1. Glucocorticoid-induced osteoporosis audit are we following guidelines ?
Dr Mohamed Ouda MRCGP
1-Reason for choice of audit
3-Standards set
6- Changes to be evaluated
Glucocorticoids are widely used in general practice to treat a wide variety of diseases and chronic inflammatory conditions and are the most common cause of secondary osteoporosis .
Therefore it is very important to manage this risk opportunity. Additionally, when we looked at our surgery QOF records we realised that this was one of the areas which could be improved.
The audit standard adopted was that 80% of eligible patients should be on appropriate therapy.
This standard was chosen taking into consideration that some patients management would be guided by other care providers such as rheumatologists, patients’ non- compliance, contraindications or patients refusal.
We distributed a chart for the guidelines
Doctors kindly asked to review patients who are on glucocorticoids to ensure they are been treated in accordance with the guidelines
We planned to re-audit after 3 months time
7-Data collection (2)
4-Preparation and planning
We did a re-audit 3 months later .
Sixteen patients over 65 years old fulfilled our audit criteria , fourteen patients from this group were on bone protection as per guidelines (87)
We also had 15 patients under the age of 65 who fulfilled the criteria. Thirteen of these patients have had a DEXA scan. The two patients who have not the scan were initiated on bone protection treatment already by the hospital consultant.
Everyone whose DEXA scan suggesting need for treatment was on the right treatment. It was also noted that two patients who were on steroids for some time have developed fragility fracture before DEXA scan/treatment was considered and that highlights the importance of following the guidelines in that context.
2-Criteria chosen
Random selection of all patients who received glucocorticoids oral treatment during June 2014 was collected using our records on system one in our Practice
Preventative osteoporotic therapy should be considered when a daily dose of 7.5 mg is likely to be continued for 3 months .
This was based on the most widely followed guidelines by Royal College of Physicians (RCP) (Glucocorticoid-induced osteoporosis :A concise guide to prevention and treatment)
The RCP guidelines divides patients into 2 groups
1- Patients >65 years old or who have previously had fragility fracture should be offered bone protection without the need for a bone density scan.
2-Patients <65 years old should be offered bone density scan, with further management depends on T score.
5-Data collection (1)
There were 49 patients aged 65 and above who were prescribed glucocorticoids during June We have excluded 16 patients as they have not fulfilled the criteria
. Analysing the remaining 33 patients has revealed that 22 patients (67%) have been prescribed bone protection while 11 patients (33%) have not.
On the other hand, out of 40 patients who were below 65 years old and received glucocorticoids, nine patients were excluded
Eighteen patients out of the remaining 31 who fit with the criterion received bone protection (58%) while 13 patients have not (42%) .DEXA scan was performed for only 12 patients (out of 31) who qualified for the investigation representing 39%.
The above results showed a scope for improvement in the management of glucocorticoid-induced osteoporosis as we have not achieved the audit standard.
8-Conclusion
The results of the second audit have shown a significant improvement in adhering to the guidelines.
The audit has contributed in raising our practice’s awareness of the guidelines and the importance of their implementation for the patient safety and best care.
Good communication and team work between primary and secondary care staff is necessary to ensure the best care of the patients and that the correct care is administered
T score
Management
Greater than 0
Reassure
0 to -1.5
Repeat bone scan in 1-3 years
<-1.5
Offer bone protection
Contact information : Dr Mohamed Ouda E .Mail Mohamed