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NICE fracture screening advice a ‘huge task’ for GPs

GPs have warned the implementation of recent NICE guidance on carrying out risk assessments for osteoporosis is a 'huge task' and will be impossible to implement without a properly funded programme.

NICE recommends millions of patients should be risk assessed for fragility fractures using the FRAX or QFracture score, including all women aged 65 years and over and all men aged 75 years and over.

Anyone aged under 65 years and men aged under 75 years should also be assessed if they have risk factors for fragility fractures, such as smoking or increased alcohol intake, although they warn this should not be routinely done in those under 50 years unless they have a serious risk factor, such as premature menopause.

In its costing report, NICE calculate that more than seven million adults qualify for risk assessment simply on the fact they smoke. A further seven million also meet the criteria because they drink more than the recommended weekly intake of alcohol.

The guideline development group estimated that risk-scoring patients would take 10 minutes of consultation time but that most could be assessed ‘opportunistically' when the patient has an appointment for other reasons.

In its guidance to commissioners, NICE also point out that practice nurses could do the risk assessment more cheaply than a GP, but GPs warned that such a large programme could not just be slotted in to appointments and proper resourcing was needed.

Dr Louise Warburton, a GPSI in Shropshire and president of the Primary Care Rheumatology Society, said GPs did not currently have the resources to support NICE's recommendations, despite osteoporosis being recently included in QOF.

‘It would be an enormous task to screen everyone as suggested by NICE.

‘QOF only covers a small part of this NICE guidance and I think practices will warm up with QOF and start to learn about FRAX as they go along.

‘Eventually, doing a FRAX assessment will become second nature like assessing cardiovascular risk, but would require a longer consultation of 20 minutes to assess all the different risks'

Dr John Canning, secretary of Cleveland LMC, said this was another example of work GPs were expected to absorb into their already intense and pressurised workload.

He said: ‘And this will be even more of a problem when CCGs want to take people out of the clinic. The reality is it is a balance and we can't do it all.'

Dr John Ashcroft, vice-chair of Derbyshire LMC said he had repeatedly put proposals to his CCG to fund preventive screening for osteoporosis but had been rejected.

‘It is just like CVD risk assessment – there is very good evidence we can save a lot of lives and money but there is no resourcing.

‘It is not just about the risk assessment, because to get a good outcome patients need to be properly followed up.'

He said there is no interest in investing in preventive care and people just assumed such initiatives would just ‘happen'.

He said: ‘These guidelines should help make the case but we shouldn't need them. CCGs should listen to the clinicians who have been saying for years that this was needed.'

NICE advise risk assessment:

In all women aged 65 years and over and all men aged 75 years and over

In women aged under 65 years and men aged under 75 years with:

  • previous fragility fracture
  • current use or frequent recent use of oral or systemic glucocorticoids
  • history of falls
  • family history of hip fracture
  • other causes of secondary osteoporosis
  • low body mass index (BMI) (less than 18.5 kg/m2)
  • smoking
  • alcohol intake of more than 14 units per week for women and more than 21 units per week for men.

Nb – anyone under 50 years should only be assessed if they have a major risk factor.

Source: NICE CG146