1. www.nos.org.uk Hippisley-Cox, J., Bayly, J., Potter, J., Fenty, J. & Parker, C. (2007) Evaluation of standards of care for osteoporosis and falls in primary care. The Health and Social Care Information Centre. n = 7860/31094 n = 1476/15025 n = 2551/15025 n = 1862/2551 n = 261/14651 n = 700/14651 n = 305/700 Secondary prevention following fragility fracture in British primary care (n= 3.4 million)

2. www.nos.org.uk HES source data: Copyright © 2009, Re-used with the permission of The Health and Social Care Information Centre. All rights reserved

3. www.nos.org.uk Prevalence of Osteoporosis in Women & Men with Fractures (18,664 fractures) % By kind permission of Dr. Alastair Mclellan, Western Infirmary, Glasgow

4. www.nos.org.uk FLS: Prevalence of Osteoporosis in Women with Fractures (18,664 fractures) n 782 874 891 946 1034 958 711 386 By kind permission of Dr. Alastair Mclellan, Western Infirmary, Glasgow

5. www.nos.org.uk Fracture incidence rate plotted against prevalent fracture pool and BMD 1.00.50.0-0.5-1.5-2.0-2.5-3.0-3.5 Fracture rate Women with fractures 0 10 20 30 40 50 0 100 200 300 400 Number of fractures Fractures/1,000 person-years Adapted from Siris E in Report of the Surgeon General's Workshop on Osteoporosis and Bone Health December 12-13, 2002, Washington, D.C

6. www.nos.org.uk Could it be we are targeting the wrong patients? 6

7. www.nos.org.uk Prescribed items: 28 day equivalents Prescription Cost Analysis, NHS Information Centre http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions Charts courtesy of P Mitchell £ millions

8. www.nos.org.uk 1 in 4 bisphosphonate prescriptions directed at those under age 65

9. www.nos.org.uk Clinical Effectiveness 38,000 adults with ≥ 2 scripts for a BP (80% OAW, 75% ALN) on GPRD 43% > 70 years and 81% female 58.3% persistent at 1 year, 23.6% at 5 years No persistence of effect after discontinuation Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first

10. www.nos.org.uk Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first Fractures (n)2029628247372590354 * More than 24 months persistence

11. www.nos.org.uk Are we treating the right populations? Adapted from Gallacher AM et al. Fracture Outcomes related to persistence and compliance with oral bisphosphonates. JBMR (2008) On line first * More than 24 months persistence

12. www.nos.org.uk Rate Hip Fx Per Year by Age Group Dell RM, Greene D, Anderson D, Williams K. Osteoporosis Disease Management: What Every Orthopaedic Surgeon Should Know. J Bone Joint Surg Am 2009;91(Supplement_6):79-86. http://www.ejbjs.org. Used with kind permission of Rick M Dell MDhttp://www.ejbjs.org

13. www.nos.org.uk Highest Absolute risk means lowest numbers needed to treat NNT = 87 NNT = 12,052 Data from SCAL Healthy Bones Programme: used with kind permission Rick M Dell MD

14. www.nos.org.uk Differential risk intervention thresholds NOGG v. NICE NOGG intervention thresholds from Kanis J, McCloskey E, Johansson H, Strom O, Borgstrom F, Oden A, et al. Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK. Osteoporosis International 2008;19(10):1395-408. http://dx.doi.org/10.1007/s00198-008-0712-1 and from www.shef.ac.uk/FRAXhttp://dx.doi.org/10.1007/s00198-008-0712-1 70% lower 71% higher

15. www.nos.org.uk What are the likely consequences of the introduction of a QOF domain for secondary osteoporotic fracture prevention?

16. www.nos.org.uk Prevalence CHD Gloucestershire before and after QOF Gloucestershire Primary and Community Care Audit Group 2005 (data on file)

17. www.nos.org.uk CHD indicators Gloucestershire before and after QOF Gloucestershire Primary and Community Care Audit Group 2005 (data on file)

18. www.nos.org.uk First fracture Second fracture Van Geel T et al ASBMR 2008 and An Rheum Dis August 2008 On-line first 4140 post menopausal women age 50-90 23% re-fractures 54% re-fractures Why should HCOs fund an FLS if QOF will deliver secondary prevention?

19. www.nos.org.uk Persistence (continuous adherence): Daily or Weekly alendronate Months of treatment Percentage DIN-LINK Report: Osteoporosis - Report 4 [GSK_OSP_004.DN2]. May 2004 There is no ‘offset of effect’ seen in the GPRD in bisphosphonate users (Gallagher AM, et al. Fracture Outcomes Related to Persistence and Compliance with Oral Bisphosphonates. J Bone Miner Res 2008;23:1569-75) 3 years treatment or 2 years with 80% MPR is required for an offset effect. (Curtis J, et al. Risk of hip fracture after bisphosphonate discontinuation: implications for a drug holiday. Osteoporosis International 2008;19(11):1613-20.

20. www.nos.org.uk Many hip fractures have had a prior fragility fracture Lyles KW et al. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. ASBMR 2006 Edwards, B. J. et al (2007) Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research, 461, 226-230 McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland. n=2124 n=632 n=701

21. www.nos.org.uk Many non-hip fractures have had a prior fragility fracture % McLellan Alastair R. et al.(2004) Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland.

22. www.nos.org.uk By 2014 the cost of 10 year’s delay in implementing a systematic approach in the UK 300,000 hip fractures will have occurred with a history of a prior fragility fracture If 20% (60,000) will have had guideline care (DXA or treatment) If treatment reduces hip fracture risk by 33%. 240,000 patients not receiving care with 33% efficacy equates to 80,000 preventable hip fractures …. or 2,000,000 bed days. …. or with 20% mortality 16,000 potentially avoidable deaths …. or with 40% dependency 32,000 unable to live independently.

23. www.nos.org.uk A single over-riding communication objective “There are 80,000 hip fractures a year costing £1.6 billion. Half of the cases are secondary fractures, and we can prevent up to half of the subsequent cases — about 20,000 cases a year — saving the NHS £400 million. Are you interested?” Prof Tim Harrington