Is Screening for Osteoporosis Worthwhile

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Is Screening for Osteoporosis Worthwhile?

• Dr David M Reid
• Professor of Rheumatology,
• University of Aberdeen

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Screening for OsteoporosisOutline of presentation

• Definitions of screening, case-finding and risk
  identification
• Effective Effective Health Care Questions and
  Answers
• Perimenopausal screening program (APOSS)
• Psychological effects of screening?
• Cost effectiveness of screening
• Population screening of the elderly?

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SCREENING FOR OSTEOPOROSISDefinitions

• Screening
• Offering an assessment to all of a predefined
  population
• Case-finding
• Opportunistic assessment in those presenting with
  concerns
• Risk identification
• Finding those who should be offered assessment

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Effective Health Care Bulletin

• Objections
• Screening will only prevent a small number of
  fractures
• Screening will not save money
• Preventative measures for the whole population
  will be more effective

• Answers
• Proportion of fractures prevented should be set
  against cost
• The cost per unit of health gain should be
  calculated
• The effectiveness and cost-effectiveness of such
  a strategy have not been tested

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Effective Health Care Questions

• Does the current burden of suffering warrant
  screening?
• Is there an efficacious treatment for preventing
  fractures?
• Is bone density measurement a good screening
  tool?
• Will women attend for screening?
• Will they accept treatment if they are at risk?
• Has the effectiveness been demonstrated in a
  randomised controlled trial?

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Effective Health Care Questions

• Does the current burden of suffering warrant
  screening?
• Is there an efficacious treatment for preventing
  fractures?
• Is bone density measurement a good screening
  tool?
• Will women attend for screening?
• Will they accept treatment if they are at risk?
• Has the effectiveness been demonstrated in a
  randomised controlled trial?

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ABERDEEN PROSPECTIVE OSTEOPOROSIS STUDY
(APOSS)METHODS 1

• 5119 women
• 45 to 54 years
• randomly selected
• community based register
• Invited to attend (1990-4)
• DXA scan
• in subset also QUS scan
• Risk factor questionnaire in approx 2,000
• FFQ in subset

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BASELINE STATISTICS
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APOSSFollow-up

• 4883 women re-invited
• 236 known to have died or moved from area
• 3645 re-attended after first invite
• further 238 after a single reminder letter
• In total 3883 (79.5) women re-attended
• Further scans
• Questionnaires
• DNA where willing

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FOLLOW-UP1998-2000

• DXA of spine and hip
• XR 26 or XR 36
• QUS of heel
• Hologic Sahara
• Serum/urine samples
• Bone turnover markers
• DNA analysis

• Questionnaires
• Fracture history
• Fall history
• Quality of life
• Nutrition (FFQ) questionnaire
• HRT / menopause status
• Family history of osteoporosis

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FOLLOW-UP INTERVAL
Women now aged on average 55 years, range 50 to
63 yrs
Years
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FRACTURES
333 (8.4) women had suffered one or more (385)
incident fracture(s)
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FRACTURE SITES
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RELATIVE RISK of Fracture
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RELATIVE RISK Total osteoporotic fractures
OP
All
1.47 (0.95-2.28)
1.26 (0.7-2.02)
BUA
1.73 (1.37-2.20)
1.50 (1.33-1.70
L2L4
1.90 (1.46-2.47)
1.52 (1.33-1.73)
Neck
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Effective Health Care Questions

• Does the current burden of suffering warrant
  screening?
• Is there an efficacious treatment for preventing
  fractures?
• Is bone density measurement a good screening
  tool?
• Will women attend for screening?
• Will they accept treatment if they are at risk?
• Has the effectiveness been demonstrated in a
  randomised controlled trial?

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Will women attend for screening

• Women aged 45 - 49 selected at random from the
  CHI
• Sent a standard (fixed fixed) or improved (open
  confirmable) appointment

Standard
Improved
Torgerson et al., BMJ 1993 307 99
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Will non-attenders be at increased risk?

• Questionnaire reminder sent to non-attenders
• Telephone survey of non-returns

P lt 0.03 - lt0.001



Torgerson et al., Osteoporosis Int 1994 4 149-53
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Will non-attenders be at increased risk?

• 6 Intial non-attenders attended for spine hip
  BMD

Torgerson et al., Osteoporosis Int 1994 4 149-53
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Effective Health Care Questions

• Does the current burden of suffering warrant
  screening?
• Is there an efficacious treatment for preventing
  fractures?
• Is bone density measurement a good screening
  tool?
• Will women attend for screening?
• Will they accept treatment if they are at risk?
• Has the effectiveness been demonstrated in a
  randomised controlled trial?

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Use of HRT 1 year after screening

• Women were labelled at risk if spine or hip BMD
  were in the lowest quarter
• One year after screning 685 women were sent a
  questionnaire

Torgerson et al. Eur J Obstet Gynecol
19955957-60
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Current HRT use 7 years later

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Annual L Spine Bone Loss
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Effect of Hormonal Status on FN BMD Change
(/year)
P lt 0.001
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Odds of sustaining a fracture compared with never
HRT
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Effective Health Care Questions

• Does the current burden of suffering warrant
  screening?
• Is there an efficacious treatment for preventing
  fractures?
• Is bone density measurement a good screening
  tool?
• Will women attend for screening?
• Will they accept treatment if they are at risk?
• Has the effectiveness been demonstrated in a
  randomised controlled trial?

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HRT USE IN SCREENED AND CONTROL WOMEN
Screened v. controls P0.02

• 43 of screened HRT users (32 of controls) were
  using treatment for osteoporosis prevention
• 35 of screened women aged 52-56 were using HRT
  (22 of control women (Plt0.01)

Torgerson et al., Arch Int Med 1997 157 2121-25
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HRT USE IN HIGH RISK AND LOW RISK WOMEN
Difference 19 (10.6 to 27.9)

• Difference in use between lowest quartile of the
  screened population and all non-screned controls
  was 19 (95 CI 11.5 to 27.5)

Torgerson et al., Arch Int Med 1997 157 2121-25
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Effective Health Care Questions

• Does the current burden of suffering warrant
  screening?
• Is there an efficacious treatment for preventing
  fractures?
• Is bone density measurement a good screening
  tool?
• Will women attend for screening?
• Will they accept treatment if they are at risk?
• Has the effectiveness been demonstrated in a
  randomised controlled trial?
• Can effectiveness be increased without inducing
  excess anxiety?

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Direct disclosure of resultsEffect on knowldege
of risk anxiety

• 800 women randomised to receive results directly
  or via their GP

Plt0.001
Campbell et al., Osteoporosis Int 1998 8 584-90
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Screening for OsteoporosisSummary

• Perimenopausal population screening for
  osteoporosis risk by BMD is
• Acceptable to women
• Produces reasonable increased uptake of HRT in a
  randomised controlled trial
• Has no adverse effect on quality of life
• Is unlikely to be cost effective (Torgerson et
  al., 2001)
• Population screening of the elderly may be cost
  effective (Eddy et al., Osteoporos Int
  199891-88)

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APOSSCurrent work immediate future plans

• Data currently being combined into a single large
  workbook in Excel
• Rob completing Access database based on agreed
  headings
• XR36 follow-up data to be adjusted to produce
  XR26 equivalence
• Manifest irregularities to be resolved and DNA
  destroyed where no resolution possible
• Christmas card and study update sent to all APOSS
  subjects in December 2001
• Fracture and treatment questionnaire to be
  circulated to all active subjects and 2,400
  matched controls by 31st March 2002

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Screening Current work in 60-80 year olds

• PIXI study
• Approximately 1,200 women assessed in Aberdeen
• 30,000 UK wide in last 3 years
• Pilot follow-up underway
• North Of Scotland Osteoporosis Study
• Spine hip DXA
• DNA
• Clinical risk factor and QoL questionnaires
• 2,500 in Aberdeen recruiting for PEARL
• 1,000 in Inverness recruiting for LIFT