Title: Can Ambulance Paramedics use FRAX® (the WHO Fracture Risk Assessment Tool) to help GPs improve Future Fracture Risk in Patients that Fall?
Funder: Department of Health (England)

Abstract: Osteoporotic fractures are painful, disabling, and increasingly frequent (300,000 annually in the UK (1)). drug treatment, such as alendronate (Fosamax), can reduce fracture rates by 35-50%(3). NICE has published guidance to help clinicians identify patients most at risk of fragility fracture(4,5,6). However the documents are complex, uptake has been poor and more than two thirds of eligible patients are still not prescribed appropriate medication to reduce fracture risk(1). FRAX® is an algorithm that allows an individual’s 10 year fracture risk to be estimated and therefore the most vulnerable patients targeted for treatment. It has been developed by the World Health Organisation (WHO) and is validated, freely available and easy to use(7,8). Further information about FRAX®, references and the online calculator are available at http://www.shef.ac.uk/FRAX/index.jsp. Falls occur increasingly frequently with advancing age(9,10,11). Many patients fall each year, some repeatedly. Post-menopausal women with osteoporosis who fall are particularly vulnerable and carry a relative fracture risk approaching 25(12). Osteoporosis treatment is proven to be both effective and cost-effective, reducing long term fracture rate in the community(13,14), however, because only 25% of people that fall contact their GP within 3 months(15,16), most patients at risk of fracture are likely to remain without treatment Ambulance paramedics now routinely implement an algorithm to assess patients for early signs of a stroke(17), and are able to facilitate improved diabetic care(18) but do not routinely assess bone health (fracture risk) in people who fall. This omission has been described as a valuable opportunity lost(16) and a spokesperson for the NOS has said “it’s time to stop ignoring osteoporosis”(19). The ultimate aim of this work is to determine whether FRAX® administered opportunistically by ambulance paramedics to people who fall informs improved diagnosis and treatment, by GPs, of patients at risk of fracture. This application is for funding to carry out a feasibility study. Our aim now is to inform a well designed, adequately powered, robust, multi-centre RCT. That RCT will then determine whether the intervention has the capacity to increase the proportion of patients prescribed osteoporosis treatment according to existing national guidelines. We will recruit patients (aged 50+) who fall and call an ambulance. Ambulance paramedics will collect data (with patient agreement) relating to osteoporotic fracture risk. Each of the 100 participating patients will be randomly allocated to intervention or control arm. GPs of participants in the intervention arm will be clearly informed of the patients’ future fracture risk, and advised on further clinical management along nationally established guidelines. All patients will receive a leaflet with general advice about falls. At 3 month follow up we will establish the number of GP visits, investigations and newly prescribed treatments in both arms of the trial. We will carry out qualitative and health economic work to determine the acceptability of the trial design. The Department of Health advocates establishing Fracture Liaison Services (FLS) in NHS orthopaedic departments because they provide improved care (through better co-ordination of services) to patients who have suffered fractures. FLS cost the salary of the co-ordinating nurse, consultant time, additional DXA investigations and increased drug costs, but all of these are offset, financially, in the savings delivered (in both direct NHS, and indirect social costs) by reduced fracture rates(20). At a national level, FLS are projected to save approximately £8.5 million over 5 years(20). It is entirely feasible that the intervention we describe might work alongside FLS to identify patients who have either already fractured (but not come under FLS services) or are at high fracture risk, but have yet to experience such an event at a time (a fall) when they have clearly demonstrated vulnerability.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: MUSCULOSKELETAL;INJURIES AND ACCIDENTS