Clinical risk evaluation contributes to case finding and diagnosis of osteoporosis in postmenopausal women.

Abstract

Clinical case finding for those at risk of osteoporosis and fractures is advocated in all guidelines of osteoporosis, but its application in daily practice remains unsatisfactory. We studied the effects of clinical fracture risk evaluation on case finding and diagnosis of osteoporosis in postmenopausal women consulted by their general practitioner (GP). From 42690 postmenopausal women age, weight and history of fractures after the menopause were recorded by 1080 GPs. The OST index was calculated from age and weight as integer of (0.2 times [weight - age]) (1). An OST of >1 indicated low risk (LR), -3 to 1 moderate risk (MR) and <-3 high risk (HR). Proportions between groups were tested by chi-square. Based on OST, LR was found in 19 509 (46%), MR in 19 901 (46%) and HR in 3 280 (8%) patients. A prior DXA had been performed in 6 637 women (16%) in 7% in the LR, 22% in the MR and 26% in the HR. After clinical evaluation 10 841 (29%) additional women were sent for DXA (p<0.001 vs. number (16%) of those with prior DXA): in 8% of the LR, 47% of the MR and 72% of the HR (p<0.001 for distribution between risk groups compared to patients with prior DXA). New cases of osteoporosis in the spine and/or hip were found in 2 353 (7%) of all clinically evaluated patients and in 23% of those send for DXA (15% of the LR , 27% of the MR and 47% of the HR, p<0.001 between risk groups). A history of fracture after age 50 was present in 6 732 (16%) of all women (in 8% of the LR , 19% of the MR and 42% of the HR ) (p<0.001). Altogether 27% of patients with a previous fracture had a prior DXA, compared to 13% of women without fracture history (p<0.001). After clinical evaluation, 66% of patients with a fracture history, but not having had a DXA , were sent for DXA (p<0.001) . In these patients, 979 (32%) new cases of osteoporosis were diagnosed (21% in the LR 36% in the MR and 57% in the HR , p<0.001 ). In patients without a fracture history, 13% had a prior DXA. After OST evaluation, 24% additional women were referred to DXA (p<0.001 vs. prior DXA), 50% of the LR , 83% of the MR and 72% of the HR (p<0.01 ). New cases of osteoporosis were diagnosed in 1 477 (20%) of those send for DXA (12% in the LR , 23% in the MR and 40% in the HR, p<0.001). We conclude that clinical screening in postmenopausal women using fracture history and the OST-index tripled the proportion of women referred for DXA, with a significant shift towards referring more women at high risk. Previously undiagnosed osteoporosis was found in <10% of all clinically evaluated women, in 25% of those referred for DXA based on OST, in 50% in the high OST risk group and in >50% in the high OST risk group with a fracture history.