title: Improving community prescribing of post-fracture denosumab after discharge.
abstract: BACKGROUND
  In the UK, denosumab is usually started by hospital clinicians and continued by primary care physicians in the community, but in the authors' region denosumab is a 'green light' drug, only prescribed by the primary care team. The authors suspected that a proportion of patients who were recommended to start the drug after a neck of femur fracture were not receiving this on discharge. They aimed to improve the prescribing of denosumab by implementing a quality improvement project.
  
  
  METHODS
  A retrospective review of electronic records and case notes in primary and secondary care was undertaken, focusing on patients who were admitted with a neck of femur fracture and recommended denosumab. Following cycle 1 of the project two interventions were implemented: Denosumab written on the inpatient prescription chart at point of treatment decision, promoting inclusion in the discharge summary A consultant letter recommending denosumab was sent separately to primary care, in addition to inclusion in the discharge summary. Following these interventions this project cycle was repeated.
  
  
  RESULTS
  A total of 91 patients with a neck of femur fracture were identified during cycle 1 and 22/91 (24%) were recommended denosumab. However, only five of these 22 patients (22%) received the drug. Following the interventions 23/26 eligible patients (88%) were prescribed denosumab (three patients did not have a prescription with no reason given), and 17/23 (74%) had the injection given. Four patients who did not receive the denosumab injection had no obvious reason for not starting treatment. In the other two patients, one discharge summary misleadingly stated that the injection had been given as an inpatient and one patient had recurrent admissions following discharge after their neck of femur fracture so primary care had not had any opportunity to administer the injection.
  
  
  CONCLUSIONS
  Prescribing denosumab on the inpatient drug chart and highlighting its use in a consultant-written letter to the primary care team improved prescribing and administering of denosumab in the community.
authors.affiliation: ST5, Geriatric Medicine, Care of the Elderly Department, Musgrove Park Hospital, Taunton TA1 5DA.
authors.forename: Helen
authors.initials: H
authors.lastname: Wood
authors.affiliation: Foundation Year 2, Care of the Elderly Department, Musgrove Park Hospital, Taunton.
authors.forename: Harriet
authors.initials: H
authors.lastname: Lewis
authors.affiliation: Core Medical Trainee, Care of the Elderly Department, Musgrove Park Hospital, Taunton.
authors.forename: Rachael
authors.initials: R
authors.lastname: Ward
authors.affiliation: Consultant Geriatrician, Care of the Elderly Department, Musgrove Park Hospital, Taunton.
authors.forename: Tarun
authors.initials: T
authors.lastname: Solanki
authors.affiliation: Consultant Geriatrician, Care of the Elderly Department, Musgrove Park Hospital, Taunton.
authors.forename: Prabhath
authors.initials: P
authors.lastname: Fernando
mesh_terms: D050071:Bone Density Conservation Agents / Q000627:therapeutic use*; D000069448:Denosumab / Q000627:therapeutic use*; D005265:Femoral Neck Fractures; D006760:Hospitalization; D006801:Humans; D010024:Osteoporosis / Q000188:drug therapy*; D058866:Osteoporotic Fractures / Q000517:prevention & control*; D011182:Postoperative Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care; D058996:Quality Improvement; D012189:Retrospective Studies
chemical_list: D050071:Bone Density Conservation Agents; D000069448:Denosumab