The effectiveness and cost-effectiveness of clinical fracture-risk assessment tools in reducing future osteoporotic fractures among older adults: a structured scoping review

Abstract

Summary

This scoping review described the use, effectiveness, and cost-effectiveness of clinical fracture-risk assessment tools to prevent future osteoporotic fractures among older adults. Results show that the screening was not superior in preventing all osteoporosis-related fractures to usual care. However, it positively influenced participants’ perspectives on osteoporosis, may have reduced hip fractures, and seemed cost-effective.

Purpose

We aim to provide a synopsis of the evidence about the use of clinical fracture-risk assessment tools to influence health outcomes, including reducing future osteoporotic fractures and their cost-effectiveness.

Methods

We followed the guidelines of Arksey and O’Malley and their modifications. A comprehensive search strategy was created to search CINAHL, Medline, and Embase databases until June 29, 2021, with no restrictions. We critically appraised the quality of all included studies.

Results

Fourteen studies were included in the review after screening 2484 titles and 68 full-text articles. Four randomized controlled trials investigated the effectiveness of clinical fracture-risk assessment tools in reducing all fractures among older women. Using those assessment tools did not show a statistically significant reduction in osteoporotic fracture risk compared to usual care; however, additional analyses of two of these trials showed a trend toward reducing hip fractures, and the results might be clinically significant. Four studies tested the impact of screening programs on other health outcomes, and participants reported positive results. Eight simulation studies estimated the cost-effectiveness of using these tools to screen for fractures, with the majority showing significant potential savings.

Conclusion

According to the available evidence to date, using clinical fracture-risk assessment screening tools was not more effective than usual care in preventing all osteoporosis-related fractures. However, using those screening tools positively influenced women’s perspectives on osteoporosis, may have reduced hip fracture risk, and could potentially be cost-effective. This is a relatively new research area where additional studies are needed.

Appendices

Appendix 1. Search Strategies for three databases

Medline
Search terms	Results
1 frax.mp	1484
2 garvan.mp	65
3 qfracture.mp	42
4 caroc.mp	22
5 (fracture* adj5 risk assessment*).mp	1639
6 risk assessment*.mp	327,007
7 Risk Assessment/	283,558
8 1 or 2 or 3 or 4 or 5 or 6 or 7	327,557
9 osteoporosis/ or osteopSearchorosis, postmenopausal/	57,951
10 osteoporosis.mp	91,742
11 osteoporotic fracture*.mp	11,997
12 fragility fracture*.mp	4084
13 hip fractures/ or femoral neck fractures/	25,509
14 hip fracture*.mp	24,547
15 or/9–14	120,913
16 8 and 15	5482
17 limit 16 to humans	5070
18 limit 17 to yr = “2000–current”	4864
19 limit 18 to dt = 20,180,701–20,210,629	762
20 fracture risk scale*.mp	6
21 19 or 20	766

Embase
Search terms	Results
1 frax.mp	4017
2 garvan.mp	154
3 qfracture.mp	110
4 caroc.mp	46
5 (fracture* adj5 risk assessment*).mp	3185
6 risk assessment*.mp	651,218
7 risk assessment/	619,253
8 1 or 2 or 3 or 4 or 5 or 6 or 7	653,210
9 exp osteoporosis/	143,291
10 osteoporosis.mp	170,261
11 osteoporotic fracture*.mp	13,188
12 fragility fracture*.mp	22,012
13 exp hip fracture/	42,826
14 hip fracture*.mp	37,422
15 or/9–14	208,790
16 8 and 15	16,518
17 limit 16 to human	15,890
18 limit 17 to yr = “2000–current”	15,084
19 limit 18 to dc = 20,180,701–20,210,629	4114
20 fracture risk scale*.mp	8
21 19 or 20	4118
22 limit 21 to (books or chapter or conference abstract or conference paper or “conference review” or editorial)	1898
23 21 not 22	2220

CINAHL
Search ID#	Search terms	Search options	Results
S16	S14 OR S15	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	497
S15	“fracture risk scale*”	Limiters—Published Date: 20,180,701–20,210,731; Human Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	1
S14	S8 AND S13	Limiters—Published Date: 20,180,701–20,210,731; Human Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	497
S13	S9 OR S10 OR S11 OR S12	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	33,588
S12	(MH “Hip Fractures”)	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	10,843
S11	“fragility fracture*”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	1,400
S10	(MH “Osteoporotic Fractures”)	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	629
S9	(MH “Osteoporosis + ”)	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	23,589
S8	S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	124,629
S7	“risk assessment”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	124,231
S6	(MH “Risk Assessment”)	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	116,820
S5	“fracture risk assessment*”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	376
S4	“caroc”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	6
S3	“qfracture”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	17
S2	“garvan”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	199
S1	“frax”	Expanders—Apply related words; Apply equivalent subjects Search modes—Boolean/Phrase	523

Appendix 2. PEDro Scales completed for the RCT studies

PEDro Criteria	LaCroix, 2005	Shepstone, 2017	Rubin, 2017	Merlijn, 2019
1. Eligibility criteria were specified	✔	✔	✔	✔
2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received)	1	1	1	1
3. Allocation was concealed	0	0	0	0
4. The groups were similar at baseline regarding the most important prognostic indicators	0	1	1	1
5. There was blinding of all subjects	1	0	0	0
6. There was blinding of all therapists who administered the therapy	0	0	0	0
7. There was blinding of all assessors who measured at least one key outcome	0	0	0	1
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups	1	1	0	1
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analyzed by “intention to treat”	1	1	1	1
10. The results of between-group statistical comparisons are reported for at least one key outcome	1	1	1	1
11. The study provides both point measures and measures of variability for at least one key outcome	0	1	1	1
Overall PEDro Score	5/10	6/10	5/10	7/10

Appendix 3. CASP tool for qualitative studies

CASP tool	Dunniway,2010	Rothman,2014
Section A: Are the results valid
1. Was there a clear statement of the aims of the research?	Yes	Yes
2. Is a qualitative methodology appropriate	Yes	Yes
3. Was the research design appropriate to address the aims of the research?	Yes	Yes
4. Was the recruitment strategy appropriate to the aims of the research?	Yes	Yes
5. Was the data collected in a way that addressed the research issue?	Yes	Yes
6. Has the relationship between researcher and participants been adequately considered	No	Unclear
Section B: What are the results?
7. Have ethical issues been taken into consideration?	Unclear	Yes
8. Was the data analysis sufficiently rigorous?	Yes	Yes
9. Is there a clear statement of findings?	Yes	Yes
Section C: Will the results help locally?
10. How valuable is the research	Page 7	Page 8

Appendix 4. CHEERS for economical evaluations

CHEERS 2022 Checklist			Studies
Item #	Items	Guidance for Reposting	Nayak, 2011	Kingkaew, 2011	Ito,2015	Walter, 2017	Soini, 2018	Su, 2018	Martin-Sanchez, 2019	Chandra, 2020
1	Title	Identify the study as an economic evaluation and specify the interventions being compared	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
2	Abstract	Provide a structured summary that highlights context, key methods, results, and alternative analyses	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
3	Background and objectives	Give the context for the study, the study question, and its practical relevance for decision-making in policy or practice	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
4	Health economic analysis plan	Indicate whether a health economic analysis plan was developed and where available	Not Reported	Not Reported	Not Reported	Reported	Reported	Not Reported	Not Reported	Not Reported
5	Study population	Describe characteristics of the study population (such as age range, demographics, socioeconomic, or clinical characteristics)	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
6	Setting and location	Provide relevant contextual information that may influence findings	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
7	Comparators	Describe the interventions or strategies being compared and why chosen	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
8	Perspective	State the perspective(s) adopted by the study and why chosen	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
9	Time horizon	State the time horizon for the study and why appropriate	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
10	Discount rate	Report the discount rate(s) and reason chosen	Reported	Reported	Reported	Reported	Reported	Not Reported	Reported	Reported
11	Selection of outcomes	Describe what outcomes were used as the measure(s) of benefit(s) and harm(s)	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
12	Measurement of outcomes	Describe how outcomes used to capture benefit(s) and harm(s) were measured	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
13	Valuation of outcomes	Describe the population and methods used to measure and value outcomes	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
14	Measurement and valuation of resources and costs	Describe how costs were valued	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
15	Currency, price date, and conversion	Report the dates of the estimated resource quantities and unit costs, plus the currency and year of conversion	Reported	Reported	Reported	Reported	Reported	Not Reported	Reported	Reported
16	Rationale and description of model	If modeling is used, describe in detail and why used. Report if the model is publicly available and where it can be accessed	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
17	Analytics and assumptions	Describe any methods for analyzing or statistically transforming data, any extrapolation methods, and approaches for validating any model used	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
18	Characterizing heterogeneity	Describe any methods used for estimating how the results of the study vary for sub-groups	Reported	Not Reported	Not Reported	Not Reported	Not Reported	Reported	Reported	Reported
19	Characterizing distributional effects	Describe how impacts are distributed across different individuals or adjustments made to reflect priority populations	Reported	Not Reported	Not Reported	Reported	Not Reported	Reported	Reported	Reported
20	Characterizing uncertainty	Describe methods to characterize any sources of uncertainty in the analysis	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
21	Approach to engagement with patients and others affected by the study	Describe any approaches to engage patients or service recipients, the general public, communities, or stakeholders (e.g., clinicians or payers) in the design of the study	Not Reported	Reported	Not Reported	Not Reported	Not Reported	Not Reported	Reported	Not Reported
22	Study parameters	Report all analytic inputs (e.g., values, ranges, references) including uncertainty or distributional assumptions	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
23	Summary of main results	Report the mean values for the main categories of costs and outcomes of interest and summarize them in the most appropriate overall measure	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
24	Effect of uncertainty	Describe how uncertainty about analytic judgments, inputs, or projections affect findings. Report the effect of choice of discount rate and time horizon, if applicable	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
25	Effect of engagement with patients and others affected by the study	Report on any difference patient/service recipient, general public, community, or stakeholder involvement made to the approach or findings of the study	Not Reported	Not Reported	Not Reported	Not Reported	Not Reported	Not Reported	Not Reported	Not Reported
26	Study findings, limitations, generalizability, and current knowledge	Report key findings, limitations, ethical or equity considerations not captured, and how these could impact patients, policy, or practice	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
27	Source of funding	Describe how the study was funded and any role of the funder in the identification, design, conduct, and reporting of the analysis	Reported	Reported	Not Reported	Reported	Reported	Reported	Reported	Reported
28	Conflicts of interest	Report authors conflicts of interest according to journal or International Committee of Medical Journal Editors requirements	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported