- Corticosteroid induced Osteoporosis Prevention (COOP)

The Clinical Practice Evaluation Group (CPEG) has a remit to develop multi-centre audit within the BGS.

The first such project has recently been carried out. Participating departments had previously registered on the CPEG audit database as enthusiasts for such work. The audit was carried out in conjunction with the Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians and it utilised a previously developed computer based audit tool to assess the appropriate prescribing in older people (1).

Aim of project
The objective of the project was to assess the appropriate use of bisphosphonates in medical patients aged >65 committed to or exposed to oral prednisolone for >3 months.

Criteria/standards for project
All medical in-patients aged >65 years committed to or exposed to corticosteroids for >3 months should be on bisphosphonate unless there is a contra-indication.

Project methodology The indicator assessing the appropriate use of bisphosphonates in medical patients aged >65 on oral prednisolone was based on recently published guidelines on prevention and treatment of glucocorticoid induced osteoporosis (2). The indicator was developed as an algorithm (Figure1). It was non-controversial, simple and quick to apply. Patients on oral prednisolone were identified from drug charts. Clinical data were collected from the clinical notes. Recruitment of hospitals to participate in the study was done via the British Geriatrics Society Clinical Practice Evaluation Group. Software was developed using Microsoft Access to facilitate data collection. Data set fields i.e. on screen data collection forms with definitions (e.g. list of contra-indications to bisphosphonates) made data collection possible by anyone with minimal training. The data set fields were developed to prevent incomplete data collection or contradictory data entry. A software manual was also produced. The software was able to produce and print local reports.

Results
The software was requested by 20 hospitals and 11 hospitals completed the data collection. Data was collected on 237 patients. The mean age of the patients was 79 years and 33% were male.

Prescribing was appropriate for 153/237 (65%) patients. The range of appropriateness of prescribing varied from 33% to 96% between the hospitals.

Table 1 summarises the data from the 11 participating hospitals. A total of 237 patients were prescribed oral prednisolone. A bisphosphonate was prescribed for 62 of these patients, hence prescribing was appropriate. Alendronate was prescribed to 22 patients; etidronate to 17 patients and 23 patients were prescribed risidronate. Of the remaining 175 patients not prescribed a bisphosphonate, 123 patients had evidence of commitment/exposure to oral steroids for > 3 months and 52 patients did not. It was therefore appropriate that the latter group were not prescribed a bisphosphonate. In 123 patients that had evidence of commitment/ exposure to oral steroids for > 3 months, there was a history of metastatic malignancy, terminal illness, adrenal or pituitary failure in 18 patients and a contra-indication to bisphosphonates in a further 21 patients, hence it was appropriate that a further 39/123 patients were not prescribed a bisphosphonate.

Summary
The results show marked variation in the appropriateness of prescribing of bisphosphonates. The audit will be repeated in early 2004 to assess whether any change has occurred following the publication of the Guidelines for Glucocorticoid induced osteoporosis.

The CPEG sees this as a successful example of BGS multi-centre audit and would be keen to facilitate further studies. If any departments have conducted an audit that they feel would be applicable on a wider scale, the CPEG would be keen to facilitate further projects. Please contact Dr Jonathan Potter at jonathan.potter@ekht.nhs.uk if you have any suggestions.

References
1. Grant RL, Aggarwal R, Lowe D, Batty GM, Potter JM, Pearson MG, Oborne A, Jackson S. National Sentinel Clinical Audit of Evidence-Based Prescribing for Older People: Methodology and Development. J Eval Clin Practice. 2002; 8: 189 – 198.

2. Bone and Tooth Society of Great Britain, National Osteoporosis Society, Royal College of Physicians. Glucocorticoid-induced Osteoporosis: Guidelines for Prevention and Treatment. Royal College of Physicians, 2002.

Acknowledgements
We would like to thank all those hospitals who participated in this pilot, without whose hard work this project would not have been possible. We would also like to thank Dr Juliet Compston and the Bone and Tooth Society of Great Britain, the National Osteoporosis Society, and the Royal College of Physicians for allowing us to use their guidelines. Funding for this project was kindly provided by an educational grant from The Alliance of Better Bone Health.

Dr Gwenno M Batty
Honorary Associate, Clinical Effectiveness & Evaluation Unit, RCP; and
Consultant Physician, Kent & Canterbury Hospital, Canterbury.

Dr Jonathon M Potter
Chairman, CPEG, BGS; and
Consultant Physician, Kent & Canterbury Hospital, Canterbury

Ms Anna-Maria Bunn
Project Co-ordinator, Clinical Effectiveness & Evaluation Unit, RCP