GP-led screening reduces hip fracture risk in older women
A family physician (GP)-led, community screening programme helped reduce the incidence of hip fracture in older women, highlighting the important role played by GPs in reducing the morbidity associated with hip fractures in this population, the UK-based SCOOP* trial revealed.
“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,” said first author Professor Lee Shepstone from the University of East Anglia, Norfolk, UK.
After excluding women already on anti-osteoporosis medications, 12,483 women aged 70–85 years from 100 GP practices in the UK were randomized to receive screening using FRAX (n=6,233) or usual care (n=6,250). Participants were also asked to complete a questionnaire to identify fracture risk factors. After randomization, researchers used the questionnaire to calculate the 10-year risk of osteoporotic and hip fractures in the screening group. Participants determined to have a high risk of hip fracture (n=3,064) were invited to undergo a DXA*** scan to assess femoral neck bone mineral density and 10-year hip fracture risk was recalculated using the DXA scan results.
Fourteen percent of the women who underwent screening (n=898) were identified as high-risk following DXA scan and recommended to receive anti-osteoporosis treatment. Over the study period, more women in the screening group had at least one prescription for anti-osteoporosis medication compared with those undergoing usual care (24 percent vs 16 percent).
Reduced hip fracture risk
Screening did not appear to impact the number of osteoporosis-related fractures with a comparable incidence between patients in the screening and usual care groups (12.9 percent vs 13.6 percent, hazard ratio [HR], 0.94, 95 percent confidence interval [CI], 0.85–1.03; p=0.178) over the 5-year follow-up period. Likewise, the number of clinical fractures was similar between patients in the screening and usual care groups (15.3 percent vs 16.0 percent, HR, 0.94, 95 percent CI, 0.86–1.03; p=0.183). [Lancet 2017;doi:10.1016/S0140-6736(17)32640-5]
However, there was a significant reduction in incidence of hip fracture among women who underwent screening compared with those who received usual care (2.6 percent vs 3.5 percent, HR, 0.72, 95 percent CI, 0.59–0.89; p=0.002).
“The discrepancy is … likely to be explained by the screening method, which used the 10-year risk of hip fracture rather than the risk of any major osteoporotic fracture, to select patients for scanning … Using the hip fracture risk as the screening approach would, of course, be more sensitive to predicting, and therefore better at preventing, hip fractures, rather than fractures at other sites,” said the researchers.
Potential long-term impact of screening
“Currently, there is a crisis in osteoporosis treatment because many women do not take osteoporosis medications because of a fear of rare side-effects,” said Professor Jane Cauley from the Department of Epidemiology, University of Pittsburgh, Pennsylvania, US, in a commentary. [Lancet 2017;doi:10.1016/S0140-6736(17)33295-6]
Cauley cited a US study which highlighted that just 20 percent of patients with hip fractures took anti-osteoporosis medications in the year following the fracture. [J Bone Miner Res 2014;29:1929-1937] In contrast, 78 percent of patients who were deemed high risk for fractures following screening in the SCOOP trial received at least one anti-osteoporosis medication prescription within 6 months of randomization.
“A hip fracture can be devastating with a loss of independence and less than one-third of patients make a full recovery. Mortality at 1-year post-fracture is approximately 20 percent,” said Shepstone.
“Results from SCOOP suggest that a targeted two-step approach might ultimately lead to increased DXA testing in individuals most at risk of fracture,” said Cauley.
“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,” said study co-author Professor Eugene McCloskey from the University of Sheffield, UK.
“While we have demonstrated clinical effectiveness of screening, we are also exploring cost-effectiveness of this approach; initial analyses also look promising in this respect,” said study co-author Professor Neil Gittoes from the University of Birmingham, Birmingham, UK.