Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group

Abstract

Summary The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. Introduction The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. Methods The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation’s Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. Results and Conclusion The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

The osteoporosis treatment gap in Switzerland between 1998 and 2018

“…In terms of total number of fractures, the end result would be that a large number of fractures would still occur in unprotected patients at risk and undermine achievable better public health results at the global population level. This triggers and further supports recent developments suggesting that a populationbased screening for fracture risk in postmenopausal women based on FRAX should be considered, in addition to the currently implemented high-risk case finding and treatment approach, for incorporation in many healthcare systems to reduce the burden of fractures [18,19].…”

Population screening for fracture risk in postmenopausal women — a logical step in reducing the osteoporotic fracture burden?

“…When the analysis was confined to major osteoporotic fractures, screening resulted in a 9-10% significant decrease (Fig. 2B) [20]. More importantly, the largest impact of the three studies combined was on the rate of hip fractures; again bearing in mind the relatively small proportion treated, the meta-analysis showed a 20% reduction (HR 0.80, 95%CI 0.71-0.91) in hip fractures (Fig.…”

“…Both recognized, however, that the ability of screening to reduce hip fracture risk had some potential and since then a meta-analysis of three prospective, randomized controlled studies of FRAX-based screening has shown a significant reduction in hip fractures [19]. Whether or not osteoporosis, or more specifically high hip fracture risk, fulfils the criteria for screening has been addressed in a recently published position statement from the Epidemiology/Quality of Life Working Group (Epi/QoL WG) of the International Osteoporosis Foundation [20]. This editorial summarises the key issues relating to the proposed screening program.…”

Declining hip fracture burden in Sweden 1998-2019 and consequences for projections through 2050

“…The naïve use of national hospital record data has been a common practice for some time (13). Nonetheless,country-speci c FRAX fracture risk assessments based on register data have been developed for 77 countries (71). The assumptions and calculations underlying these predictions have not been published (72)(73)(74), limiting their relevance as a prediction tool (75,76).…”