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A Comparative Study Between the Implementation of the FRIDEX Calibration and the NOGG Guideline in the Management of Osteoporosis in Routine Clinical Practice
Estudio comparativo de la aplicación de la calibración FRIDEX y de la guía NOGG en el manejo de la osteoporosis en la práctica clínica habitual
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"apellidos" => "Ballesteros-Pomar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Isidoro" "apellidos" => "Cano-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Sección de Endocrinología y Nutrición, Complejo Asistencial Universitario de León, León, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Ciencias Biomédicas, Universidad de León, León, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro de Salud Jesús Marín, Molina de Segura, Murcia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio comparativo de la aplicación de la calibración FRIDEX y de la guía NOGG en el manejo de la osteoporosis en la práctica clínica habitual" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1395 "Ancho" => 1742 "Tamanyo" => 125228 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Application of the NOGG diagnostic and therapeutic algorithm in our sample.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">BMD, bone mineral density; NOGG, National Osteoporosis Guideline Group.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Around 200 million individuals worldwide have been diagnosed with osteoporosis and, each year, there are 1.7 million osteoporotic fractures involving the hip.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> In Spain it has been estimated that over the next 10<span class="elsevierStyleHsp" style=""></span>years there will be 714,000 osteoporotic fractures, most of them in women over 70<span class="elsevierStyleHsp" style=""></span>years of age.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> However, many cases of osteoporosis are not diagnosed and, frequently, no treatment is prescribed even after the patient has had a fracture.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3,4</span></a> The impact on public health is enormous because of the high morbidity and mortality rates and the effect of these fractures on quality of life, in addition to their being accountable for increasing health costs.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">At the present time, attention is focused on identifying individuals with a high osteoporotic fracture risk, more than on detecting those with osteoporosis diagnosed exclusively by measuring bone mineral density (BMD).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> This identification is carried out with the help of tools—like the FRAX<span class="elsevierStyleSup">®</span> score—which, integrating the information from different risk factors, enables the calculation of the absolute risk of fracture in coming years as the most accurate way to decide the need for ancillary diagnostic tests or of initiating a specific therapy. The intervention thresholds are established depending on local factors, such as reimbursement policies, health economic evaluation, willingness to pay for osteoporosis care and access to dual-energy X-ray absorptiometry (DXA).<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The recommendations issued by the National Osteoporosis Guideline Group (NOGG) of the United Kingdom, one of the guidelines with the greatest international influence, are based on this model of intervention and are supported by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the International Osteoporosis Foundation (IOF), although many European countries have their own policies.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> In Spain, at this moment, there is no consensus on the thresholds for intervention; however, researchers working with the Risk Factors and Densitometry by Dual-energy X-ray Absorptiometry (FRIDEX) cohort, recently proposed a cost-effective calibration of the FRAX<span class="elsevierStyleSup">®</span>.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of our study is to evaluate the impact of the application of the FRIDEX calibration in routine clinical practice and determine whether it translates into a reduction in the number of densitometries and treatments prescribed and, thus, increasing the efficiency of the associated costs. Moreover, it is compared with the NOGG guideline thresholds to detect possible differences.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Design</span><p id="par0025" class="elsevierStylePara elsevierViewall">We designed a cross-sectional study to be carried out in a sample of women referred from different health care settings (primary and specialized care) of the health area of León, in northwestern Spain, to undergo axial DXA in the morning shift of the University Health Care Complex of León between May 2014 and December 2014.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Inclusion and Exclusion Criteria</span><p id="par0030" class="elsevierStylePara elsevierViewall">Women between 40 and 90<span class="elsevierStyleHsp" style=""></span>years of age with no previous treatment for osteoporosis (bisphosphonates, calcitonin, hormone replacement therapy, strontium ranelate, denosumab, teriparatide, raloxifene or bazedoxifene) were consecutively enrolled. We excluded patients who were referred to undergo DXA during follow-up after bariatric surgery and those diagnosed with a metabolic bone disease other than osteoporosis (for example, osteomalacia or Paget's disease), myeloma or any cancer involving bone.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study Process</span><p id="par0035" class="elsevierStylePara elsevierViewall">Ancillary staff of the radiology department, properly trained, gathered the necessary clinical information by means of a structured questionnaire. In addition, the same members of the team performed the pertinent measurements for the physical examination. In every case, the patient's history was reviewed to reduce possible information biases. One month after the test, the women who met the criteria for inclusion were telephoned regarding the post-DXA approach of their attending physicians.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The risk factors considered were those included in the FRAX<span class="elsevierStyleSup">®</span> tool.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Bone mass measurements were made by the same qualified technical staff using the same densitometer. The technique employed for the measuring the bone mass was DXA. For this purpose, we used a Lunar Prodigy Primo densitometer equipped with an EnCORE Windows-driven software platform (GE Healthcare, Wilmington, MA, United States).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evaluation of Fracture Risk</span><p id="par0050" class="elsevierStylePara elsevierViewall">To calculate the 10-year probability of a hip fracture and of a major fracture we utilized the FRAX<span class="elsevierStyleSup">®</span> application for the Spanish and the United Kingdom populations which is freely available on the Internet: <a href="http://www.shef.ac.uk/FRAX/">http://www.shef.ac.uk/FRAX/</a>.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">FRIDEX Calibration</span><p id="par0055" class="elsevierStylePara elsevierViewall">The FRIDEX cohort is a dynamic cohort of Spanish women aged 40 to 90<span class="elsevierStyleHsp" style=""></span>years who were selected by their attending physicians to undergo DXA and were followed for a period of 10<span class="elsevierStyleHsp" style=""></span>years.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> A model of the FRAX<span class="elsevierStyleSup">®</span> tool calibrated for the Spanish population based on the FRIDEX cohort was recently reported. It enables the identification of groups of women with a low and high risk of fragility fracture over a 10-year period and involves a cost-effective assessment.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> The flow chart based on this model can be observed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">National Osteoporosis Guideline Group</span><p id="par0060" class="elsevierStylePara elsevierViewall">The British guidelines, referred to as NOGG, propose the FRAX<span class="elsevierStyleSup">®</span> tool for population screening and establish 3 categories depending on the absolute risk of fracture over a 10-year period: high risk, intermediate risk and low risk.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Based on these results and an analysis of cost-effectiveness, NOGG proposes an algorithm for diagnostic decisions and certain thresholds for the initiation of drug therapy that vary according to patient age (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Cost Comparison</span><p id="par0065" class="elsevierStylePara elsevierViewall">For the comparative analysis of the costs we utilized the NOGG guidelines and the FRIDEX calibration. The cost estimated for DXA was the rate applied by the public health service of the Spanish autonomous community of Castile and León (Sacyl) for agreements with third parties, amounting to €58.6 (Official Gazette of Castile and León 31/1/2011, available at: <a href="http://bocyl.jcyl.es/boletin.do?fechaBoletin=31/01/2011">http://bocyl.jcyl.es/boletin.do?fechaBoletin=31/01/2011</a>). To calculate the mean cost of 1 year of treatment, we used data from the publication of the <span class="elsevierStyleItalic">Instituto de Salud CarlosIII</span>, Madrid, based on the medications most frequently administered in the treatment of osteoporosis in Spain during 2010, with the exception of calcium and vitamin D supplements.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> The mean cost, according to the profile for the consumption of medications for osteoporosis in Spain, was €427/year in 2010. The cost of 5years of treatment was estimated (€2135) for all of the models (approach adopted, NOGG and FRIDEX calibration).</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Statistical Analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">Based on previous studies, we calculated a sample size of 607 patients to be able to detect 25% of preventable BMD with a 95% confidence interval and an error of 3%.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> All of the collected variables (categorical and continuous) were loaded onto a database (Microsoft Access) and then analyzed using a statistical software package (SPSS version 15.0, SPSS Inc., Chicago, IL, United States). The normal distribution of the continuous data was confirmed with the Kolmogorov–Smirnov test; if the distribution was normal, they are presented as the mean (standard deviation [SD]) and if it was not normal, as the median (interquartile range [IQR]). The categorical data are expressed as percentages. For the analysis of the data, we used the chi-square test for the comparison of proportions and categorical variables, the Wilcoxon signed-rank test for continuous variables in which the data was not normally distributed and Student's <span class="elsevierStyleItalic">t</span> test for unpaired or paired data for variables with a normal distribution. The confidence intervals were calculated by means of a bootstrapping technique. Cohen's kappa coefficient was utilized to evaluate agreement in each system for diagnostic and drug intervention, and the level of agreement was considered high when the kappa statistic was >0.8 and good when it was >0.6. A <span class="elsevierStyleItalic">P</span> value <.05 was considered to indicate statistical significance. This report is adapted to the guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical Aspects</span><p id="par0075" class="elsevierStylePara elsevierViewall">The nature of the study was explained in detail to each patient and they provided their verbal informed consent. The study protocol was approved by the research committee of our center.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">The study population included 607 women with a median age of 59.4 (IQR<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>14) years; the average body mass index (BMI) was 26.3 (SD<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4.5)<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>. According to the densitometry performed, they had a <span class="elsevierStyleItalic">T</span>-score of −1.4 in spine (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.3), −1.4 in femoral neck (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.3) and −2.2 in total hip (SD<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.2). The prevalences of the risk factors that are included in the FRAX<span class="elsevierStyleSup">®</span> tool were, in descending order: secondary osteoporosis (24.1%), tobacco use (16.5%), parental hip fracture (15.2%), prior clinical fracture (12.4%), corticosteroid therapy (8.4%), rheumatoid arthritis (7.6%) and alcohol consumption (2.1%). In all, 31.4% of the women in the sample were prescribed medication by their attending physician after densitometry, whereas 36% of those who had a history of a fragility fracture were not being treated.</p><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Application of the FRIDEX Calibration</span><p id="par0085" class="elsevierStylePara elsevierViewall">According to this calibration (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the women in the study were classified as follows: 392 (64.6%) as low risk, 77 (12.7%) as intermediate risk and 138 (22.7%) as high risk. The FRIDEX calibration proposes that bone densitometry be performed in those patients with high and intermediate risk, that is, 35.4% of the women in this study sample. Of the women analyzed, 26.7% required treatment.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Application of the NOGG Guidelines</span><p id="par0090" class="elsevierStylePara elsevierViewall">The utilization of the NOGG guidelines allocated the women into 3 risk groups (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>): 322 (53.0%) as low risk, 194 (32.0%) as intermediate risk and 91 (15.0%) as high risk. Only the group at intermediate risk (32.0%) required DXA. In accordance with the therapeutic intervention thresholds, drug therapy would be indicated in 21.3% of the participants.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Comparison Including the Approach Adopted, the FRIDEX Calibration and the NOGG Guidelines</span><p id="par0095" class="elsevierStylePara elsevierViewall">The percentage of DXA requested on the basis of the NOGG guidelines and of the FRIDEX calibration was not statistically significant (<span class="elsevierStyleItalic">P</span>=.059). However, according to Cohen's kappa coefficient, the level of agreement was low (0.16; 95% CI: 0.09–0.24). With respect to therapy, according to the FRIDEX calibration, it would be indicated in 26.7% of the women, a lower proportion than the number actually treated (31.3%, <span class="elsevierStyleItalic">P</span><.001), but higher than that of the NOGG guidelines (21.3%, <span class="elsevierStyleItalic">P</span><.001). The level of agreement between the FRIDEX calibration and the therapeutic approach adopted was 0.29 (95% CI: 0.31–0.47). The characteristics of the women in which the results differed can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Cost Comparison</span><p id="par0100" class="elsevierStylePara elsevierViewall">The application of the FRIDEX calibration in our sample would increase the cost of treatment by 60.7% in women over 65<span class="elsevierStyleHsp" style=""></span>years of age, but would decrease it by 74.5% in those aged less than 65. In addition, there would be a savings of 64.6% in DXA in both groups and of 14.7% in treatment over 5<span class="elsevierStyleHsp" style=""></span>years. The overall outcome would be a reduction in costs at 5<span class="elsevierStyleHsp" style=""></span>years of 18.8%, equivalent to €352.4/patient (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). This cost savings would be greater with the use of the NOGG guidelines, equivalent to a 5-year reduction of €725.4/patient, mainly because of the decrease in the number of densitometries indicated and treatments prescribed in women over 65<span class="elsevierStyleHsp" style=""></span>years of age.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The application of the FRIDEX calibration in our sample results in an improvement in the efficiency of the management of osteoporosis both at the diagnostic level and at the time of indicating drug therapy. Moreover, it reduces costs in comparison with routine clinical practice in the León health area.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The cost analysis includes the direct costs of DXA and 5<span class="elsevierStyleHsp" style=""></span>years of drug therapy in accordance with the cost of DXA in Castile and León and the real treatment profile in Spain.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> The direct and indirect costs related to the fractures were not included in the assessment. In short, the use of the thresholds for the FRIDEX calibration in our sample would make it possible to save €37.4/patient in DXA and €314.6/patient in medication costs. The total expense (DXA and treatment) would be reduced over 5<span class="elsevierStyleHsp" style=""></span>years by 18.8% with respect to the approach adopted in our area. In contrast, the NOGG guideline would reduce overall costs by 35.0% over 5<span class="elsevierStyleHsp" style=""></span>years. This would mean a savings in our sample of €39.9/patient in DXA and €685.4/patient in treatment for 5<span class="elsevierStyleHsp" style=""></span>years. In a study on the FRIDEX model, the overall costs decreased by 28.7% compared to the standard strategy based on DXA to detect the same number of women who had fractures.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">When the FRIDEX cost-effectiveness proposal is compared with the NOGG guideline thresholds for a population in the United Kingdom, it is observed that both recommendations reduce the number of DXA requested and that of prescribed treatments when compared with the approach adopted in our health area. However, the level of agreement between the two is low. Thus, although the absolute number of DXA and that of treatments that are indicated by the study do not differ much, the persons to which they are directed are different. The FRIDEX calibration recommends the measurement of BMD in older individuals with a high body mass index, whereas the NOGG guidelines are aimed mainly at persons who have more severe clinical risk factors. The FRIDEX proposal helps by identifying more cases of osteoporosis in the lumbar spine as well as in hip with respect to NOGG. Likewise, when it comes to suggesting therapy, the NOGG guidelines would indicate treating young persons in whom risk factors were detected, whereas the FRIDEX calibration would focus more on elderly individuals and on patients with osteoporosis involving the lumbar spine. Clinical practice guidelines should integrate in the best possible way the information from models that predict the risk of fracture to enable the identification of the individuals who would most benefit from bone densitometry. The purpose would be to evaluate risk more accurately, which would lead to a better selection of candidates for antiresorptive therapy.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The NOGG guidelines and FRIDEX calibration are based on the FRAX<span class="elsevierStyleSup">®</span> score, the only tool that takes into account life expectancy and the epidemiological differences among countries.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> The thresholds proposed by the FRIDEX calibration are of interest as they focus on the Spanish population and are corroborated by cost-effectiveness studies with national considerations. Therefore, the use of these thresholds would be more appropriate than those concerning the British population. On the other hand, the NOGG guidelines are those with the best results, but they have not been validated for the Spanish population. They are different in that the intervention threshold is flexible, and varies depending on age, a parameter that is important in cost-effectiveness studies.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> However, in several studies, it has been seen that the NOGG guidelines are associated with difficulties when it comes to preventing fragility fractures, since, for example, elderly individuals should have an elevated risk as candidates for treatment, despite the fact that studies have demonstrated that the treatment in those patients is cost-effective with smaller thresholds.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">17,18</span></a> To make an accurate evaluation of the cost-effectiveness of guidelines, it is necessary to assess savings both over the short term—reduction in the number of bone densitometries and of prescribed treatment—and the long term, with savings related to fracture prevention.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> Thus, guidelines like those proposed by the NOGG, which are cost-effective over the short term, may not be over the long term, since they have the inconvenience of being less precise in their identification of high-risk patients, at least at the time of indicating whether or not they should be treated.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18,20</span></a> This means that it is necessary to conduct national studies for the purpose of identifying the intervention thresholds at which the benefits of treatment, over both the short and the long term are maximized, while the risks and costs that accompany treatment are limited, always taking into consideration the amount society is willing to pay. In Spain, at the present time, according to FRAX<span class="elsevierStyleSup">®</span>, there are no valid thresholds for high-risk of fracture. Moreover, providing a single value to represent the risk of fracture may not be wholly suitable, when the incidence of hip fractures can be up to 2-fold higher depending on the Spanish autonomous community.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> Until we have those thresholds, the proposal of the FRIDEX calibration may continue to have a role, as it is an improvement in the efficiency of the management of osteoporosis and better identifies densitometric osteoporosis in our setting than the British NOGG guidelines.</p><p id="par0125" class="elsevierStylePara elsevierViewall">This report reveals the implications of the utilization of the NOGG guidelines and the FRIDEX calibration in the diagnostic and therapeutic efficiency in the management of osteoporosis in routine clinical practice, demonstrating a considerable heterogeneity among the recommendations for approaching this condition, which can influence decision-making concerning our patient population. However, it has certain limitations that we consider we should mention. First, the sample may have selection and reference biases, as it was made up of individuals who were referred to undergo DXA in accordance with the criteria of a physician. This may affect the results, since these persons have been subjected to some type of prior selection and the sample cannot be totally representative of the general population, compromising the external validity. However, this question would not affect analyses comparing different guidelines. Second, the Spanish version of the FRAX<span class="elsevierStyleSup">®</span> tool has weaknesses, such as its underestimation of the risk of major fracture.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> The lack of robust Spanish epidemiological data concerning the incidence of major osteoporotic fractures has been approached through the application of the Swedish ratio of hip fractures to major fractures. However, the Spanish epidemiological findings on hip fractures and on nonvertebral and nonfemoral fractures indicate that, while the incidence of hip fractures in Sweden is approximately twice that reported in Spain, the frequency of the latter is relatively similar.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">11,22</span></a> This underestimation of the risk was one of the reasons why we decided to employ the British FRAX<span class="elsevierStyleSup">®</span> when applying the NOGG decision thresholds in our study, taking into account the associated difference in risk assessment, as well.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">22,23</span></a> The British FRAX<span class="elsevierStyleSup">®</span> tool duplicates risk in comparison with the Spanish version.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> As a result, the use of the latter would lead to a further underestimation of the risk of fracture when the NOGG thresholds are utilized. Third, the NOGG guidelines are validated for a specific population. This means that the characteristics may be different (prevalence of risk factors, fracture incidence, etc.), possibly compromising external validation and, thus, extrapolating the results requires caution. A fourth limitation is that the presence of silent vertebral fractures was not assessed, a fact that could affect therapeutic decisions based on the guidelines.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">Both the FRIDEX calibration and the NOGG guidelines have considerable heterogeneity. This signifies that there can be substantial variability in the number of individuals in which performance of DXA is recommended, as well as in those for whom the decision is made to initiate treatment. The use of either of them in our routine clinical practice would increase our efficiency in the management of osteoporosis, and we would achieve a significant reduction in costs. Nevertheless, further studies will help us to identify the intervention thresholds applicable in the Spanish population to maximize the cost-benefit.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Ethical Disclosures</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Protection of human and animal subjects</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Confidentiality of data</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Right to privacy and informed consent</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflicts of Interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres884912" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec871111" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres884913" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec871112" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and Methods" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Inclusion and Exclusion Criteria" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Study Process" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Evaluation of Fracture Risk" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "FRIDEX Calibration" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "National Osteoporosis Guideline Group" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Cost Comparison" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Statistical Analysis" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Ethical Aspects" ] ] ] 6 => array:3 [ "identificador" => "sec0060" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Application of the FRIDEX Calibration" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Application of the NOGG Guidelines" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Comparison Including the Approach Adopted, the FRIDEX Calibration and the NOGG Guidelines" ] 3 => array:2 [ "identificador" => "sec0080" "titulo" => "Cost Comparison" ] ] ] 7 => array:2 [ "identificador" => "sec0085" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0095" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-04" "fechaAceptado" => "2016-05-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec871111" "palabras" => array:4 [ 0 => "FRIDEX" 1 => "NOGG" 2 => "Osteoporosis" 3 => "FRAX<span class="elsevierStyleSup">®</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec871112" "palabras" => array:4 [ 0 => "FRIDEX" 1 => "NOGG" 2 => "Osteoporosis" 3 => "FRAX<span class="elsevierStyleSup">®</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The recent FRIDEX calibration proposed cost-effectiveness thresholds for the Spanish population. The aim of our study is to evaluate the impact of its application in routine clinical practice and to compare its thresholds with those of the National Osteoporosis Guideline Group (NOGG).</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study in women referred to a bone densitometry unit who were not receiving antiresorptive therapy. The absolute risk of major fracture or hip fracture was calculated with the Spanish and British formulas of the FRAX<span class="elsevierStyleSup">®</span> tool using the intervention thresholds of the FRIDEX calibration and the NOGG guideline, respectively.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 607 women with a median age of 59.4 (IQR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14) years. Treatment was initiated in 31.4% after bone mineral densitometry. With the application of the FRIDEX calibration, bone mineral density testing would have been indicated in 35.4% of the sample and treatment in 26.7%, reducing costs by 18.8% over a 5-year period. The NOGG guideline would have recommended testing in 32% and treatment in 21.3% of the participants, resulting in a reduction in costs of 35% over 5 years, when compared with the standard approach. Agreement between the FRIDEX calibration and the NOGG guideline, as defined by Cohen's kappa coefficient, was low in terms of both diagnostic (0.16 [95% CI, 0.09–0.24]) and therapeutic indications (0.39 [95% CI, 0.31–0.47]).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The application of the FRIDEX calibration and the NOGG guideline improves efficiency in the management of osteoporosis, although the level of agreement between the two is low.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En España, el estudio FRIDEX ha aportado recientemente unos umbrales de riesgo coste-efectivos para el manejo de la osteoporosis. El objetivo del estudio es evaluar el impacto de su aplicación en la práctica clínica habitual, comparándola también con los umbrales de la <span class="elsevierStyleItalic">National Osteoporosis Guidelines Group</span> (NOGG).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal realizado en mujeres remitidas a una unidad de densitometría ósea. El riesgo absoluto de presentar una fractura mayor o de cadera se calculó mediante la fórmula FRAX<span class="elsevierStyleSup">®</span> española y británica para poder emplear los umbrales de intervención de la calibración FRIDEX y de la guía NOGG, respectivamente. Se descartaron mujeres con tratamiento antirresortivo.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Fueron incluidas 607 mujeres con una mediana de edad de 59,4 (RIQ<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14) años. El 31,4% recibieron tratamiento después de la densitometría ósea. El empleo de la calibración FRIDEX indicaría una densitometría ósea al 35,4% y tratamiento al 26,7%, lo que supondría una reducción de gastos a los 5<span class="elsevierStyleHsp" style=""></span>años del 18,8%. Según la guía NOGG precisarían densitometría ósea el 32% y tratamiento el 21,3%, siendo el ahorro de un 35% a los 5<span class="elsevierStyleHsp" style=""></span>años respeto a la actitud habitual. La concordancia de la guía NOGG y del FRIDEX según el coeficiente kappa de Cohen fue baja tanto a nivel diagnóstico (0,16 [IC 95%: 0,09-0,24]) como terapéutico (0,39 [IC 95%: 0,31-0,47]).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La aplicación de la calibración FRIDEX y de la guía NOGG aumentaría la eficiencia del manejo de la osteoporosis, aunque su concordancia es baja, indicando tratamiento en diferentes perfiles de mujeres.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Kyriakos G, Vidal-Casariego A, Quiles-Sánchez LV, Calleja-Fernández A, Ávila-Turcios D, Urosa-Maggi JA, et al. Estudio comparativo de la aplicación de la calibración FRIDEX y de la guía NOGG en el manejo de la osteoporosis en la práctica clínica habitual. Reumatol Clin. 2017;13:258–263.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1481 "Ancho" => 1742 "Tamanyo" => 155520 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Application of the FRIDEX risk thresholds in our sample.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BMD, bone mineral density; FRIDEX, risk factors and densitometry by dual-energy X-ray absorptiometry.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1395 "Ancho" => 1742 "Tamanyo" => 125228 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Application of the NOGG diagnostic and therapeutic algorithm in our sample.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">BMD, bone mineral density; NOGG, National Osteoporosis Guideline Group.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">BMD, bone mineral density; BMI, body mass index; DXA, dual-energy X-ray absorptiometry; FRIDEX, Risk Factors and Densitometry by Dual-energy X-ray Absorptiometry; NOGG, National Osteoporosis Guideline Group; NS, not significant.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Indication for DXA</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Indication for treatment</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NOGG yes, FRIDEX no \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NOGG no, FRIDEX yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NOGG yes, FRIDEX no \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NOGG no, FRIDEX yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">124 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">— \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.9 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.8 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.7 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.4 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.7 (11.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.2 (10.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62.2 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.2 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Height (cm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">159.7 (7.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">154.8 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">158.5 (8.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">153.4 (6.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI (kg/m<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.4 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.9 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.002 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.8 (3.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.7 (3.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tobacco use \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (23.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (33.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (3.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alcohol consumption \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (12.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (8.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (12.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (10.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Secondary osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (43.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (18.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (20.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (32.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatoid arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (7.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (6.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (10.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (10.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Parental hip fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (35.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (15.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (32.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (16.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.013 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No clinical risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (28.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (36.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lumbar spine <span class="elsevierStyleItalic">T</span>-score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.1 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.7 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.6 (1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.4 (1.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Femoral neck <span class="elsevierStyleItalic">T</span>-score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.0 (0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.7 (0.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.7 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.6 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total hip <span class="elsevierStyleItalic">T</span>-score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.3 (1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.0 (1.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.9 (1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.9 (1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lumbar spine osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (15.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (30.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (22.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (31.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Femoral neck osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (4.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (16.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (8.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (8.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total hip osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (15.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (47.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (32.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 (48.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">.034 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1494193.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the Women in Whom the Results Based on the NOGG Guidelines and on the FRIDEX Calibration Differed With Regard to Recommending DXA and Indicating Antiresorptive Therapy.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Sample</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">FRIDEX calibration</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Difference in costs between FRIDEX and sample</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">NOGG guidelines</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Difference in costs between NOGG and sample</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">€ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">€ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">€/patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">€ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">€/patient \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="11" align="left" valign="top"><span class="elsevierStyleItalic">DXA</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>≤65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">410 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24,026 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3047 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−87.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−51.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7032 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−70.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−41.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>>65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">197 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11,544 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">163 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9552 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−17.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−10.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4322 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−62.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−36.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total sample \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">607 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35,570 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">215 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12,599 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−64.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−37.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">194 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11,354 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−68.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−39.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="11" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="11" align="left" valign="top"><span class="elsevierStyleItalic">Treatment</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>≤65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">226,310 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57,645 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−74.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1591.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">155,855 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−31.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−664.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>>65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">179,340 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">135 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">288,225 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">+60.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">+1296.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">119,560 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−711.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Total sample \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">190 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">405,650 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">162 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">345,870 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−14.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−314.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">129 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">275,415 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−32.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−685.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="11" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="11" align="left" valign="top"><span class="elsevierStyleItalic">Overall</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">441,220 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">358,469 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−18.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−352.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">286,769 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−35.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−725.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1494192.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Mean cost of 5 years of antiresorptive therapy.</p> <p class="elsevierStyleNotepara" id="npar0010">DXA, dual-energy X-ray absorptiometry; FRIDEX, Risk Factors and Densitometry by Dual-energy X-ray Absorptiometry; NOGG, National Osteoporosis Guideline Group.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Comparison of Costs of the Approach Employed in the León Health Area and the Application of the FRIDEX Calibration and NOGG Guidelines.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An estimate of the worldwide prevalence and disability associated with osteoporotic fractures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O. 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| 2024 November | 9 | 10 | 19 |
| 2024 October | 39 | 35 | 74 |
| 2024 September | 41 | 16 | 57 |
| 2024 August | 63 | 44 | 107 |
| 2024 July | 43 | 21 | 64 |
| 2024 June | 50 | 29 | 79 |
| 2024 May | 61 | 27 | 88 |
| 2024 April | 62 | 23 | 85 |
| 2024 March | 53 | 20 | 73 |
| 2024 February | 36 | 20 | 56 |
| 2024 January | 34 | 18 | 52 |
| 2023 December | 34 | 27 | 61 |
| 2023 November | 49 | 23 | 72 |
| 2023 October | 58 | 31 | 89 |
| 2023 September | 79 | 35 | 114 |
| 2023 August | 43 | 12 | 55 |
| 2023 July | 41 | 22 | 63 |
| 2023 June | 38 | 20 | 58 |
| 2023 May | 46 | 23 | 69 |
| 2023 April | 34 | 13 | 47 |
| 2023 March | 105 | 32 | 137 |
| 2023 February | 80 | 29 | 109 |
| 2023 January | 31 | 14 | 45 |
| 2022 December | 97 | 30 | 127 |
| 2022 November | 53 | 38 | 91 |
| 2022 October | 97 | 39 | 136 |
| 2022 September | 42 | 38 | 80 |
| 2022 August | 34 | 32 | 66 |
| 2022 July | 66 | 54 | 120 |
| 2022 June | 49 | 48 | 97 |
| 2022 May | 58 | 37 | 95 |
| 2022 April | 76 | 58 | 134 |
| 2022 March | 59 | 61 | 120 |
| 2022 February | 63 | 33 | 96 |
| 2022 January | 103 | 65 | 168 |
| 2021 December | 65 | 41 | 106 |
| 2021 November | 51 | 48 | 99 |
| 2021 October | 175 | 67 | 242 |
| 2021 September | 58 | 30 | 88 |
| 2021 August | 60 | 43 | 103 |
| 2021 July | 56 | 23 | 79 |
| 2021 June | 87 | 35 | 122 |
| 2021 May | 86 | 48 | 134 |
| 2021 April | 133 | 104 | 237 |
| 2021 March | 60 | 29 | 89 |
| 2021 February | 51 | 21 | 72 |
| 2021 January | 48 | 23 | 71 |
| 2020 December | 44 | 17 | 61 |
| 2020 November | 42 | 21 | 63 |
| 2020 October | 34 | 16 | 50 |
| 2020 September | 52 | 37 | 89 |
| 2020 August | 24 | 22 | 46 |
| 2020 July | 17 | 12 | 29 |
| 2020 June | 40 | 26 | 66 |
| 2020 May | 57 | 12 | 69 |
| 2020 April | 36 | 18 | 54 |
| 2020 March | 21 | 2 | 23 |
| 2020 February | 1 | 0 | 1 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 October | 0 | 1 | 1 |
| 2018 May | 9 | 0 | 9 |
| 2018 April | 56 | 7 | 63 |
| 2018 March | 143 | 11 | 154 |
| 2018 February | 39 | 8 | 47 |
| 2018 January | 37 | 10 | 47 |
| 2017 December | 33 | 9 | 42 |
| 2017 November | 48 | 12 | 60 |
| 2017 October | 69 | 33 | 102 |
| 2017 September | 58 | 30 | 88 |
| 2017 August | 31 | 18 | 49 |
| 2017 July | 2 | 11 | 13 |
| 2017 June | 3 | 12 | 15 |
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