Osteoporosis International

, Volume 17, Issue 12, pp 1808–1814 | Cite as

Using computers to identify non-compliant people at increased risk of osteoporotic fractures in general practice: a cross-sectional study

  • S. de Lusignan
  • J. van Vlymen
  • N. Hague
  • N. Dhoul
Original Article



National guidelines recommend bisphosphonates for secondary prevention of osteoporotic fractures; however, poor compliance may result in sub-optimal prevention.


This study reports the feasibility of using GP electronic records to identify poorly compliant post-menopausal women who may be at increased risk of fragility fractures.


Cross-sectional study of general practice computer records.


Women over 45 years, registered in 29 practices across England with a total population of approximately 200,000.


MIQUEST (Morbidity Information Query and Export Syntax) a data extraction application was used to extract prescription, diagnostic data and probable fragility fractures (hip, vertebral, wrist). All women >45 years who received a first prescription for a weekly bisphosphonate (alendronate or risedronate) at least a year before data extraction were identified. Each record was examined to determine the number of days of prescribed treatment.


Of 97992 registered women, 44% (42734) were >45 years. Prevalence of likely fragility fractures in women over 45 was 5.1% (2195/42734). 3.0% (1286/42734, mean age 72 years) received a prescription for a bisphosphonate in the 360 day period prior to data extraction with a median duration of treatment of 267 days. 45% (584/1286) received prescriptions covering >288/360 days (Medicine Possession Ratio >80%); 13% (161/1286) collected prescriptions covering >360 days. In those prescribed bisphosphonates, 23% (294/1286) had a likely fragility fracture.


Women >45 years with probable fragility fractures are more likely to be prescribed bisphosphonates, though less than half will be actually taking them as prescribed. GPs should use computer technology to identify poorly compliant patients who are unnecessarily at risk of fracture.


Biphosphonates Computerised Fractures Medical records systems Osteoporosis Patient compliance Postmenopausal Spontaneous Treatment refusal 


  1. 1.
    Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 348(9041):1535–1541PubMedCrossRefGoogle Scholar
  2. 2.
    Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, Chesnut CH 3rd, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD (1999) Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomised controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA 282(14):1344–1352PubMedCrossRefGoogle Scholar
  3. 3.
    Delmas PD, Ensrud KE, Adachi JD, Harper KD, Sarkar S, Gennari C, Reginster JY, Pols HA, Recker RR, Harris ST, Wu W, Genant HK, Black DM, Eastell R (2002) Mulitple Outcomes of Raloxifene Evaluation Investigators. Efficacy of raloxifene on vertebral fracture risk reduction in postmenopausal women with osteoporosis: four-year results from a randomised clinical trial. J Clin Endocrinol Metab 87(8):3609–3617PubMedCrossRefGoogle Scholar
  4. 4.
    Chesnut CH 3rd, Skag A, Christiansen C, Recker R, Stakkestad JA, Hoiseth A, Felsenberg D, Huss H, Gilbride J, Schimmer RC, Delmas PD (2004) Oral Ibandronate Osteoporosis Vertebral Fracture Trial in North America and Europe (BONE). Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis. J Bone Miner Res 19(8):1241–1249CrossRefGoogle Scholar
  5. 5.
    Recker RR, Gallagher R, MacCosbe PE (2005) Effect of dosing frequency on bisphosphonate medication adherence in a large longitudinal cohort of women. Mayo Clin Proc 80(7):856–861PubMedCrossRefGoogle Scholar
  6. 6.
    McCombs JS, Thiebaud P, McLaughlin-Miley C, Shi J (2004) Compliance with drug therapies for the treatment and prevention of osteoporosis. Maturitas 48(3):271–287PubMedCrossRefGoogle Scholar
  7. 7.
    Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA, Fujiwara S, Kroger H, Mellstrom D, Meunier PJ, Melton LJ 3rd, O’Neill T, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20(7):1185–1194PubMedCrossRefGoogle Scholar
  8. 8.
    Caro JJ, Ishak KJ, Huybrechts KF, Raggio G, Naujoks C (2004) The impact of compliance with osteoporosis therapy on fracture rates in actual practice. Osteoporos Int 15(12):1003–1008PubMedCrossRefGoogle Scholar
  9. 9.
    Pols HA, Felsenberg D, Hanley DA, Stepan J, Munoz-Torres M, Wilkin TJ, Qin-sheng G, Galich AM, Vandormael K, Yates AJ, Stych B (1999) Multinational, placebo-controlled, randomised trial of the effects of alendronate on bone density and fracture risk in postmenopausal women with low bone mass: results of the FOSIT study. Foxamax International Trial Study Group. Osteoporos Int 9(5):461–468PubMedCrossRefGoogle Scholar
  10. 10.
    Huybrechts KF, Ishak KJ, Caro JJ (2005) Assessment of compliance with osteoporosis treatment and its consequences in a managed care population. Bone Dec 1 [Epub ahead of print]Google Scholar
  11. 11.
    National Institute for Clinical Excellence (NICE) Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. London; NICE Technology Appraisal 87, 2005Google Scholar
  12. 12.
    de Lusignan S, Chan T, Wood O, Hague N, Valentin T, Van Vlymen J (2005) Quality and variability of osteoporosis data in general practice computer records: implications for disease registers. Public Health. 119(9):771–780PubMedCrossRefGoogle Scholar
  13. 13.
    Mitchell E, Sullivan F (2001) A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980–1997. BMJ 322(7281):279–282PubMedCrossRefGoogle Scholar
  14. 14.
    de Lusignan S, Valentin T, Chan T, Hague N, Wood O, van Vlymen J, Dhoul N (2004) Problems with primary care data quality: osteoporosis as an exemplar. Inform Prim Care 12(3):147–156Google Scholar
  15. 15.
    de Lusignan S, Chan T, Stevens P, O’Donoghue D, Hague N, Dzregah B, Van Vlymen J, Walker M, Hilton S (2005) Identifying patients with chronic kidney disease from general practice computer records. Fam Pract 22(3):234–241PubMedCrossRefGoogle Scholar
  16. 16.
    de Lusignan S, Hague N, Brown A, Majeed A (2004) An educational intervention to improve data recording in the management of ischaemic heart disease in primary care. J Public Health (Oxf) 26(1):34–37CrossRefGoogle Scholar
  17. 17.
    de Lusignan S, Chan T, Wells S, Cooper A, Harvey M, Brew S, Wright M (2003) Can patients with osteoporosis, who should benefit from implementation of the national service framework for older people, be identified from general practice computer records? A pilot study that illustrates the variability of computerised medical records and problems with searching them. Public Health 117(6):438–445PubMedCrossRefGoogle Scholar
  18. 18.
    van Vlymen J, de Lusignan S, Hague N, Chan T, Dzregah B (2005) Ensuring the Quality of Aggregated General Practice Data: Lessons from the Primary Care Data Quality Programme (PCDQ). Stud Health Technol Inform 116:1010–1015PubMedGoogle Scholar
  19. 19.
    van Vlymen J, de Lusignan S. A system of metadata to control the process of query, aggregating, cleaning and analysing large datasets of primary care data. Accepted for publication. Informatics in Primary Care September 2005Google Scholar
  20. 20.
    Clinical Information Consultancy. MIQUEST (Morbidity Information Query and Export Syntax). URL: http://www.clininfo.co.uk/main/miquest.htm
  21. 21.
    NHS Public Health Network. Directly age-standardised rates. Downloaded from: http://www.avon.nhs.uk/phnet/methods/directly_age_standardised_rates.htm. Accessed 3rd July 2005
  22. 22.
    National Statistics. Population Trends 2003; 113 (Autumn): 45 (Table 1.4). Downloaded from: http://www.statistics.gov.uk/downloads/theme_population/PT113.pdf. Accessed 3rd July 2005
  23. 23.
    Sanders KM, Nicholson GC, Watts JJ, Pasco JA, Henry MJ, Kotowicz MA, Seeman E (2006) Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost-effective? Bone 38(5):694–700PubMedCrossRefGoogle Scholar
  24. 24.
    Krueger KP, Felkey BG, Berger BA (2003) Improving adherence and persistence: a review and assessment of interventions and description of steps toward a national adherence initiative. J Am Pharm Assoc 43(6):668–678CrossRefGoogle Scholar
  25. 25.
    Richter A, Anton SE, Koch P, Dennett SL (2003) The impact of reducing dose frequency on health outcomes. Clin Ther 25(8):2307–2335PubMedCrossRefGoogle Scholar
  26. 26.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359(9319):1761–1767PubMedCrossRefGoogle Scholar
  27. 27.
    Holt G, Khaw KT, Reid DM, Compston JE, Bhalla A, Woolf AD, Crabtree NJ, Dalzell N, Wardley-Smith B, Lunt M, Reeve J (2002) Prevalence of osteoporotic bone mineral density at the hip in Britain differs substantially from the US over 50 years of age: implications for clinical densitometry. Br J Radiol 75(897):736–742PubMedGoogle Scholar
  28. 28.
    Vik SA, Maxwell CJ, Hanley DA (2005) Treatment of osteoporosis in an older home care population. BMC Musculoskelet Disord 6(1):7PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2006

Authors and Affiliations

  • S. de Lusignan
    • 1
  • J. van Vlymen
    • 1
  • N. Hague
    • 1
  • N. Dhoul
    • 1
  1. 1.Community Health SciencesSt. George’s University of LondonLondonUK

Personalised recommendations