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A Before-and-After Study of Fracture Risk Reporting and Osteoporosis Treatment Initiation

William D. Leslie, MD, MSc; Suzanne Morin, MD, MSc; and Lisa M. Lix, PhD
[+] Article, Author, and Disclosure Information

From the University of Manitoba, Winnipeg, Manitoba; McGill University, Montreal, Quebec; and University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Acknowledgment: The authors thank Manitoba Health for providing data (Health Information Privacy Committee file 2007/2008-35). The results and conclusions are those of the authors, and no official endorsement by Manitoba Health is intended or should be inferred. The authors also thank Mr. Mahmoud Azimaee for SAS programming support. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0584.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Leslie (e-mail, bleslie@sbgh.mb.ca).

Requests for Single Reprints: William D. Leslie, MD, MSc, Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada; e-mail, bleslie@sbgh.mb.ca.

Current Author Addresses: Dr. Leslie: Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada.

Dr. Morin: Division of General Internal Medicine, McGill University Health Center (MUHC), 1650 Cedar Avenue, Room B2-118, Montreal, Quebec H3G 1A4, Canada.

Dr. Lix: School of Public Health, University of Saskatchewan, 107 Wiggins Road, Saskatoon, Saskatchewan S7N 5E5, Canada.

Author Contributions: Conception and design: W.D. Leslie.

Analysis and interpretation of the data: W.D. Leslie, S. Morin, L.M. Lix.

Drafting of the article: W.D. Leslie, S. Morin, L.M. Lix.

Critical revision of the article for important intellectual content: W.D. Leslie, S. Morin.

Final approval of the article: W.D. Leslie, S. Morin, L.M. Lix.

Provision of study materials or patients: W.D. Leslie.

Statistical expertise: W.D. Leslie, L.M. Lix.

Administrative, technical, or logistic support: W.D. Leslie.

Collection and assembly of data: W.D. Leslie.

Ann Intern Med. 2010;153(9):580-586. doi:10.7326/0003-4819-153-9-201011020-00007
Text Size: A A A

Background: Several national organizations recommend that fracture risk assessment and osteoporotic treatment be based on estimated absolute 10-year fracture risk rather than bone mineral density (BMD) alone.

Objective: To assess the changes in physician prescribing behavior after introduction of absolute 10-year fracture risk reporting.

Design: Before-and-after study.

Setting: Manitoba, Canada, which has an integrated BMD program in which tests are linkable to a population-based administrative health database repository.

Patients: Women 50 years or older who were not receiving osteoporosis medication (2042 before and 3889 after intervention).

Intervention: Introduction of a system reporting absolute 10-year fracture risk along with dual-energy x-ray absorptiometry results.

Measurements: The proportion of untreated women who were prescribed osteoporosis medications in the year after baseline BMD measurement.

Results: Absolute fracture risk reporting reclassified more women (32.7%) into lower-risk categories than into higher-risk categories (10%). This effect was more prominent in women younger than 65 years. Fewer women per physician were prescribed osteoporosis drugs after introduction of absolute fracture risk reporting. The absolute fracture risk reporting system was associated with an overall reduction in osteoporosis medications dispensed (adjusted absolute reduction, 9.0 percentage points [95% CI, 3.9 to 14.2 percentage points]; relative reduction, 21.3% [CI, 9.2% to 33.5%]; P < 0.001). The reduction was attributed to fewer drugs dispensed to women at low and moderate risk for fracture. No differences in fracture rates were observed.

Limitations: This was a nonrandomized study. The risk assessment system studied differs slightly from other 10-year fracture risk assessment models.

Conclusion: Change from a T-score–based fracture risk reporting system to a system based on absolute 10-year fracture risk was associated with appropriate, guideline-based changes in prescription of osteoporosis medications.

Primary Funding Source: None.


Grahic Jump Location
Appendix Figure.
Change in screening category with T-score–based compared with absolute fracture risk reporting.

Red shading indicates an increase in risk category, and blue shading indicates a decrease in risk category.

Grahic Jump Location




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Evaluating Risk Factors for Osteoporosis Related Fractures: BMD and what else?
Posted on November 15, 2010
Francisco Ramirez Lafita, MD, FACP*
*Hospital de Tortosa Verge de la Cinta. Tortosa, Spain
Conflict of Interest: None Declared

Osteoporosis is a disorder characterized by a compromised bone strength that predisposes to an increased risk of fracture. Bone strength integrates concepts as bone density and bone quality (1). Factors as bone mineral turnover have been related to bone quality. Osteoporosis can unfortunately be diagnosed when a fragility fracture happens. In patients who have never experienced fragility fractures, diagnosis is currently based on low bone density. Measurement of Bone Mineral Density (BMD) by dual x-ray absorptiometry (DXA) plays an important role in the diagnosis of osteoporosis in people without previous osteoporotic fractures, but also in the decision to initiate drug therapy, and in the follow-up for the efficacy of treatment. However, normal BMD values cannot be considered as reliable indicators of bone strength to rule out risk of fractures as it depends on risk factors in addition to BMD (2).

Leslie et al (3) found that reporting absolute fracture risk, in addition to BMD, was associated with less physician-prescription of osteoporosis treatments, in accordance with guidelines recommendations.

In the last years there has been an increasing interest in risk factors others than BMD when assessing risk for osteoporosis fractures or the response to anti-resorptive therapy. Bone mineral turnover can predict fracture risk independently of BMD. Since changes in bone turnover after the initiation of therapy with bone resorption inhibitors occur much more rapidly than changes in BMD, the efficacy and compliance with the treatment could, in theory, be assessed within weeks of therapy (4). Other factors as Calcium and Vitamin D levels are growing in interest as overall health markers and particularly as risk marker for osteoporosis and fractures (5). Deficiency/insufficiency of vitamin D could represent a thread to bone quality and the development of a secondary hyperparathyroidism...increasing bone resorption markers. This point could represent special interest in patients with normal BMD. The article by Leslie and colleagues suggest new studies on fracture risk assessment and the study of incident fractures over the time.


1. Qaseem A, Snow V, Shekelle P, Hopkins R, Forciea MA, Owens DK. Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2008;149:404-415

2. Lafita FR, Garcia B. Effect of Low-Dose Continuous Estrogen and Progesterone Therapy with Calcium and Vitamin D on Bone in Elderly Women. (letter) Ann Intern Med February 1, 2000 132:244

3. Leslie WD, Morin S, Lix LM. A Before-and-After Study of Fracture Risk Reporting and Osteoporosis Treatment Initiation. Ann Intern Med. 2010;153:580-586.

4. Szulc P, Delmas PD. Biochemical markers of bone turnover: potential use in the investigation and management of postmenopausal osteoporosis. Osteoporos Int. 2008;19(12):1683-1704

5. Lips P, Bouillon R, van Schoor NM, Vanderschueren D, Verschueren S, Kuchuk N, Milisen K, Boonen S. Reducing fracture risk with calcium and vitamin D. Clin Endocrinol (Oxf). 2010;73(3):277-285

Conflict of Interest:

None declared

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Summary for Patients

Osteoporosis Treatment Based on a Woman's Probability of Fracture

The summary below is from the full report titled “A Before-and-After Study of Fracture Risk Reporting and Osteoporosis Treatment Initiation.” It is in the 2 November 2010 issue of Annals of Internal Medicine (volume 153, pages 580-586). The authors are W.D. Leslie, S. Morin, and L.M. Lix.


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