Catching it early: detection and management in primary care
Early identification and management of osteoporosis in primary care offers the greatest opportunity to prevent fragility fractures.
Five things you need to know
- Clear guidance on identifying and treating people at high risk of fragility fractures can, if implemented, prevent fractures from occurring.1
- Primary care professionals have a key role in identifying and managing people at high risk.2 3
- Fragility fractures are commonly overlooked in primary care, and people at risk are often identified only after a fracture, or not at all.1 4
- Gaps in knowledge among primary care professionals, in addition to a lack of incentives, may hinder the early identification and effective management of people at risk of fragility fractures.5 6
- Policymakers should foster the use of evidence-based and effective strategies for risk identification and management in primary care.
What is it and why is it important?
Identifying people at high risk of fractures is vital in enabling prevention.2 It can be very difficult for people to regain independence and pre-fracture quality of life following a fragility fracture.7 Once people at high risk are identified, simple measures can help to reduce their risk of fracture. Osteoporosis medication can cut the risk of fragility fractures by 30–70% depending on risk factors, type of medication and type of fracture.1
Primary care is a person’s first point of contact with the healthcare system, so primary care professionals have a crucial role in detecting osteoporosis and managing care for people at high risk of fragility fractures.3 In many countries, primary care also has a role in prescribing and monitoring treatments to reduce the risk of sustaining a fracture.6 8
How do we know it works?
Osteoporosis screening programmes for postmenopausal women offer an opportunity to prevent fragility fractures from occurring. For example, a UK study found that community screening among women aged 70–85 years using the Fracture Risk Assessment Tool (FRAX) reduced the number of hip fractures by 28% and was cost-effective.9 10 Screening also led to women at high fracture risk taking their anti-osteoporosis medication for longer.11 More evidence is needed, though, as none of the screening approaches piloted in Europe reduced the number of all symptomatic osteoporosis-related fractures.12
Primary care professionals have a range of evidence-based and effective tools available to implement targeted screening and manage people at risk of a fragility fracture. Tools such as FRAX, which consider several risk factors, including age, gender, lifestyle and bone mineral density, can accurately predict fracture risk and help inform treatment decisions.13 14 In addition, the Comprehensive Geriatric Assessment (CGA) provides an opportunity to assess bone health as part of a holistic appraisal of health and wellbeing, and initiate treatment for people at high risk of fragility fracture. It has been shown to be cost-effective and to improve patient outcomes.15 16
What is the current situation?
Despite the availability of tools, primary care frequently fails to detect people at high risk of a fragility fracture and initiate appropriate treatment.1 4 A recent European study in primary care found that of those women at increased risk of fragility fractures, under a third were diagnosed with osteoporosis and almost three quarters were untreated.17 Similarly, data from the Netherlands found that the proportion of people officially diagnosed with osteoporosis was just 4.3% of women and 0.5% of men aged 50 years and over – up to five times less than the proportion of the population estimated to be living with the condition.18 19 Alarmingly, in some cases, diagnosis rates have been in decline: France has seen a drop in the number of bone mineral density assessments each year by approximately 6% despite good availability of dual-energy X-ray absorptiometry (DXA) machines.20
These missed opportunities occur partly because fragility fractures are underprioritised in many primary care consultations. The severity of fragility fractures may be underestimated by primary care physicians.21 Management of an individual’s fracture risk factors often falls to the sidelines in light of their other care needs.6 22
Without a national consensus on best practice for identifying people at high risk of a fracture, and with gaps in the existing evidence, clinical practice varies widely.1 When osteoporosis is detected early, it is mostly through opportunistic case finding (e.g. on a person-by-person basis) rather than systematic assessment of people with risk factors. Currently, screening for osteoporosis is not reimbursed in the EU, but Poland plans to launch a national screening programme for osteoporosis in 2023.12
Primary care professionals in many countries are not adequately equipped to identify and manage people at high risk of a fragility fracture. They may not always understand when and how to investigate fracture risk.5 6 Primary care physicians may be uncertain about the safety and effectiveness of the available tools and medications, hindering their ability to implement guideline-recommended care.6 21 In addition, in some countries, including Spain, there is no consensus or clear guidance on the risk assessment tools and criteria to support primary care professionals in initiating treatment.23
What needs to be done?
Policymakers must work to develop clear national guidance on identifying people with osteoporosis, informed by national scientific consensus. The current evidence base for screening is inconclusive12 but, as it evolves, policymakers must develop a position on which groups should be assessed, which healthcare professionals should be involved and how the results should be interpreted. Guidance should be developed in collaboration with leading clinicians and academics.
Primary care professionals must be given the training, support and tools they need to effectively identify and manage people at risk of osteoporosis and fragility fractures. Training should include risk assessment tools developed for use in primary care, appropriate referral pathways, and tools to support decisions on treatment which consider the other conditions and treatments that a person may be managing.
Osteoporosis and fragility fractures must be integrated into existing person-centred care models with proven effectiveness. These models include, for example, frameworks for the comprehensive management of the older and frail population, such as the CGA.
- Kanis JA, Cooper C, Rizzoli R, et al. 2019. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 30(1): 3-44
- International Osteoporosis Foundation. 2018. Broken bones, broken lives: A roadmap to solve the fragility fracture crisis in Europe. Nyon: IOF
- Geusens P, Bours SPG, Wyers CE, et al. 2019. Fracture liaison programs. Best Practice & Research Clinical Rheumatology 33(2): 278-89
- Mendis AS, Ganda K, Seibel MJ. 2017. Barriers to secondary fracture prevention in primary care. Osteoporos Int 28(10): 2913-19
- Seaman AT, Steffen M, Doo T, et al. 2018. Metasynthesis of Patient Attitudes Toward Bone Densitometry. J Gen Intern Med 33(10): 1796-804
- Merle B, Haesebaert J, Bedouet A, et al. 2019. Osteoporosis prevention: Where are the barriers to improvement in French general practitioners? A qualitative study. PLoS One 14(7): e0219681
- Darba J, Kaskens L, Perez-Alvarez N, et al. 2015. Disability-adjusted-life-years losses in postmenopausal women with osteoporosis: a burden of illness study. BMC Public Health 15: 324
- Kanis JA, Borgstrom F, Compston J, et al. 2013. SCOPE: a scorecard for osteoporosis in Europe. Arch Osteoporos 8: 144
- Turner DA, Khioe RFS, Shepstone L, et al. 2018. The Cost-Effectiveness of Screening in the Community to Reduce Osteoporotic Fractures in Older Women in the UK: Economic Evaluation of the SCOOP Study. J Bone Miner Res 33(5): 845-51
- Shepstone L, Lenaghan E, Cooper C, et al. 2018. Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet 391(10122): 741-47
- Parsons CM, Harvey N, Shepstone L, et al. 2019. Systematic screening using FRAX((R)) leads to increased use of, and adherence to, anti-osteoporosis medications: an analysis of the UK SCOOP trial. Osteoporos Int: 10.1007/s00198-019-5142-z
- European Network for Health Technology Assessment. 2019. Screening for osteoporosis in the general population. Copenhagen: EUnetHTA
- Viswanathan M, Reddy S, Berkman N, et al. 2018. Screening to Prevent Osteoporotic Fractures: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 319(24): 2532-51
- Kanis JA, Harvey NC, Cooper C, et al. 2016. A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 11(1): 25
- Lundqvist M, Alwin J, Henriksson M, et al. 2018. Cost-effectiveness of comprehensive geriatric assessment at an ambulatory geriatric unit based on the AGe-FIT trial. BMC Geriatr 18(1): 32-32
- Ríos Germán PP, Alarcón T, Ramírez-Martín R, et al. 2017. Comprehensive geriatric assessment for identifying older people at risk of hip fracture: cross-sectional study with comparative group. Fam Pract 34(6): 679-84
- McCloskey EV, J. Rathi SH, Blagden M, et al. 2019. Osteoporosis (op) diagnosis and treatment of women aged ≥70 years in primary care: results from a large european cross-sectional study. Breda: Amgen
- Dunnewind T, Dvortsin EP, Smeets HM, et al. 2017. Economic Consequences and Potentially Preventable Costs Related to Osteoporosis in the Netherlands. Value Health 20(6): 762-68
- Svedbom A, Hernlund E, Ivergard M, et al. 2013. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 8: 137
- Association Française de Lutte Antirhumatismale (AFLAR), Alliance Nationale Contre L’Osteoporose. 2017. ‘Livre Blanc – États Généraux De L’ostéoporose – Pour un plan de santé publique contre les fractures liées à l’ostéoporose’. Paris: AFLAR
- Flais J, Coiffier G, Le Noach J, et al. 2017. Low prevalence of osteoporosis treatment in patients with recurrent major osteoporotic fracture. Arch Osteoporos 12(1): 24
- Puth M-T, Klaschik M, Schmid M, et al. 2018. Prevalence and comorbidity of osteoporosis– a cross-sectional analysis on 10,660 adults aged 50 years and older in Germany. BMC Musculoskelet Disord 19(1): 144
- Martinez-Laguna D. 2018. Osteoporosis y Atención Primaria. Como valorar el riesgo de fractura. Utilización de las escalas de riesgo. Revista de osteoporosis y metabolismo mineral 10(1): Supplement: 5-8