Should healthy people be screened to help reduce their risk of fragility fractures? A new interactive online Fragility Fracture Decision Aid for shared decision-making can help clinicians and patients visualize their individual risk of fracture and the potential benefits and harms of preventive treatment.
The decision aid is part of a new guideline https://www.cmaj.ca/lookup/doi/10.1503/cmaj.221219 from the Canadian Task Force on Preventive Health Care on screening to prevent fragility fractures. The guideline, published in CMAJ (Canadian Medical Association Journal), recommends a "risk assessment–first" screening process for women 65 years and older, centred around shared decision-making with their primary care providers regarding testing and preventive treatment.
What are fragility fractures?
Fragility fractures are bone breaks at the hip, spine, wrist and other areas; these usually occur after a fall, due to underlying weakened bone structure, and they would not normally cause a break if bones were sufficiently strong. Fractures can lead to chronic pain, disability, hospitalization, a need for long-term institutional care and earlier death.
Fragility fractures can severely affect quality of life for older adults. For women over age 65, there is good evidence that screening and preventive treatment may reduce fragility fractures. Surprisingly, screening occurs in younger women and men, although there is no evidence of benefit."
Dr. Guylène Thériault, Chair of the Task Force Fragility Fractures Working Group
Key recommendations of the guideline
- Females aged 65 years and older may be able to avoid fracture with screening and preventive medication
- Screening is not recommended for females younger than 65 years or males of any age
- Clinicians should use a risk assessment–first screening strategy for females 65 years and older:
- Use the Fragility Fractures Decision Aid, which uses the Canadian FRAX risk assessment tool to estimate an individual's risk
- Help patients consider their risk of fragility fracture and the potential benefits and harms of treatment
- Engage in shared decision-making to help patients decide if they would take prescription medication based on their personal risk level
- If the patient is considering prescription medication, clinicians should:
- Request a bone mineral density (BMD) test
- Re-estimate fracture risk by adding the T-score into FRAX to decide on treatment
Patients can use the online Fragility Fracture Decision Aid to calculate their individual risk level; if the risk of fracture is low, then the benefit of treatment is also low. The decision aid can help inform the patient–clinician conversation, as it calculates the potential effect of medication and describes the potential harms.
"Patients should ask for their actual risk and talk to their primary care provider," said Dr. Roland Grad, a coauthor of the guideline. "Not everyone gets the same benefit from preventive medication. In fact, there's no good evidence to support screening men to prevent fragility fractures."
"Prescription medications can help prevent fragility fractures, and these should be taken for about 5 years," said Dr. Grad. "This means the best time to take them is at an age when fracture risk is higher. Even then, shared decision-making between a patient and their clinician is important."
Notably, the guideline is for community-dwelling adults aged 40 years and older. It does not apply to people already taking prescription medication to prevent fragility fractures.
The task force engaged patients and reviewed evidence to understand patient values and preferences. Women aged 50–65 years were interested in screening; however, a high percentage, after having been informed of their individual risk, said they would not choose to be treated with medication.
This new guideline is designed to help physicians and is based on the latest evidence.
"We hope a risk assessment–first approach will help reduce unnecessary BMD tests both for patients and the health care system," said Dr. Donna Reynolds, a family physician and task force member. "It doesn't make sense to order tests that will not lead to treatment decisions."
"This is surprising," said Marie-France, a patient in her 50s living in Quebec who has had many BMD tests. "This new information will surely help family physicians and patients have meaningful discussions and forgo unnecessary tests. Why do a test if your risk is low and you're not interested in taking preventive medication?"
Treatment and prevention without prescribed medication (e.g., vitamin D, calcium, falls prevention and exercise), was beyond the scope of the task force guideline. Guidelines on falls prevention and related topics are planned.
The College of Family Physicians of Canada (CFPC) has endorsed the guideline.
Thériault, G., et al. (2023). Recommendations on screening for primary prevention of fragility fractures. Canadian Medical Association Journal. doi.org/10.1503/cmaj.221219.