Access to fracture risk assessment by FRAX and linked National Osteoporosis Guideline Group (NOGG) guidance in the UK-an analysis of anonymous website activity

Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures.

INTRODUCTION

The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture.

METHODS

The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized.

RESULTS AND CONCLUSION

The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

Estimation of fracture risk by the FRAX tool in patients with systemic lupus erythematosus: a 10-year longitudinal validation study

Background:

The fracture risk assessment tool has been widely used to stratify the 10-year fracture risk to guide therapy. Using the actual fracture data of a 10-year longitudinal cohort of older patients with systemic lupus erythematosus, we reported an underestimation of the tool in predicting major symptomatic osteoporotic fractures. Treatment of osteoporosis in systemic lupus erythematosus should not be based on fracture risk estimation alone. Relevant time-dependent risk factors should be taken into account for an individualized decision.

Objective:

To compare the observed fracture incidence in a 10-year longitudinal cohort of patients with systemic lupus erythematosus (SLE) with the fracture risk prediction from the fracture risk assessment (FRAX) tool.

Methods:

Adult patients (⩾40 years) with SLE who had a first DEXA scan performed in 2005–2009 were studied. The 10-year rates of major osteoporotic and hip fractures were estimated by FRAX using clinical data at DEXA with adjustment for prednisolone dosage. The actual incidence of clinical fractures at 10 years was compared with the estimated rates. Factors associated with new fractures were studied by logistic regression.

Results:

A total of 229 SLE patients were studied (age: 50.2 ± 6.6 years, 93% women). Glucocorticoid was used in 148 (65%) patients at baseline (mean dose: 7.3 ± 6.9 mg/day; 34% ⩾ 7.5 mg/day). Osteoporosis (bone mineral density T score ⩽ –2.5) at the hip, femoral neck, or spine was present in 61 (27%) patients. The estimated 10-year risk of major osteoporotic and hip fractures by FRAX was 3.4 ± 4.5% and 0.95 ± 2.3%, respectively. After 10 years, three patients developed hip fracture, 6 patients had limb fractures and 20 patients had symptomatic vertebral fractures (major osteoporotic fracture 12.7%, hip fracture 1.3%). The actual major osteoporotic fracture rate was significantly higher than the FRAX estimation (12.7% vs 3.4%; p < 0.001). Logistic regression revealed that osteoporosis (odds ratio (OR): 4.07 [1.51–10.9]), previous fragility fracture (OR: 3.18 [1.02–9.90]), and a parental history of fracture (OR: 4.44 [1.16–17.0]) were independently associated with new clinical fractures at 10 years.

Conclusion:

The FRAX tool underestimates the major clinical fracture risk at 10 years in patients with SLE.

FRAX-Based Intervention Thresholds for Osteoporosis Treatment in Ukraine

OBJECTIVES

Osteoporosis, in addition to its consequent fracture burden, is a common and costly condition. FRAX^® is a well-established, validated, web-based tool which calculates the 10-year probability of fragility fractures. A FRAX model for Ukraine has been available since 2016 but its output has not yet been translated into intervention thresholds for the treatment of osteoporosis in Ukraine; we aimed to address this unmet need in this analysis.

METHODS

In a referral population sample of 3790 Ukrainian women, 10-year probabilities of major osteoporotic fracture (MOF) and hip fracture separately were calculated using the Ukrainian FRAX model, with and without femoral neck bone mineral density (BMD). We used a similar approach to that first proposed by the UK National Osteoporosis Guideline Group, whereby treatment is indicated if the probability equals or exceeds that of a woman of the same age with a prior fracture.

RESULTS

The MOF intervention threshold in females (the age-specific 10-year fracture probability) increased with age from 5.5% at the age of 40 years to 11% at the age of 75 years where it plateaued and then decreased slightly at age 90 (10%). Lower and upper thresholds were also defined to determine the need for BMD, if not already measured; the approach targets BMD measurements to those at or near the intervention threshold. The proportion of the referral populations eligible for treatment, based on prior fracture or similar or greater probability, ranged from 44% to 69% depending on age. The prevalence of the previous fracture rose with age, as did the proportion eligible for treatment. In contrast, the requirement for BMD testing decreased with age.

CONCLUSIONS

The present study describes the development and application of FRAX-based assessment guidelines in Ukraine. The thresholds can be used in the presence or absence of access to BMD and optimize the use of BMD where access is restricted.

Global impact of COVID-19 on non-communicable disease management: descriptive analysis of access to FRAX fracture risk online tool for prevention of osteoporotic fractures

The COVID-19 pandemic, and its management, is markedly impacting the management of osteoporosis as judged by access to online FRAX fracture risk assessments. Globally, access was 58% lower in April than in February 2020. Strategies to improve osteoporosis care, with greater use of fracture risk assessments, offer a partial solution.

INTRODUCTION

The COVID-19 pandemic is having a significant detrimental impact on the management of chronic diseases including osteoporosis. We have quantified the global impact by examining changes in the usage of online FRAX fracture risk assessments before and after the declaration of the pandemic (11 March 2020).

METHODS

The study comprised a retrospective analysis using GoogleAnalytics data on daily sessions on the FRAX® website ( www.sheffield.ac.uk/FRAX ) from November 2019 to April 2020 (main analysis period February-April 2020), and the geographical source of that activity.

RESULTS

Over February-April 2020, the FRAX website recorded 460,495 sessions from 184 countries, with 210,656 sessions in February alone. In March and April, the number of sessions fell by 23.1% and 58.3% respectively, a pattern not observed over the same period in 2019. There were smaller reductions in Asia than elsewhere, partly related to earlier and less-marked nadirs in some countries (China, Taiwan, Hong Kong, South Korea and Vietnam). In Europe, the majority of countries (24/31, 77.4%) reduced usage by at least 50% in April. Seven countries showed smaller reductions (range - 2.85 to - 44.1%) including Poland, Slovakia, Czech Republic, Germany, Norway, Sweden and Finland. There was no significant relationship between the reduction in FRAX usage and measures of disease burden such as COVID-attributed deaths per million of the population.

CONCLUSION

This study documents a marked global impact of the COVID-19 pandemic on the management of osteoporosis as reflected by FRAX online fracture risk assessments. The analysis suggests that impact may relate to the societal and healthcare measures taken to ameliorate the pandemic.

Bone Evaluation by High-Resolution Peripheral Quantitative Computed Tomography in Patients With Adrenal Incidentaloma

CONTEXT

Data regarding high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with adrenal incidentaloma (AI) are unknown.

PURPOSE

To evaluate the areal bone mineral density (aBMD), microstructure, and fractures in patients with nonfunctioning AI (NFAI) and autonomous cortisol secretion (ACS).

METHODS

We evaluated 45 patients with NFAI (1 mg dexamethasone suppression test [DST] ≤1.8 µg/dL) and 30 patients with ACS (1 mg DST 1.9-5.0 µg/dL). aBMD was measured using dual-energy X-ray absorptiometry; vertebral fracture by spine X-ray; and bone geometry, volumetric bone mineral density (vBMD), and microstructure by HR-pQCT.

RESULTS

Patients with ACS showed lower aBMD values at the spine, femoral neck, and radius 33% than those with NFAI. Osteoporosis was frequent in both groups: NFAI (64.9%) and ACS (75%). Parameters at the distal radius by HR-pQCT were decreased in patients with ACS compared to those with NFAI: trabecular vBMD (Tb.vBMD, P = 0.03), inner zone of the trabecular region (Inn.Tb.vBMD, P = 0.01), the bone volume/tissue volume ratio (BV/TV, P = 0.03) and trabecular thickness (P = 0.04). As consequence, a higher ratio of the outer zone of the trabecular region/inner zone vBMD (Meta/Inn.vBMD, P = 0.003) was observed. A correlation between the cortisol levels after 1 mg DST and Meta/Inn.vBMD ratio was found (r = 0.29; P = 0.01). The fracture frequency was 73.7% in patients with ACS vs 55.6% in patients with NFAI (P = 0.24).

CONCLUSION

Our findings point to an association between trabecular bone microarchitectural derangement at the distal radius and ACS. Our data suggest that AI have a negative impact on bone when assessed by HR-pQCT, probably associated to subclinical hypercortisolism.

Dental care for patients taking antiresorptive drugs: a literature review

Antiresorptive drugs (ARDs), such as bisphosphonates or denosumab, that prevent bone resorption are widely used in patients with osteoporosis or with cancer that has metastasized to the bones. Although osteonecrosis of the jaw (ONJ) is a well-documented complication of ARD use, the benefits ARDs outweigh the complication. Thus, research has focused on finding ways to prevent or reduce the risk of developing ONJ. Dentists, as part of a multi-professional team, have a critical role in preventing ONJ. However, many dentists tend to hesitate to provide dental care to patients with ONJ, or tend to think that it is a problem to be dealt with by oral surgeons. This review gives an overview of ARD-related ONJ and provides the guidelines for dental care in patients taking ARDs to lower the risk of developing ONJ.

Fracture prediction, imaging and screening in osteoporosis

Osteoporosis is associated with increased fragility of bone and a subsequent increased risk of fracture. The diagnosis of osteoporosis is intimately linked with the imaging and quantification of bone and BMD. Scanning modalities, such as dual-energy X-ray absorptiometry or quantitative CT, have been developed and honed over the past half century to provide measures of BMD and bone microarchitecture for the purposes of clinical practice and research. Combined with fracture prediction tools such as Fracture Risk Assessment Tool (FRAX) (which use a combination of clinical risk factors for fracture to provide a measure of risk), these elements have led to a paradigm shift in the ability to diagnose osteoporosis and predict individuals who are at risk of fragility fracture. Despite these developments, a treatment gap exists between individuals who are at risk of osteoporotic fracture and those who are receiving therapy. In this Review, we summarize the epidemiology of osteoporosis, the history of scanning modalities, fracture prediction tools and future directions, including the most recent developments in prediction of fractures.

Assessing the risk of osteoporotic fractures: the Ecuadorian FRAX model

The FRAX tool incorporates data on the incidence of fractures and mortality in each country. The epidemiology of fractures changes over time, this makes it necessary to update the specific FRAX model of each population. It is shown that there are differences between old and new FRAX models in older individuals.

PURPOSE

A new FRAX® model for Ecuador was released online in April 2019. This paper describes the data used to build the revised model, its characteristics, and how intervention and assessment thresholds were constructed.

METHODS

The national rates of hip fracture incidence standardized by age and sex from the age of 40 years for 2016 were used to synthesize a FRAX model for Ecuador. For other major fractures, Ecuadorian incidence rates were calculated using ratios obtained in Malmö, Sweden, for other major osteoporotic fractures. The new FRAX model was compared with the previous model released in 2012. Assessment and intervention thresholds were based on age-specific probabilities of a major osteoporotic fracture equivalent to women with a previous fracture.

RESULTS

Fracture incidence rates increase with age. The probability of hip or major fractures at 10 years increased in patients with a clinical risk factor, lower BMI, female sex, a higher age, and a lower BMD T-score. Compared to the previous model, the new FRAX model gave similar 10-year fracture probabilities in men and women age less than70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the two models (> 0.99) so that the revision had little impact on the rank order of risk.

CONCLUSIONS

The FRAX tool provides a country-specific fracture prediction model for Ecuador. This update of the model is based on the original FRAX methodology, which has been validated externally in several independent cohorts. The FRAX model is an evolving tool that is being continuously refined, as the databases of each country are updated with more epidemiological information.

Temporal changes in access to FRAX® in Thailand between 2010 and 2018

The usage of FRAX® tool in Thailand and other countries was explored using Google Analytics data. Over the period 2010-2018, Thailand ranked 35th in the world for FRAX usage (the US is ranked first). Incorporation of FRAX into a national osteoporosis guideline in Thailand appears to have increased its usage.

PURPOSE

To document access to the web-based FRAX® tool and specifically its access in Thailand between 2010 and 2018.

METHODS

A descriptive retrospective study using data from Google Analytics that provides numerical and geographical information on internet access to the FRAX tool website worldwide.

RESULT

In Thailand, Bangkok is the highest ranked site for FRAX access with more than 20,000 usage sessions since 2010 (3.6 usage session per 1000 population) followed by Khon Kaen and Chiang Mai. It has been accessed from within 76 out of 77 provinces (98.7%). There was a steady increase in access to FRAX from within Thailand of approximately 1000 usage sessions per year between 2010 and 2016. After the FRAX fracture risk calculation was included in the national guideline for osteoporosis management published in late 2016, the rate of increase in access was four-fold higher compared with the previous period. In world ranking, the USA is the country with the most frequent access to the FRAX tool, whereas Thailand was ranked 35th in the world. There were weak but significant correlations between the absolute number of FRAX sessions and population size (r = 0.165, p = 0.011) and land area (r = 0.375, p < 0.001).

CONCLUSION

Access to the FRAX tool website is increasing in Thailand. The incorporation of FRAX into national guidelines, in parallel to the adoption of osteoporosis fracture prevention into national policy, has had a rapid and significant impact on its use.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

A Process Evaluation of a Web-Based Mental Health Portal (WalkAlong) Using Google Analytics

BACKGROUND

Despite the increasing amount of research on Web-based mental health interventions with proven efficacy, high attrition rates decrease their effectiveness. Continued process evaluations should be performed to maximize the target population's engagement. Google Analytics has been used to evaluate various health-related Web-based programs and may also be useful for Web-based mental health programs.

OBJECTIVE

The objective of our study was to evaluate WalkAlong.ca, a youth-oriented mental health web-portal, using Google Analytics to inform the improvement strategy for the platform and to demonstrate the use of Google Analytics as a tool for process evaluation of Web-based mental health interventions.

METHODS

Google Analytics was used to monitor user activity during WalkAlong's first year of operation (Nov 13, 2013-Nov 13, 2014). Selected Google Analytic variables were overall website engagement including pages visited per session, utilization rate of specific features, and user access mode and location.

RESULTS

The results included data from 3076 users viewing 29,299 pages. Users spent less average time on Mindsteps (0 minute 35 seconds) and self-exercises (1 minute 08 seconds), which are important self-help tools, compared with that on the Screener tool (3 minutes 4 seconds). Of all visitors, 82.3% (4378/5318) were desktop users, followed by 12.7 % (677/5318) mobile phone and 5.0% (263/5318) tablet users. Both direct traffic (access via URL) and referrals by email had more than 7 pages viewed per session and longer than average time of 6 minutes per session. The majority of users (67%) accessed the platform from Canada.

CONCLUSIONS

Engagement and feature utilization rates are higher among people who receive personal invitations to visit the site. Low utilization rates with specific features offer a starting place for further exploration of users in order to identify the root cause. The data provided by Google Analytics, although informative, can be supplemented by other evaluation methods (ie, qualitative methods) in order to better determine the modifications required to improve user engagement. Google Analytics can play a vital role in highlighting the preferences of those using Web-based mental health tools.

Appropriateness of bone density measurement in Switzerland: a cross-sectional study

Background

According to the WHO, osteoporosis is one of the most important non- communicable diseases worldwide. Different screening procedures are controversially discussed, especially concerning the concomitant issues of overdiagnosis and harm caused by inappropriate Dual X-ray Absorptiometry (DXA). The aim of this study was to evaluate the frequency and appropriateness of DXA as screening measure in Switzerland considering individual risk factors and to evaluate covariates independently associated with potentially inappropriate DXA screening.

Methods

Retrospective cross-sectional study using insurance claim data of 2013. Among all patients with DXA screening, women < 65 and men < 70 years without osteoporosis or risk factors for osteoporosis were defined as receiving potentially inappropriate DXA. Statistics included descriptive measures and multivariable regressions to estimate associations of relevant covariates with potentially inappropriate DXA screening.

Results

Of 1,131,092 patients, 552,973 were eligible. Among those 2637 of 10,000 (26.4%) underwent potentially inappropriate DXA screening. Female sex (Odds ratio 6.47, CI 6.41–6.54) and higher age showed the strongest association with any DXA screening.

Female gender (Odds ratio 1.84, CI 1.49–2.26) and an income among the highest 5% (Odds ratio 1.40, CI 1.01–1.98) were significantly positively associated with potentially inappropriate DXA screening, number of chronic conditions (Odds ratio 0.67, CI 0.65–0.70) and living in the central region of Switzerland (Odds ratio 0.67, CI 0.48–0.95) negatively.

Conclusion

One out of four DXAs for screening purpose is potentially inappropriate. Stakeholders of osteoporosis screening campaigns should focus on providing more detailed information on appropriateness of DXA screening indications (e.g. age thresholds) in order to avoid DXA overuse.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5305-0) contains supplementary material, which is available to authorized users.