Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation

Transcription

1 Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation Below is the form you need to fill out. NAME Health Hawke s Bay DATE NOVEMBER 2012 TITLE OF ACTIVITY OSTEOPOROSIS RISK REDUCTION WITH BISPHOSPHONATES FOR PATIENTS ON LONG TERM STEROIDS NEW GENERAL PRACTITIONERS INVOLVED IN ACTIVITY This CQI activity has been requested by The Doctors WAIPAWA; however it will be made available to all interested General Practitioner members of Health Hawke s Bay. 1. TOPIC This audit is to identify those patients currently taking long term oral steroids (hydrocortisone, prednisone) and who are not concurrently taking a bisphosphonate for the prevention of osteoporosis. Medications that can increase the risk of osteoporosis include: steroids (>5mg/day for more than three months), lithium, anticonvulsants, cancer chemotherapy drugs, depo-medroxyprogesterone and proton pump inhibitors. 1 (Note: Prednisone 5mg is equivalent to hydrocortisone 20mg in regard to glucocorticoid or anti-inflammatory properties. 2 ) The contribution of individual risk factors towards the development of osteoporosis has not yet been quantified, however major risk factors include: age, female gender, low BMI, untreated premature menopause, family history of maternal hip fracture before the age of 75 years, conditions affecting bone metabolism (primarily inflammatory conditions, hyperthyroidism and prolonged immobility) and chronic steroid use. 1 Alendronate is indicated for the treatment of osteoporosis, as well as the treatment and prevention of glucocorticoid-induced osteoporosis in men, premenopausal women and postmenopausal women receiving oestrogen. 3 Due to the rapidity of bone loss and increase in fracture risk after the start of glucocorticoid therapy, primary prevention should be advised in high-risk individuals, for example older women and men, individuals with a previous fracture history and those with low bone mineral density. 4 The long term use of inhaled or nasal steroid are not considered in this audit, as except at high doses of inhaled steroids, this route of administration is not associated with an increased risk of fractures. 5 Fracture risk declines rapidly after glucocorticoids are withdrawn, therefore it may be appropriate to withdraw bone protective therapy when glucocorticoids are stopped. 4 Osteonecrosis of the jaw and atypical fractures are very rare adverse events that may be causally linked to bisphosphonate therapy, and there is some evidence that glucocorticoid therapy is a risk factor for these conditions. 4 RNZCGP MOPS Programme

2 Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation 2. PLAN This section should be based on the best evidence available, e.g. evidence-based guidelines. INDICATORS (what element of practice performance are you going to measure?) This audit will identify those patients who are currently taking long term steroids (hydrocortisone or prednisone orally) and assess them for osteoporosis prevention therapy using bisphosphonates and vitamin D. Use the audit tool to identify all patients currently taking either hydrocortisone >20mg / day or prednisone > 5mg / day Patients must be enrolled and registered with the Practice. Prescriptions for either steroid will have been generated within the previous six months. CRITERIA (How will you measure if you are meeting the indicator?) This audit will identify patients currently prescribed either oral hydrocortisone (>20mg/day) or oral prednisone (>5mg/day) by running a query through the patient management system (PMS). The following will be measured: Number of patients currently prescribed hydrocortisone >20mg / day Number of patients currently prescribed prednisone > 5 mg /day Number of patients also currently prescribed a bisphosphonate Number of patients also currently prescribed cholecalciferol Number of patients to be considered for bisphosphonate and cholecalciferol treatment. STANDARDS (what standards of performance do you want to achieve?) 100% of patients aged 18 years and older, currently taking either oral hydrocortisone or prednisone should be identified. 100% of these patients are to have notes reviewed to determine total daily dose. 100% of these patients are to have notes reviewed to determine if they are on either / or a bisphosphonate or cholecalciferol e.g. Cal D Forte. 100% of patients currently taking oral prednisone or hydrocortisone without cholecalciferol or bisphosphonate are assessed for the need to have both prescribed. Describe the process used to develop the indicators and criteria above: List guidelines and other resources used. Process was 1. GP request for audit 2. Review of literature (see references at end of document) 3. DATA Describe data (to be) collected. Identify patients Patients will be identified by running a query through the patient management system. Sample size All patients currently prescribed oral hydrocortisone (>20mg/day) or oral prednisone (>5mg/day) Review process Once patients have been identified the medicines are reviewed according to the process outlined in Appendix 1. Data analysis Data analysis will be captured in Appendix 2. Cycle 1 aim for 100% patients on oral hydrocortisone (>20mg/day) or oral prednisone (>5mg/day) to be assessed for requirement of bisphosphonate (and cholecalciferol). Cycle 2 aim for 100% patients on oral hydrocortisone (>20mg/day) or oral prednisone (>5mg/day) assessed for requirement of bisphosphonate (and cholecalciferol) and if not stating why not in patient notes. RNZCGP MOPS Programme

3 Application for Endorsement of CQI Activities for MOPS Points Allocation When is a second cycle planned? (This includes repeating data, check, act and monitor stages.) Cycle 2 is planned to be carried out between 10 and 12 months after Cycle 1. REFERENCES 1. Professor Ian Reid and Dr Rebecca Grainger. Bones and Joints Prevention of osteoporosis. Best Practice Journal. October 2008 [cited 6 November 2012]. Available from: 2. Martindale The Complete Drug Reference. 35 th Edition Pharmaceutical Press. London. 3. Merck Sharp & Dohme (New Zealand) Limited. Fosamax Data Sheet. 26 April 2010 [cited 6 November 2012]. Available from: 4. Juliet Compston. Clinical Question: What is the best approach to managing glucocorticoidinduced osteoporosis? Clinical Endocrinology (2011) 74, Available from: 5. Samy Suissa, Marc Baltzan, Richard Kremer, and Pierre Ernst. Inhaled and Nasal Corticosteroid Use and the Risk of Fracture. Am J Respir Crit Care Med [cited 6 November 2012];169: Available from: RNZCGP MOPS Programme

4 Application for Endorsement of CQI (Clinical Audit) Activities for MOPS Credits Allocation APPENDIX 1 REVIEW PROCESS Identify patients prescribed oral hydrocortisone or prednisone in the past 6 months. Review each patient s file to determine total daily dose If dose > 20mg hydrocortisone or > 5mg prednisone, record NHI in data collection sheet (Appendix 2) Is the patient currently prescribed bisphosphonate? Bisphosphonates Bisphosphonate options include: a) Alendronate 70mg once weekly b) Zolendronic acid 5mg annually Yes review for Vit D (see below) No - review Is it appropriate to add bisphosphonate to regimen? Yes place note in patient file to change at next appointment No, document reason in patient notes. Is the patient also prescribed cholecalciferol? Yes no further action No - review Cholecalciferol Cholecalciferol can be prescribed as c) Cal D Forte 1.25mg once a month d) Fosamax Plus once a week Is it appropriate to prescribe either Fosamax Plus or Cal D Forte? Yes place note in patient file to change at next appointment No, document reason in patient notes. RNZCGP MOPS Programme

5 Application for Endorsement of CQI Activities for MOPS Points Allocation APPENDIX 2 Patient NHI Current oral steroid is Is patient on bisphosphonate? Is patient on cholecalciferol? If no for either question review and either prescriber, or add note why not suitable. Hydrocortisone > 20mg/day Prednisone >5mg/day Yes No Yes No Yes No TOTAL % Aim 100% Cycle 2 or docum ented reason why not. 100% assessed - Cycle 1 100% prescribed or reason not documented - Cycle 2 RNZCGP MOPS Programme