When should GPs refer a patient to Secondary Care?

Referral to a bone specialist or specialist bone centre should result from an assessment of the patient's individual needs and circumstance.

The decision to refer to Secondary Care is often multi-factorial and influenced by resource factors with respect to access and expertise within Primary and Secondary care as well as those pertaining to the patient.



The following patient, therapy and resource factors should be considered:

Patient factors:

  • Secondary cause identified or suspected (i.e. BMD Z-score < 2; Z-scores provide a comparison, in terms of standard deviations, to the average BMD measurement for the patient's age group)
  • Initial assessment indicating unexpectedly severe osteoporosis
  • Unusual features at the time of initial assessment (i.e. large variability between T-scores in lumbar spine and hip)
  • Having a suspected or known condition that may underlie osteoporosis, particularly in men and pre-menopausal women, where management may be more complex
  • Presence of complex comorbidities
  • Continuing to experience fragility fractures despite normal bone density
  • Presence of fragility fractures due to other bone disease (i.e. Paget's disease, metastatic bone disease)
  • Patient choice to be referred to Secondary Care

Therapy factors:

  • Contraindications to oral therapy (i.e. oral bisphosphonates, or raloxifene if appropriate), if your local CCG does not allow initiation of denosumab in primary care.
  • Adverse effects and difficulties with standard therapies (i.e. patients unable to take or tolerate the usual oral therapies or contraindications to therapy)
  • Failing to respond to current treatment (i.e. continuing to fracture despite the patient being compliant with therapy for 1 year or more)
  • Requiring complex therapy, in some cases intravenous therapy with bisphosphonates
  • Where there is no Primary Care access to the required treatments or therapies (i.e. women meeting the criteria for parathyroid hormone/teriparatide)
  • Painful acute vertebral fractures or multiple vertebral fractures (for pain control; assessment of suitability for kyphoplasty or vertebroplasty is also recommended)

Resource factors:

  • Lack of direct access to appropriate investigations (e.g. poor local provision of bone densitometry, difficulties in establishing a secure diagnosis, blood tests to exclude secondary causes or vitamin D assessment)
  • Lack of access to appropriate services within primary care, specialist physiotherapy, pain clinics, neurosurgical or spinal surgeon opinion
  • Required expertise only available within Secondary Care

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