Management of Patients With High Baseline Hip Fracture Risk by FRAX Reduces Hip Fractures—A Post Hoc Analysis of the SCOOP Study

Abstract

The Screening for Osteoporosis in Older Women for the Prevention of Fracture (SCOOP) study was a community-based screening intervention in women aged 70 to 85 years in the United Kingdom. In the screening arm, licensed osteoporosis treatments were recommended in women identified to be at high risk of hip fracture using the FRAX risk assessment tool (including bone mineral density measurement). In the control arm, standard care was provided. Screening led to a 28% reduction in hip fractures over 5 years. In this planned post hoc analysis, we wished to examine for interactions between screening effectiveness on fracture outcome (any, osteoporotic, and hip fractures) on the one hand and baseline FRAX 10-year probability of hip fracture on the other. All analyses were conducted on an intention-to-treat basis, based on the group to which women were randomized, irrespective of whether screening was completed. Of 12,483 eligible participants, 6233 women were randomized to screening, with treatment recommended in 898 (14.4%). No evidence of an effect or interaction was observed for the outcomes of any fracture or osteoporotic fracture. In the screening arm, 54 fewer hip fractures were observed than in the control arm (164 versus 218, 2.6% versus 3.5%), and commensurate with treatment being targeted to those at highest hip fracture risk, the effect on hip fracture increased with baseline FRAX hip fracture probability (p = 0.021 for interaction); for example, at the 10th percentile of baseline FRAX hip probability (2.6%), there was no evidence that hip fractures were reduced (hazard ratio [HR] = 0.93; 95% confidence interval [CI] 0.71 to 1.23), but at the 90th percentile (16.6%), there was a 33% reduction (HR = 0.67; 95% CI 0.53 to 0.84). Prior fracture and parental history of hip fracture positively influenced screening effectiveness on hip fracture risk. We conclude that women at high risk of hip fracture based on FRAX probability are responsive to appropriate osteoporosis management. © 2018 American Society for Bone and Mineral Research.

The Cost of Osteoporosis, Osteopenia, and Associated Fractures in Australia in 2017

“…In the majority of countries, population screening approaches targeted to the prevention of osteoporosis‐related fractures have not been adopted due to the perception of cost inefficiency . However, recent research has demonstrated the efficacy of screening approaches in reducing the incidence of fractures among community‐dwelling older people . There is substantial evidence including Australian data that demonstrates the mid‐ to long‐term cost efficiencies of fracture liaison services .…”

Cost-Effectiveness of Osteoporosis Screening Using Biomechanical Computed Tomography for Patients With a Previous Abdominal CT

“…Although our results for clinical efficacy are theoretical, their feasibility is supported by evidence from real world clinical experience. In the recent SCOOP study of community‐based women aged 70 to 85 years in the United Kingdom, screening by FRAX/DXA of all participants in an intervention arm was compared against usual care; this interventional screening led to a net reduction of 54 hip fractures over 5 years versus usual care . In that study, the treatment rate in the identified high‐risk patients was 78%, which was approximately 50% higher than for usual care.…”

A brief history of FRAX

“…Most of these were post hoc but, in the case of denosumab, was a pre-planned analysis. In addition, the ‘SCreening of Older wOmen for the Prevention of fractures’ (SCOOP) study (see below) was a prospective randomised study that demonstrated efficacy for hip fracture in women selected on the basis of hip fracture probability assessed using FRAX [137, 138]. …”

“…This seven-centre pragmatic randomised controlled trial with 5-year follow-up, included 12,483 women aged 70-85 years, who were randomised to receive a care algorithm including FRAX and drug targeting versus usual primary care for osteoporosis based on opportunistic case-finding. Screening on the basis of hip fracture probability reduced the incidence of hip fractures by an average of 28%, an effect that was somewhat greater in women with the higher fracture probabilities targeted for treatment [138]. The screening algorithm resulted in a pronounced increase in the use of anti-osteoporosis medication, and greater compliance with therapy, over the period of follow-up.…”

“…The first point that the osteoporosis T-score has low sensitivity is well recognised and was actually the very reason for the development of FRAX. The other two points simply ignore the scientific literature [138, 180–183], yet the latest article was published by the British Medical Journal [178], thus fulfilling its own agenda of an over-diagnosis and over-treatment theme, despite the advice of its own referees [184]. To confuse risk assessment with intervention thresholds, established by independent national and international bodies, is to suggest that inanimate sphygmomanometers are the direct cause of increased treatment of hypertension.…”