Anti-resorptive drugs are efficacious in reducing hip fracture risk, but they have had limited impact on the incidence of hip fracture, and with concern about side effects, the use of these drugs is declining. There is therefore a need to formulate a more cost effective strategy in selecting older people for DXA and drug treatment. Based on the ten-year fracture incidence data of a well-characterized cohort of 4000 older men and women in Hong Kong, we sought to identify a more cost effective screening and treatment strategy for osteoporosis to prevent hip fracture.   

In people aged 65 to 74 years (young-old), use of FRAX hip score (by questionnaire) reduced effectively the need for DXA screening. In men and women aged 75 years or greater (old-old), pre-screening by osteoporosis self assessment tool (OSTA) and heel ultrasound (QUI) reduced the need for DXA screening, though more preventable fractures were missed after five years.

In the young old men, FRAX hip score (with BMD and trabecular bone score, TBS) ³ 6% reduced the number needed to treat to prevent hip fracture, when compared with the recommended threshold of 3%.  In old-old people, FRAX hip score (with BMD) ³ 3% or low TBS in men, and FRAX hip score (with BMD and TBS) ³ 7% in women had lower number of subjects needed to treat to prevent one hip fracture, when compared with current guideline.

In the old-old men and women, pre screening by OSTA and QUI, when combined with more cost effective treatment thresholds resulted in 30% overall cost reduction in preventing one hip fracture. We concluded that pre-screening by OSTA and QUI, and the use of TBS and higher FRAX hip score threshold is a more cost effective strategy to prevent hip fractures in people older than 75 years.