As a general practitioner, you automatically prioritise diseases according to:
- your patient’s reasons for encounter
- perceived seriousness (conditions that need to be addressed)
- perceived urgency (conditions that need to be dealt with in the immediate consultation).
In the following pre-activity, we are interested in how you prioritise some of the common conditions you see in general practice.
Pre-activity questionnaire
Part one - prioritisation matrix
DRAG AND DROP...
Referring to the four-quadrant matrix below, please drag and drop each of the following conditions to the appropriate quadrant. As these conditions are presented without patient context, please consider in general terms whether you would rate the condition as serious or not serious and urgent or not-urgent.
HT - Hypertension T2D –Type 2 diabetes OP - Osteoporosis UTI - Urinary Tract Infection OA - Osteoarthritis
Please complete the question.
Pre-activity questionnaire
PART TWO - CASE STUDIES
Hypothetical patient
Mrs Flava aged 74 years
Asthma and COPD diagnosed aged 58 years — long-term inhaled corticosteroid plus long-acting beta2-agonist use required, oral corticosteroids used periodically to control flare-ups of COPD.
Smoker — 38 pack-year history.
Type 2 diabetes diagnosed 10 years ago — treated with metformin/gliptin fixed-dose combination, most recent HbA1c 7.8%.
Scenario 1
Reason for encounter: “Doctor I am visiting today for a repeat prescription for my inhaler.”
In addition to Mrs Flava’s repeat prescription, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Flava in this consultation?
Please enter.
Scenario 2
Reason for encounter: “Doctor I have seen some information about bowel cancer and I am wondering whether I need to get checked?”
In addition to discussing bowel cancer screening, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Flava in this consultation?
Please enter.
All fields highlighted are mandatory.
Pre-activity questionnaire
PART TWO - CASE STUDIES
Hypothetical patient
Mrs Bambinetti aged 61 years
Anxiety disorder diagnosed 10 years ago, recently ceased her SSRI and is using CBT.
Atrial fibrillation diagnosed 4 years ago - treated with non-Vitamin K antagonist oral anticoagulant.
Chest X-ray taken following a recent bout of pneumonia: Radiologist reports 2 moderate wedge fractures at T7, T8. She reports no history of trauma.
Scenario 1
Reason for encounter: “Doctor, I finished my antibiotics for my pneumonia a week ago and you asked me to come back for a follow-up appointment.”
In addition to assessing Mrs Bambinetti’s pneumonia recovery, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Bambinetti in this consultation?
Please enter.
Scenario 2
Reason for encounter: “Doctor, I have come in today for my annual flu shot.”
In addition to Mrs Bambinetti’s flu shot, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Bambinetti in this consultation?
DEXA ordered after she recently broke her wrist in a fall after tripping over her cat in the lounge room. BMD T-score lumbar spine –2.6, femoral neck –1.9.
PART FOUR - STRENGTHENING THE CRITICAL CONSULTATIONS
How often do you initiate discussions about osteoporosis prevention with your patients aged over 50 years?
Patients at risk of osteoporosis often have multimorbidity and priorities within each consultation that need to be established. What would prompt you to consider osteoporosis to be serious and urgent enough to prioritise for investigation in a consultation?
Osteoporosis is asymptomatic until a fracture occurs, however the majority of vertebral fractures do not come to clinical attention.1 A patient with a vertebral fracture today is at 2.3-fold increased risk of becoming a patient with a hip fracture in the future.2
Based on your knowledge of the patients in your practice, identify five patients who you will review during their next consultation for either kyphosis or loss of height ≥3cm – both of which are indicators of vertebral fractures.3 Alternatively, you may have a recent chest X-ray in your records that you could assess for compression or wedge vertebral fractures.
1
2
3
4
5
1. Lewiecki EM. Cleve Clin J Med 2009;76:457–66.
2. Sambrook P, Cooper C. Lancet 2006;367:2010–18
3. The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd ed. East Melbourne, Vic: RACGP, 2017.
All fields highlighted are mandatory.
Success.
Back in practice activity
PART ONE – IDENTIFYING PATIENTS AT RISK
This activity requires you to be back in your practice to complete. There are three parts to the activity:
To complete part one of this back-in-practice activity you need to gather some information from your practice system for a total of NINE patients.
These patients can be from any of the three categories defined below. Please complete and save an entry per patient, adding patients to the appropriate category until you reach a total of nine.
We recommend that you collect the information requested first and then complete the relevant sections below. Once you have the information, completing part one should take no more than 10 to 15 minutes.
Tip: You can opportunistically assess patients who visit your surgery over the next few weeks OR you can actively search your database to identify relevant patients for evaluation.
Category 1 - Patients aged over 70 years with at least two additional risk factors for osteoporosis (e.g. gender, physical inactivity, smoking, concomitant disease) without a diagnosis for osteoporosis
Category 3 - Patients diagnosed with osteoporosis and initiated on treatment who have not visited the surgery for 12 months or longer (potentially non-adherent)
Identify ONE process or system that you will introduce into your practice to assist you to identify patients whose risk of fracture is serious and requires evaluation.
How will you routinely identify risk of osteoporosis in: (please select)
Patients aged over 70 years
Example practice system: Each year set a database flag for each patient who will be turning 70 to discuss their bone health
OR
Patient aged over 50 years with a history of fracture in the last 12months
Example practice system: Set a database flag for each patient aged over 50 to ask about their fracture history in the past year, and if they have fractured, assess whether it was a minimal trauma (fragility) fracture
The system I will introduce into my practice is:
What strategies will you utilise to ensure the practice team understand the need for this system change and that it is implemented practice-wide?
Reviewing your approach to discussions about bone health
Using your most recent day in practice, review the list of patients you consulted with and identify any patients without a diagnosis of osteoporosis who fall into a risk category for osteoporosis.
Number of patients identified
Have you discussed bone health or risk of fragility fracture with any of these patients?
Are there any patients you haven’t yet discussed bone health with whom you would proactively raise bone health in the next consultation?
TIP: Make a note in the file of patients you will proactively discuss bone health with next time they visit.
Consider proactive bone health discussions
Having completed this review do you think it is valuable to identify patients who would benefit from a discussion about discuss bone health and risk of fragility fracture and make a note in their file to discuss bone health at their next visit?
All fields highlighted are mandatory.
Back in practice activity
PART THREE – ASSESSMENT OF LEARNING OUTCOMES
How have/will you facilitate the prioritisation of consultations for chronic disease?
What factors do/will you consider when selecting treatment for osteoporosis?
What factors do/will you consider to determine the management needs of individuals at risk of fragility fracture?
How do/will you approach the development of education strategies to improve self-management?
How do/will you assess the risk of non-adherence in your patients with osteoporosis?
Tel: +61 (2) 9870 1333 Fax: +61 (2) 9870 1344. ABN 31 051 057 428. SC-AUS-AMG162-00555 Approved May 2020.
REINFORCING ACTIVITY QUESTIONNAIRE
Part one - prioritisation matrix
As a general practitioner, you automatically prioritise diseases according to:
- your patient’s reasons for encounter
- perceived seriousness (conditions that need to be addressed)
- perceived urgency (conditions that need to be dealt with in the immediate consultation).
In this reinforcing activity, we ask you to revisit how you prioritise some common conditions you see in general practice.
REINFORCING ACTIVITY QUESTIONNAIRE
Part one - prioritisation matrix
DRAG AND DROP...
Referring to the four-quadrant matrix below, please drag and drop each of the following conditions to the appropriate quadrant. As these conditions are presented without patient context, please consider in general terms whether you would rate the condition as serious or not serious and urgent or not-urgent.
HT - Hypertension T2D –Type 2 diabetes OP - Osteoporosis UTI - Urinary Tract Infection OA - Osteoarthritis
Please complete the question.
REINFORCING ACTIVITY QUESTIONNAIRE
PART TWO - CASE STUDIES
Hypothetical patient
Mrs Flava aged 74 years
Asthma and COPD diagnosed aged 58 years — long-term inhaled corticosteroid plus long-acting beta2-agonist use required, oral corticosteroids used periodically to control flare-ups of COPD.
Smoker — 38 pack-year history.
Type 2 diabetes diagnosed 10 years ago — treated with metformin/gliptin fixed-dose combination, most recent HbA1c 7.8%.
Scenario 1
Reason for encounter: “Doctor I am visiting today for a repeat prescription for my inhaler.”
In addition to Mrs Flava’s repeat prescription, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Flava in this consultation?
Please enter.
Scenario 2
Reason for encounter: “Doctor I have seen some information about bowel cancer and I am wondering whether I need to get checked?”
In addition to discussing bowel cancer screening, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Flava in this consultation?
Please enter.
All fields highlighted are mandatory.
REINFORCING ACTIVITY QUESTIONNAIRE
PART TWO - CASE STUDIES
Hypothetical patient
Mrs Bambinetti aged 61 years
Anxiety disorder diagnosed 10 years ago, recently ceased her SSRI and is using on CBT.
Atrial fibrillation diagnosed 4 years ago - treated with non-Vitamin K antagonist oral anticoagulant.
Chest X-ray taken following a recent bout of pneumonia: Radiologist reports 2 moderate wedge fractures at T7, T8. She reports no history of trauma.
Scenario 1
Reason for encounter: “Doctor, I finished my antibiotics for my pneumonia a week ago and you asked me to come back for a follow-up appointment.”
In addition to assessing Mrs Bambinetti’s pneumonia recovery, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Bambinetti in this consultation?
Please enter.
Scenario 2
Reason for encounter: “Doctor, I have come in today for my annual flu shot.”
In addition to Mrs Bambinetti’s flu shot, which (if any) of the following comorbidities would you consider serious and urgent enough to discuss with Mrs Bambinetti in this consultation?
DEXA ordered after she recently broke her wrist in a fall after tripping over her cat in the lounge room. BMD T-score lumbar spine –2.6, femoral neck –1.9.
PART FOUR - STRENGTHENING THE CRITICAL CONSULTATIONS
1. I will recommend a DEXA scan to check bone mineral density to my patients aged 70 years and over.
Barrier:
Strategy to overcome barrier:
2. I will prioritise a discussion about osteoporosis with patients over the age of 50.
Barrier:
Strategy to overcome barrier:
3. I will determine if a fracture is a minimal trauma fracture with patients over the age of 50.
Barrier:
Strategy to overcome barrier:
4. I will set up database reminders to follow-up patients when their osteoporosis medication script renewal is due.
Barrier:
Strategy to overcome barrier:
5. I will include bone health in a GP Management Plan for multimorbid patients with osteoporosis.
Barrier:
Strategy to overcome barrier:
The steering committee will be developing a publication on the impact of the Critical Consultations in Osteoporosis program. Your responses will be deidentified and aggregated for inclusion in this publication.
Please indicate if you DO NOT consent to your responses being part of this collated data set.
All fields highlighted are mandatory.
Thank you for participating in Critical Consults in Osteoporosis online. Please provide us with your feedback.
1. Please identify your top two learning points from the learning activity:
2. Has your participation in this activity influenced how you will prioritise osteoporosis with your patients? If so, how?
3. Please rate the degree the learning outcomes were met by selecting the relevant answer
After participating in this activity, I will be able to:
Prioritise consultations for chronic disease, such as osteoporosis, to ensure timely diagnosis and effective ongoing management to reduce risk of fracture.
Assess the characteristics and preferences of the patient in order to individualise appropriate treatment of osteoporosis.
Determine individual need for treatment and lifestyle modifications to reduce fracture risk.
Design education strategies to enhance patients' understanding of their disease to improve self-management in chronic diseases.
Create practice systems to support patient adherence to their management plan.
4. Please rate the degree your individual learning needs were met
5. Please rate how relevant this activity is to your practice
6. Please rate the delivery of the education:
Online modules
Back-in-practice activity
7. Please rate content:
Overall scientific quality
Fairness and balance of content
Suitability of format
8 . Does this activity motivate you to change systems or processes in your practice that would improve patient safety?
If yes, describe what changes you would make:
9. On a scale of 1–10, how likely are you to recommend Critical Consults in Osteoporosis ONLINE to a colleague?
(Highly unlikely)
(Highly likely)
10. Are there any other topics in relation to osteoporosis that you would like to know more about?
11. Do you have any comments or suggestions for improving the format or program as a whole?
This website is intended for Australian healthcare professionals only.
This activity challenges you to think about approaching consultations with patients with chronic disease in a new way; optimising individual interactions to increase the efficiency and effectiveness of long-term chronic disease management.
Why focus on osteoporosis?
The effects of a fracture due to osteoporosis can be serious, yet it remains an underdiagnosed and undertreated disease.4
Less than 20% of patients with a minimal trauma fracture are investigated for osteoporosis.4
Critical Consults in Osteoporosis ONLINE provides critical information and evidence to support increasing the priority of the diagnosis and management of osteoporosis.
References:
1. Watts JJ, et al. Osteoporosis costing all Australians: A new burden of disease analysis 2012 to 2022. Osteoporosis Australia 2013.
2. PBS criteria for treatment. Available from http://www.pbs.gov.au
3. Henry MJ, et al. J Clin Densitom 2000;3:261–68.
4. Osteoporosis National Action Plan Working Group. Osteoporosis National Action Plan 2016, Sydney, 2016.
Congratulations, you have now completed this module. Your e-certificate is available for download from the main menu.
Thank you for registering for Critical Consults in Osteoporosis ONLINE.
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Critical Consults in Osteoporosis ONLINE is a CPD Accredited Activity worth 40 points in the RACGP CPD program or 4.5 CPD hours in the ACRRM PDP. The program consists of 11 modules; you can work through these in your own time but to be eligible for points please complete all 11 modules. Once you have completed Modules 1 to 10 you will be reminded to complete the final Module 11 within four weeks. Points will then be awarded and you will be able to access and print a statement of completion for your records.
Modules 2 to 8 take approximately 15 minutes each to complete online. You can revisit the site as often as you like to work your way through these modules. Module 10, the back-in-practice component of Critical Consults in Osteoporosis, is a key part of the education activity that asks you to gather information and report back on 9 patients in your practice.
Learning outcomes
After completing this activity you will be able to:
Prioritise consultations for chronic disease to ensure timely diagnosis and effective ongoing management
Assess the characteristics and preferences of the patient to individualise appropriate treatment of osteoporosis
Determine individual need for treatment and lifestyle modifications to reduce fracture risk
Design education strategies to enhance patients’ understanding of their disease to improve self-management in chronic diseases
Create practice systems to support adherence to management plans
This activity has been developed in consultation with an expert steering committee:
Professor Deborah Saltman AM, General Practitioner and Honorary Professor in the Faculty of Medicine at Imperial College and the University of Sydney and Visiting Professor at the University of Technology, Sydney (Chair)
Professor Peter Ebeling AO, Professor of Medicine, Monash University, VIC
Dr Jane Elliott, General Practitioner, North Adelaide, SA
Dr Chrys Michaelides, General Practitioner, Woolloongabba, QLD
Dr Anita Sharma, General Practitioner, Chermside, QLD
Dr Simon Vanlint, General Practitioner, Adelaide, SA