Introduction
Methods
Sample
Ethics
Interview procedure
Data analysis
Results
Characteristics of participants
Case finding (Box 1)
Osteoporosis assessment (Box 1)
DXA scanning
Case finding
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It depends which doctors have been on the night before as to how much has been put onto [the computer system]… some of it turns out to be rubbish [Participant ID: 010] |
Osteoporosis assessment
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I’d love to see a nurse specialist in there because I think some of those older people are far less intimidated… to see a fracture nurse in that setting actually exploring what those answers mean, getting the detail would be brilliant. [Participant ID: 016] |
You know breaking your hip is huge, there’s lots of psychological things… Being flexible about [the timing] is probably a bit more patient-centred. [Participant ID: 029] |
DXA scanning
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It really depends how able they are to get on and off the bed and stick their legs in the air and that sort of thing. [Participant ID: 008] |
I think having it done as an Outpatient is more appropriate because most of them are generally quite sick or unwell or they’re still in pain so it would be difficult to get them to the DEXA. [Participant ID: 019] |
Our biggest barrier is obviously the fact that we have to drag our patients from [another town] down to [the city]. [Participant ID: 004] |
We should just be able to refer directly… It just adds in an additional communication where we know there’s problems, where referral forms get missed, go missing, patients fail to attend their appointment and no one follows that up. [Participant ID: 030] |
The powers that be… don’t like us DEXA-ing people internally, because they like the money flow, so they prefer them to go out and then come back. [Participant ID: 009] |
Treatment initiation (Box 2)
Aged 75 and over
Aged under 75
Monitoring (Box 2)
By primary care
By secondary care
Treatment initiation
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Aged 75 and over
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I don’t think there’s an option for it to be initiated in Primary Care for us at the moment because even when we send people home on it the GPs don’t always continue it [Participant ID: 017] |
It’s not missed because if I missed it the nurses would pick up… the Fracture Liaison Nurses would pick it up or the Pharmacist would, you know there are various checks that they wouldn’t go out without their bone protection. [Participant ID: 005] |
GPs get probably 400 or 500 letters a day, do they read everything? Hopefully they do. [Participant ID: 035] |
Aged under 75
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[We] don’t know how many have treatment initiated [by GPs] [Participant ID: 017] |
It’s almost like [GPs] need a package of almost instructions with a tick box… so that yeah it’s straight forward for them. [Participant ID: 037] |
I think that there are sort of conflicts in having guidelines that are actually useful in making an individual treatment decision whilst being sufficiently simplistic enough for someone to be able to commit to memory and remember. [Participant ID: 024] |
GPs are fantastic, but how can they be experts and know everything… And that’s why I think we have a duty to them and to our patients to inform appropriately. [Participant ID: 042] |
Monitoring
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We know that compliance is the issue, and we know that less than 50 % are taking them at the year mark. [Participant ID: 010] |
By primary care
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This has to be owned by Primary Care, I mean this is a long term condition, osteoporosis and fracture prevention, and GPs are responsible for managing long term conditions [Participant ID: 026] |
I think in the hospital we have to remember that these are the GP’s patients not our patients… we have to put responsibility onto the GP and onto the patients to make sure that they do take their tablets. It’s a bit buck passing really but that’s how it needs to be [Participant ID: 002] |
Well in theory the GPs should be monitoring these patients… But it doesn’t happen. It might happen on the odd GP, but that isn’t happening [Participant ID: 011]. |
The GPs that liaise with you are probably the GPs that you’re not worried about because they are trying to improve their knowledge; it’s the ones that you never hear about that never call you that think they can manage this condition that they can’t [Participant ID: 020] |
By secondary care
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The patients didn’t realise [taking the medication] was that important, I don’t think. Whereas if they’re getting a phone call at three months to check they’re going to think, “Well it must be important because they’re phoning me to see if I’m taking the tablet. Oh I’d better carry on taking it. [Participant ID: 010] |
It was a waste for them coming in, ten minute appointment, and it was a waste of a clinic slot that could be done for someone that is struggling or not responding or needing treatment. [Participant ID: 042] |
Usually [undertaking a ward round in a nursing home] is simpler than the patient coming here and if the patients come here they usually come with an escort who doesn’t have additional information, whereas if we go there the patient has the nurses that have been looking after the patient and we get a lot more information from them that way. [Participant ID: 038] |
I would like far more time to be able to follow these patients up more thoroughly [Participant ID: 002] |
I just don’t have the resource to [follow-up] [Participant ID: 023] |
Six months down the line, the horse has already bolted and they won’t remember what you said beforehand, so I think three months is at least the initial thing [Participant ID: 024] |
[6 – 12 weeks is] a nice length of time to revisit all the information you gave them at the diagnosis, and make sure that they’re understanding everything, and that you can go through the lifestyle again… I think any sooner would be too quick, and maybe a bit longer is too long. [Participant ID: 042] |
So [monitoring] doesn’t become so unwieldy… identify your patients that you really need to follow up and identify the patients that you may [Participant ID: 028] |
It’s more that you need flexibility within the service to be able to account for the differences in individuals. [Participant ID: 024] |
Coordination of care (Box 3)
Coordinator-based models of care
Additional strategies for coordinating care
Coordination of care between primary and secondary care
Are they having that continuity of care, are they having a regular orthogeriatric input? No, and I think that’s something that we can improve upon [Participant ID: 006] |
Coordinator-based models of care
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It needs a strong lead, it needs a me or equivalent of me really… In terms of the Orthopaedic Team, you know you’re working with Orthopaedic Nurses so it’s a different culture set… So you need to sort of pull in the ethos [Participant ID: 026] |
There is a communication pathway which we never had before [Participant ID: 008] |
You often establish relationships and people can become more trusting and they can tell you if they’re actually taking their medications or not [Participant ID: 022] |
Well the only problem we have is the service is so good when she’s here; it’s a problem when she’s not. [Participant ID: 001] |
Additional strategies for coordinating care
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It’s much easier to communicate with people that are on the end of the phone and because we have meetings every month [Participant ID: 009] |
It’s just about encouraging people to know that they all have a role, we all have a responsibility to deliver the quality care and all of us are important in making that so. You know each of you can’t do it without the other and it’s actually about ownership and responsibility [Participant ID: 026] |
Coordination of care between primary and secondary care
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There seem to be very – two separate camps: there’s what actually happens in trauma and then there’s what happens in primary care, and the communication is difficult. [Participant ID: 009] |
I don’t think it’s very good at all… its very much them and us isn’t it situation. [Participant ID: 002] |
It’s about making sure GPs are happy with that and they are happy because they’ve been involved in the decision making. [Participant ID: 002] |
I mean it is a big hole really, we ought to find out what they think of the discharge summaries and things… I suppose I need to go back to the GPs and say “well what do you think of this service now? [Participant ID: 004] |