Impact of UK National Guidelines based on FRAX®--comparison with current clinical practice

Abstract

Objective: To assess whether clinician-determined treatment intervention thresholds are in line with the assessment of fracture risk provided by FRAX® and treatment recommendations provided by UK guidelines produced by the National Osteoporosis Guidelines Group (NOGG).

Design, patients and measurements: This was a retrospective cohort analysis of 288 patients consecutively referred for dual-energy X-ray absorptiometry (DXA) scanning from primary care immediately prior to the introduction of the FRAX® algorithm. In addition to DXA assessment, patients completed a clinical risk factor questionnaire which included risk factors used in the FRAX® algorithm. Initial risk assessment and treatment decisions were performed after DXA. FRAX® was used, retrospectively, with femoral neck T-score, to estimate fracture risk which was applied to NOGG to generate guidance on treatment intervention. Clinician- and NOGG-determined outcomes were audited for concordance.

Results: There was concordance between clinician and NOGG treatment decisions in 215 (74.6%) subjects. Discordance was observed in 73 (25.3%) subjects. In the discordant group, seven subjects were given lifestyle advice when NOGG recommended treatment, 42 given treatment when NOGG recommended lifestyle advice only, and 24 were referred to a metabolic bone clinic for further evaluation. The reasons for treatment differences in subjects recommended treatment by clinician but not NOGG were largely (90.2%) attributed to the use of lumbar spine bone mineral density (BMD).

Conclusions: There is high concordance between clinician-determined and FRAX®-NOGG intervention. The absence of spine BMD from FRAX® is the primary source of discrepancy. This study provides some assurance of the validity of the treatment thresholds generated from FRAX®-NOGG in 'real-world' usage.