Screening could prevent 25% of hip fractures

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Community screening for osteoporosis could prevent more than a quarter of hip fractures in older women – according to new research led by the University of East Anglia (UEA). A study has revealed that a simple questionnaire, combined with bone mineral density measurements for some, would help identify those at risk of hip fracture.

The research, which involved more than 12,000 older women, found that screening through GP practices allowed patients to be targeted for treatment. In women agreeing to participate, this led to a 28% reduction in hip fractures over five years.

Lead researcher Professor Lee Shepstone, from UEA’s Norwich Medical School, said: “Approximately one in three women and one in five men aged over 50 years will suffer a fragility fracture during their remaining lifetime. In the UK around 536,000 people suffer fragility fractures each year, including 79,000 hip fractures.

“A hip fracture can be devastating with a loss of independence and less than one third of patients make a full recovery. Mortality at one-year post-fracture is approximately 20%.”

“We wanted to find out whether screening, like screening for breast cancer, could help identify those at risk of suffering a fracture.”

The large multi-centre UK-based community screening study was a collaboration primarily between UEA and the University of Sheffield, and involved researchers at the Universities of Southampton, Bristol, Birmingham, Manchester and York, and over 100 primary care practices.

The team used a University of Sheffield developed tool called FRAX, which predicts the probability of a hip fracture or a major osteoporotic fracture (a hip, spine, upper arm or lower arm fracture), to identify older women at high risk.

A total of 12,483 women aged 70-85 were recruited from 100 GP practices in seven regions (Birmingham, Bristol, Manchester, Norwich, Sheffield, Southampton, and York). Half of the women were screened to compare screening with routine care.

Among those screened, treatment was subsequently recommended for one in seven women deemed at high risk of hip fracture. This recommendation was acted upon by the women and their GPs so that over three quarters of the women at high risk were on osteoporosis medications within six months of screening.

While screening did not reduce the incidence of all osteoporosis-related fractures, there was strong evidence for a reduction in hip fractures. In the screening group, there were 54 fewer women who suffered one or more hip fractures compared to the routine care group.

The study suggests that one hip fracture could be prevented for every 111 women screened and early analysis suggests the approach is likely to be cost-effective.

Shepstone said: “This is the first trial to show that a community-screening approach based on the FRAX fracture risk tool is both feasible and effective. Given that the number of costly and debilitating hip fractures are expected to increase with an ageing population, the results of this study potentially have important public health implications.”

Professor Eugene McCloskey, University of Sheffield, said: “Low-cost screening with FRAX among the older population could result in effective, targeted intervention to reduce the human and socioeconomic burden of hip fractures. If the SCOOP screening strategy was taken up in exactly the same way as in the study in all UK women aged 70-85 years, we estimate that the strategy could prevent up to 8,000 hip fractures per year in the UK. Even greater gains could be made if we could reach out to women similar to those who did not take part in the study.”

The randomised controlled trial ‘SCreening for Osteoporosis in Older women for the Prevention of fracture’ (SCOOP) was funded by the Medical Research Council and Arthritis Research UK.

Dr Natalie Carter, head of research liaison and evaluation at Arthritis Research UK, said: “Ten of thousands of people a year present with hip fractures in the UK. As well as significantly increasing mortality, a hip fracture can stop a person’s ability to live independently, with 43% no longer being able to walk independently in the year after the fracture.

We welcome this community based screening programme and any other research that reduces the likelihood of fractures.”

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). The 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. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN 55814835.
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, and 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 (hazard ratio [HR] 0·94, 95% CI 0·85–1·03, p=0·178), nor the overall incidence of all clinical fractures (0·94, 0·86–1·03, p=0·183), but screening reduced the incidence of hip fractures (0·72, 0·59–0·89, 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.

Lee Shepstone, Elizabeth Lenaghan, Cyrus Cooper, Shane Clarke, Rebekah Fong-Soe-Khioe, Richard Fordham, Neil Gittoes, Ian Harvey, Nick Harvey, Alison Heawood, Richard Holland, Amanda Howe, John Kanis, Tarnya Marshall, Terence O’Neill, Tim Peters, Niamh Redmond, David Torgerson, David Turner, Eugene McCloskey

University of East Anglia material
The Lancet article summary

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