Comparison of treatment strategies and thresholds for optimizing fracture prevention in Canada: a simulation analysis
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This comparison of osteoporosis treatment strategies and intervention thresholds highlights tradeoffs in terms of number of individuals qualifying for treatment and estimated fractures prevented.
The current analysis was performed to inform the following key question as part of the Osteoporosis Canada’s Osteoporosis Guidelines Update: “What is the best strategy to identify those at high fracture risk for pharmacotherapy in order to prevent the most fractures, considering both population and patient perspectives?”
The study population consisted of 66,878 women age 50 years and older (mean age 66.0 ± 9.7 years) with documented fracture probability assessment (FRAX) and fracture outcomes. Fractures over the next 5 years were identified through linked administrative healthcare data. We estimated the fraction of the population that would warrant treatment and the number of fractures avoided per 1000 person-years according to multiple strategies and thresholds. Strategies were then rank ordered using 19 metrics.
During mean 4.4 years, 863 (3.5%) sustained one or more major osteoporotic fractures (MOF), 212 (0.8%) sustained a hip fracture, and 1210 (4.9%) sustained any incident fracture. For woman age 50–64 years, the highest ranked strategy was treatment based upon total hip T score ≤ −2.5, but several other strategies fell within 0.5 overall ranking. For women age 65 years and older, MOF > 20% was the highest ranked strategy with no closely ranked strategies. Pooling both age subgroups gave MOF > 20% as the highest ranked strategy, with several other strategies within 0.5 overall ranking.
Choice of treatment strategy and threshold for osteoporosis management strongly influences the number of individuals for whom pharmacologic treatment would be recommended and on estimated fracture rates in the population. This evidence-based approach to comparing these strategies will help to inform guidelines development in Canada and may be on interest elsewhere.
KeywordsOsteoporosis Fractures Clinical practice guidelines Dual-energy x-ray absorptiometry FRAX
The authors thank the Osteoporosis Canada Guidelines Update Fracture Risk Assessment Working Group for guidance as this work evolved. The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository (HIPC 2016/2017-29).
The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Seniors and Active Living, or other data providers is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.
Conception, design, analysis, drafting the article (WDL), interpretation of data (All Authors); critically revising the article for important intellectual content (All Authors); final approval of the version to be published (All Authors); and agreement to be accountable for all aspects of the work (All Authors). WDL had full access to all the data in the study and takes the responsibility for the integrity of the data and the accuracy of the data analysis.
No funding was reserved for this research. SNM is chercheur-boursier des Fonds de Recherche du Québec en Santé. LML is supported by a Tier I Canada Research Chair.
Compliance with ethical standards
The study was approved by the Health Research Ethics Board for the University of Manitoba.
Conflict of interest
William Leslie and Lisa Lix: No conflicts of interest.
Suzanne Morin: Nothing to declare for the context of this paper, but has received research grants: Amgen.
Neil Binkley: Nothing to declare for the context of this paper, but has received research support (paid to institution) from Radius, RTI Health Solutions, GE Healthcare; consultant/advisory board fees from Amgen.
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