Improving Compliance with Bone Health Assessment in Elderly Patient Admissions: A Closed-Loop Audit Against NOGG Guidance

Introduction 

Fragility fractures are associated with increased morbidity and mortality in the elderly population. The National Osteoporosis Guideline Group (NOGG) guidance recommends fracture risk assessment (FRAX), blood tests, and DEXA scan where indicated for patients admitted with falls. This audit evaluates whether formal bone health assessments were consistently completed and documented following admission to the Older People’s Medicine (OPM) wards at Norfolk and Norwich University Hospital, risking missed opportunities for fracture prevention in a high-risk population. 

Methods 

Patients admitted following a fall to OPM (n=109) over a one-week period were included in the first cycle audit. Patient electronic records with blood and imaging requests were reviewed prospectively for documented FRAX score calculation, DEXA scan requests, vitamin D and calcium testing. Interventions consisted of a department-wide teaching session, poster displays on the wards, and email reminders on the NOGG guideline. A second cycle audit (n=91) was conducted 3 months after the intervention to investigate for improvement in formal bone health assessment. Results FRAX documentation (0.0% to 2.2%), vitamin D level assessment (16.5% to 22.0%), and documentation of prior DEXA imaging (8.3% to 12.1%) have improved across the department. Calcium assessment (50.5% to 40.7%) and in-admission DEXA requests (3.7% to 2.2%) fell. None of the observed changes reached statistical significance in both audit cycles. 

Conclusion 

Educational interventions did not significantly improve adherence to recommended bone health assessment. Persistently low compliance may therefore reflect competing clinical priorities, fragmented documentation, and the absence of structured bone health assessment within routine admission processes. These findings suggest that improving inpatient bone health assessment is primarily an implementation and workflow challenge rather than a knowledge gap alone. Future quality-improvement projects should prioritise system-level interventions, including electronic FRAX prompts, standardised admission templates, and embedded clinical decision-support tools.