April 2012

Up front

Letters to the editor

Volume 41, No.4, April 2012 Pages 169-169

The opinions expressed by correspondents in this column are in no way endorsed by either the Editors or The Royal Australian College of General Practitioners.

Osteoporosis challenges

Dear Editor

We were delighted to see the March 2012 issue of Australian Family Physician, which had a significant focus on osteoporosis. Dr O’Shea’s1 editorial eloquently described the challenges and opportunities relating to the management of osteoporosis. One comment resonated with our colleague from the Royal College of General Practitioners in the United Kingdom: ‘An area of clarity around what we should do is secondary prevention after the first fracture, but here reality is often not the ideal.’

This has been confirmed in national audits in the UK. For example, the QResearch study reported that only 25% of women aged over 75 years with a fracture were treated for osteoporosis and less than 10% of women aged 65–74 years with a fracture had a DXA scan.2

From 1 April 2012, secondary fracture prevention will be included in the general practice performance-related payment system in the UK, the Quality and Outcomes Framework (QOF). In order to fulfil the osteoporosis component of the QOF, general practices will be required to deliver the following quality standards:3

  • OST1 – the practice can produce a register of patients: aged 50–74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan; and aged 75 years and over with a record of a fragility fracture after 1 April 2012
  • OST2: the percentage of patients aged 50–74 years, with a fragility fracture, in whom osteoporosis is confirmed on DXA scan, who are currently treated with an appropriate bone sparing agent
  • OST3: the percentage of patients aged 75 years and over with a fragility fracture, who are currently treated with an appropriate bone sparing agent.

Inclusion of secondary fracture prevention in the QOF is the most recent step in development of a comprehensive suite of professional consensus guidance,4 national prescribing policy5–7 and service commissioning recommendations8 issued by the Department of Health and other government agencies. The rationale for a determined effort to improve secondary preventive care is simple; studies from Australia,9 the United States10 and the UK11 have consistently shown that half of hip fracture patients suffer a prior fragility fracture before breaking their hip. Deployment of evidence based interventions to reduce fracture risk among those presenting with fragility fractures today, therefore, is too good an opportunity to miss.12

To support UK GPs to deliver improved osteoporosis care, the Royal College of General Practitioners has worked collaboratively with the UK National Osteoporosis Society to develop a web resource ( The site was launched on 28 February and to date the number of visitors to the site is very encouraging.

Like the UK, osteoporosis imposes a significant burden on older Australians and challenges to the Australian healthcare system with more than 17 000 hip fractures per year.13 In addition, 1.2 million Australians have osteoporosis, while 5.4 million have osteopenia and are at risk.14 We hope that sharing this positive experience from our colleagues on the other side of the world may stimulate discussion on strategies to constrain osteoporosis at home through similar collaborations between The Royal Australian College of General Practitioners and Osteoporosis Australia.


  1. O’Shea C. Bones and other challenges. Aust Fam Physician 2012;41:85.
  2. Hippisley-Cox J, Bayly JR, Potter J, et al. Evaluation of standards of care for osteoporosis and falls in primary care. QResearch for the NHS Information Centre for health and social care. 2007. Available at www.ic.nhs. uk/pubs/osteocare [Accessed 9 March 2012].
  3. NHS Employers. Summary of 2012/13 QOF changes. Available at SiteCollectionDocuments/Summary%20of%20QOF%20changes%20for%202012–13%20-ja21111.pdf [Accessed 9 March 2012].
  4. British Orthopaedic Association. The care of patients with fragility fracture. 2007. Available at www.fractures. com/pdf/BOA-BGS-Blue-Book.pdf [Accessed 9 March 2012].
  5. National Institute for Health and Clinical Excellence. Alendronate (review), etidronate (review), risedronate (review), raloxifene (review), strontium ranelate and teriparatide (review) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 161. 2011. Available at [Accessed 9 March 2012].
  6. National Institute for Health and Clinical Excellence. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. Technology Appraisal 160. 2011. Available at [Accessed 9 March 2012].
  7. National Institute for Health and Clinical Excellence. Osteoporotic fractures – denosumab. Technology Appraisal 204. 2010. Available at Guidance/TA204 [Accessed 9 March 2012].
  8. Department of Health in England. Falls and fractures: effective interventions in health and social care. July 2010. Available at groups/dh_digitalassets/@dh/@en/@pg/documents/ digitalasset/dh_109122.pdf [Accessed 9 March 2012].
  9. Port L, Center J, Briffa NK, et al. Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int 2003;14:780–4.
  10. Edwards BJ, Bunta AD, Simonelli C, et al. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res 2007;461:226–30.
  11. McLellan AR, Reid DM, Forbes K, et al. NHS Quality Improvement Scotland. Effectiveness of strategies for the secondary prevention of osteoporotic fractures in Scotland. 2004. Available at www.healthcareimprovementscotland. org/previous_resources/audit_report/ osteoporotic_fractures_audit.aspx [Accessed 9 March 2012].
  12. Marsh D, Akesson K, Beaton DE, et al. Coordinatorbased systems for secondary prevention in fragility fracture patients. Osteoporos Int 2011;22:2051–65.
  13. Australian Institute of Health and Welfare and Department of Health and Ageing. A snapshot of osteoporosis in Australia 2011. Available at www.aihw. [Accessed 9 March 2012].
  14. Henry MJ, Pasco JA, Nicholson GC, Kotowicz MA. Prevalence of osteoporosis in Australian men and women: Geelong Osteoporosis Study. Med J Aust 2011;195:321–2.


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