What Should our Priorities be in Primary Care?
The Department of Health in England has produced commissioning guidance for the NHS in the Falls and fractures section of the Prevention Package for Older People. The key objectives illustrated in the pyramid below provide GPs and service commissioners with a stepwise implementation plan, based on the size of the impact, from a clinical and cost-effectiveness standpoint.
Hip fracture patients: Require effective acute care and a bone health assessment whilst an inpatient with possible subsequent outpatient DXA follow up, falls interventions on discharge, or as soon as is practical thereafter, as described in the British Orthopaedic Association's The Care of Patients with Fragility Fracture (also known as the 'Blue Book') and NICE hip fracture clinical guidelines. The Blue Book and the Department of Health Prevention Package guidance was written with expert input from UK general practice.
Non-hip fragility fracture patients: Half of hip fracture patients suffer a prior fragility fracture before breaking their hip. By routinely managing osteoporosis and falls risk in these patients, in accordance with appropriate national guidance, future hip fracture incidence could be halved amongst these patients. The primary fracture sites include wrist, hip and humerus, in addition to vertebral compression fractures.
Individuals at high risk of first fragility fracture: As UK general practice has done so effectively in cardiovascular disease management, once the secondary preventive actions described for hip and non-hip fragility fracture patients are completed, the issue of primary fracture prevention can be addressed. NICE has published guidance on the primary prevention of osteoporotic fractures that provides more information about groups to target for primary fracture prevention. Those patients who are experiencing recurrent falls but have not fractured yet represent a high-risk group to be targeted for falls prevention measures and bone health assessment. A fracture risk assessment tool such as FRAX or QFracture can be used to assess future fracture risk for all older people.
Resources to support GPs to implement this strategy are provided in the implementation section of this website.