Dr' Nigel Hague

1
3rd May 2006
7th UK Invest in Your Bones Campaign
Implementation Meeting
A phased quality improvement programme for
osteoporosis in primary care
- a deliverable QOF target in osteoporosis ?
Dr. Nigel Hague
GP at Park Road Camberley Research
Fellow St Georges
2
Primary Care Informatics

• Senior Clinical Staff
• Simon de Lusignan
• Nigel Hague

• Not Osteoporosis experts per se
• Working GPs
• Informaticians quality improvement
• Worked with o.p. data for 5 yrs
• Clear view on effective intervention programme
• Workable process

3
Guidelines

• Shift from management of falls towards prevention
  of
• NSF for older people improved management of
  falls and osteoporosis integration
• Case finding strategy (also RCP Bone Tooth
  Soc)
• NICE risk recognition, DEXA, 2ndry prevention.
• WHO risk tool added parameters - variable
  recording
• Age Sex BMI Smoking Previous fracture
  Parental fracture Smoking Alcohol
  Rheumatoid arthritis ( incomplete data)

Need for integration - and recognising value of
work measured in terms of getting the right
people on Rx eventually of actual fracture
reduction
4
What we have found so far
78 practice study (½ million pop) 29 practice
study (200,000 pop)

• Fractures under recorded
• OP diagnosis too low even in best practices
• Variability in much of the relevant associated
  data
• Prescribing data good quality can be analysed
  in detail
• Other data issues no frag codes, cant record T
  scores
• Much known disease not treated
• Often poor compliance in treated group
• Easy to identify target patients

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Variability in data recording 2003 data
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Fracture recording 2004 data
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Results show workload is manageable

• Study of 29 practices and 200,000 patients showed
  that a practice of 10,000 implementing NICE
  guidance on osteoporosis would expect to find
• 96 women over 45 with recorded fractures not
  taking bisphosphonates. (22 aged 65 to 74, 46
  gt75)
• 9 women over 45 with a fracture, who are not
  adherent to bisphosphonates (3 aged 65 to 74
  5 gt75)
• 37 post menopausal women who are not adherent to
  therapy (MPR lt80)
• 24 of the women over 45 who have a fracture, and
  are not taking a bisphosphonate have a computer
  diagnosis of osteoporosis (6 aged 65 to 74 14
  are 75 and over)

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The quality improvement programme

• What is known to work for GPs
• Brevity
• Educational focus
• Protected time
• Relevant
• Evidence based
• Peer led

Manageable amount of work Realistic pace of
change Obvious benefits DQ, Patient
care/disease prevention
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What we propose
Objectives Literature review, protocol, test
queries, ethics Facilitate existing NICE
guidelines for secondary prevention of Adapt
method to embrace NICE steroid WHO guidance
etc Run queries in nationally representative
localities Disseminate findings Develop toolkit
for practices (inc local queries), PCTs DOH
QOF Research use problems with data,
Prevalence Rx Quality improvement monitoring
Phased approach Phase 1 Set-up, governance
and permissions Phase 2 First data collection
and feedback Phase 3 Second data collection and
feedback Phase 4 Analysis and write-up

• Collaborative work
• Advisory Board

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What we propose
Simple tool for use in Primary Care which

• IMPLEMENTS EVIDENCE BASED GUIDELINES
• (eg NICE aim to cover all the WHO list need
  to build on existing)
• IS MANAGEABLE
• IMPROVES PATIENT CARE DIRECTLY, QUICKLY
  EFFECTIVELY
• INCREASES CHANCE OF QOF INCLUSION
• based on - register no Rx and
• D of op no Rx
• Encourages helps the linking of 2ndry care
  data (coded XR letters)
• Can include steroids other linked diseases
  later (NICE guidelines)

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What we propose

• recognises that data can be collected easily in
  large quantities
• uses proven methodology
• data cleaning assembly
• includes osteoporosis diagnoses
• includes recorded fractures
• able to assess which are likely fragility
  fractures
• provides comparison of recorded with predicted
  op fracture data
• includes Rx MPR
• could include co-morbidities, steroids, other
  WHO parameters
• includes behaviour modifying educational
  feedback local tools
• includes re-collection of data to monitor
  improvement incidence
• proposes simple improvements in coding data from
  2ndry care
• paves the way for workable QOF indicators
• complements falls approach

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QOF

• QOF not in this time too complex
• KISS (NB CKD - despite Gd A ev, only KD
  HT!)
• Would incentivise
• Based on fracture register treatment targets
• Implements guidelines is do-able!

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Summary

• Assessment of risk and data is available
• Effective treatment is available
• Poor and inconsistent data recording makes
  implementing quality improvement hard
• There probably is enough data to start looking at
  secondary prevention in fractures
• Financial incentives placing practices in a
  feedback loop does improve data quality quality
  of care
• Time to start exploiting computerised data to
  improve osteoporosis management
• Recommend starting with something manageable in
  practice

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Recommendations

• Additional codes for fragility fractures
• List Read SNOMED CT terms on X-ray reports
  letters
• Recommended list for coding in practice
• Endorse a staged quality improvement programme
  staged over three years
• Start with fractures Rx (NICE 20 prevention)
• Next add steroids
• Create an option that allows implementation of
  WHO guidance
• Fund pilot updating queries for all practice
  systems

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RCGP wants to improve quality

• Acknowledge the base-line position
• Alignment of QOF WHO guidance
• Where will NICE guidance fit?
• Develop an evidence-base for quality improvement
• (S de L was asked to present how the RCGP might
  help roll out the coming WHO guidance)

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A phased quality improvement programme for
osteoporosis in primary care
- a deliverable QOF target in osteoporosis ?