Osteoporosis (OP) is a common process in rheumatology consultations. A cross-sectional study conducted in the Community of Madrid, that studied the healthcare activity of 41 rheumatologists with data from a total of 2311 patients, showed that metabolic bone disease was the most frequent reason for consultation, 19.7% of consultations, ahead of peripheral osteoarthritis (16%) and soft tissue disease (14%).1

In 2010, an estimated 21% of women and 5% of men>50 years of age in Spain suffered from OP.2 The care process for postmenopausal OP generally starts in primary care (PC), and some cases are referred to specialist care.

Concern about OP, both in the healthcare setting and in the population, leads to the frequent use of diagnostic tests and treatments; it is a major healthcare problem that needs to be improved.

The high prevalence of OP, the complexity of its management due to the many professionals involved and the importance of the role of the rheumatologist as the leader of this process, prompted this improvement group that set out to study current the clinical management of OP by rheumatology specialists. Opinion studies on the perception of rheumatologists can be a good method for detecting healthcare problems and identifying areas for improvement in clinical management and quality of care for these patients by consensus.3 Along the same lines, consensus documents seek to reach agreement on controversial issues such as, in this case, the management of OP by rheumatologists.4

The aim of this study, therefore, was to identify and analyse the organisational and clinical approach adopted by rheumatologists in the management of OP in Spain to define strategic lines and priorities and establish a list of quality indicators and standards to enable better management and continuous improvement in the care of OP and its complications.

The study design was qualitative and quantitative, and the approach was based on the consensus technique. The project was conducted between September 2017 and December 2018 with a mixed method, in 2 stages, combining a qualitative and quantitative approach.5

Qualitative research is considered particularly appropriate in the exploratory phase of a project; through it an in-depth understanding can be gained of individual experiences, opinions and beliefs associated with an object of study.6 To this end, a focus group was held with rheumatology experts who raised key issues in the care of the OP patient. The expert rheumatology opinion was based on more than 15 years’ clinical experience in the care and management of consultations, including OP.

The qualitative phase, given its inductive nature and limited representativeness, justifies a second quantitative phase to measure and weigh up the facts. In this second phase, data were collected from a sample of professionals through a self-administered online survey on the aspects previously identified by the experts. Since the ultimate aim of the work was to define strategic lines of action, a Delphi round was then conducted with the group of experts who prioritised the decisions to be taken. In total, 2 Delphi rounds were performed via e-mail.

This paper presents the first consensus document on strategic priorities in OP from the rheumatologist’s perspective.

Several European medical associations support quality access to rheumatology services for the care of rheumatic diseases, including OP.7 This position is in contrast with the fact that about half the rheumatologists had no concrete idea of the position of OP compared to other rheumatic diseases. However, it is striking how often other specialties refer patients with OP to our clinics, giving us the lead in this disease. OP is included in the programme of the speciality and rheumatologists can lead OP in the same way as, for example, systemic autoimmune diseases. In our opinion, the areas for improvement identified in the survey pave the way for rheumatology to lead the field in OP.

There have been some new developments in recent years that affect the management of OP, such as the importance of secondary fracture prevention, generalised computerised histories and telematic connection with PC.

In this survey, the volume of total and new patients is 10–11 and 3.4 per week, respectively, while in a study of bone metabolism units in Spain it was 20 and 15 per week, respectively.8 Furthermore, the proportion of primary OP is higher in our study (65% vs. 48%). These results indicate that the survey was answered by rheumatologists whose focus of interest is not only OP.

Reasons for referral to rheumatology are very varied in our case, whereas in another study, half the referrals to primary care due to OP were motivated by doubts related to treatment.9

The characteristics of the PC physician mean that most patients with postmenopausal OP can be assessed and, if necessary, treated at primary care level10 and only in the case of concerns would they be susceptible to referral to rheumatology. The rheumatologists responded that almost half the referred patients could have been treated in PC. Rationalising referrals from PC and providing space in the rheumatologist's clinic for the care of secondary OP emerged in our survey as organisational approaches or areas for improvement in the management of OP. In this regard, different scientific societies are attaching a major role to the management of OP as a comorbidity.11

To reduce the variability of care, joint protocols would need to be drawn up for action with other specialities, especially PC. Only 31% of those surveyed work with a referral protocol agreed with PC.

In terms of the tests brought in the referral process from PC, the rheumatologists surveyed consider clinical risk assessment, bone metabolism analysis and plain x-ray of the lumbar spine to be more important than DXA. The frequency with which patients are referred with the tests performed is low, and between 50% and 75% of cases do not provide any tests at all. From this arises another area for improvement identified in our survey, encouraging the autonomy of the PC physician in the care of the patient with OP.

In various studies carried out in Spain, little use is made of FRAX® and other tools for the assessment of fracture risk.12,13 Nevertheless, in our survey the professionals agree that fracture risk factors are necessary to assess OP. Furthermore, when protocols for referral from PC are drawn up, priority is given to the assessment of clinical risk over DXA, as in the EPISER 2016 study in comparison with EPISER 2000.14

The approach is heterogeneous among physicians who manage OP. The need for a national consensus guideline on the management of OP containing recommendations for the appropriate use of clinical risk assessment tools and DXA is another area for improvement identified in our paper. This could reduce the variability that exists in the management of OP.15

Regarding other strategies on OP, the liaison rheumatologist consultant and telematic consultation, with a great deal of future projection, are not very well implemented. It should be noted that, although the specialist or monographic OP clinic is little implemented, when it is, it is very developed.

Regarding the secondary prevention of fractures, the rheumatologists believe that the fracture patient at high risk of presenting further fractures should be seen in rheumatology. Although there is experience and there are FLS models at national level that are rheumatologist-led,16 they are little implemented among the rheumatologists surveyed, more than half do not consider implementing them in the medium term, which contrasts with other strategies. The implementation of FLS in the rheumatological care of OP should clearly be a strategic line promoted by the SER.

Quality patient care, especially if there is multimorbidity and a focus on the complex patient, requires adequate care times. Among the rheumatologists surveyed, the average delay for the first visit was 6 weeks (SER standard: 5.6 weeks), while the average delay for revision was 12 weeks (SER standard: 9.5 weeks).17

The quality indicators set by the SER regarding OP consultations include the recommendation for dedicated OP consultations, that the delay for a first visit should not exceed 8 weeks and that the average length of a first visit should be 20 min.18 These SER indicators are only used by 43% of respondents, but their implementation is recognised as an area for improvement. EULAR has recently established recommendations for the prevention and management of osteoporotic fracture by non-medical health professionals.19 Quality nursing care has been outlined by the SER,20 but its implementation at a general level and in OP in particular is demanded by the majority of respondents in our study. In a review of the literature quality standards for hip fracture were defined.21 However, the SER does not have specific documents on OP or fracture management.

Telematic connection with PC is another organisational change that the rheumatologists indicate as an expectation, thus facilitating non-face-to-face consultations, as has been published.22

Our study has some limitations. As it is a small sample of respondents, it may not represent the opinion of the entire community of rheumatologists or routine clinical practice. The results reflect clinical experience and are exploratory in nature, providing a guiding view. The specialists being from all over Spain and the size of the sample make them illustrative. Despite the bias associated with recall in the responses when dealing with numerical figures, the few related questions give results that are close to the figures collected in other studies.

The authors of this paper believe that the organisation of OP care in rheumatology needs to change with the times. With the implementation of electronic media for interaction with PC and the current relevance of fragility fractures, we believe that the strategic priorities set out here contain a balanced message regarding the organisation of care in OP. The results of the survey bring us closer to the current situation of care in OP ("white paper") and identify possible areas for improvement at an organisational and structural level and in the development and implementation of quality standards in this disease.

The authors have no conflict of interests to declare.