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Effectiveness Bulletin Review Osteoporosis

The first Effectiveness Bulletin from the University of Leeds concerned screening for osteoporosis to prevent fractures. It examined the question whether population based screening programmes should be established to prevent fractures in elderly women. It assumed a model of identifying a high-risk group by screening the whole population at the time of the menopause.

The size of the problem

Fractures in post-menopausal women are an important cause of morbidity, mortality and cost.
  • During any five-year period, 10% of a population of women aged 70 years and above will suffer a hip fracture. 10-20% of these will die as a result.
  • The average length of hospital stay is 23 days.
  • Patients with hip fracture account for over 20% of all orthopaedic beds.
  • The average cost of hospital stay is £2500.
  • Only one third of survivors are fully mobile after six months.
The incidence of hip fractures in women is age-related. From an incidence of about 0.5% in the range 70-74 years, it rises to nearly 1.5% a decade later and is very high in women over 85 years.

Is there an effective treatment?

There are no simple treatments for established osteoporosis. Treatment is therefore aimed at the time of rapid bone loss during the menopause. HRT based on oestrogen, alone or in combination with progesterone, has been shown to retard, stop or even reverse bone loss after the menopause.

HRT is recommended for a maximum of 10 years. That leaves a treatment gap of about 15 years between stopping HRT and the age at which fractures become common. HRT has been shown to reduce fracture incidence by about 50% in relatively young women, and that probably overestimates the protective effects of HRT in elderly women.

It is not clear how long the HRT effect persists. There is evidence that the treatment effect diminishes after treatment stops, and within a few years the protective effect may have worn off.

Estimating the effectiveness of HRT on reducing fractures in elderly women is impossible.

Can high-risk patients be identified?

The standard test is for bone density. The sensitivity and specificity of bone density measurements in identifying those women who will go on to have fractures later in life is not established.

If the 20% of women with lowest bone density measurements are taken as the high risk group, then only 28% of those would have gone on to suffer fractures later in life in the absence of therapy. Women with bone densities above this cut-off will suffer 63% of all fractures.

It is possible that biochemical measures to identify rapid bone losers would be more effective, and some new assays are becoming available, but have yet to be fully evaluated.

Will women come for screening?

It expected that even with a lot of effort only 70% of women will take up screening opportunities.

Will women accept long-term HRT?

Long-term compliance with HRT is as low as 30%.

What is the overall impact?

It is likely that a screening programme using bone density measurement and long-term HRT in the high risk group will prevent fewer than 3% of fractures in elderly women.

Implications for Health Authorities & GPFHs

This is a detailed and well reasoned review, as well as being a good read. It has assembled a solid body of evidence, and is a paradigm for anyone considering and screening programme.

Effective Health care Bulletins are available from Nick Fremantle, School of Public Health, University of Leeds, 32 Hyde Terrace, Leeds LS2 9LN. Price £3 or £25 for a series of nine bulletins.

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