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Osteoporosis : secondary prevention of fragility fractures (OST)

Register Part 1 - 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

Fragility Fracture codes (Earliest after the 1st April 2012)

N331N Fragility fracture
N331M Fragility fracture due to unspecified osteoporosis

And Osteoporosis diagnosis codes

N330. Osteoporosis
N3300 Osteoporosis, unspecified
N3301 Senile osteoporosis
N3302 Postmenopausal osteoporosis
N3303 Idiopathic osteoporosis
N3304 Dissuse osteoporosis
N3305 Drug-induced osteoporosis
N3306 Postoophorectomy osteoporosis
N3307 Post-surg malabsorp osteoporos
N330A Osteoporosis in endocr disord
N330B Vertebral osteoporosis
N330C Osteoporosis localized to spine
N330D Osteoporos due corticosteroid
N330z Osteoporosis NOS
N3312 Postoophorectomy osteoporosis with pathological fracture
N3313 Osteoporosis of disuse with pathological fracture
N3314 Postsurgical malabsorption osteoporosis with pathological fracture
N3315 Drug-induced osteoporosis with pathological fracture
N3316 Idiopathic osteoporosis with pathological fracture
N3318 Osteoporosis + pathological fracture lumbar vertebrae
N3319 Osteoporosis + pathological fracture thoracic vertebrae
N331A Osteoporosis + pathological fracture cervical vertebrae
N331B Postmenopausal osteoporosis with pathological fracture
N331H Collapse of cervical vertebra due to osteoporosis
N331J Collapse of lumbar vertebra due to osteoporosis
N331K Collapse of thoracic vertebra due to osteoporosis
N331L Collapse of vertebra due to osteoporosis NOS
N331M Fragility fracture due to unspecified osteoporosis
NyuB0 [X]Other osteoporosis with pathological fracture
NyuB1 [X]Other osteoporosis
NyuB2 [X]Osteoporosis in other disorders classified elsewhere
NyuB8 [X]Unspecified osteoporosis with pathological fracture
N3746 Osteoporotic kyphosis

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And DXA codes

a DXA scan result without requiring a T score value

58EG. Hip DXA scan result osteoporotic
58EM. Lumbar DXA scan result osteoporotic
58EV. Femoral neck DEXA scan result osteoporotic

a DXA scan result requiring a T score value of less than -2.5

58EE. Hip DXA scan T score
58EK. Lumbar spine DXA scan T score
58ES. Femoral neck DEXA scan T score

Register Part 2 - patients aged 75 years and over with a record of a fragility fracture after 1 April 2014 and a diagnosis of osteoporosis :

Fragility Fracture codes (Earliest fter the 1st April 2014)

N331N Fragility fracture
N331M Fragility fracture due to unspecified osteoporosis

Osteoporosis exception reporting codes

9hP.. Exception reporting: osteoporosis quality indicators
9hP0. Excepted from osteoporosis quality indicators: patient unsuitable
9hP1. Excepted from osteoporosis quality indicators: informed dissent

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Osteoporosis 004.1 Rationale

Fragility fractures are fractures that result from low-level trauma, which means mechanical forces that would not ordinarily cause fracture. The WHO has described this as a force equivalent to a fall from a standing height or less. Reduced bone density is a major risk factor for fragility fractures.

Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue. The WHO defines osteoporosis as a bone mineral density of 2.5 or more standard deviations below that of a normal young adult (T-score of -2.5 or less) measured by a central dual-energy X-ray absorptiometry (DXA) scan. Bone mineral density is the major criterion used to diagnose and monitor osteoporosis.

The NICE clinical guideline on osteoporosis fragility fractures recommends that a diagnosis of osteoporosis may be assumed in women and men aged 75 or over with a fragility fracture if the responsible clinician considers a DXA scan to be clinically inappropriate or unfeasible. The SIGN clinical guideline on the management of osteoporosis recommends that in frail elderly women (aged 80 or over) a DXA scan would be a prerequisite to establish that bone mass density (BMD) is sufficiently low before starting treatment with bone-sparing agents (bisphosphonates), unless the patient has suffered multiple vertebral fractures.

In April 2014 the register for people aged 75 or over was amended to require that practices record a diagnosis of osteoporosis in addition to a fragility fracture.

Osteoporotic fragility fractures can cause substantial pain and severe disability, and are associated with decreased life expectancy. Osteoporotic fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur) and wrist (distal radius). They also occur in the arm (humerus), pelvis, ribs and other bones. Fractures of the hands and feet (for example, metacarpal and metatarsal fractures) are not generally regarded as osteoporotic fragility fractures.

In women, the prevalence of osteoporosis increases markedly with age after menopause, from approximately two per cent at 50 years, rising to more than 25 per cent at 80 years. The NICE cost impact report for technology appraisal TA161 uses a prevalence of 11 per cent of post-menopausal women aged 50 or over with osteoporosis and a clinically apparent osteoporotic fragility fracture, rising to 19 per cent for ages 65 or over. There are an estimated 180,000 new fragility fractures in postmenopausal women in the UK each year; three quarters in women aged 65 or over.

Postmenopausal women with an initial fracture are at substantially greater risk of subsequent fractures. Half of patients with a hip fracture have previously had a fragility fracture of another bone.

Hip fractures are associated with increased mortality; estimates of the relative mortality risk vary from two to greater than ten in the 12 months following hip fracture. However, it is unclear to what extend this can be attributed to fracture alone, as opposed to pre-existing co-morbidity.

The SIGN clinical guideline recommends that patients who have suffered one or more fragility fractures are priority targets for investigation and treatment of osteoporosis.

This indicator promotes structured case finding for osteoporosis in patients who have had a fragility fracture. Its aim is to promote the secondary prevention of fragility fracture in patients with osteoporosis.

World Health Organisation (1998) Guidelines for preclinical evaluation and clinical trials in osteoporosis
NICE (2008) Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. (amended January 2010 and January 2011). NICE technology appraisal guidance 161. Available from www.nice.org.uk/guidance/TA161
NICE (2008) Costing report for technology appraisal guidance 161 on Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women
World Health Organisation (1998) Guidelines for preclinical evaluation and clinical trials in osteoporosis

Osteoporosis 004.2 Reporting and verification

The Business Rules for the two-part register will look for the following criteria:

In patients aged 50 or over and who have not attained the age of 75:

In patients aged 75 years and over:

Patients aged 50 or over and under the age of 75 in whom a diagnosis of osteoporosis has not been confirmed with DXA scanning will not be included in the register.

For patients aged 75 or over the diagnosis of osteoporosis can be either confirmed with DXA scanning or clinically assumed (if DXA scan is considered to be clinically inappropriate or unfeasible).

Patients with fragility fractures sustained in the last three months of the year will be excepted from this indicator.

Although this indicator defines two separate registers, The disease register for the purpose of calculating the APDF is defined as the sum of the number of patients on both registers.

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Prepared By Jean Keenan