Improving Bone Health Assessment in Older Inpatients Living with Frailty: A Closed-Loop Audit

Introduction

Fragility fractures are associated with substantial morbidity and mortality in older people. National Osteoporosis Guideline Group (NOGG) guidance recommends formal fracture-risk assessment in patients >50 or postmenopausal with risk factors for fragility fracture, including frailty. All patients admitted to the Older People’s Medicine (OPM) wards included in this audit had documented frailty (Clinical Frailty Scale ≥ 6). This closed-loop audit aimed to improve fracture-risk and wider bone-health assessment and documentation in this high-risk population.

Methods

Patients admitted to OPM wards at Norfolk and Norwich University Hospital over one week were included in cycle one (n=109). Electronic records, blood results and imaging requests were prospectively reviewed. Fracture Risk Assessment Tool (FRAX) documentation was assessed in patients not already receiving bisphosphonate therapy (n=101). Secondary measures across the whole cohort included vitamin D and calcium testing, previous dual-energy X-ray absorptiometry (DEXA) imaging and DEXA requests during admission. Interventions comprised department-wide teaching, ward posters and email reminders regarding NOGG guidance. Cycle two was conducted four months later (n=91; n=86 not receiving bisphosphonates). Differences were assessed using two-sided Fisher’s exact tests.

Results

Among patients not receiving bisphosphonates, FRAX documentation remained very low, increasing from 0/101 (0.0%) to 1/86 (1.2%; p=0.460). Across the whole cohort, vitamin D assessment increased from 18/109 (16.5%) to 20/91 (22.0%; p=0.368), while calcium assessment decreased from 55/109 (50.5%) to 37/91 (40.7%; p=0.200). Documentation of previous DEXA increased from 9/109 (8.3%) to 11/91 (12.1%; p=0.479), while inpatient DEXA requests decreased from 4/109 (3.7%) to 2/91 (2.2%; p=0.689). No changes between the audit cycles reached statistical significance.

Conclusions 

Despite educational interventions, formal fracture-risk assessment and documentation remained low. The limited impact of education could suggest competing clinical priorities and under-documentation of FRAX. Future improvement should focus on system-level interventions, including electronic FRAX prompts and standardised admission templates incorporating bone-health assessment, to better integrate bone health assessment into clinical practice.