Enhancing Osteoporosis Screening and Management in General Practice

Despite osteoporosis affecting over one million Australians and costing the health care system over $3 billion, it remains a largely undiagnosed and under-treated disease.¹ In 2023, more than 193,000 fractures occurred in Australia due to poor bone health, many of which were preventable.²

Primary care providers play a critical role in the prevention, screening, early diagnosis and optimal management of osteoporosis. This activity focuses on how to increase the screening and early diagnosis of osteoporosis in general practice to optimise management and reduce fracture risk and improve patient outcomes.

Setting a goal

Increase screening for osteoporosis, thereby increasing its early diagnosis and subsequent optimal management to reduce fractures and improve patient outcomes.

Resources to support your QI

To achieve this goal, you can access a range of resources:

Review current best practice clinical guidelines. RACGP, in partnership with Healthy Bones Australia, have recently updated guidelines for managing bone health, osteopenia and osteoporosis: Osteoporosis management and fracture prevention in postmenopausal women and men over 50 years of age
The FRAX Fracture Risk Assessment Tool is an individualised model that assesses absolute fracture risk.
HealthPathways: Use HealthPathways to explore locally tailored approaches for osteoporosis. Simply enter “Osteoporosis” in the search bar to get started.
Healthy Bones Australia (formerly Osteoporosis Australia) is the leading consumer body for bone health in Australia and has a range of resources for clinicians and consumers.
The Department of Health, Disability and Ageing has the National Strategic Action Plan for Osteoporosis aiming to reduce the impact of Osteoporosis in Australia

Bringing the team together

Kickstart your quality improvement activity by bringing together a quality improvement team. Together, you’ll identify the key challenges and come up with innovative solutions, ensuring you all share a clear understanding of the improvement objectives and strategies.

Engage with your Primary Health Coordinator from CCQ; they can offer tailored support, resources and guidance to enhance your QI efforts wherever you are in your QI journey. Your Primary Health Coordinator can support your practice to:
- Bring a QI team together to decide on an improvement idea
- Plan, start and finish a QI activity
- Facilitate QI meetings
- Create practice-wide systems improvement

Gather data and information. Review current practice data and processes for osteoporosis screening and management.
Identify and discuss any common barriers to osteoporosis screening and management. Consider using process maps, flow charts or driver diagrams to generate change ideas and improve processes.

Maximising your data

What data might you need? You’ll need data to understand the problem and measure your outcomes. We suggest you start with:

Primary Sense can provide insight, detailed reports and guidance on improving data quality. The following functions are available within Primary Sense:
- Frailty Care Management Report: Identify patients with a history of falls.
- Due Bone Density Nurse Prompt: Review of actions following nurse prompts to see actions taken or follow up required.

Improvement ideas for inspiration

To achieve your goal, you can consider several improvement ideas such as:

Set up a practice protocol for the consistent use of the FRAX Fracture Risk Assessment Tool.
Run a patient education campaign to inform patients about the importance of bone health and screening for osteoporosis. Hint: Osteoporosis Awareness and Prevention Month occurs every May.
Leverage the Primary Sense ‘Due bone density’ nurse prompt – consider using this prompt for opportunistic screening during health assessments and care plans, or reviewing actions.
Set up an annual bone health/osteoporosis practice audit.
Set up and audit a recall/reminder system for patients on Denosumab (Prolia).

Remember to self-report your QI project as a CPD activity: QI is a great tool for measuring tangible outcomes and demonstrating improvement in patient care!

Share your results: With your CCQ practice support team and with your patients. Ensure you document your quality improvement activity to meet PIP QI guidelines and for CPD purposes.

References

Australian Government Department of Health, Disability and Ageing, (2019) National Strategic Action Plan for Osteoporosis, accessed 15 October 2024.
Healthy Bones Australia | healthdirect, accessed 6 December 2024.

Ready to begin this QI activity?

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