Original Title: Initier un examen d’ostéodensitométrie à la suite de l’évaluation du risque fracturaire avec l’outil FRAX

Authors' objectives: In 2015-2016, the Canadian prevalence of osteoporosis was estimated at 11.9% among people aged 40 and over (4.4% for men and 18.9% for women) [Public Health Agency of Canada, 2020]. One in three women and one in five men with osteoporosis will suffer a fracture related to their condition during their lifetime, while 22% of women and 33% of men with a hip fracture will die within a year [Osteoporosis Canada, 2023b]. Given the large number of people without a family doctor, and as part of the development of primary care access points (GAP), measures enabling nurses or other authorized professionals to initiate certain screening examinations could promote optimal care for the population. Accordingly, the Ministère de la Santé et des Services sociaux has asked the Institut national d'excellence en santé et en services sociaux (INESSS) to develop national medical protocols (NMPs) to support front-line healthcare professionals, while promoting harmonized practice across the province. As part of this work, a national medical protocol has been developed to guide the initiation of bone densitometry examinations based on fracture risk assessment. This protocol will help guide practice not only within the primary care access points (GAP) context, but throughout the healthcare network.

Authors' results and conclusions: Ten clinical practice guidelines of adequate methodological quality were selected for this study. In addition, five collective prescriptions from the healthcare network were gathered. (#1 TARGET CLIENTELE FOR FRACTURE RISK ASSESSMENT): Making sure, from a shared decision-making perspective, that the person understands the benefits, risks and implications of fracture risk assessment, in particular the consequences of an abnormal result which may involve taking medication, or significant lifestyle changes, this PMN should be considered for any woman aged 65 or over, or any man aged 70 and over. (#2 CONTRAINDICATIONS TO PROTOCOL APPLICATION): A bone densitometry request should not be initiated when the person is using drug therapy for osteoporosis, has been diagnosed with osteoporosis, or when a bone densitometry has been performed within the last three years. (#3 HEALTH ASSESSMENT AND FRACTURE RISK ASSESSMENT): Fracture risk factors are researched and documented using the FRAX tool. This tool can then be used, in the absence of bone densitometry results (without T-score), to assess the risk of major osteoporotic fracture over a 10-year time horizon (FRAX without Tscore). (#4 COURSE OF ACTION): When the patient has a history of fragility fracture at age 40 or over, the protocol should be discontinued, and the patient referred to an appropriate healthcare professional. When the result of the FRAX evaluation without T-score is: • Equal to or greater than 20%, the protocol should be discontinued, and the patient referred to an appropriate healthcare professional. • Between 10% and 20%, a request for bone densitometry is written. On receipt of the bone densitometry result, a new fracture risk calculation is made, including the T-score (FRAX with T-score): o If the FRAX with T score result is equal to or greater than 15%, the patient should be referred to an appropriate healthcare professional. o If the FRAX with T score result is less than 15%, referral is not required. Follow-up in 3 years or more is recommended. • Less than 10%, bone densitometry is not required and follow-up in 5 years or more is recommended. CONCLUSION: Using this NMP should promote optimal management of the target population and help standardize clinical practice in the use of bone densitometry for fracture risk assessment. With a view to optimizing resources, this NMP uses a clinical assessment tool (FRAX) to target people at high risk of fracture, thereby optimizing the use of bone densitometry examinations and better guiding the need for consultations. Results will depend on the adoption of these tools by front-line care teams and their appropriation by the healthcare professionals concerned. It should also be noted that all the recommendations and clinical information detailed in the present work concern fracture risk assessment in the context of opportunistic osteoporosis screening, and that the relevance or otherwise of systematic screening throughout the province has not been addressed here.

Authors' methods: The integration of data gathered from a rapid review of the literature on best practices, contextual information, and experiential knowledge from various stakeholders allowed, together with the members of the Advisory Committee, to draw conclusions on which this national medical protocol is based.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/initier-un-examen-dosteodensitometrie-a-la-suite-de-levaluation-du-risque-fracturaire-avec-loutil-frax.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/initier-un-examen-dosteodensitometrie-a-la-suite-de-levaluation-du-risque-fracturaire-avec-loutil-frax.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)