Quality statement 1: Assessment of fragility fracture risk

Quality statement

Adults who have had a fragility fracture or use systemic glucocorticoids or have a history of falls have an assessment of their fracture risk.

Rationale

Risk assessment of adults who may be at increased risk of a fragility fracture enables healthcare professionals to estimate their fracture risk. This can be used to consider options for prevention and treatment, which will reduce the risk of future fractures.

Quality measures

Structure

Evidence of local arrangements to ensure that adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, have an assessment of their fracture risk.

Data source: Local data collection, for example, service specifications.

Process

a) Proportion of adults who have had a fragility fracture who have an assessment of their fracture risk.

Numerator – the number in the denominator who have an assessment of their fracture risk.

Denominator – the number of adults who have had a fragility fracture.

Data source: Local data collection, for example, local audit of patient records. The Quality and Outcomes Framework captures data on patients aged 50 to 74 with a record of a fragility fracture and a diagnosis of osteoporosis confirmed on dual-energy X-ray absorptiometry (DXA) scan, and aged 75 or over with a record of a fragility fracture and a diagnosis of osteoporosis.

b) Proportion of adults who use systemic glucocorticoids who have an assessment of their fracture risk.

Numerator – the number in the denominator who have an assessment of their fracture risk.

Denominator – the number of adults who use systemic glucocorticoids.

Data source: Local data collection, for example, local audit of patient records.

c) Proportion of adults aged 50 and over who have a history of falls who have an assessment of their fracture risk.

Numerator – the number in the denominator who have an assessment of their fracture risk.

Denominator – the number of adults aged 50 and over who have a history of falls.

Data source: Local data collection, for example, local audit of patient records.

Outcome

Incidence of fragility fractures.

Data source: Local data collection, for example, local audit of patient records.

What the quality statement means for different audiences

Service providers (general practices, secondary care services and fracture liaison services) ensure that systems are in place for adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, to have an assessment of their fracture risk.

Healthcare professionals (GPs, specialists, specialist nurses and fracture liaison practitioners) assess fracture risk, or confirm that assessment has taken place, in adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, to estimate their risk of fracture and determine their treatment options.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults who have had a fragility fracture, use systemic glucocorticoids or have a history of falls, have their fracture risk assessed.

Adults who have had a fragility fracture or falls in the past, or who are taking steroid treatment have their risk of fracture assessed. Fragility fractures happen in people with fragile bones that break easily, usually older people with osteoporosis. There are treatments available to help prevent fractures in people who are at increased risk. An assessment can help to decide if treatment will reduce the chance of having a fracture.

Source guidance

Osteoporosis: assessing the risk of fragility fracture (2012) NICE guideline CG146, recommendations 1.1 and 1.2

Definitions of terms used in this quality statement

Fragility fracture

Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or 'low energy') trauma. The World Health Organization has quantified this as forces equivalent to a fall from a standing height or less. Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur) and wrist (distal radius). They may also occur in the arm (humerus), pelvis, ribs and other bones.

[NICE's guideline on osteoporosis: assessing the risk of fragility fracture, introduction]

Use of systemic glucocorticoids

Adults currently using systemic glucocorticoids, or who have been using systemic glucocorticoids for more than 3 months, at a dose of prednisolone of 5 mg daily or more (or equivalent doses of other glucocorticoids).

[Expert opinion and The University of Sheffield's FRAX fracture risk assessment tool]

History of falls

One or more falls in the last 12 months. A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level. Adults aged 50 and over should have a fracture risk assessment if they have a history of falls.

[NICE's clinical knowledge summary on falls – risk assessment and NICE's guideline on osteoporosis: assessing the risk of fragility fracture, recommendations 1.1 and 1.2]

Assessment of fracture risk

An assessment of fracture risk should include estimating absolute fracture risk (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage). Either FRAX (without a bone mineral density [BMD] value if a DXA scan has not previously been undertaken) or QFracture should be used within their allowed age ranges. Above the upper age limits defined by the tools, consider people to be at high risk. Measure BMD to assess fracture risk in people aged under 40 years.

[Adapted from NICE's guideline on osteoporosis: assessing the risk of fragility fracture, recommendations 1.3, 1.4 and 1.9]