Search from Other Resources

Manual search yielded 15 articles and from each, a tool was derived. Of these, 12 were duplicates leaving 3 articles from which 3 tools were derived. Grey literature search did not yield any publication.

84

2.4.1.3 :Total Number of Tools (electronic and other searches)

The flow chart for the retrieval of tools is shown in Figure 2.

Figure 2: Flow diagram of search and study selection of the first part of the systematic literature review.

Interpretation Figure 2 shows that of the initial 1,343 articles identified, 33 fulfilled the criteria for the second part of the systematic literature review.

Finally, 33 tools were left. Of these, 4 tools were derived from literature review, 2 tools were derived from meta-analyses and 27 tools were derived from original studies. The tools selected are shown in table 12.

ABSTRACT TEXT SCREENING N=37

FULL TEXT SCREENING N=30 AMED N=0 CINAHL N=204 EMBASE N=392 MEDLINE N=487 COCHRANE LIBRARY N=260

TOTAL NUMBER OF CITATIONS AFTER DUPLICATES WERE REMOVED N=1343

IRRELEVANT, N =721 CASE REPORTS, N=7 EXPERIMENTAL, N=485 STATISTICAL MODELSN=5 LANGUAGES (Non English) N=96 NO PERFORMANCE CHARACTERISTICS,N =5 NO FULL TEXT AVAILABLE,N=2 Excluded Excluded

STUDIES IDENTIFIED BY MANUAL SEARCH =15

GREY LITERATURE =0 DUPLICATES = 12

NUMBER LEFT AFTER DUPLICATES REMOVED =3

N=33

85 Table 12: The 33 tools derived from the first part of the systematic literature review

Tools derived from literature review (Tool no as list below)

Tools derived from meta-analyses

(Tool no as list below)

Tools derived from original studies (Tool no as list below)

12,13,18, 29 1, 25 2-11,14 -17,19-24, 26-32,33

1. Bone mineral density (Marshall, Johnell & Wedel, 1996)

2. Markers of Bone Resorption Predict Hip Fracture in Elderly Women: The EPIDOS Prospective Study (Garnero et al., 1996)

3. A Simple Risk Score for the Assessment of Absolute Fracture Risk in General Practice Based on Two Longitudinal Studies (Pluijm et al., 2009)

4. Evaluation of a Hip Fracture Risk Score for Assessing Elderly Women: The Melton Osteoporotic Fracture (MOF) Study (McGrother et al., 2002)

5. An assessment Tool for Predicting Fracture Risk in Postmenopausal Women (Black et al., 2001a)

6. A triage strategy based on clinical risk factors for selecting women for treatment or bone densitometry: the EPIDOS prospective study (Dargent-Molina, Piault & Breart, 2005)

7. QFractureScores (Hippisley-Cox, Coupland, 2009) 8. Garvan nomogram (Nguyen et al., 2008)

9. A nomogram for individualizing hip fracture risk in men and women (Nguyen et al., 2007a) 10. Fracture Risk Score and absolute Risk of Fracture (FRISK) (Henry et al., 2011)

11. Added value of Bone Mineral Density in Hip Fracture Risk Scores (Burger et al., 1999)

12. Osteoporosis: Assessing the risk of a fragility fracture (National Institute for Clinical Excellence (NICE), 2012b)

13. Clinician`s Guide to Prevention and Treatment of Osteoporosis (NOF 1998) (Anonymous, 2013) 14. FRAX (Kanis, 2007)

15. Peripheral DXA measurements (Barr et al., 2005) 16. Homocysteine and fracture risk (Perier et al., 2007)

17. Osteoporotic Hip Fracture Combining Clinical Risk Factors and Heel Ultrasound (Hans et al., 2008) 18. Simplified System for Absolute Fracture Risk Assessment (CAROC) (Siminoski et al., 2007) 19. Prediction of Hip Fractures from Pelvic radiographs: (Gluer et al., 1994)

20. Prediction of hip fracture in elderly women (Porter et al., 1990)

21. Prediction of fracture Risk by radiographic Absorptiometry (RA) and Quantitative Ultrasound (Huang et al., 1998)

22. Risk factors for Hip Fractures in White Women (Cummings et al., 1995)

23. Use of clinical risk factors to identify postmenopausal women with vertebral fractures (Tobias et al., 2007) 24. Prediction of absolute risk of non-spinal fractures using clinical risk factors and heel quantitative ultrasound

(Diez-Perez et al., 2007)

25. Body Mass Index(De Laet et al., 2005)

26. Use of Clinical Risk factors in Elderly Women with Low Bone Mineral density to Identify Women at Higher Risk of Hip Fracture (Dargent-Molina et al., 2002)

27. Assessment of osteoporotic fracture risk in community settings; a study of post (Tan et al., 2008) 28. Vertebral fracture risk (VFR) score (Lillholm et al., 2011)

29. Hip Geometry and Its Role in Fracture (Brownbill, Ilich, 2003)

30. Independent predictors of all osteoporotic-related fractures in healthy postmenopausal women (Albrand et al., 2003)

31. A simple clinical score for estimating the long-term risk of fracture in post-menopausal women (van Staa et al., 2006)

32. Factors Associated With 5-Year Risk of Hip Fracture in Postmenopausal Women (Robbins et al., 2007) 33. The Fracture and Immobilisation Score (FRISC) for risk assessment of osteoporotic and immobilisation in

postmenopausal women-A joint analysis of the Nagano, Miyama, and Taiji Cohorts (Tanaka et al., 2010) Interpretation

Table 12 shows that the majority (27/33 [82%]) of the tools were derived from original studies, 4/33 (12%) were from literature review and 2/33 (6%) were from meta-analyses.

86 The results of this part of the systematic review are presented in three sections: review articles, meta-analyses and original articles.

87 2.4.1.3.1 Review Articles

The review articles are shown in Table 13.There were 3 reviews of general guidelines on the management of fragility fractures and osteoporosis (National Institute for Clinical Excellence (NICE), 2012, National Osteoporosis Foundation (NOF), 1998, Siminoski et al., 2007) and one general review of hip geometry and its association with hip fractures (Brownbill, Ilich, 2003).

The general reviews recommended guidelines for risk assessment in the management of fragility fractures. The reviews were sponsored Government agencies and osteoporosis organisations and cost effectiveness was a prime consideration. The tool by NICE is applicable to both sexes, NOF is applicable to post-menopausal Caucasian females in the USA and the tool by Siminoski and colleagues is a recommendation by Osteoporosis Canada & the Canadian Association of Radiologists for both sexes.

The review of hip geometry and its association with hip fractures found that hip axis length. (HAL), neck shaft angle (NSA) and femoral neck width (FNW) show promise for enhancing fracture risk assessment in clinical settings. The review showed that both age and/ or loss of body weight are associated with changes in some geometric parameters which affect hip strength. It was shown that the greater hip strength in black men and women may be related to more favourable geometric parameters. Asian women who have a lower incidence of hip fractures compared to Caucasian women have a shorter HAL and a smaller NSA. The authors concluded that a longer HAL, wider NSA and FNW, increase the risk of hip fracture.

88 Table 13: Review articles of the systematic literature review from which four tools were derived

Author(s) Year of review

Type of review

Title of article Conclusion(s)

NICE 2012 General Osteoporosis: assessing the risk of fragility fracture Guideline for management recommended

NOF 1998 General Osteoporosis: Review of the evidence for prevention, diagnosis and treatment and cost-effective analysis

Guideline for management recommended

Siminoski et al

2007 General Recommendations of bone mineral density reporting in Canada: A shift to absolute fracture risk assessment

Guideline for management recommended

Brownbill RA et al

2003 General Hip Geometry and Its Role in Fracture: What Do We Know so far

Parameters of hip geometry are helpful but more research is needed

National Institute for Health and Care Excellence (NICE), National Osteoporosis Foundation (NOF) Interpretation

Table 13 shows that the review articles addressed different questions. NICE, NOF and Siminoski et al recommended guidelines for the management of osteoporosis and fragility fractures. Brownbill et al explored the role of hip geometry as a predictor of hip fractures and although some parameters of hip geometry may predict hip fractures, they suggested further research be conducted.

89 2.4.1.3.2 Meta-analyses

2.4.1.3.2.1 Meta-analysis of how Well Measures of Bone Mineral Density Predict Occurrence of Osteoporotic Fractures. (Marshall, et al 1996)

Aim

The aim of the study was to determine by a systematic review of the literature for all prospective studies if measurements of bone density in women could predict fractures of any type. The main outcome measure was the relative risk of fracture for a decrease in bone mineral density of one standard deviation below age adjusted mean.

Methods

Only women were included and two types of studies were used for the study: prospective cohort studies and case-control studies.

Prospective cohort studies

Table 14 shows a summary of the findings of the prospective cohort studies. There were twenty-five publications from 11 populations. The majority of the studies were from the USA (18 [72%]), 3(12%) were from Australia, 2(18%) were from Sweden and one each from the UK and Finland (1 [4%]). The studies were undertaken between 1977 and 1994 and the ethnicities of the participants were not stated. The population range was from 135 to 9704. The mean age range of the participants was from 57 to 83 years, the age was not reported in two studies. The follow-up was from 0.7 to 24 years equating to about 90,000 person years of observations.

There were more than 2000 incident fractures during the period of observation. The fracture sites were the forearm, hip, non-spine, vertebral, proximal humerus, distal forearm, proximal

90 femur wrist and any site. The authors stated that it was not possible to calculate the proportions of the fractures by site because definite numbers were not reported in 11 studies. The site of bone density measurements were different, the majority was in the proximal radius (8 [24%]), the distal radius and calcaneus (7 [21%]), the lumbar spine (3 [9%]), the middle radius, proximal femur and forearm (2 [6%]) and the spine and femoral neck 1 [3%]) each. The risks were reported as relative risk with the corresponding 95% confidence interval (CI) in all publications.

The range of the relative risk (RR) of 1SD deviation in BMD for all the studies was from 1.1 to 4.4. Most of the sites which were used for BMD measurements had predictive ability for a decrease of 1 SD in bone density of from 1.4 to 2.6. The measurement of BMD at the spine had predictive ability for a decrease of 1 SD of 2.3 (95% CI 1.9 to 2.8) while measurement at the hip had predictive ability for hip fractures of 2.6 (95% CI 2.0 to 3.5). The average total scores for quality of the studies ranged from 11.7 to 19.3 out a possible 25.

91 Table 14: Summary of the findings from the 25 prospective cohort studies of the predictive value of bone mineral density for fractures

Countries No of studies n (%) USA Australia Sweden UK Finland 18(72) 3(12) 2(8) 1(4) 1(4)

Population characteristics (min – max) Population size range of cohorts (n)

Mean age of participants (years) Duration of follow-up in (years) Quality scores 135 – 9704 57 – 83 0.7 – 24 11.7 – 19.3 Sites of BMD measurement n (%) Proximal radius Distal radius Calcaneus Lumbar spine Middle radius Proximal femur Forearm Femoral neck 8(24) 7(21) 7(21) 3(9) 2(6) 2(6) 2(6) 1(3)

Fracture risk (min – max)

Relative risk of fracture for 1SD decrease in BMD

1.1 – 4.4