Department of Rheumatology, Dudley Group of Hospitals NHS Trust, The Guest Hospital, Tipton Road, Dudley, West Midlands DY1 4SE
1 Department of Rheumatology, University Hospital Birmingham NHS Trust, Selly Oak Hospital, Raddlebarn Road, Selly Oak, Birmingham B29 6JD,
2 Department of Rheumatology, The Medical School, University of Birmingham, Edgbaston, Birmingham B9 5SS,
3 The Highfield Rheumatology Unit, Worcestershire Acute Hospitals NHS Trust, Newtown Road, Worcester WR5 1JG and
4 Department of Rheumatology, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QH, UK
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Methods. Adult patients attending rheumatology follow-up clinics in 10 units, during a 2-week period were assessed using the 1998 National Osteoporosis Society (NOS) guidance on the prevention and management of CIOP. The audit standard adopted was that 80% of eligible patients should be on appropriate therapy.
Results. Data was collected on 1766 (95.2%) of 1855 patients during the audit period. Two hundred and thirty-five (13.3%) were currently being prescribed or about to commence 7.5 mg daily of oral prednisolone for
6 months. Dual X-ray absorptiometry scans were performed in 102 patients (43.4%). Of these, 53 (52%) had a T score of 1.5 or below at the hip or spine. Of the 235 patients, 202 (86%) were receiving osteoporosis treatment. One hundred and forty-eight patients (63%) were receiving appropriate osteoporosis medication according to the NOS 1998 guidelines and 87 (37%) were inappropriately treated. Of these, 71 (81.6%) were under-treated and 16 (18.4%) were over-treated.
Conclusions. Overall, the Region failed to meet the audit standard. The audit highlighted a number of differences and potential problems in the West Midlands with regard to CIOP which are currently being addressed by individual units and the West Midlands Rheumatology Services and Training Committee (WMRSTC). The Committee plan to re-audit in 2 yr.
KEY WORDS: Regional audit, Corticosteroid-induced osteoporosis, Rheumatology, Clinical governance.
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The multi-centre nature of a regional audit demands that the audit standard by which clinical practice is to be judged must be set out at the start and acceptable to all participants. The introduction of guidelines has helped to standardize the management of some conditions and can be used as a baseline against which an audit standard can be set. In rheumatology a number of guidelines exist regarding assessment and management of corticosteroid-induced osteoporosis (CIOP) [6]. Osteoporosis is a well recognized complication of steroid usage. Previous studies prior to the publication of guidelines on the prevention of CIOP indicate only a small proportion of patients were co-prescribed therapy to prevent bone loss [7, 8]. In 1998 the National Osteoporosis Society (NOS) published guidance on the prevention and management of CIOP [9].The NOS guidelines can be applied to most groups of adult patients on corticosteroids including rheumatology patients. These guidelines were chosen to assess practice against in this audit, as they are practical to follow within the National Health Service structure, do not require mandatory measurement of bone density to decide on initial management and are endorsed by the BSR. A well laid out and easy to apply flow chart is included in the guidelines making the assessment rapid and simple in individual cases.
![]() |
Methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Data was collected anonymously on all adult patients attending rheumatology clinic follow-up appointments over a 2-week period. The following information was recorded: age, sex, rheumatology unit attended, current dose of corticosteroids, the condition for which corticosteroids were being prescribed, a personal or family history of low trauma fracture, menopausal status in females, presence or absence of slender build and or immobility, T score if patient had ever had a dual X-ray absorptiometry (DEXA) scan and any medication for prevention or treatment of osteoporosis that the patient was receiving. This information allowed each patient to be assessed individually by following the flow chart given in the NOS guidelines to determine if management was appropriate.
Audit standard
The NOS 1998 Guidance on the prevention and management of CIOP was used to set the audit standard. These guidelines recommend that any adult patient about to commence or currently being prescribed an oral dose of 7.5 mg per day of prednisolone, or equivalent dose of another corticosteroid for
6 months, should be assessed for osteoporosis and treated if appropriate. It was decided that the audit standard should be that 80% of patients attending rheumatology follow-up appointments during the audit period should be appropriately assessed and managed according to these guidelines.
Analysis
Audit proformas were scanned using Formic scanning software. Results were analysed using SPSS version 9.0 statistical package.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
A total of 1855 patients attended follow-up appointments in the participating units, and of these 1766 (95.2%) had data collected. Numbers of patients attending each unit are shown in Table 1. The sex ratio was approximately 1:2 male:female across the units. Two hundred and thirty-five (13.3%) patients were being prescribed 7.5 mg or greater of oral prednisolone per day, or an equivalent dose of an alternative steroid, and had been so for
6 months, or were about to commence the above medication (throughout the remainder of this paper patients taking corticosteroids refers to this group). The percentage of patients taking corticosteroids varied greatly between the 10 units (see Table 1
). The low rate of steroid prescription in Units 3, 8 and 10 resulted in data being collected on less than 10 patients in each unit; this needs to be borne in mind when comparing across units. In the steroid-treated group, 115 (48.9%) had rheumatoid arthritis, 40 (17%) connective tissue disease, 30 (12.8%) polymyalgia rheumatica, 12 (5.1%) vasculitis, 10 (4.3%) other inflammatory arthritis, 12 (5.1%) non-rheumatological diagnosis, 11 (4.7%) multiple diagnoses and in five (2.1%) the diagnosis was not stated.
|
Risk factors for osteoporosis were assessed in the steroid-treated group. Of the 167 female patients taking steroids, 127 (76.0%) were post-menopausal and 32 (19.2%) had undergone the menopause before the age of 45. Five (12.5%) of the pre-menopausal patients were recorded as having had a period of amenorrhoea. Forty-four (18.7%) of all individuals were considered to be of slender build and 32 (13.6%) were immobile. Twenty-nine (12.3%) patients had suffered a low trauma fracture.
DEXA scanning was performed in 102 (43.4%) patients taking steroids, and of these scans 53 (52.0%) revealed a T score of -1.5 or below at the hip or spine. DEXA scanning rates were markedly different between units (see Table 1).
Medication used for prophylaxis and treatment of CIOP in steroid-treated patients consisted of calcium in 51 (21.7%) patients, calcium and vitamin D in 73 (31.1%) patients, bisphosphonates in 111 (47.2%) patients, hormone replacement therapy in 17 (7.2%) patients, calcitriol in two (0.9%) patients, and testosterone in one (0.4%) patient. No patients were receiving calcitonin or a selective oestrogen receptor modulator. Fifty-three (22.6%) patients were receiving more than one medication; this tended to be a combination of calcium, with or without vitamin D, and a bisphosphonate. Thirty-three (14.0%) patients were not receiving any medication.
By reviewing the data on each patient against the NOS guidelines, patients were assigned to appropriate or inappropriate treatment groups. The inappropriate treatment group was further subdivided into under-treated, and over-treated (individuals who according to the NOS guidelines were receiving too much medication for their personal combination of risk factors and steroid dosage). One hundred and forty-eight (63.0%) patients were appropriately treated and 87 (37.0%) inappropriately treated. Of those inappropriately treated, 16 (18.4%) were over-treated and 71 (81.6%) under-treated. There was marked variation between units (see Fig. 1).
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
In this audit a high percentage of proformas were returned (95.2%). We consider that this was due to organizational features. Three SpRs under consultant supervision carried out audit development, organization and data analysis centrally. A pilot study was undertaken in one unit to highlight any unforeseen problems. The proforma was condensed to one side of A4 and utilized a tick box method of recording data to reduce completion time. In addition the proforma was read by an optical reader avoiding manual data input and the associated error in recording repetitive results. Local data collection was delegated to the SpR in each of the participating units who handled local organizational issues. Not all rheumatology units in the West Midlands have an SpR attached and further regional audits need to be designed to include all units who wish to participate regardless of their staffing structure.
Overall, 13.3% of patients in the audit were taking steroids. This is a low percentage of patients on oral corticosteroids compared with previous studies; however, it is emphasized that only patients on 7.5 mg were recorded, as this was the group that needed further assessment according to the NOS guidelines. The considerable variation in steroid prescription rate between units may reflect a difference in the underlying case mix across the region. Data were not collected on the diagnosis of all patients attending follow-up appointments and so it is not possible to assess the total case mix; this has prompted two units to carry out separate audits to determine their local case mix.
DEXA scanning rates were another area where significant variations in practice were observed. DEXA scans are not necessary to decide on initial management in the NOS guidelines, and it would appear that performing a DEXA scan did not have a consistent impact on the appropriateness of treatment. Unit 1 who did not have a DEXA scanner available, and did not perform any scans, had 64% of patients appropriately treated according to the NOS guidelines. These results were very similar to Unit 5 who had a DEXA scanner available and scanned 56% of their steroid-treated patients. Units without DEXA scanning facilities within their trust tended to do less scans that those with on-site facilities, but this was not a universal finding. It is impossible to monitor changes in bone density and response to treatment without performing some scanning; the NOS guidelines suggest reassessment of BMD every 13 yr with DEXA. Unit 1 is currently addressing its osteoporosis service including the provision of DEXA scanning.
Overall, the Region failed to meet the selected audit standard of 80% of corticosteroid-treated patients being appropriately managed for CIOP according to the NOS guidelines, with only 63% of patients appropriately managed. The majority of patients inappropriately managed were under-treated (81.6%). This group consisted largely of patients either on no treatment or on calcium, with or without vitamin D, alone, which is not adequate prophylaxis or treatment according to the NOS guidelines. The audit was not designed to assess the quality of the NOS guidelines but the performance of rheumatology units according to these guidelines. The evidence base for management of CIOP has expanded considerably over the last 5 yr and guidelines need to be updated regularly to take account of new evidence. Variations in local management from nationally recognized guidelines need to be supported by good clinical evidence.
This audit has highlighted a variety of differences and potential problems in the West Midlands Region regarding the assessment and treatment of CIOP. Each unit has been informed of their individual and the combined results. Results have been presented at local, regional and national levels. Each unit has been able to assess its performance and compare it with other anonymous units. A number of units have already taken steps to address problems highlighted by this audit. The WMRSTC aim to repeat the audit in 2 yr time.
Regional audit shows promise as a valuable tool in the development of clinical governance and the improvement of local rheumatology services. SpR involvement in regional audit is important as part of their training programme. On this basis, future regional audits are planned by the WMRSTC and their potential impact will be assessed.
![]() |
Acknowledgments |
---|
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|