FRAX Screening Reduces Hip Fractures in Healthy Older Women

Pam Harrison

January 02, 2018

A two-step screening program targeting older women in the community significantly reduces the risk for hip fracture, although not other osteoporotic fractures, compared with usual care, the first community-based screening study of its kind suggests.

After a follow-up of 5 years, rates of any osteoporosis-related fracture were similar at 12.9% in women randomly assigned to the screening group compared with 13.6% for those who received usual care.

Similar results were seen for any clinical fracture where 15.3% of women who had been screened experienced a clinical fracture compared with 16% for the usual care group.

On the other hand, at the end of 5 years, there was a 28% relative risk reduction in hip fracture among women who had been screened compared with the usual care group at 2.6% vs 3.5%, respectively (P = .002).

"This is the first trial to show that a community-screening approach based on the FRAX fracture risk [assessment] tool is both feasible and effective," Lee Shepstone, PhD, reader in medical statistics, University of East Anglia, Norwich, United Kingdom, said in a statement.

“Given that the number of costly and debilitating hip fractures is expected to increase with an aging population, the results of this study potentially have important public health implications,” she added.

The study was published online December 15 in The Lancet.

SCOOP Trial Results

The Screening for Osteoporosis in Older Women for the Prevention of Fracture (SCOOP) trial recruited 12,483 women aged 70 to 85 years from 100 general practices in and around seven regions in England.

"Before randomization, a self-completed questionnaire captured the FRAX risk factors of all participants," investigators explain.

Once participants had been randomized, responses on the initial FRAX questionnaire were used to determine a participant's 10-year probability of sustaining either a hip or another major osteoporotic fracture.

Women were deemed to be "low risk" or "high risk," depending on their 10-year hip fracture probability score on FRAX assessment. 

"The primary end point was the proportion of participants who had at least one osteoporosis-related fracture over the 5-year follow-up," researchers note. 

Almost half of women randomly assigned to the screening group were judged to be at high risk for fracture and were invited to undergo bone mineral density (BMD) testing with dual-energy X-ray absorptiometry (DEXA) at the femoral neck. 

DEXA results indicated that 14% of women in the screening group were at high risk for hip fracture. The mean femoral neck T-score for this group of participants was -2.6.

At 12 months of follow-up, 15% of screening participants had received at least one prescription for an anti-osteoporotic drug compared with 4% in the usual care group. 

In fact, for those classified as high risk for fracture, 78% of women had received at least one prescription for the treatment of osteoporosis within 6 months of being randomized to the screening group.

Over the full study interval, 24% of women in the screening group received at least one anti-osteoporosis medication compared with 16% in the usual care group. 

At the end of 5 years, investigators documented a total of 1975 osteoporosis-related fractures, approximately 13% of them occurred in women who had been assigned to the screening group. 

"The most common site of fracture was the distal forearm," researchers note. 

Importantly, investigators observed no difference in mortality rates between the screening and usual care groups at 8.8% vs 8.4%, respectively, over the 5-year follow-up. Nor were any differences detected between the groups in anxiety levels or quality of life. 

"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," Eugene McCloskey, MD, professor in adult bone disease and honorary consultant at the University of Sheffield in the United Kingdom, said in a statement.

"If the SCOOP screening strategy was taken up in exactly the same ways as in the study in all UK women aged 70–85 years, we estimate that the strategy could prevent up to 8000 hip fractures per year in the UK and even greater gains could be made if we could reach out to women similar to those who did not take part in the study," Dr McCloskey added. 

"Important Public Health Implications"

Commenting on the study in an accompanying commentary, Jane Cauley, DrPH, professor of epidemiology, University of Pittsburgh, Pennsylvania, points out that high-risk women in the current study had a 17.9% probability of sustaining a hip fracture and a 30% probability of sustaining a major osteoporotic fracture at 10 years.

"Thus, despite the absence of a positive impact on the primary outcome, the results of the SCOOP study nevertheless have important public health implications," Dr Cauley reaffirms.

The US Preventive Services Task Force now recommends that all women aged 65 years and older be screened for BMD — even though uptake of DEXA screening appears to be under 20% in some parts of the United States based on Medicare claims data and is currently on the decline.

Thus, SCOOP trial results suggest that the same two-step approach might increase DEXA testing in individuals most at risk for fracture, as Dr Cauley suggested.

Dr Shepstone and Dr Cauley have disclosed no relevant financial relationships. Disclosures for the coinvestigators are listed in the paper.

Lancet. Published online December 15, 2017. Abstract, Commentary

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