Section 12: Review criteria for audit and quality improvement

Quality standards for osteoporosis

  1. Four quality standards for osteoporosis were produced by the National Institute for Health and Care Excellence (NICE) in 2017 (QS149) (
  2. Seven quality standards for osteoporosis and the prevention of fragility fractures were produced by the Royal Osteoporosis Society in 2017 (

Primary Care

  1. Documentation of the proportion of postmenopausal women, and men age ≥50 years, registered with a general practice:
    1. With a fracture code, who have been assessed to determine whether their fracture was a fragility (low-trauma) fracture
    2. With one or more risk factors for fragility fracture, who receive formal fracture risk assessment.
    3. With a prior fragility fracture, who have had a DXA scan with the result recorded.
    4. Calculated to be high or very high risk by FRAX assessment, who have been offered drug treatment.
    5. With an incident hip fracture, those who receive pharmacological drug therapy for osteoporosis within 16 weeks of their fracture.
    6. Who are prescribed pharmacological drug therapy for osteoporosis and who have had confirmed adherence to osteoporosis therapy within the last 12 months.
    7. Who are prescribed pharmacological drug therapy for osteoporosis and have had a 5-year and 10-year review.
    8. Who are prescribed denosumab, who have received timely (within 4 weeks of due date) follow-up injection.
    9. Who are on oral glucocorticoids for ≥3 months who have had a fracture risk assessment.
    10. With documented discussion of fracture risk assessment and a treatment decision.

Fracture Liaison Services

  1. The Royal Osteoporosis Society (ROS) published in 2019 six key standards for FLS with a corresponding timeline for the achievement of these six steps, with examples of audit and evidence 297.
  2. The Royal College of Physicians Fracture Liaison Service (FLS) Database National Audit ( is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the Falls and Fragility Fracture Audit Programme. The FLS-DB is included in the HQIP listing for national audits that must be reported in each English hospital trust’s Quality Account, and is required by the Welsh Government for all Health Boards in Wales. These form part of the National Clinical Audit Patient Outcomes Programme. All FLS sites that treat fractures are eligible to participate. The FLS-DB sets out 11 Key Performance Indicators (KPIs) which are designed to measure performance against technology assessments, guidance on osteoporosis and clinical standards for FLSs from the NICE, the ROS and NOGG.
  3. The International Osteoporosis Foundation (IOF) Capture the Fracture Best Practice Framework outlines 13 standards for FLS delivery with criteria and targets specified for bronze, silver or gold levels of achievement (

DXA reporting

  1. The ROS published in 2019 six quality standards for DXA reporting with a corresponding audit template 39.