Abstract
Patients suffering a low-energy fracture are at high risk of subsequent fractures. Investigation of all fragility fracture patients above the age of 50 years is recommended in order to prevent further fractures. The aim of this study was to investigate alternative strategies including known risk factors (age, sex, and body weight) for selecting fracture patients for osteoporosis assessment and investigate how these strategies would affect the proportion of patients with osteoporosis identified and the number of patients referred for Dual X-ray Absorptiometry (DXA) compared with the original FLS strategy. From OFELIA; a cohort study comprising 794 fragility fracture patients we included 622 patients aged 18 + years (mean age 56 ± 17) with fragility fractures. We investigated the predictive value of clinical risk factors using ROC curves and AUC analyses. The revised strategies were compared by analyzing sensitivity and specificity of different strategies based on sex, age, BMI, and bodyweight. For patients 50 + years, a strategy investigating men and women with body weight ≤ 85 kg resulted in sensitivity and specificity of 94% and 25%, respectively, reducing the number of DXAs by 21%. For patients < 50 years, the prevalence of osteoporosis was low and it was, therefore, difficult to develop an acceptable strategy. We found that the original FLS strategy can be modified to include substantially fewer patients and still only miss the osteoporosis diagnosis in a very few patients. A modified strategy would potentially save costs and concerns in many patients.
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References
Johnell O, Kanis J (2005) Epidemiology of osteoporotic fractures. Osteoporosis Int 16:S3–S7
Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD (2006) Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum 35:293–305
Eisman JA, Bogoch ER, Dell R, Harrington JT, McKinney RE, McLellan A, Mitchell PJ, Silverman S, Singleton R, Siris E (2012) Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner R 27:2039–2046
McLellan AR, Wolowacz SE, Zimovetz EA, Beard SM, Lock S, McCrink L, Adekunle F, Roberts D (2011) Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: a cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int 22:2083–2098
Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, Eisman JA, March L, Seibel MJ (2013) Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int 24:393–406
Åkesson K, Marsh D, Mitchell PJ, McLellan AR, Stenmark J, Pierroz DD, Kyer C, Cooper C (2013) Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporosis Int 24:2135–2152
Hansen L, Petersen KD, Eriksen SA, Langdahl BL, Eiken PA, Brixen K, Abrahamsen B, Jensen JB, Harsløf T, Vestergaard P (2014) Subsequent fracture rates in a nationwide population-based cohort study with a 10-year perspective. Osteoporos Int 26:513–519
Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739
Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382
Cooper C, Mitchell P, Kanis JA (2011) Breaking the fragility fracture cycle. Osteoporos Int 22:2049–2050
Health Government in Denmark (2018) http://www.medstat.dk. Accessed Nov 2018
McLellan AR, Gallacher SJ, Fraser M, McQuillian C (2003) The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 14:1028–1034
Tei RMH, Ramlau-Hansen CH, Plana-Ripoll O, Brink O, Langdahl BL (2018) OFELIA: prevalence of Osteoporosis in Fragility Fracture Patients. Calcif Tissue Int. https://doi.org/10.1007/s00223-018-0476-3
Kanis JA, McCloskey EV, Harvey NC, Johansson H, Leslie WD (2015) Intervention thresholds and the diagnosis of osteoporosis. J Bone Miner Res 30:1747–1753
Kanis JA, Oden A, Johnell O, Jonsson B, de Laet C, Dawson A (2001) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–427
Kanis JA, McCloskey EV, Johansson H, Oden A, Melton LJ III, Khaltaev N (2008) A reference standard for the description of osteoporosis. Bone 42:467–475
Tei R, Langdahl B, Brink O, Dreyer P (2019) Screening for underlying osteoporosis in fragility fracture patients: the patients’ perspectives. Open Nurs J 13:3–11
Langdahl BL (2017) Osteoporosis in premenopausal women. Curr Opin Rheumatol 29:410–415
Ellen GHM, van den Heuvel EGHM, Steijns JMjM (2018) Dairy products and bone health: how strong is the scientific evidence? Nutr Res Rev 31:167–178
Favus MJ (1993) Primer on the metabolic bone diseases and disorders of mineral metabolism, In: Harvey N, Dennison E, Cooper C (eds) Raven, New York, pp 348–356
Fischer JE, Bachmann LM, Jaeschke R (2003) A readers’ guide to the interpretation of diagnostic test properties: clinical example of sepsis. Intensive Care Med 29:1043–1051
Eekman DA, van Helden SH, Huisman AM, Verhaar HJJ, Bultink IEM, Geusens PP, Lips P, Lems WF (2014) Optimizing fracture prevention: the fracture liaison service, an observational study. Osteoporos Int 25:701–709
Acknowledgements
We wish to express our gratitude to all participants in OFELIA for their willingness to make this study possible and to our colleagues at the Department of Orthopaedic Surgery and the Department emergency and acute medicine (FAA) at Aarhus University Hospital (AUH) for identifying fracture patients for this study. Also, many thanks to the staff at The Osteoporosis Clinic, AUH for their great work performing the DXAs.
Funding
For financial support, we wish to thank the Health Research Fund of Central Denmark Region, Aarhus University Hospital (“Spydspidspuljen”), Department of Endocrinology and Internal Medicine, AUH and the Danish Osteoporosis Society.
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RMHT, OP-R, and OB have no conflict of interests. BLL has received honoraria for consulting and lecturing for Amgen, Merck, UCB, and TEVA and received research grants from Amgen and Novo Nordisk. The main author; Tei RMT has full control of all primary data and she agrees to allow the journal to review their data if requested.
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The study complies with the principles outlined in the Declaration of Helsinki. The study was approved by the Danish Data Protection Agency (J. No. 2007-58-0016). AIn accordance to the OFELIA study all patients gave written informed consent to participate in the study.
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Tei, R.M.H., Plana-Ripoll, O., Brink, O. et al. An Optimised Fracture Liaison Service Model: Maintained Diagnostic Sensitivity Despite Reduced Number of Diagnostic Tests Performed. Calcif Tissue Int 104, 641–649 (2019). https://doi.org/10.1007/s00223-019-00535-y
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DOI: https://doi.org/10.1007/s00223-019-00535-y