Clinical Edge

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Screening to Reduce Fractures in Older Women

Lancet; ePub 2017 Dec 15; Shepstone, et al

Community-based screening programs of fracture risk in older women is feasible, and may be effective in reducing hip fractures, a recent study found. The 2-arm randomized controlled trial included women aged 70 to 85 years and compared a screening program using the Fracture Risk Assessment Tool with usual management. The primary outcome was the proportion of individuals who had ≥1 osteoporosis-related fracture over a 5-year period. Among the findings:

  • 12,483 eligible women participated in the trial, with 6,233 randomly assigned to the screening group between April 15, 2008, and July 2, 2009.
  • Treatment was recommended in 898 (14%) of 6,233 women.
  • Use of osteoporosis medication was higher at the end of year 1 in the screening group compared with controls, with uptake particularly high in the screening high-risk subgroup (78% at 6 months).
  • Screening significantly reduced the incidence of hip fractures (HR, 0.72), but did not reduce the primary outcome, nor the incidence of all clinical fractures.

Citation:

Shepstone L, Lenaghan E, Cooper C, et al. Screening in the community to reduce fractures in older women (SCOOP): A randomized controlled trial. [Published online ahead of print December 15, 2017]. Lancet. doi:10.1016/S0140-6736(17)32640-5.

Commentary:

1 in 3 women and 1 in 5 men aged ≥50 years will have a fragility fracture at some point in their life, with hip fractures being the most devastating of fractures. After a hip fracture, many people are left with significant impairment and there is approximately a 20% mortality rate over the subsequent year. This study was unique in utilizing a 2-step approach to screening. In the screened group the Fracture Risk Assessment Tool (FRAX) was administered to all patients. FRAX is a simple clinical scoring system that looks at risk factors for osteoporosis and fracture including age, gender, weight, history of previous fracture, parental history of hip fracture, current smoking, steroid use history of rheumatoid arthritis, history of secondary osteoporosis, and >3 drinks of alcohol daily. FRAX then calculates a 10-year risk of any osteoporotic fracture and 10-year risk of hip fracture. Approximately half of the screened group had a >10% 10-year risk of any fracture and were invited to have bone mineral density (BMD) testing. The t-score obtained from BMD testing was used to calculate if the patient was at high risk of hip fracture and those patients received treatment for osteoporosis, which decreased the risk for hip fracture. Decreasing the risk of fracture is a clinically meaningful result, supporting using the FRAX score for screening. —Neil Skolnik, MD

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