Osteoporosis Resources for Primary Care: Practice nurses

Practice nurses play an essential part in the delivery of quality primary care, and due to the increasing shift of care from acute to primary they have a growing responsibility in management of long term conditions including osteoporosis. Effective fracture prevention is best addressed via a whole system response to the challenge of identifying fragility fractures. Practice nurses and GPs are well placed to identify fragility fractures, assess patients for osteoporosis, treat them and monitor their adherence to treatment, thereby preventing further disabling and costly fractures. For more information about osteoporosis, go to the Introduction section of Osteoporosis Resources for Primary Care.

The practice nurse can screen patients for risk factors for osteoporosis, including family history, low BMI, coeliac disease, rheumatoid arthritis, smoking or heavy drinking. Similarly, with the relevant knowledge, practice nurses can identify patients treated with medications that put them at greater risk of osteoporosis such as glucocorticoid (‘steroids’), anti-epileptic drugs, breast cancer treatments such as aromatase inhibitors and prostate cancer drugs. For more information about risk factors for osteoporosis, go to the Introduction section of Osteoporosis Resources for Primary Care.

Patients who are flagged for consideration should also be given lifestyle advice including eating a balanced diet and undertaking appropriate exercise. More information is available on the in our patient publications including the Healthy Living for Strong Bones leaflet.

Fractures that occur because of reduced bone strength are described as 'fragility fractures' and many of these will be caused by osteoporosis.

Practice nurses and GPs can play a part in low trauma fracture prevention by identifying all people over 50 years of age with a fracture in their practice, and referring them to a FLS (where there is one) for an assessment for osteoporosis. This should include all fragility fractures excluding face and skull.

If a practice nurse sees a patient who has had a fragility fracture after the age of 50 who has not had a DXA scan or an assessment for osteoporosis, then this should be flagged up for consideration. The practice nurse can refer the patient to the FLS at the local hospital (where available), or arrange for them to be seen by the GP for an assessment and treatment with bone sparing medication and lifestyle advice where necessary. The GP or practice nurse can conduct both an online FRAX assessment and a dietary assessment for calcium intake, refer the patient for a DXA scan if appropriate or start bone-sparing medication such as alendronic acid or risedronate (both administered weekly oral +/- calcium/vitamin D). Where the patient is complex, and where oral treatments have not been tolerated or successful, they can be referred to rheumatology or the local FLS.

Find out more about Fracture Liaison Services.

About Vertebral fractures:

• Vertebral fractures are the most common osteoporotic fracture, but the most challenging to identify systematically (Kanis et al 2000; Samelson et al 2006). Currently, 50-70% of vertebral fractures remain undiagnosed (NICE 2011).
• They are an important cause of morbidity, accounting for 14 additional GP visits per year, compared to 9 after hip fracture and 4 after a wrist fracture (Dolan 1998). It is likely that the significant proportion of the vertebral fractures that currently go undiagnosed, are symptomatic and generate costs to the NHS in repeated GP visits.
• Vertebral fractures are also associated with an 8-fold increase in age-adjusted mortality, similar to that observed following hip fracture. Vertebral fractures are also a strong predictor of costly hip fracture – an increase of risk by 2.8-times (Black et al, 1999; Klotzbluecher et al, 2000).
• A woman with one vertebral fracture has a 5.8 times increased risk of another vertebral fracture and 2.8 times increased risk of hip fracture (Black et al 1999). However, vertebral fractures are highly responsive to treatment, which is known to modify the risk of fracture after 6-12 months (Kirsten et al 2014, Harris et al 1999, Black et al 1996, Chesnut et al, 2004; Meunier et al, 2004).

The role of the Practice Nurse in identifying Vertebral fractures:

• Practice nurses can play a vital role in the identification of osteoporotic vertebral fractures in primary care where most vertebral fractures will present as acute onset back pain with no obvious trauma. Without an assessment for osteoporosis, these fractures are otherwise easily missed. Action to identify and treat vertebral fractures by the practice nurse can quickly modify the patient’s risk of future debilitating fractures.
• If a practice nurse sees a patient with risk factors for osteoporosis, acute onset of back pain and no obvious trauma and/or loss of height, or receives a CT/MRI or X-ray report that highlights a vertebral fracture then it should be highlighted to the GP as a matter of priority for assessment. The patient should be sent for a DXA scan or started on treatment for osteoporosis, whichever is most appropriate.

Follow-up of all patients to check adherence to treatment is central, both to achieving best practice standards and realising the clinical and cost benefits of fracture prevention. Practice nurses are well placed to do this, especially for complex patients and where there is no FLS in place. Patients will benefit form a good working relationship between their practice nurse and the local osteoporosis service or FLS (where there is one).

The ROS publishes a range of leaflets and fact sheets for health professionals to use with their patients to support them to understand and manage their osteoporosis and/or fragility fractures. Visit our Publications page or telephone our nurse-led helpline on 0808 800 0035.

Denosumab is a drug that slows bone loss in osteoporosis. It is given as an injection twice a year. It can be taken by postmenopausal women who can’t take alendronate, risedronate, and etidronate (oral bisphosphonates). Some women can’t take oral bisphosphonates because of side effects, such as heartburn, or because they have trouble swallowing. Also, a woman might not be able to take certain bisphosphonates if she can’t follow the special instructions for taking them – for example, having to stay upright for half an hour after taking the drug, and not eating for a while before and after taking it. See "Understanding NICE guidance: Information for people who use NHS services. Denosumab for preventing bone fractures in postmenopausal women with osteoporosis".

In some practices, denosumab injections are given by a GP or Practice Nurse. In these instances, a ‘Shared Care Agreement’ will be in place between specialist services and primary care which will outline how the prescribing and administering responsibilities for denosumab can be shared between the specialist service and primary care.

Practice Nurses and GPs should refer to their local shared care guideline and the NICE Technology Appraisal 204 “Denosumab for the prevention of osteoporotic fractures in post-menopausal women”.

For further information, please refer to the ROS factsheet on Denosumab.

Closing the health and well-being gap: practicing in ways which prevent avoidable illness, protect health and promote well-being and resilience

Closing the care and quality gap: practicing in ways which provide safe evidence-based care which maximises choice for patients

Closing the funding and efficiency gap: practising in ways which manage resources well including time, equipment and referral

For staff: Nursing and care staff can complete the online Fracture Prevention Practitioner Training. This will give them an understanding of the causes of osteoporosis and the tools to support patients to improve their bone health. ROS training and events also support nurses with their professional revalidation.

To use with patients: nurses and care staff can signpost their patients to the range of patient leaflets and booklets available from the ROS. These publications can also be used by staff to help patients understand osteoporosis and bone health. Our nurse-led helpline also provides support and information to patients to improve their understanding of osteoporosis and their resilience for living with the condition.

For staff: the ROS produces clinically assured, evidence-based guidance for services to use to ensure they are providing safe and effective treatment for patients. Our guidance includes: Fracture Prevention Practitioner Competency Framework, Clinical Standards for Fracture Liaison Services and Guidelines for the provision of a clinical bone densitometry service. Moreover, our health professional training and networking events, including specific networks for Allied Health Professionals, support the sharing of best practice and creation of equitable service across the UK.

To use with patients: raise awareness amongst all patients, and potential patients, of the risk of osteoporosis by sharing our Stop At One resources and quiz to encourage patients, wherever they live, to seek the care they are entitled to.

For staff: our Service Delivery Team, made up of registered health professionals, engage with front line staff and commissioners to disseminate good practice from around the UK and to set up or improve a Fracture Liaison Service (FLS). The ROS team will give support preparing a business case (including up to date, evidence based clinical pathways) and evidencing the cost benefit such a service has on the health economy. Our FLS Implementation Toolkit provides NHS services with pre-made resources, saving you time and providing the opportunity to learn from best practice examples from across the UK. Our Peer Review service supports osteoporosis and metabolic bone health services to improve their use of resources and quality of service by providing peer feedback from expert reviewers.

To use with patients: the ROS recognises that nurses and care workers are often under a great deal of time pressure and may not be able to spend as much time with their patient explaining their condition to them as they would like to in an ideal world. Our Patient Information Events and Support Groups provide patients with an opportunity to learn about their condition and give and receive peer support alongside the clinical support they are receiving.

Fracture Prevention Practitioner e-learning course:

The ROS offers online, accredited, Fracture Prevention Practitioner training for Practice Nurses, developed by leading experts in the field of osteoporosis. This is the only training of its kind that provides the knowledge underpinning best practice in secondary fracture prevention. The training course takes 4 – 5 hours to complete, involves a modest charge of £50, and is structured at two levels: foundation and advanced. It has been approved for 4 distance learning CPD Credits by the Federation of the Royal Colleges of Physicians of the UK. At both levels, self-assessment is undertaken to check understanding and knowledge at the end of each section. Formal (accredited) assessment of learning may be undertaken at the end of both levels to provide foundation and advanced certification as a Fracture Prevention Practitioner. Annual re-validation will be available to maintain continuing professional development and to ensure clinical practice is kept up to date.

Allied Health Professional Network:

Join our FREE supportive and inspirational Allied Health Professional (AHP) Network. Benefits include:

• Straight forward, easy to access support to help you
• Expertise sharing at free regional AHP network meetings
• Relevant information on current local and national service provision, best practice resources and educational events.

Free osteoporosis helpline:

The ROS also provides a free helpline for both patients and health professionals which is manned by experienced specialist osteoporosis nurses who are well placed to field more difficult clinical queries.

• Do you have a good understanding of osteoporosis?
  
  
• Do you have a local FLS? Where is your nearest?
  
  
• If you have a local FLS, do you have a named contact and telephone number?
  
  
• Are you familiar with the patient pathway of the FLS, and the role of Primary Care in this? Do you have a good working relationship with your local FLS?
  
  
• Using the computerised patient record, could your practice undertake a systematic audit of at-risk groups such as women who experienced early menopause, those on anticonvulsant or steroid medications, those with long-term health conditions and those with a history of non-traumatic fracture?
  
  
• Could your practice screen patients with acute-onset back pain for indications of an undiagnosed vertebral fracture? Are you familiar with IT software solutions that can assist in this?
  
  
• When you see a patient taking bone-sparing medication, could you include adherence to treatment in the appointment?
  
  
• Do you know enough about osteoporosis and bone-sparing medications?
  
  
• Can you consider fracture prevention training for your CPD?
  
  
• Can you share your knowledge of osteoporosis, bone-sparing medication and fracture prevention with your colleagues?
  
  
• Would you consider Fracture Prevention nursing or a role in a FLS as a career?

Record your learning:

You can use the Nurses and Midwifery Council’s ‘Reflective accounts form’ to record your learning. Download the form here: http://revalidation.nmc.org.uk/download-resources/forms-and-templates