Should you screen healthy patients for fragility fractures?

Doctors can help female patients aged 65 years or older avoid fragility fractures with screening that uses a risk assessment-first approach and, if the assessment deems it necessary, followed by bone mineral density (BMD) testing and preventive medication. That’s the key recommendation from a new guideline for preventing fragility fractures from the Canadian Task Force on Preventive Health Care, which includes an interactive online decision aid that patients and physicians can use to assess for risk of fragility fractures. Current screening for fragility fractures typically include the use of a fracture risk assessment tool (FRAX) or measurement of bone density, or both. With the new guideline, physicians are encouraged to start first with a FRAX before ordering a bone density test. This runs counter to Osteoporosis Canada’s recommendation to do BMD testing first, followed by risk assessment. “Some physicians don’t know that they can calculate FRAX without a BMD,” said Dr. Guylène Thériault, chair of the Task Force Fragility Fractures Working Group at the Canadian Task Force on Preventive Health Care, an independent panel of preventive health care and guideline methodology experts that develops evidence-based clinical practice guidelines for primary care. “I was one of those physicians a few years ago—I thought I couldn’t do a FRAX without a BMD, because that’s how we were all trained.” Read: A shot prevents frailty: Reframe your message about adult vaccinations, experts say Usually caused by a minor impact that would not damage normal bone, fragility fractures are a risk for patients with weakened bone structure—low bone mass or low mineral density, often referred to as osteoporosis. The new guideline, which recommends against screening for female patients younger than 65 years or males of any age, advises clinicians to screen with its accompanying Fragility Fractures Decision Aid, which uses the Canadian FRAX tool to estimate a patient’s risk over 10 years. After discussing the risk of fragility fracture with the patient, physicians are encouraged to engage in shared decision-making by providing information, such as potential benefits and harms of treatment of prescription medication. Doctors can order bone density testing after their patients have advised them they’re considering preventive medication, according to the new guideline. When the test results come in, the risk for fracture should be re-estimated by adding the T-score into FRAX. Some doctors may worry that following the new guideline will mean more work for them. But Dr. Thériault said that by halting the screening of female patients under 65 and focusing on women 65 years and older, physicians can save time while achieving similar results. “There are no studies anywhere that say if we’re doing bone density testing first, we’re going to prevent more fractures,” she said. Read: How to optimize bone health in men receiving androgen deprivation therapy

Should you screen healthy patients for fragility fractures?

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