for treatment (see table 1). Men and women with a 10-year probability between the upper and lower assessment threshold should be referred for bone mineral density measurement and their fracture probability reassessed. If their 10-year fracture probability is above the intervention threshold after reassessment (see table 1), treatment should be offered.
|
Age (years) |
Lower assessment threshold (10-year probability of a major osteoporotic fracture %) |
Upper assessment threshold (10-year probability of a major osteoporotic fracture %) |
Intervention threshold (10-year probability of a major osteoporotic fracture %) |
|---|---|---|---|
|
40 |
2.6 |
7.1 |
5.9 |
|
45 |
2.7 |
7.2 |
6.0 |
|
50 |
3.4 |
8.6 |
7.2 |
|
55 |
4.5 |
11 |
9.4 |
|
60 |
5.9 |
14 |
12 |
|
65 |
8.4 |
19 |
16 |
|
≥70 |
11 |
24 |
20 |
Table reproduced with permission from McCloskey et al. (2015) FRAX-based assessment and intervention thresholds – an exploration of thresholds in women aged 50 years and older in the UK. Osteoporosis International 26 (8), 2091–9. [Adapted from National Osteoporosis Guideline Group's Clinical guideline for the prevention and treatment of osteoporosis, section 11, recommendation 7]
Drug treatment to reduce fracture risk
Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy). [Adapted from National Osteoporosis Guideline Group's Clinical guideline for the prevention and treatment of osteoporosis, section 6]
Full details of the licensed indications for these drugs can be found in the summary of product characteristics. At the time of publication (April 2017), some bisphosphonate and non-bisphosphonate drugs were off label for this use. See NICE's information on prescribing medicines.