Read our interview with Roland Grad and Guylène Thériault – who estimated the clinician time needed (TNT) to implement recommendations on screening to prevent fragility fractures – and found that engaging in shared decision making at the start will substantially reduce demands on clinician time.
You were involved in a new guideline on screening to prevent fragility fractures from the Canadian Task Force on Preventive Health Care (CTFPHC) – what did this guideline recommend?
We recommended “risk assessment–first” screening for the prevention of fragility fractures for women 65 years and older, using the Canadian Fracture Risk Assessment Tool (FRAX), initially without bone mineral density (BMD). The FRAX result should be used to facilitate shared decision-making about the possible benefits and harms of preventive pharmacotherapy, for which we developed a decision aid (https://frax.canadiantaskforce.ca/). After this discussion, if preventive pharmacotherapy is being considered, clinicians can then request a BMD and use the T-score from the femoral neck to re-estimate fracture risk in FRAX. This is a conditional recommendation based on low-certainty of evidence.
We recommended NOT screening females 40–64 years and males 40 years and older. This is a strong recommendation based on very low-certainty of evidence.
These recommendations were based on a systematic review done for the Canadian Task Force by a team at the University of Alberta. Recommendations apply to community-dwelling individuals who are not currently on pharmacotherapy to prevent fragility fractures.
Recommendations on screening for primary prevention of fragility fractures
How is this recommendation different from most other guidelines on screening to prevent fragility fractures?
About 5 months after the Canadian Task Force guideline was published, a second guideline on fracture prevention was published in the same journal. This second guideline was broader in scope and sponsored by Osteoporosis Canada, a specialty society.
25 recommendations and 10 good practice statements can be found in the 2023 Osteoporosis Canada guideline – grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. This specialty society also recommended a patient’s risk of fracture be based on a validated fracture risk assessment tool, but after a clinical assessment for those aged 50-69 years followed by a BMD for those with risk factors. Postmenopausal women and men 50 years of age and older are to be assessed for risk factors based on a list that also includes measurements of height, distances between pelvis and ribcage as well as occiput and wall. People 50-69 years with 1, 2 or more specific risk factors (depending on age) are recommended to undergo BMD and then risk calculation using FRAX or CAROC (another commonly used tool in Canada). Those who are 70 years and older should undergo a BMD and their results applied using a risk assessment tool. At the Canadian Task Force, we call this a “BMD-first” approach to differentiate it from what we recommended, which we call “risk assessment-first”.
The 2023 Osteoporosis Canada guideline recommended preventive pharmacotherapy using arbitrary thresholds of T-score, 10-year fracture risk or age without shared decision-making. Repeat BMD testing was recommended every 3 to 10 years (depending on risk), even if patients had previously decided not to initiate preventive therapy.
The concept of clinician time (TNT) to implement these recommendations was neither mentioned nor estimated in the 2023 Osteoporosis Canada guideline. Other guidelines start with BMD-first and/or do not use a continuum of risk, preferring arbitrary risk strata, and do not consider shared decision-making in the management of the patient.
It seems that guidelines from specialty groups have been recommending more interventions for primary care to implement, without considering the metric of TNT or the problem of competing demands. We believe TNT should be routinely considered by any guideline group recommending a new intervention.
You also estimated the clinician “time needed to treat” (TNT) to implement the recommendations from this guideline compared to other suggested approaches to screening for fragility fractures – what did you find?
Our findings are summarized at Screening for primary prevention of fragility fractures | The College of Family Physicians of Canada. In brief, we compared the recommendation from the 2023 Canadian Task Force guideline (risk assessment-first) with the 2010 Osteoporosis Canada recommendations (BMD-first). We used the 2010 version from Osteoporosis Canada as their 2023 guideline was not available at the time. On screening, the most significant changes in 2023 are delaying universal screening with BMD-first from age 65 to age 70 in both genders, as well as adding physical measurements in the 50-69 year age group.
Interestingly, engaging patients in the risk assessment-first strategy takes less time than the BMD-first approach. This is primarily because far fewer repeat BMDs would be conducted over 25 years of follow-up time, as BMD tests would only be needed for those women 65-84 years of age who expressed interest in pharmacotherapy. Of note, the risk assessment-first approach incorporated a strategy of not repeating BMD tests more often than every 8 years, as more frequent testing has not been shown to be beneficial.
As seen in the figure below, an approach based on risk assessment-first took about one-quarter of the time to implement compared to the 2010 Osteoporosis Canada recommendation of screening all men and women at age 65 and beyond. Comparing the two strategies for women 65 years of age and older, it would take about twice the time to implement the Osteoporosis Canada recommendation. We could not calculate the TNT for people 50-64 years of age as recommended by Osteoporosis Canada – but this will be high given that every such person would need to be assessed for specific risk factors, while many deemed to be at risk would undergo BMD and follow-up visits. Adding clinician time to measure pelvis to rib cage and occiput to wall distances for people < 70 years (as per the 2023 Osteoporosis Canada recommendation) would further increase the TNT compared with the Canadian Task Force approach.