Quality standard

Quality statement 3: Adverse effects and adherence to treatment

Quality statement 3: Adverse effects and adherence to treatment

Quality statement

Adults prescribed drug treatment to reduce fracture risk are asked about adverse effects and adherence to treatment at each medication review.

Rationale

People prescribed drugs to prevent fragility fractures sometimes stop taking them because of adverse effects. Adherence to treatment, including taking their medicine by the recommended method, is needed to ensure that fracture risk is reduced effectively. Checking how well a person is managing their treatment at each medication review means that any problems can be discussed and their treatment adjusted if needed, which will improve adherence and quality of life.

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 prescribed drug treatment to reduce fracture risk are asked about adverse effects and adherence to treatment at each medication review.

Data source: Local data collection, for example, service specifications.

Process

Proportion of medication reviews for adults prescribed drug treatment to reduce fracture risk that include a record of adverse effects and adherence to treatment.

Numerator – the number in the denominator that include a record of adverse effects and adherence to treatment.

Denominator – the number of medication reviews for adults prescribed drug treatment to reduce fracture risk.

Data source: Local data collection, for example, local audit of patient records.

Outcomes

a) Adults adhering to drug treatment to reduce fracture risk.

Data source: Local data collection, for example, local audit of patient records. The Royal College of Physicians' Fracture Liaison Service Database records adherence to drug treatment at 52 weeks.

b) Incidence of fragility fracture.

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.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and pharmacies) ensure that systems are in place for adults prescribed drug treatment to reduce fracture risk to be asked if they have had any adverse effects and about adherence to treatment at each medication review.

Healthcare professionals (GPs, specialists, specialist nurses and pharmacists) carry out medication reviews with adults prescribed drug treatments to reduce fracture risk. At the reviews, they ask if the person has had any adverse effects and if they are taking their medicine by the recommended method and as prescribed. If any problems are raised, these should be discussed and treatment adjusted if needed, which may involve input from a specialist.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults prescribed drug treatment to reduce fracture risk are asked if they have had any adverse effects and about adherence to treatment at each medication review.

Adults taking medicine to help prevent fractures have regular medicine reviews with their doctor to check if they are having any side effects, such as heartburn or reflux, and that they are taking the medicine correctly. The review gives the chance for any problems to be discussed and treatment can be adjusted if needed to help with side effects.

Definitions of terms used in this quality statement

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.

Medication review

The review should include:

  • asking about adverse effects, including upper gastrointestinal adverse effects (such as dyspepsia or reflux), symptoms of atypical fracture (including new onset hip, groin, or thigh pain), and dental problems

  • asking about adherence to treatment, including following the recommended method of taking the treatment

  • discussing alternative treatment options if adverse effects are unacceptable or the person has difficulty adhering to treatment.

[Expert opinion and NICE's clinical knowledge summary on osteoporosis – prevention of fragility fractures]