Appendix 1: Fracture Risk Determination Scenarios

Each scenario depicts a fictional patient with one or more risk factors for osteoporotic fracture. Please read each scenario and respond to the following four questions. Note that “major osteoporotic fracture” refers to non-traumatic fractures of the humerus, radius, spine, or hip. The cases are not designed to contain tricks and there are no necessarily wrong answers. The purpose is simply to understand how physicians approach osteoporotic fracture risk.

  1. Joanne is a fifty-five year old woman who presents to your office for advice. She is a non-smoker and consumes 1-2 alcoholic beverages per month. Her only medication is Ramipril for well controlled hypertension. She is otherwise healthy and has a BMI of 22. Her last BMD revealed a T-score at the hip of -2.4.
  2. Please estimate Joanne’s ten year risk for osteoporotic fracture:___%
  3. Please estimate Joanne’s ten year risk for hip fracture:_____%
  4. Would you offer Joanne pharmacologic treatment for the prevention of osteoporotic fractures? □Yes □No
  5. What main factors influenced your decision? (please list at least one)
  1. How confident are you in your risk estimate? (4= very confident, 3= somewhat confident, 2= not very confident, 1= completely unsure)

□4 □3 □2 □1

  1. Margaret is a seventy year old woman who presents to your office with concerns about bone health. She has been taking Prednisone 15mg/day for the past four months for temporal arteritis. She is a non-smoker and consumes 1-2 alcoholic beverages per month. She has never suffered a fragility fracture and has no family history of fractures. She takes an ACEi and a statin. She is otherwise healthy and has a BMI of 24. Her BMD is -2.0.
  2. Please estimate Margaret’s ten year risk for osteoporotic fracture:___%
  3. Please estimate Margaret’s ten year risk for hip fracture:_____%
  4. Would you offer Margaret pharmacologic treatment for the prevention of osteoporotic fractures? □Yes □No
  5. What main factors influenced your decision? (please list at least one)
  1. How confident are you in your risk estimate? (4= very confident, 3= somewhat confident, 2= not very confident, 1= completely unsure)

□4 □3 □2 □1

  1. Stanley is a seventy year old gentleman admitted to the medical teaching unit for pneumonia. He drinks 3-4 beers per night and smokes half a pack of cigarettes per day. Once he is stabilized, the junior resident approaches you about prevention measures for this man. Stanley has never had a fragility fracture and has no known family history of such. He currently takes no medications. He has a BMI of 19 and a BMD of -1.9.
  2. Please estimate Stanley’s ten year risk for osteoporotic fracture:___%
  3. Please estimate Stanley’s ten year risk for hip fracture:_____%
  4. Would you offer Stanley pharmacologic treatment for the prevention of osteoporotic fractures? □Yes □No
  5. What main factors influenced your decision? (please list at least one)
  1. How confident are you in your risk estimate? (4= very confident, 3= somewhat confident, 2= not very confident, 1= completely unsure)

□4 □3 □2 □1

  1. Elizabeth is a sixty-three year old woman who presents to your practice for follow-up of her bone mineral density (BMD) results. She was tested because her mother suffered two fragility fractures in her fifties and sixties. Elizabeth has rheumatoid arthritis but has never taken steroids. She takes Methotrexate and a multivitamin. She is a non-smoker and does not consume alcohol. Her BMI is 20. Her BMD testing reveals a T-score at the femoral neck of -2.6.
  2. Please estimate Elizabeth’s ten year risk for osteoporotic fracture:___%
  3. Please estimate Elizabeth’s ten year risk for hip fracture:_____%
  4. Would you offer Elizabeth pharmacologic treatment for the prevention of osteoporotic fractures? □Yes □No
  5. What main factors influenced your decision? (please list at least one)
  1. How confident are you in your risk estimate? (4= very confident, 3= somewhat confident, 2= not very confident, 1= completely unsure)

□4 □3 □2 □1

  1. Louisa is a seventy-two year old lady who presents for her annual check-up. You are concerned as she has lost twenty pounds in the last year following the death of her husband. She now has a BMI of 17. She has never had a fragility fracture, but her mother fractured her hip at the age of sixty after a ground-level fall. She takes a multivitamin. Aside from GERD and mild depression, she is healthy. She is a non-smoker and drinks one glass of wine at Christmas and Easter. She has a BMD of -3.
  2. Please estimate Louisa’s ten year risk for osteoporotic fracture:___%
  3. Please estimate Louisa’s ten year risk for hip fracture:_____%
  4. Would you offer Louisa pharmacologic treatment for the prevention of osteoporotic fractures? □Yes □No
  5. What main factors influenced your decision? (please list at least one)
  1. How confident are you in your risk estimate? (4= very confident, 3= somewhat confident, 2= not very confident, 1= completely unsure)

□4 □3 □2 □1

Fracture Risk Determination Questionnaire

  1. Please check one of the following that applies to you:

□Internal Medicine resident

□Internal Medicine physician

□Endocrinologist

□Family Physician

  1. Year of graduation from medical school:_____
  1. Age:_____
  1. Gender:

□Female

□Male

  1. In what proportion of cases do you think you rely on a formal estimate of fracture risk to assist with patient management?

□0-10%

□10-25%

□25-50%

□50-75%

□>75%

  1. Do you use other fracture risk determination tools? If so, please list.

□Yes:______

□No

  1. What do you think are major barriers to more routine use of formal fracture risk determination tools? (check all that apply)

□ Lack of time

□ Lack of familiarity with these tools

□ Lack of awareness that tools exist

□ Lack of usefulness of tools

□ Other (please list)

  1. How much weight do you place on BMD in determining fracture risk? (1=very little weight, 2=some weight, 3= a lot of weight, 4=sole determinant)

□4 □3 □2 □1

  1. What risk factors are you most likely to consider in treatment decisions for osteoporotic fracture prevention? Please list your top three factors in order of importance.

______

______

______

  1. For what level of ten year fracture risk would you be inclined to offer pharmacotherapy for fracture risk reduction? (%risk of major osteoporotic fracture per year):_____%
  1. How useful is it to determine fracture risk before counselling patients about drug options for fracture risk reduction?

□Very useful

□Somewhat useful

□Not very useful

□Not useful at all

  1. Comments and questions: