A nurse-delivered fracture risk assessment for patients with inflammatory rheumatological conditions in primary care: a mixed-methods study.
Problem
The INCLUDE (INtegrating and improving Care for patients with infLammatory rheUmatological DisordErs in the community) pilot trial aimed to evaluate the feasibility and acceptability of a nurse-delivered review in primary care, for people with inflammatory rheumatological conditions (IRCs). The purpose was to identify and manage common comorbidities including anxiety and depression, cardiovascular and fracture risk. The aim of this study was to identify the feasibility and implementation of the FRAX component of the review.
Approach
Ethical approvals obtained. Semi-structured interviews were conducted to explore experiences of participating in INCLUDE with 20 patients, the two nurses delivering the intervention and three General Practitioners (GPs) within participating practices. Interviews were digitally recorded, transcribed and anonymised. Additionally, 24 consenting patients had their INCLUDE review recorded for fidelity checking, and extracts relating to FRAX assessment were transcribed for analysis. Analysis was conducted utilising the Theoretical Domains Framework (TDF), which allows for the cognitive, affective, social and environmental influences on behaviour to be examined.
Findings
Fidelity checks showed that FRAX was appropriately calculated for 22/24 patients. Consultation data showed that although nurses introduced the reason for calculating fracture risk, explanations of the meaning of risk were limited, and patient’s understanding was not always checked. Patient interview findings confirmed a limited understanding of FRAX and the subsequent outcome of the review. Facilitators to implementation, as identified by TDF, related to the domain of beliefs about capabilities and skills. Nurses reported confidence in undertaking FRAX assessments and found the FRAX tool practical and straightforward.Barriers to implementation related to the domains of memory, attention and decision processes, knowledge, beliefs about capabilities, skills, social/professional role and environmental context. GPs and study nurses reported a lack of knowledge and skills in relation to the identification and management of osteoporosis. Reasons for this included a perceived lack of experience, and repeated changes in clinical guidance making keeping up to date difficult. Opinions differed about whether assessment of fracture risk in people with IRCs was the role of primary or secondary care. GPs and nurses had contrasting views about the limits of the nurse role in communicating risk. They described practical barriers to using FRAX including the difficulty navigating between different IT systems. Nurses also described uncertainty over when to refer to the GP within the INCLUDE trial.
Consequences
Screening for fracture risk in people with IRCs in a review consultation is feasible and nurses correctly calculated FRAX in 22/24 consultations. Barriers to routine FRAX implementation for those with IRCs include the lack of integration into existing IT systems and lack of clarity over professional roles and boundaries. More work is needed to explore the barriers and enablers of fracture risk assessment in primary care in order to inform the design of targeted interventions.