"Identify first, then intervene" paradigm is confirmed for hip fractures

Despite effective assessment methods and medications targeting osteoporosis and related fractures, screening for fracture risk is not currently advocated in the UK. Study tested whether a community-based screening intervention could reduce fractures in older women.

Results showed that systematic, community-based screening programme of fracture risk in older women in the UK is feasible, and could be effective in reducing hip fractures.

Lancet

 

Also see: 

Other osteoporosis related articles.

 


The Lancet

Randomized

December 2017

 

Background

Despite effective assessment methods and medications targeting osteoporosis and related fractures, screening for fracture risk is not currently advocated in the UK. We tested whether a community-based screening intervention could reduce fractures in older women.

 

Methods

We did a two-arm randomised controlled trial in women aged 70–85 years to compare a screening programme using the Fracture Risk Assessment Tool (FRAX) with usual management. Women were recruited from 100 general practitioner (GP) practices in seven regions of the UK: Birmingham, Bristol, Manchester, Norwich, Sheffield, Southampton, and York.

We excluded women who were currently on prescription anti-osteoporotic drugs and any individuals deemed to be unsuitable to enter a research study (eg, known dementia, terminally ill, or recently bereaved).

Primary outcome was the proportion of individuals who had one or more osteoporosis-related fractures over a 5-year period. In the screening group, treatment was recommended in women identified to be at high risk of hip fracture, according to the FRAX 10-year hip fracture probability.

Prespecified secondary outcomes were the proportions of participants who had at least one hip fracture, any clinical fracture, or mortality; and the effect of screening on anxiety and health-related quality of life.

 

Findings

12,483 eligible women were identified and participated in the trial, and 6233 women randomly assigned to the screening group between April 15, 2008 - July 2, 2009. Treatment was recommended in 898 (14%) of 6233 women. Use of osteoporosis medication was higher at the end of year 1 in the screening group compared with controls (15% vs 4%), with uptake particularly high (78% at 6 months) in the screening high-risk subgroup.

Screening did not reduce the primary outcome of incidence of all osteoporosis-related fractures (p=0.178), nor the overall incidence of all clinical fractures ( p=0·183), but screening reduced the incidence of hip fractures (0·72, p=0·002). There was no evidence of differences in mortality, anxiety levels, or quality of life.

 

Interpretation

Systematic, community-based screening programme of fracture risk in older women in the UK is feasible, and could be effective in reducing hip fractures.