Incorporating FRAX into a Nurse-delivered Integrated Care Review: a Multi-method Qualitative Study

Background: People with inflammatory rheumatological conditions (IRCs) are at increased risk of common comorbidities including osteoporosis.

Aim: To explore the barriers to and facilitators of implementing nurse-delivered fracture risk assessments in primary care, in the context of multimorbidity reviews for people with IRCs.

Design & Setting: A multi-method qualitative study in primary care.

Method: As part of a process evaluation in a pilot trial, semi-structured interviews were conducted with 20 patients, two nurses, and three GPs. Twenty-four patient-nurse INCLUDE review consultations were audiorecorded and transcribed. A framework analysis was conducted using the Theoretical Domains Framework (TDF).

Results: Nurses reported positive views about the value of the Fracture Risk Assessment Tool (FRAX) and they felt confident to deliver the assessments following training. Barriers to implementation, as identified by TDF, particularly related to the domains of knowledge, skills, professional roles, and environmental context. GPs reported difficulty keeping up to date with osteoporosis guidelines and voiced differing opinions about whether fracture risk assessment was the role of primary or secondary care. Lack of integration of FRAX into IT systems was a barrier to use. GPs and nurses had differing views about the nurse role in communicating risk and acting on FRAX findings; for example, explanations of the FRAX result and action needed were limited. Patients reported limited understanding of FRAX outcomes.

Conclusion: The findings suggest that, with appropriate training including risk communication, practice nurses are likely to be confident to play a key role in conducting fracture risk assessments, but further work is needed to address the barriers identified.