Stroke and hip fracture following a fall have a lot in common. They can both be viewed as clinical areas with huge cost to both patient and nation.

Both involve extensive rehabilitation in survivors. Fractures and stroke in over 60 year olds each involve just over 2 million hospital bed days in England each year. We can add more than another 2 million to the total bed days if we add in falls in over 75 year olds. The social care consequences for both dominate NHS costs. Both may have ‘signal’ events that flag up the need for interventions aimed at secondary prevention – the TIA, the first mild stroke or the first fragility fracture. Both have robust evidence for the effectiveness of secondary interventions and both have issues about cost-effectively managing primary prevention where the greatest incidence of stroke and hip fracture is unfortunately seen.

How these two comparable but distinct clinical areas are now faring in primary care is instructive. Let us examine a third area to set the scene.

Standards in coronary heart disease (CHD) have seen early benefits from one of the first National Service Frameworks (NSF) to be published. In three PCTs in Gloucestershire, we have been able to track point prevalence estimates from case-finding increasingly approaching the expected national norms. At the same time, activity around documented evidence-based interventions have also shown steady improvements. These surrogates of beneficial health outcomes have undoubtedly come about partly as a result of comparative cyclical audit that is published in the public domain but probably more directly as a consequence of the Quality Outcomes Framework (QOF) of the new GP contract. Rigorous stroke secondary prevention has always lagged behind that for CHD but we are now able to document very high standards of care and almost certainly a more rapid translation of research outcomes into clinical practice. Evidence of improving standards in the management of stroke within primary care is also demonstrated in the QResearch database that was part of the National Sentinel Audit of Stroke and the National Audit Office Report. Falls and subsequent fragility fractures have not however, seen such benefits because neither have been viewed by GP academics or negotiators on both sides of the equation as being of sufficient importance to warrant the systematic approach that would follow incorporation into the new GP contract.

What is the QOF?
The QOF is a way of providing incentives for general practitioners and their fellow clinicians to identify and manage patients with a range of certain diseases. Though the QOF is more a quality process framework with precious few outcomes, the targets and interventions embedded in the different domains can be expected to beneficially affect the age specific disease incidence. Effectively, a significant part of a practice’s income depends upon identifying the prevalent population in the respective domains and recording the diagnosis and interventions against the QOF indicators in an electronically retrievable form, using the agreed nationally adopted Read codes. The disease areas included in the 2006 framework are listed in table 1. The aggregated results from performance against the indicators are uploaded to a Quality Management Analysis System (QMAS) which validates and determines payments. This has focused attention to a large extent on the included domains at the cost of other disease areas.

The consequences
The consequence is that osteoporosis and falls lack systematic care and those at risk are poorly identified and under-treated. Repeated published studies have indicated poor data quality on GP systems in relation to osteoporosis and lack of appropriate interventions in even the highest risk patients such as those presenting with fragility fracture, on glucocorticoids or in the extended care setting. Standards of care for both falls and osteoporosis in primary care are currently being evaluated across more than half a million patients resident in Gloucestershire and a pilot in a population of 60,000 has already suggested that the reality unfortunately matches the expectations. Even in the highest risk populations such as over 75 year old females with a prior peripheral fragility fracture, almost always the result of a fall, the prevalence identified is probably nearer a third that which would be expected, and the proportion with currently documented interventions in line with NICE guidance on secondary prevention is at a similar level. Sadly the numbers identified as fallers or with evidence of referral to falls services are so small as to make comparative analysis invalid. It could be argued that these are data gaps rather than care gaps. However, evidence from the published research with respect to osteoporosis would tend to suggest it is the latter. In considering falls interventions, it is fairly clear from the recently released national audit of falls and bone health that the number of patients referred for multi-disciplinary assessment is tiny, running at about 1.7 new patients per week per 100,000 of the population.

It is probably true that until we see the identification and appropriate management of fallers, and those at high risk of osteoporotic fractures, targeted as a domain within QOF we will not see system wide improvements in the standards of management within primary care. Primary care could probably manage the largely pharmacological interventions for the majority of those with poor bone health but one question remains. If GPs were able to identify the expected numbers of recurrent fallers that we know are out there, would the currently resourced level of integrated falls services cope? Are there enough properly trained professionals to deliver the complex evidence-based interventions that reduce falls? If not, is there any hope in the present financial climate that we could expect sufficiently increased service provision?

Nevertheless, it is encouraging to note that two of the recommendations from the recent Clinical Effectiveness and Evaluation Unit report included firstly, that osteoporosis and falls should be incorporated in to QOF and secondly, that every acute hospital trust should have a fracture liaison service. A third recommendation was for further clinical audit which will be launched from April 2007 onwards and will concentrate on evaluating falls and osteoporosis interventions in patients presenting to accident and emergency units with injurious falls. It has been estimated in one retrospective study in primary care in Europe, that patients with a recent fall and osteoporosis have a risk of further fracture that is nearly 25 times that of those with neither risk. We can only hope that for the sake of our patients in primary care, eventually the penny will drop at a strategic level and we will see this high morbidity, high mortality and high cost area effectively and systematically managed.

The referenced version of this paper may be downloaded here.

Jonathan Bayly
Clinical Lead, Gloucestershire Primary and Community Care Audit Group
Associate Lecturer, Faculty of Education Health and Sciences, University of Derby