www.nos.org.ukHippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre.

n = 7860/31094

n = 1476/15025

n = 2551/15025

n = 1862/2551

n = 261/14651

n = 700/14651

n = 305/700

Secondary prevention following fragility fracture in British primary care

(n= 3.4 million)

www.nos.org.uk

Estimated Hospital Bed Days for Major Disease Areas (2008-09)

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

All fractures >60yr.*

Fracture femur>60 yr.*

Diabetes allages

Cardiacischaemia all

ages

Heart failure allages

COPD + asthmaall ages

Stroke >60 yr*

* Estimated from ratio of FCEs by age

HES source data: Copyright © 2009, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved

www.nos.org.uk

0

10

20

30

40

50

60

70

80

Radius/ulna Hip Humerus Ankle Hand/foot Clavicle

FemaleMale

Prevalence of Osteoporosis in Women & Men with Fractures (18,664 fractures)

%

By kind permission of Dr. Alastair Mclellan, Western Infirmary, Glasgow

www.nos.org.uk

FLS: Prevalence of Osteoporosis inWomen with Fractures (18,664 fractures)

0%10%20%30%40%50%60%70%80%90%

100%

50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Osteoporosis Not

n 782 874 891 946 1034 958 711 386

By kind permission of Dr. Alastair Mclellan, Western Infirmary, Glasgow

www.nos.org.uk

Fracture incidence rate plotted against prevalent fracture pool and BMD

1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5

Fracture rate

Women with fractures

0

10

20

30

40

50

0

100

200

300

400

Num

ber of fractures

Fra

ctur

es/1

,000

pe

rso

n-ye

ars

Adapted from Siris E in Report of the Surgeon General's Workshop on Osteoporosis and Bone Health December 12-13, 2002, Washington, D.C

www.nos.org.uk

Could it be we are targeting the wrong patients?

6

www.nos.org.uk

Prescribed items: 28 day equivalents

Prescription Cost Analysis, NHS Information Centre

http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions

Charts courtesy of P Mitchell

£ millions

0.0

1000.0

2000.0

3000.0

4000.0

5000.0

6000.0

7000.0

8000.0

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Alendronate

Etidronate

Ibandronate

Risedronate

Zoledronate

Raloxifene

Teriparatide

Strontium

Market

www.nos.org.uk

Proportion of patients on specific osteoporosis treatment with evidence of a recorded diagnosis

50.656.0

72.0

0

10

20

30

40

50

60

70

80

90

100

Qresearch Gloucestershire Stroud Valleys

Pe

rce

nta

ge

1 in 4 bisphosphonate prescriptions directed at those under age 65

www.nos.org.uk

Clinical Effectiveness

• 38,000 adults with ≥ 2 scripts for a BP (80% OAW, 75% ALN) on GPRD

• 43% > 70 years and 81% female

• 58.3% persistent at 1 year, 23.6% at 5 years

• No persistence of effect after discontinuation

Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first

www.nos.org.ukGallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first

Adjusted fracture relative risk for persitent versus discontinued bisphosphonate users

0

0.2

0.4

0.6

0.8

1

1.2

1.4

rela

tive

risk

current use 0.85 0.78 0.66 0.77 1.04 0.92

osteoporotic hip/femur Hip femur* vertebra radius/ulna Humerus

Fractures (n) 2029 628 247 372 590 354

* More than 24 months persistence

www.nos.org.uk

Are we treating the right populations?

Incident rate past users (100 py) 2.47 0.76 0.76 0.47 0.62 0.36"Baseline" 10 year # risk 0.247 0.076 0.076 0.047 0.062 0.036Treated incident rate 2.35 0.7 0.54 0.41 0.68 0.41ARR/year 0.12 0.06 0.22 0.06 -0.06 -0.05NNT/year 833 1667 455 1667 -1667 -2000

Adapted from Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first

* More than 24 months persistence

www.nos.org.uk

Rate Hip Fx Per Year by Age Group

Dell RM, Greene D, Anderson D, Williams K. Osteoporosis Disease Management: What Every Orthopaedic Surgeon Should Know. J Bone Joint Surg Am 2009;91(Supplement_6):79-86. http://www.ejbjs.org . Used with kind permission of Rick M Dell MD

www.nos.org.uk

Highest Absolute risk means lowest numbers needed to treat

60-64 65-69 70-74 75-79 80-84 >85 TotalTotal Patients 168,729 114,927 88,393 64,959 43,032 32,559 512,599Expected Hip Fx 90 165 180 445 703 961 2,544Actual Hip Fx 76 121 172 273 345 587 1,574Saved Hip Fx 14 44 8 172 358 374 970

NNT = 87NNT = 12,052

Data from SCAL Healthy Bones Programme: used with kind permission Rick M Dell MD

www.nos.org.uk

Differential risk intervention thresholds NOGG v. NICE

NOGG intervention thresholds from Kanis J, McCloskey E, Johansson H, Strom O, Borgstrom F, Oden A, et al. Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK. Osteoporosis International 2008;19(10):1395-408. http://dx.doi.org/10.1007/s00198-008-0712-1 and from www.shef.ac.uk/FRAX

70% lower

71% higher

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What are the likely consequences of the introduction of a QOF domain for

secondary osteoporotic fracture prevention?

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Prevalence CHD Gloucestershirebefore and after QOF

Gloucestershire Primary and Community Care Audit Group 2005 (data on file)

www.nos.org.uk

CHD indicators Gloucestershirebefore and after QOF

Gloucestershire Primary and Community Care Audit Group 2005 (data on file)

www.nos.org.uk

0

1

2

3

4

5

6

7

0 2 4 6 8 10 12 14 16 18 20

Abs

olut

e ris

k

Years of follow up

First fracture

Second fracture

Van Geel T et al ASBMR 2008 and An Rheum Dis August 2008 On-line first

4140 post menopausal women age 50-90

23% re-fractures

54% re-fractures

Why should HCOs fund an FLS if QOF will deliver secondary prevention?

www.nos.org.uk

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12

Daily alendronateWeekly alendronate

Persistence (continuous adherence): Daily or Weekly alendronate

Months of treatment

Per

cent

age

DIN-LINK Report: Osteoporosis - Report 4 [GSK_OSP_004.DN2]. May 2004

There is no ‘offset of effect’ seen in the GPRD in bisphosphonate users (Gallagher AM, et al. Fracture Outcomes Related to Persistence and Compliance with Oral Bisphosphonates. J Bone Miner Res 2008;23:1569-75)

3 years treatment or 2 years with 80% MPR is required for an offset effect. (Curtis J, et al. Risk of hip fracture after bisphosphonate discontinuation: implications for a drug holiday. Osteoporosis International 2008;19(11):1613-20.

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Many hip fractures have had a prior fragility fracture

Percentage of patients with hip fracture reporting prior fragility fracture

45.3 44.6 45.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Lyles et al Edwards et al Mclellan et al

Per

cent

age

Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006

Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230

McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.

n=2124 n=632 n=701

www.nos.org.uk

Many non-hip fractures have had a prior fragility fracture

%

McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.

www.nos.org.uk

By 2014 the cost of 10 year’s delay in implementing a systematic approach in the UK

• 300,000 hip fractures will have occurred with a history of a prior fragility fracture

• If 20% (60,000) will have had guideline care (DXA or treatment)

• If treatment reduces hip fracture risk by 33%. • 240,000 patients not receiving care with 33% efficacy equates

to 80,000 preventable hip fractures • …. or 2,000,000 bed days.  • …. or with 20% mortality 16,000 potentially avoidable deaths• …. or with 40% dependency 32,000 unable to live

independently.

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A single over-riding communication objective

“There are 80,000 hip fractures a year costing £1.6 billion.

Half of the cases are secondary fractures, and we can prevent up to half of the subsequent cases — about 20,000 cases a year — saving the NHS £400 million.

Are you interested?”

Prof Tim Harrington