Clinical guideline adherence in the primary care management of osteoporosis

Background and objective To test a medication assessment tool (MAT) used for application to a database of patient records. To demonstrate its use in the evaluation of the level of adherence to osteoporosis guidelines in two practices.
Design Retrospective survey with the application of a tool specifically designed for medication assessment in this field (21 criteria, each representing a separate guideline recommendation). Setting Patients diagnosed with osteoporosis or osteopenia in records from the databases (GPASS) in two general medical practices; A (n = 154) and B (n = 62). Main outcome measures Inter-rater reliability of the tool. Percent applicability and adherence to each criterion and total adherence. Comparison of prescribing outcomes between the two practices.
Results The inter-rater reliability testing of the MAT by two independent
raters for applicability and adherence showed mean agreements of 99.1% (minimum 89.6% with 100% shown in 15/21) and 99.6% (minimum 95% with 100% shown in 18/21), respectively. In the study overall guideline adherence was 61.9% (95% CI: 59.7 and 64.1%). Comparison between the two practices showed higher adherence (P\0.0001; Fisher) in practice A than in practice B; 65.8% (95% CI: 62.3, 69.3; n = 2,926 criteria applied in 154 patients) compared with 52.1% (95% CI: 47.8 and 56.4%; n = 1,178 criteria applied in 62 patients).
Of the 200 patients with osteoporosis, 111/200 (55.5%) received bisphosphonates; 76 (38.0%) were untreated; and 19 (22.6%) received only vitamin D and calcium. Of all patients with osteoporosis alendronate was the bisphosphonate first used in 97/195 (49.7%). There were 33/200 (16.5%) secondary prevention candidates and 21/ 33 (63.6%) received a bisphosphonate. Overall only 2 patients no treated with a bisphosphonate were treated with an alternative (strontium ranelate). Conclusions The tool offers systematic and reliable audit using a database search facility to enable large scale audit of medication use in osteoporosis. The identification of an overall non-adherence of
38.1% to clinical guidelines represents a first stage in addressing pharmaceutical care issues prior to informed discussion between pharmacist prescribing advisor and general medical practitioners.