Around 3.5 million people over the age of 50 are affected by osteoporosis in the UK, with an estimated cost to the NHS of £4.5 billion per year.1 It is estimated that one in five men and one in three women over 50 fracture bones due to osteoporosis. The most serious fracture types tend to be vertebral and hip fractures. These can be associated with problems such as pain, disability and sometimes even death.2
Osteoporosis specialist nurses are experts in the field of this and other bone conditions, and they have the benefit of being able to review patients in a timely manner, thereby increasing patient satisfaction. Patients can be directly referred to the service from both primary and secondary care. As osteoporosis nurses are autonomous practitioners, they can initiate tests, review and interpret results, prescribe treatments if required, monitor, and discharge where appropriate.3 This results in a service which benefits patients: in addition to being more accessible, specialist nurses can offer continuity of care and reduce the consultant burden.3
PRACTICALITIES OF RUNNING THE SERVICE
Our current nurse-led osteoporosis service operates from Monday to Thursday with two nurses (one band 6 and one band 7), covering seven clinics per week between them. A typical clinic includes new and follow-up patients.
For new patients, we would usually organise a bone density scan (dual-energy X-ray absorptiometry; DXA) and a variety of baseline blood tests. The initial consultation with the patient includes fracture history, past medical/surgical history, social history and a falls risk assessment. Once an individual’s results have been reviewed and assessed, these are discussed with the patient and a fracture risk assessment (FRAX)4 is carried out. A plan of action is then mutually agreed with the patient. This usually incorporates oral, intravenous or subcutaneous treatments or monitoring only.
'As osteoporosis nurses are autonomous practitioners, they can initiate tests, review and interpret results, prescribe treatments if required, monitor, and discharge where appropriate.'
In the case of follow-up patients, DXA scans are usually performed every 2–3 years, or as often as clinically indicated. Patients are reviewed in clinic. Blood tests are usually carried out, including bone turnover markers, which indicate whether further treatment is needed or whether the patient can commence a treatment holiday. Treatments are evaluated for tolerability, efficacy and rare side effects, such as atypical femoral fracture and osteonecrosis of the jaw or auditory canal.
The osteoporosis specialist nurses refer patients to their local falls clinic if necessary. They also operate a telephone advice line, liaise with other members of the multidisciplinary team and attend meetings and conferences. Part of the role of the specialist nurse is health promotion, which includes dispensing advice such as regular weight-bearing exercise, plenty of dietary calcium and regular vitamin D supplements, as well as minimal alcohol and no smoking.5,6
Working within the NHS can be challenging in terms of time, manpower, space, resources and workload, though the advent of COVID-19 has presented unprecedented challenges.
Pre-COVID-19, one of the challenges experienced in the nurse-led osteoporosis service was capacity – limited clinic space and a shared office. Other challenges included the telephone helpline: this is an excellent point of access for patients but, depending on the nature of the call, it can be time-consuming. Secretarial support can be variable, and letters dictated from clinic can be delayed by several weeks, which can delay management for patients who are being treated by their GP.
RISING TO THE COVID CHALLENGE
Due to the SARS-CoV-2 pandemic, all outpatient clinical activity was cancelled immediately. This led to a reduced service and redeployment of one member of staff to the COVID wards. The remaining osteoporosis nurse ran a basic service, ensuring treatments were delivered in a timely manner. The phone calls on the telephone helpline escalated during this time, as our patients were anxious and concerned about their diagnoses and treatments.
During the pandemic, when face-to-face clinic appointments were cancelled, GPs aided the delivery of our service. Some were able to offer blood tests and, due to a shared-care protocol, were able to organise and administer some 6-monthly injections of denosumab. This ensured the patient was not at an increased risk of vertebral fracture. Arrangements were made to deliver injections to the homes of patients who were able to self-inject. District nurses were organised to inject patients who were shielding at home. Occasional patients were given their injections in clinic if there was no viable alternative.
'Arrangements were made to deliver injections to the homes of patients who were able to self-inject. District nurses were organised to inject patients who were shielding at home.'
At the time of writing (early January 2021), we are mainly offering telephone appointments, with only around 20% of patients being seen face- to-face. However, due to the demographic of our patients, some are hard of hearing and do not like speaking on the telephone.
The benefit to the patient of a telephone appointment is that there is no travelling to a hospital site or problems with parking or locating the outpatient clinic. This reduces cancellations and pressures on hospital transport. Also, patients who are at risk and shielding avoid the risk of exposure to COVID-19 in the hospital.
GPs can undertake blood tests, and treatments can still be offered. However, GPs are unable to request measurement of bone turnover markers, and some are unable to test for vitamin D. This delays treatment, as patients must attend hospital for these tests. Additionally, osteoporotic patients are at a higher risk of fracturing their vertebrae and may need X-rays, which can only be offered after a physical review.
Overall, even with the difficulties experienced during the pandemic, the resilience of the staff and patients means that an expert service can still operate well, and provide safe and effective care for patients.
CAROLINE JAGGER AND WENDY ROWE
Osteoporosis Specialist Nurses, Manchester Royal Infirmary
- International Osteoporosis Federation 2021 Key Statistics for Europe www.osteoporosis.foundation/facts-statistics/key-statistic-for-europe.
- Svedbom A et al. 2013 Archives of Osteoporosis 8 137.
- Khair K & Chaplin S 2018 Journal of Haemophilia Practice doi:10.17225/ jhp00100.
- University of Sheffield 2019 FRAX Version 4.2 www.sheffield.ac.uk/FRAX.
- Royal Osteoporosis Society 2020 https://theros.org.uk/information-and-support/bone-health/bone-health-checklist.
- Abrahamsen B et al. 2014 BoneKEy Reports 3 574.