Effect of implementation of guidelines on assessment and diagnosis of vertebral fractures in patients older than 50 years with a recent non-vertebral fracture

Osteoporos Int. 2017 Oct;28(10):3017-3022. doi: 10.1007/s00198-017-4147-4. Epub 2017 Jul 26.


We evaluated the impact of a new Dutch guideline on systematic implementation of densitometric Vertebral Fracture Assessment (VFA) in patients with a recent non-vertebral fracture. Systematic implementation resulted in a significant increase of VFA, diagnosis of vertebral fractures (VFs), and percentage of patients eligible for treatment.

Introduction: VFs are underdiagnosed although they are important predictors of fracture risk, independent of age and bone mineral density (BMD). The Dutch guideline on osteoporosis and fracture prevention recommends VFA in all patients aged >50 years with a recent non-VF. Our aim was to evaluate the effect of systematic implementation of densitometric VFA in patients with a recent non-VF at the fracture liaison service (FLS).

Methods: VFA was performed on lateral images of the spine using dual-energy X-ray absorptiometry (DXA) and graded according to Genant using Spine Analyzer software.

Results: We evaluated 582 patients before and 484 after implementation (mean age 67 and 66 years; 71 and 74% women, respectively). Performing VFA increased from 4.6 to 97.1% (p < 0.001) and the diagnosis of VFs from 2.2 to 26.2% for grade ≥ 1 (p < 0.001) and from 0.9 to 14.7% for grade ≥ 2 (p < 0.001). Prevalence of VFs increased with age (5.2% in 50-59-year olds to 27.8% in 80+-year olds, p < 0.001), but was similar for both genders, non-VF locations, and BMD. Including patients with osteopenia and a VF increased the percentage of patients eligible for treatment by a quarter, from 31.0% in the pre-guideline to 38.4% in the post-guideline cohort.

Conclusions: Systematic guideline implementation resulted in a significant increase of VFA, diagnosis of VFs, and percentage of patients eligible for treatment. VFA contributes to documenting the high prevalence of VFs in patients visiting the FLS with a non-VF in both genders, at any age, non-VF location, and BMD.

Keywords: BMD; Fracture liaison service; Guideline; Osteoporosis; VFA; Vertebral fracture.

Publication types

  • Evaluation Study

MeSH terms

  • Absorptiometry, Photon / methods
  • Absorptiometry, Photon / statistics & numerical data
  • Aged
  • Bone Density / physiology
  • Bone Diseases, Metabolic / diagnosis
  • Bone Diseases, Metabolic / epidemiology
  • Bone Diseases, Metabolic / physiopathology
  • Female
  • Humans
  • Male
  • Middle Aged
  • Netherlands / epidemiology
  • Osteoporosis / diagnosis
  • Osteoporosis / epidemiology
  • Osteoporosis / physiopathology
  • Osteoporotic Fractures / diagnosis*
  • Osteoporotic Fractures / epidemiology
  • Osteoporotic Fractures / etiology
  • Osteoporotic Fractures / physiopathology
  • Practice Guidelines as Topic
  • Spinal Fractures / diagnosis*
  • Spinal Fractures / epidemiology
  • Spinal Fractures / etiology
  • Spinal Fractures / physiopathology