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Multimorbidity

About

What is covered

Multimorbidity is usually defined as when a person has 2 or more long-term health conditions. This interactive flowchart covers the optimisation of care for:
  • adults with 2 or more long-term physical health conditions
  • adults with 1 or more mental health condition and at least 1 physical health condition.
Multimorbidity matters because it is associated with reduced quality of life, higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services use (including unplanned or emergency care). A particular issue for health services and healthcare professionals is that treatment regimens (including non-pharmacological treatments) can easily become very burdensome for people with multimorbidity, and care can become uncoordinated and fragmented.
The aim of these recommendations is to inform patient and clinical decision-making and models of care for people with multimorbidity who would benefit from a tailored approach because of the high impact of their conditions or treatment on their quality of life or functioning. This is a particular concern for generalist medical professionals such as GPs and geriatricians and healthcare professionals such as pharmacists and nurses working in those services; these recommendations are also relevant to specialist services because many of the patients they care for will have significant other conditions.

Updates

Updates to this interactive flowchart

28 June 2017 Multimorbidity (NICE quality standard 153) added.
27 April 2017 Osteoporosis (NICE quality standard 149) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on optimising care for people with 2 or more long-term health conditions in an interactive flowchart

What is covered

Multimorbidity is usually defined as when a person has 2 or more long-term health conditions. This interactive flowchart covers the optimisation of care for:
  • adults with 2 or more long-term physical health conditions
  • adults with 1 or more mental health condition and at least 1 physical health condition.
Multimorbidity matters because it is associated with reduced quality of life, higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services use (including unplanned or emergency care). A particular issue for health services and healthcare professionals is that treatment regimens (including non-pharmacological treatments) can easily become very burdensome for people with multimorbidity, and care can become uncoordinated and fragmented.
The aim of these recommendations is to inform patient and clinical decision-making and models of care for people with multimorbidity who would benefit from a tailored approach because of the high impact of their conditions or treatment on their quality of life or functioning. This is a particular concern for generalist medical professionals such as GPs and geriatricians and healthcare professionals such as pharmacists and nurses working in those services; these recommendations are also relevant to specialist services because many of the patients they care for will have significant other conditions.

Updates

Updates to this interactive flowchart

28 June 2017 Multimorbidity (NICE quality standard 153) added.
27 April 2017 Osteoporosis (NICE quality standard 149) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Multimorbidity (2017) NICE quality standard 153
Osteoporosis (2017) NICE quality standard 149
QTUG for assessing falls risk and frailty (2016) NICE medtech innovation briefing 73

Quality standards

Multimorbidity

These quality statements are taken from the multimorbidity quality standard. The quality standard defines clinical best practice for multimorbidity and should be read in full.

Osteoporosis

These quality statements are taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statements

Identification

This quality statement is taken from the multimorbidity quality standard. The quality standard defines clinical best practice for multimorbidity and should be read in full.

Quality statement

Adults with multimorbidity are identified by their GP practice.

Rationale

Identifying all adults with multimorbidity is the first step towards finding those who may benefit from an approach to care that takes account of multimorbidity. Multimorbidity is often associated with reduced quality of life, higher mortality, polypharmacy and high treatment burden, higher rates of adverse drug events, and much greater health services use. Some people with multimorbidity have conditions that significantly affect their everyday functioning. Some people find that managing their care is burdensome and involves a number of services working in an uncoordinated way.

Quality measures

Structure
Evidence that GP practices identify all adults with multimorbidity.
Data source: Local data collection from service protocols.
Process
Proportion of adults with multimorbidity identified by the GP practice.
Numerator – the number in the denominator identified as having multimorbidity by the GP practice.
Denominator – the number of adults registered with the GP practice.
Data source: GP practice health records.
Outcome
Number of adults with multimorbidity identified by the GP practice who may benefit from an approach to care that takes account of multimorbidity.
Data source: GP practice health records.

What the quality statement means for different audiences

Service providers (GP practices) ensure that systems are in place to identify all adults with multimorbidity. Identification may be opportunistic during routine care or involve a systematic search of electronic health records.
Healthcare practitioners (such as GPs, practice nurses and practice managers) identify adults with multimorbidity proactively using health records and opportunistically during routine care. They record this information in health records.
Commissioners (clinical commissioning groups and NHS England) ensure that GP practices identify all adults with multimorbidity and have monitoring arrangements that show this is being done.
Adults with more than 1 long-term health condition, including a physical condition, are identified by their GP practice. The practice may do this by looking at health records or having discussions about health problems during routine appointments.

Source guidance

Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendation 1.3.1

Definitions of terms used in this quality statement

Adults with multimorbidity
Adults with multimorbidity have 2 or more long-term health conditions where at least 1 of these conditions must be a physical health condition.
Long-term health conditions can include:
  • defined physical and mental health conditions such as diabetes or schizophrenia
  • ongoing conditions such as learning disability
  • symptom complexes such as frailty or chronic pain
  • sensory impairment such as sight or hearing loss
  • alcohol and substance misuse.
People who have multiple mental health problems and no physical health conditions are not included because their care will be largely delivered by psychiatric services.
[Adapted from NICE’s guideline on multimorbidity, recommendation 1.1.1 and full guideline]
Identifying adults with multimorbidity
GP practices can identify adults with multimorbidity:
  • opportunistically during routine care
  • proactively using electronic health records.
[NICE’s guideline on multimorbidity, recommendation 1.3.1]

Assessing values, priorities and goals

This quality statement is taken from the multimorbidity quality standard. The quality standard defines clinical best practice for multimorbidity and should be read in full.

Quality statement

Adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.

Rationale

A person’s values, priorities and goals can affect how they experience long-term health problems and how these affect their life. They can also affect their need for care and support. Discussing and exploring what is important to a person with multimorbidity, recording this in their individualised management plan, and sharing the information can ensure that the planning and delivery of care reflects personal preferences. A person’s circumstances may change, so values, priorities and goals should be reviewed and updated.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with an individualised management plan for multimorbidity are given opportunities to discuss their values, priorities and goals.
Data source: Local data collection from service protocols.
Process
Proportion of adults with an individualised management plan for multimorbidity whose plan has a record of values, priorities and goals.
Numerator – the number in the denominator whose individualised management plan has a record of values, priorities and goals.
Denominator – the number of adults with an individualised management plan for multimorbidity.
Data source: Audit of patient’s individualised management plans.
Outcome
Adults with an individualised management plan for multimorbidity feel that the decisions about their treatment have taken into account their values, priorities and goals.
Data source: Patient survey.

What the quality statement means for different audiences

Service providers (such as GP practices, district nursing services, community pharmacies, hospitals) ensure that staff providing care to adults with an individualised management plan for multimorbidity give them opportunities to discuss values, priorities and goals, and record these in the management plan.
Healthcare professionals (such as GPs, practice nurses, district nurses, community pharmacists) give adults with an individualised management plan for multimorbidity opportunities to discuss values, priorities and goals. They ask if the person would like a relative, friend or independent advocate to join the discussion; they explore if the person has any advance care plans or other preferences for care; they check throughout care if the person has any new or changed preferences. They record the discussions in the person’s individualised management plan.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that use individualised management plans to deliver and coordinate care for adults with multimorbidity, and that these include up-to-date details of personal values, priorities and goals.
Adults with a management plan for multimorbidity are given chances to discuss what is important to them with a member of their care team. This includes their quality of life, their values, priorities and future life goals. Discussions are recorded in the plan so that all those providing care can take them into account.

Source guidance

Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendation 1.6.7

Definitions of terms used in this quality statement

Individualised management plan for multimorbidity
A plan for a person’s care that takes account of multimorbidity based on personalised assessment. The aim is to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care. The plan includes a person's individual needs, preferences for treatments, health priorities and lifestyle. It aims to improve coordination of care across services, particularly if this has become fragmented.
[Adapted from NICE’s guideline on multimorbidity]
Values, priorities and goals
These may include:
  • maintaining independence
  • undertaking paid or voluntary work, taking part in social activities and playing an active part in family life
  • preventing specific adverse outcomes (for example, stroke)
  • reducing harms from medicines
  • reducing treatment burden
  • lengthening life.
[NICE’s guideline on multimorbidity, recommendation 1.6.7]

Equality and diversity considerations

Healthcare professionals should take into account the needs of adults who are less able to understand and express their values, priorities and goals (for example, those with learning disabilities, cognitive impairment or language barriers). They should also assess a person’s knowledge, skills and confidence in managing their own health and care. Reasonable adjustments should be made such as providing information in a format that suits their needs and preferences, asking if a friend or relative should be involved, and providing access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's accessible information standard.

Coordination of care

This quality statement is taken from the multimorbidity quality standard. The quality standard defines clinical best practice for multimorbidity and should be read in full.

Quality statement

Adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.

Rationale

Managing multiple long-term conditions can be difficult because of the complexity of the conditions and treatment options. An individualised management plan helps ensure that decisions about optimising treatment take account of a person’s preferences, needs and priorities; and that the resulting actions are clear. A key aspect is agreement between the person with multimorbidity and the healthcare professional about who is responsible for coordinating care. It is important that the person feels comfortable with the decision and that this information is clearly recorded in the management plan. This can then be shared with healthcare professionals, a partner, family members and carers.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care.
Data source: Local data collection from service specifications.
Process
Proportion of adults with an individualised management plan for multimorbidity whose plan states who is responsible for coordinating their care.
Numerator – the number in the denominator whose individualised management plan states who is responsible for coordinating their care.
Denominator – the number of adults with an individualised management plan for multimorbidity.
Data source: Audit of patient’s individualised management plans.
Outcome
a) Number of adults with an individualised management plan for multimorbidity who feel they were involved in the discussion about who is responsible for coordinating their care.
Data source: Patient survey.
b) Number of adults with an individualised management plan for multimorbidity who know which healthcare professional is coordinating their care.
Data source: Patient survey.

What the quality statement means for different audiences

Service providers (such as primary care services) ensure that systems are in place for adults with an individualised management plan for multimorbidity to know who is responsible for coordinating their care, and to record this in the individualised management plan.
Healthcare professionals (such as GPs, practice nurses and practice pharmacists) agree who is responsible for coordinating care with adults with an individualised management plan for multimorbidity. They record this in the management plan, and share the plan with the person and (with the person’s permission) other people involved in the care, including other healthcare professionals, a partner, family members and carers.
Commissioners (clinical commissioning groups and NHS England) commission services in which adults with an individualised management plan for multimorbidity know who is responsible for coordinating their care and have this information recorded in the plan.
Adults with a management plan for multimorbidity are involved in deciding who is responsible for coordinating their care. This is recorded in their plan and the plan is given to the person, and if they wish, to family members and carers. Doing this will make sure everyone knows who will organise different parts of the care so that they work well together.

Source guidance

Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendation 1.5.2 and 1.6.17

Definitions of terms used in this quality statement

Individualised management plan for multimorbidity
A plan for a person’s care that takes account of multimorbidity based on personalised assessment. The aim is to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care. The plan includes a person's individual needs, preferences for treatments, health priorities and lifestyle. It aims to improve coordination of care across services, particularly if this has become fragmented.
[Adapted from NICE’s guideline on multimorbidity]

Reviewing medicines and other treatments

This quality statement is taken from the multimorbidity quality standard. The quality standard defines clinical best practice for multimorbidity and should be read in full.

Quality statement

Adults having a review of their medicines and other treatments for multimorbidity discuss whether any can be stopped or changed.

Rationale

Once preferences and priorities have been explored and any burdens of treatment understood, a healthcare professional and patient can review medicines and other treatments and consider whether they are serving a person’s interests. This review might lead to treatments being stopped or changed, or new treatments being started. A family member, friend, or independent advocate may help a person to explain their preferences and better understand their choices. Discussions should include agreement on how frequently future reviews should happen to take account of changes in circumstances.

Quality measures

Structure
Evidence of local arrangements to ensure that adults having a review of their medicines and other treatments for multimorbidity discuss whether any can be stopped or changed.
Data source: Local data collection from service protocols.
Process
Proportion of adults having a review of their medicines and other treatments for multimorbidity who discussed whether any could be stopped or changed.
Numerator – the number in the denominator who discussed whether any treatments could be stopped or changed.
Denominator – the number of adults having a review of their medicines and other treatments for multimorbidity.
Data source: Audit of health records.
Outcome
a) Number of adverse events from medicines in adults with multimorbidity.
Data source: Audit of health records.
b) Adults having a review of their medicines and other treatments for multimorbidity feel that the decisions about their treatments have taken into account the outcomes they felt were important.
Data source: Patient survey.
c) Adults having a review of their medicines and other treatments for multimorbidity feel that their treatment burden is reduced.
Data source: Patient survey.

What the quality statement means for different audiences

Service providers (such as primary care services) ensure that reviews of medicines and other treatments for adults with multimorbidity include discussing whether any can be started, stopped or changed and the frequency of future reviews.
Healthcare professionals (such as GPs and practice nurses) discuss with adults having a review of their medicines and other treatments for multimorbidity whether any can be stopped or changed to better serve the person’s interest. They agree a frequency for ongoing reviews and record this in the individualised management plan.
Commissioners (clinical commissioning groups and NHS England) commission services in which adults having a review of their medicines and other treatments for multimorbidity discuss whether any can be started, stopped or changed and the frequency of future reviews.
Adults with multimorbidity who are having a review of their treatments with their GP or practice nurse discuss if some treatments can be stopped or changed. The aim of this is to improve the person’s quality of life.

Source guidance

Multimorbidity: clinical assessment and management (2016) NICE guideline NG56, recommendations 1.5.2 and 1.6.11

Definitions of terms used in this quality statement

Review of their medicines and other treatments for multimorbidity
A review of medicines and non-pharmacological treatments, such as diets and exercise programmes, that takes account of likely benefits and harms for the individual patient, and outcomes for the patient.
[Adapted from NICE’s guideline on multimorbidity, recommendation 1.5.2 and full guideline]
Multimorbidity
The presence of 2 or more long-term health conditions where at least 1 of these conditions must be a physical health condition.
Long-term health conditions can include:
  • defined physical and mental health conditions such as diabetes or schizophrenia
  • ongoing conditions such as learning disability
  • symptom complexes such as frailty or chronic pain
  • sensory impairment such as sight or hearing loss
  • alcohol and substance misuse.
Multiple mental health problems and no physical health conditions are not included. Care for people with only mental health problems would largely be delivered by psychiatric services and is not covered by this quality standard.
[Adapted from NICE’s guideline on multimorbidity, recommendation 1.1.1 and full guideline]
Stopped or changed
Stopping, changing or starting of medicines and non-pharmacological treatments.
[Adapted from NICE’s guideline on multimorbidity, recommendations 1.6.11 and 1.6.15]

Equality and diversity considerations

Healthcare professionals should take into account the needs of adults who may find it difficult to fully participate in a review of medicines and other treatments (for example, those with learning disabilities, cognitive impairment or language barriers). They should also assess a person’s knowledge, skills and confidence in managing their own health and care. Reasonable adjustments should be made such as providing information in a format that suits their needs and preferences, and providing access to an interpreter or advocate if needed. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's accessible information standard.

Assessment of fragility fracture risk

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults who have had a fragility fracture or use systemic glucocorticoids or have a history of falls have an assessment of their fracture risk.

Rationale

Risk assessment of adults who may be at increased risk of a fragility fracture enables healthcare professionals to estimate their fracture risk. This can be used to consider options for prevention and treatment, which will reduce the risk of future fractures.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, have an assessment of their fracture risk.
Data source: Local data collection, for example, service specifications.
Process
a) Proportion of adults who have had a fragility fracture who have an assessment of their fracture risk.
Numerator – the number in the denominator who have an assessment of their fracture risk.
Denominator – the number of adults who have had a fragility fracture.
Data source: Local data collection, for example, local audit of patient records. The Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis.
b) Proportion of adults who use systemic glucocorticoids who have an assessment of their fracture risk.
Numerator – the number in the denominator who have an assessment of their fracture risk.
Denominator – the number of adults who use systemic glucocorticoids.
Data source: Local data collection, for example, local audit of patient records.
c) Proportion of adults aged 50 and over who have a history of falls who have an assessment of their fracture risk.
Numerator – the number in the denominator who have an assessment of their fracture risk.
Denominator – the number of adults aged 50 and over who have a history of falls.
Data source: Local data collection, for example, local audit of patient records.
Outcome
Incidence of fragility fractures.
Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and fracture liaison services) ensure that systems are in place for adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, to have an assessment of their fracture risk.
Healthcare professionals (GPs, specialists, specialist nurses and fracture liaison practitioners) assess fracture risk, or confirm that assessment has taken place, in adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, to estimate their risk of fracture and determine their treatment options.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, have their fracture risk assessed.
Adults who have had a fragility fracture or falls in the past, or who are taking steroid treatment have their risk of fracture assessed. Fragility fractures happen in people with fragile bones that break easily, usually older people with osteoporosis. There are treatments available to help prevent fractures in people who are at increased risk. An assessment can help to decide if treatment will reduce the chance of having a fracture.

Source guidance

Osteoporosis: assessing the risk of fragility fracture (2012) NICE guideline CG146, recommendations 1.1 and 1.2

Definitions of terms used in this quality statement

Fragility fracture
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or 'low energy') trauma. The World Health Organization has quantified this as forces equivalent to a fall from a standing height or less. Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur) and wrist (distal radius). They may also occur in the arm (humerus), pelvis, ribs and other bones.
[NICE’s guideline on osteoporosis: assessing the risk of fragility fracture, introduction]
Use of systemic glucocorticoids
Adults currently using systemic glucocorticoids, or who have been using systemic glucocorticoids for more than 3 months, at a dose of prednisolone of 5 mg daily or more (or equivalent doses of other glucocorticoids).
[Expert opinion and The University of Sheffield’s FRAX fracture risk assessment tool]
History of falls
One or more falls in the last 12 months. A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level. Adults aged 50 and over should have a fracture risk assessment if they have a history of falls.
[NICE’s clinical knowledge summary on falls – risk assessment and NICE’s guideline on osteoporosis: assessing the risk of fragility fracture, recommendations 1.1 and 1.2]
Assessment of fracture risk
An assessment of fracture risk should include estimating absolute fracture risk (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage). Either FRAX (without a bone mineral density [BMD] value if a DXA scan has not previously been undertaken) or QFracture should be used within their allowed age ranges. Above the upper age limits defined by the tools, consider people to be at high risk. Measure BMD to assess fracture risk in people aged under 40 years.
[Adapted from NICE’s guideline on osteoporosis: assessing the risk of fragility fracture, recommendations 1.3, 1.4 and 1.9]

Starting drug treatment

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.

Rationale

Fragility fractures can cause substantial pain and severe disability, often leading to a reduced quality of life and sometimes to decreased life expectancy. Taking drug treatment to improve bone density reduces the chance of future fractures and related problems.

Quality measures

Structure
Evidence of local arrangements to ensure that adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local protocols.
Process
Proportion of adults at high risk of fragility fracture receiving drug treatment to reduce fracture risk.
Numerator – the number in the denominator who receive drug treatment to reduce fracture risk.
Denominator – the number of adults at high risk of fragility fracture.
Data source: Local data collection, for example, local audit of patient records. The Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis, who are currently treated with an appropriate bone-sparing agent.
Outcomes
a) Incidence of fragility fractures.
Data source: Local data collection, for example, local audit of patient records.
b) Hospital admission rates for fragility fractures.
Data source: Local data collection, for example, Hospital episode statistics from NHS Digital.

What the quality statement means for different audiences

Service providers (general practices and secondary care services) ensure that systems are in place for adults at high risk of fragility fracture to be offered drug treatment to reduce fracture risk.
Healthcare professionals (GPs, specialists and specialist nurses) are aware of when to prescribe drug treatments to reduce fracture risk, and offer them to adults at high risk of fragility fracture.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults at high risk of fragility fracture are offered drug treatment to reduce fracture risk.
Adults with a high chance of fragility fracture are offered medicine to help strengthen their bones and prevent fractures.

Source guidance

Definitions of terms used in this quality statement

At high risk of fragility fracture
Women with a prior fragility fracture (particularly hip or vertebral fracture) and men and women with a 10-year probability of a major osteoporotic fracture derived from FRAX, above the upper assessment threshold, should be considered for treatment (see table 1). Men and women with a 10-year probability between the upper and lower assessment threshold should be referred for bone mineral density measurement and their fracture probability reassessed. If their 10-year fracture probability is above the intervention threshold after reassessment (see table 1), treatment should be offered.
Table 1. Lower and upper assessment thresholds and intervention thresholds for major osteoporotic fracture probability based on fracture probabilities derived from FRAX (BMI set to 25 kg/m2)
10-year probability of a major osteoporotic fracture (%)
Age (years)
Lower assessment threshold
Upper assessment threshold
Intervention threshold
40
2.6
7.1
5.9
45
2.7
7.2
6.0
50
3.4
8.6
7.2
55
4.5
11
9.4
60
5.9
14
12
65
8.4
19
16
≥70
11
24
20
Reproduced with permission from McCloskey et al. (2015) FRAX-based assessment and intervention thresholds – an exploration of thresholds in women aged 50 years and older in the UK. Osteoporosis International 26 (8), 2091–9
[Adapted from National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 11, recommendation 7]
Drug treatment to reduce fracture risk
Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy).
[Adapted from National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 6]

Equality and diversity considerations

Guidance on treatment to prevent fragility fractures has been focused on treating post-menopausal women, because of their increased risk. Clinicians should ensure that other populations who might benefit from recommended treatments are also considered.  

Adverse effects and adherence to treatment

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults prescribed drug treatment to reduce fracture risk are asked about adverse effects and adherence to treatment at each medication review.

Rationale

People prescribed drugs to prevent fragility fractures sometimes stop taking them because of adverse effects. Adherence to treatment, including taking their medicine by the recommended method, is needed to ensure that fracture risk is reduced effectively. Checking how well a person is managing their treatment at each medication review means that any problems can be discussed and their treatment adjusted if needed, which will improve adherence and quality of life.

Quality measures

Structure
Evidence of local arrangements to ensure that adults prescribed drug treatment to reduce fracture risk are asked about adverse effects and adherence to treatment at each medication review.
Data source: Local data collection, for example, service specifications.
Process
Proportion of medication reviews for adults prescribed drug treatment to reduce fracture risk that include a record of adverse effects and adherence to treatment.
Numerator – the number in the denominator that include a record of adverse effects and adherence to treatment.
Denominator – the number of medication reviews for adults prescribed drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Adults adhering to drug treatment to reduce fracture risk.
Data source: Local data collection, for example, local audit of patient records.
b) Incidence of fragility fracture.
Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and pharmacies) ensure that systems are in place for adults prescribed drug treatment to reduce fracture risk to be asked if they have had any adverse effects and about adherence to treatment at each medication review.
Healthcare professionals (GPs, specialists, specialist nurses and pharmacists) carry out medication reviews with adults prescribed drug treatments to reduce fracture risk. At the reviews, they ask if the person has had any adverse effects and if they are taking their medicine by the recommended method and as prescribed. If any problems are raised, these should be discussed and treatment adjusted if needed, which may involve input from a specialist.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults prescribed drug treatment to reduce fracture risk are asked if they have had any adverse effects and about adherence to treatment at each medication review.
Adults taking medicine to help prevent fractures have regular medicine reviews with their doctor to check if they are having any side effects, such as heartburn or reflux, and that they are taking the medicine correctly. The review gives the chance for any problems to be discussed and treatment can be adjusted if needed to help with side effects.

Source guidance

Definitions of terms used in this quality statement

Drug treatment to reduce fracture risk
Drugs that can be prescribed to prevent fragility fractures include bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid) and non-bisphosphonates (raloxifene, denosumab, teriparatide, calcitriol and hormone replacement therapy).
[Adapted from National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 6]
Medication review
The review should include:
  • asking about adverse effects, including upper gastrointestinal adverse effects (such as dyspepsia or reflux), symptoms of atypical fracture (including new onset hip, groin, or thigh pain), and dental problems
  • asking about adherence to treatment, including following the recommended method of taking the treatment
  • discussing alternative treatment options if adverse effects are unacceptable or the person has difficulty adhering to treatment.
[Expert opinion and NICE’s clinical knowledge summary on osteoporosis – prevention of fragility fractures]

Long-term follow-up

This quality statement is taken from the osteoporosis quality standard. The quality standard defines clinical best practice for managing osteoporosis and should be read in full.

Quality statement

Adults having long-term bisphosphonate therapy have a review of the need for continuing treatment.

Rationale

The optimal duration of bisphosphonate therapy is unclear and there are possible adverse effects of long-term treatment. A medication review for people having long-term bisphosphonate therapy gives the opportunity to consider whether continuing treatment is the best option, or if treatment should be changed or stopped. The response to treatment may also be evaluated to help determine whether to continue treatment.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults taking zoledronic acid for 3 years have a review of the need for continuing treatment.
Data source: Local data collection, for example, local protocols.
b) Evidence of local arrangements to ensure that adults taking alendronate, ibandronate or risedronate for 5 years have a review of the need for continuing treatment.
Data source: Local data collection, for example, local protocols.
Process
a) Proportion of adults taking zoledronic acid for 3 years who have a review of the need for continuing treatment.
Numerator – the number in the denominator who have a review of the need for continuing treatment.
Denominator – the number of adults taking zoledronic acid for 3 years.
Data source: Local data collection, for example, local audit of patient records.
b) Proportion of adults taking alendronate, ibandronate or risedronate for 5 years who have a review of the need for continuing treatment.
Numerator – the number in the denominator who have a review of the need for continuing treatment.
Denominator – the number of adults taking alendronate, ibandronate or risedronate for 5 years.
Data source: Local data collection, for example, local audit of patient records.
Outcomes
a) Patient satisfaction with long-term bisphosphonate therapy.
Data source: Local data collection, for example, patient surveys.
b) Health-related quality of life for adults having long-term bisphosphonate therapy.
Data source: Local data collection, for example, patient surveys.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and pharmacies) ensure that systems are in place for adults having long-term bisphosphonate therapy to have a review of the need for continuing treatment.
Healthcare professionals (GPs, specialists, specialist nurses and pharmacists) offer adults having long-term bisphosphonate therapy a medication review to discuss the risks and benefits of continuing treatment and assess their response to treatment, if needed.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults having long-term bisphosphonate therapy have a review of the need for continuing treatment.
Adults taking a type of medicine called a bisphosphonate over a long time to help prevent fractures have a review to discuss the risks and benefits of continuing with the treatment. They might also have a scan to check whether their bone strength has improved to help decide whether to continue treatment.

Source guidance

Definitions of terms used in this quality statement

Long-term bisphosphonate therapy
Adults who have been taking zoledronic acid for 3 years or alendronate, ibandronate or risedronate for 5 years should have a review of the need for continuing treatment.
[National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 7, recommendation 6]
Review of the need for continuing treatment
Continuation of treatment is recommended for people with any of the following risk factors:
  • age over 75 years
  • previous hip or vertebral fracture
  • one or more low trauma fractures during treatment (after poor adherence to treatment, for example less than 80% of treatment has been taken, and causes of secondary osteoporosis have been excluded)
  • current treatment with oral glucocorticoids of 7.5 mg or more prednisolone/day or equivalent.
For people without risk factors, arrange a dual-energy X-ray absorptiometry (DXA) scan and consider:
  • Continuing treatment if the T-score is less than -2.5, and reassessing fracture risk and bone mineral density (BMD) every 3 to 5 years.
  • Stopping treatment if the T-score is greater than -2.5, and reassessing their fracture risk and BMD after 2 years.
[Adapted from NICE’s clinical knowledge summary on osteoporosis – prevention of fragility fractures and National Osteoporosis Guideline Group’s Clinical guideline for the prevention and treatment of osteoporosis, section 7, recommendation 4]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

Paths in this pathway

Pathway created: September 2016 Last updated: July 2017

© NICE 2017

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