Abstract
Approximately 12% of postmenopausal women have osteoporotic vertebral fractures (VFs); these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures. Despite this, less than one-third come to clinical attention, partly due to lack of clear clinical triggers for referral for spinal radiographs. The aim of this study was to investigate whether a novel primary care–based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis. A randomized controlled trial was undertaken in 15 general practices within the Bristol area of the UK. A total of 3200 women aged 65 to 80 years were enrolled, with no exclusion criteria. A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs. All identified high-risk women were offered a diagnostic thoracolumbar radiograph. Radiographs were reported using standard National Health Service (NHS) reporting, with results sent back to each participant's general practitioner (GP). Participants in the control arm did not receive the screening tool or radiographs. The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a random 5% subsample verified against electronic GP records. Secondary outcome was self-reported incidence of new fractures. Results showed that allocation to screening increased prescription of osteoporosis medications by 124% (odds ratio [OR] for prescription 2.24 at 6 months; 95% confidence interval [CI], 1.16 to 4.33). Allocation to screening also reduced fracture incidence at 12-month follow-up (OR for new fracture 0.60; 95% CI, 0.35–1.03; p = 0.063), although this did not reach statistical significance. This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK. © 2012 American Society for Bone and Mineral Research
Highlights
Osteoporosis is one of the most common diseases affecting elderly women
Less than one-third of osteoporotic vertebral fractures (VFs) come to clinical attention.[11]. Possible explanations include inaccurate reporting of spinal radiographs and failure of appropriate recognition and coding of radiograph reports in primary care
We previously carried out a population-based cross-sectional study to define clinical risk factors for identifying women at high risk of prevalent VFs, to serve as a preselection tool for spinal radiographs.[12]. In that study we examined associations between the presence of VF and risk factors for VF ascertained from ‘‘hands-on’’ assessment by a nurse, in 509 women 65 to 75 years old recruited from general practices in southwest UK
Summary
Osteoporosis is one of the most common diseases affecting elderly women. One of the most serious consequences of osteoporosis is vertebral fractures (VFs), which are common: data from the European Vertebral Osteoporosis Study (EVOS) suggest that 6% to 21% of postmenopausal women have at least one vertebral deformity, the majority of which will be osteoporotic in origin, with an average prevalence of 12%.(1) These 12% of women have a reduced quality of life,(2) functional limitations including respiratory compromise,(3) a modest excess mortality,(4) and immediate costs to health care providers of between$2000(5) and $7300.(6) Perhaps most important, they are at high risk of further vertebral[7] and other osteoporotic fractures.[8]. Using a threshold of four, good separation of osteoporosis risk scores was observed according to the presence or absence of more than one VF If this threshold had been applied to the original population in order to preselect patients for radiographs, this would have reduced the number of X-ray referrals by approximately 70%, while identifying one-half of those with one VF and most of those with more than one VF. We postulated that these four independent clinical predictors could be used as a simple screening tool for identifying women at high risk of more than one VF in a population-based setting
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