Can paramedics use FRAX (the WHO Fracture Risk Assessment Tool) to help GPs improve future fracture risk in patients who fall? Protocol for a randomised controlled feasibility study.

INTRODUCTION: Currently identification, and therefore, management of patients at risk of osteoporotic fracture in the UK is suboptimal. As the majority of patients who fracture have fallen, it follows that people who fall can usefully be targeted in any programme that aims to reduce osteoporotic fracture. Targeting vulnerable patients who are likely to benefit from intervention may help shift the management of fracture prevention into primary care, away from emergency departments. Paramedics who attend to patients who have fallen may be well placed to assess future fracture risk, using the Fracture Risk Assessment Tool (FRAX) and communicate that information directly to general practitioners (GPs). METHODS AND ANALYSIS: This feasibility study takes the form of a pragmatic, randomised controlled trial aimed at exploring and refining issues of study design, recruitment, retention, sample size and acceptability preceding a large-scale study with fracture as the end point. Patients (aged >50) who fall, call an ambulance, are attended by a study paramedic and give verbal consent will be asked FRAX and fall questions. Patients who subsequently formally consent to participation will be randomised to control (usual care) or intervention groups. Intervention will constitute transmission of calculated future fracture risk to the patients' GP with suitable, evidence-based recommendations for investigation or treatment. 3 months after the index fall, data (proportion of patients in each group undergoing investigation or starting new treatment, quality of life and health economic) will be collected and analysed using descriptive statistics. A nested qualitative study will explore issues of acceptability and study design with patients, paramedics and GPs. ETHICS AND DISSEMINATION: This protocol was approved by NRES Committee South Central Oxford C in October 2012. Research Ethics Committee ref.12/SC/0604. The study findings will be disseminated through peer-reviewed journals, conference presentations and local public events. A publication plan and authorship criteria have been preagreed. TRIAL REGISTRATION NUMBER ISRCTN: 36245726.

Acceptability of screening to prevent osteoporotic fractures: a qualitative study with older women.

BACKGROUND: Osteoporotic fractures have a detrimental impact on health and quality of life, are more common in older women and are costly to treat. Screening to identify older women at high risk of fracture has the potential to offer substantial benefits. Understanding women's and professionals' experiences of screening will inform the implementation of screening in routine care. OBJECTIVE: To explore the views of older women and GPs about the acceptability of screening to prevent fractures. METHODS: A qualitative study conducted within a multi-centre randomized controlled trial of the effectiveness and cost-effectiveness of screening women aged 70-85 years for the prevention of fractures; 30 women randomized to the trial screening group and 15 GPs were recruited from general practices in North Somerset and Norfolk, UK. All 30 women and 11 of the GPs participated in face-to-face semi-structured interviews. Four GPs participated in a focus group. Data were analysed thematically, using the Framework Approach. RESULTS: Women and GPs viewed screening positively, recognizing its potential to improve fracture prevention and future health. Attending screening was not found to result in anxiety or excessive activity restriction. Demonstrating cost-effectiveness was key to the acceptability of screening amongst GPs. Implementing similar screening in routine care would require consideration of access to bone density scans, information provision to participants and mode of administration. CONCLUSIONS: Our findings suggest an effective and cost-effective screening programme to reduce osteoporotic fractures could be implemented in routine care and would be well received by women and GPs.

Fragility fracture risk in cirrhosis: a comparison of the fracture risk assessment tool, British Society of Gastroenterology and National Institute for Health and Clinical Excellence guidelines.

OBJECTIVE: Low bone mineral density (BMD) is common in chronic liver disease and predisposes to fracture. We aimed to compare British Society of Gastroenterology (BSG) and National Institute for Health and Clinical Excellence (NICE) osteoporosis guidelines with the fracture risk assessment tool (FRAX). FRAX is a web-based algorithm used to estimate fracture risk with or without dual-emission x-ray absorptiometry (DXA). Pre-BMD FRAX categorises patients to low, intermediate or high risk according to thresholds set by the National Osteoporosis Guidelines Group (NOGG) and recommends lifestyle advice, DXA or anti-osteoporosis treatment, respectively. DESIGN: The guidelines were applied to 132 patients with cirrhosis (91% Child-Pugh A). The number that would require DXA and be recommended treatment was determined. Using post-BMD FRAX/NOGG as a reference point, high-risk patients not recommended treatment and low-risk patients treated 'unnecessarily' were identified. RESULTS: BSG guidelines were applicable to 100% of the cohort, 88% required DXA and 30% would be recommended treatment. Equivalent figures for NICE guidelines were 30%, 17% and 12%, and for FRAX/NOGG guidelines were 78%, 27% and 15%, respectively. Using BSG guidance 8% of high-risk patients were not recommended treatment and 62% of those treated were low risk, compared with NICE: 3%, 60% and FRAX/NOGG: 13%, 40%, respectively. CONCLUSION: For patients with Child-Pugh A cirrhosis BSG guidelines are the most inclusive, but have high cost implications in terms of DXA scanning and unnecessary treatment. Risk stratification using FRAX requires fewer DXA scans with minimal impact in terms of missing high-risk patients, and yields a modest reduction in unnecessary treatment.