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Primary care osteoporosis screening 'could prevent a quarter of hip fractures'

Screening for osteoporosis in GP practices could prevent more than a quarter of hip fractures in older females, according to a UK-wide study.

The research, published in The Lancet, found that a simple questionnaire, combined with bone mineral density measurements for some, would help identify those at risk of hip fracture and allow patients to be targeted for treatment. This led to a 28 per cent reduction in hip fractures over five years.

The large multicentre community screening study, funded by the Medical Research Council and Arthritis Research UK, involved 12,483 women aged 70-85, from 100 GP practices in seven regions - Birmingham, Bristol, Manchester, Norwich, Sheffield, Southampton and York. Half of the women were screened, with the control group receiving routine care.

Some 536,000 people have fragility fractures each year, with hip fractures alone costing £3.5bn in 2010 and expected to rise to £5.5bn by 2025. There is a 20% risk of death in the first year after a hip fracture.

The researchers from UEA and University of Sheffield said: ‘For the individual, a hip fracture can be devastating, causing loss of independence, and less than one-third of patients make a full recovery.’

They used a tool called FRAX, which predicts the probability of a hip fracture or a major osteoporotic fracture, to identify older women at high risk.

Of 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 more than three-quarters of the women at high risk were on osteoporosis medication within six months of screening.

Screening did not reduce the incidence of all osteoporosis-related fractures but there was strong evidence for a reduction in hip fractures, with 54 fewer women suffering one or more hip fractures compared with the routine care group.

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

Professor Lee Shepstone, lead researcher, from UEA’s Norwich Medical School, said: ‘We wanted to find out whether screening, like screening for breast cancer, could help identify those at risk of suffering a fracture.

‘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 is expected to increase with an ageing population, the results of this study potentially have important public health implications.’

Professor Eugene McCloskey, co-lead from the 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 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.’

GPC prescribing lead Dr Andrew Green said: 'Hip fractures in the elderly are a huge problem, with many causing loss of independence or indeed being the precipitating factor for a general decline in health, so at first glance screening to reduce them would seem of value. However, any potential benefits have to be weighed against both the financial costs and also the known side-effects of osteoporosis treatments. Bisphosphonates in particular carry significant potential adverse effects.

'No screening should ever take place in the NHS without a positive assessment from the UK Screening Committee, a national funded scheme, and most importantly validated patient decision-making aids so that people choosing to undergo screening do so with full knowledge of the possible benefits and risks.'



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Readers' comments (10)

  • More unfunded work coming our way. It’s must be Christmas.

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  • Dexa scans in our area are not allowed in the over 70s so we would be entirely reliant on frax score. So in addition to the 10 drugs they are already on for cardiovascular, diabetes, hypertension etc we will add adcalD3 and alendronate. You can see what drives polypharmacy in modern medicine.

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  • Vinci Ho

    While I do not want to be anti-academics all the time , there are some very practical issues on the frontline:
    (1) National Osteoporosis Society advocated the use of FRAX scoring to assess risk of fragility fracture . FRAX scores are both available with and without DEXA scan results (hence , T-scores). The fracture risk calculated are to be projected on the treatment graph(10 year probability of major osteoporotic fracture in %) and treatment e.g.bisphosphonates is recommended if the risk exceeded a the treatment threshold line and this is related to the actual age of an individual patient. So it could be a threshold of about 7% for a 45 years old as opposed to about 20% in a 70 years old . This approach is sensible to me.
    (2) But what did our NICE guys say ? Simply commence biphosphonates if the risk is above 1% . Use either Qfracture( which does not need to include T score) OR FRAX. Potentially, we will treat a lot of elderly patients with biphosphonates for argument sake.
    (3) I yet to get an automatic calculator on EMIS for Qfracture or FRAX although both are READ CODES by default. Time is a resource here and quite rightly, this work is unfunded considering one has to follow up and review medication for biphosphonates as they are not without side effects and a treatment holiday may be necessary after 3 to 5 years .

    I just wish before academics want to fulfill their mission of bringing ‘changes’ with guidances , talk to grass root GPs in the frontline first.

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  • Cobblers

    No, just no.

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  • And in 2018 primary care will be expected to prevent all illness and all deaths or no cash at all. Typical work shy incompetent GPs will continue to allow death to follow life. Call the GMC.

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  • National Hopeless Service

    Dear MRC and all known medical charities,


    Lots of Love from a GP who doesnt have the capacity during most working days to have a wee let alone service your pet ideas.

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  • ‘This is the first trial to show that a community-screening approach based on the FRAX fracture risk tool is both feasible and effective

    Well clearly none of us would go that far,and since we would be delivering it,the researchers may wish to reconsider

    Full marks for expressing their results as NNT,if you cannot express your results as an NNT why bother doing the research in the first place

    It would have enormously enhanced the validity of the paper if the cost of providing this service entirely through secondary care were given.GP's are not the only doctors

    So; at what level of NNT is the average elderly person, prepared to take tablets daily, to prevent hip fracture? What is their attitude to risk?

    Does 111 fall within the range?

    What proportion of the elderly currently taking a dozen tablets a day would also remember these tablets?

    There is a theoretical case but I think practical and feasible is a little hopeful

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  • David Banner

    Random thoughts...
    1- compliance with these drugs is notoriously poor.
    2- GI side effect with alendronate are common, with risk of potentially fatal GI bleed
    3- hypercalcaemia is a rare but serious consequence, should we be monitoring?
    4- Falls Team agenda pushes these drugs whilst stopping hypotensives and analgesia. Yet they come back hypertensive and in pain. Is it such a great swap?
    5- to echo others, this needs funding as an enhanced service or it is just hot air.

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  • Given enough time to look at any area, it will improve. We are told to see more patients, deal with more meetings and submit more figures. Nobody has the time.

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  • While polypharmacy may reduce some risks I suspect, in my area , the local aothority gritting pavements would be much more beneficial!!

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