Were you identified to be at high fracture risk by FRAX® before your osteoporotic fracture occurred?

Comparison of methods to improve fracture risk assessment in chinese diabetic postmenopausal women: a case-control study

PURPOSE

This study evaluated the predictive power of adjusted FRAX and standard FRAX models based on the actual prevalence of osteoporosis in type 2 diabetic (T2DM) postmenopausal women, and to explore the optimal strategy to better predicted fracture risk in postmenopausal women with diabetes in China.

METHODS

We recruited 434 patients from community-medical centers, 217 with T2DM and 217 without T2DM (non-T2DM). All participants completed self-reported questionnaires detailing their characteristics and risk factors. Bone mineral density (BMD) and spinal radiographs were evaluated. The China FRAX model calculated all scores. The area under the receiver operator characteristic curve (ROC-AUC) evaluated the sensitivity, specificity, and accuracy for predicting 10-year risk for major (MOF) and hip (OHF) osteoporotic fractures in T2DM patients.

RESULTS

T2DM patients had higher BMD but lower average FRAX values than non-T2DM patients. The unadjusted FRAX ROC-AUC was 0.774, significantly smaller than that for 0.5-unit femoral neck T-score-adjusted FRAX (0.800; p = 0.004). Rheumatoid arthritis (RA; AUC = 0.810, p = 0.033) and T-score (AUC = 0.816, p = 0.002) adjustments significantly improved fracture prediction in T2DM patients.

CONCLUSIONS

Femoral neck T-score adjustment might be the preferred method for predicting MOF and OHF in Chinese diabetic postmenopausal women, while RA adjustment only effectively predicted HF risk.

Setting the new FRAX reference threshold without bone mineral density in Chinese postmenopausal women

PURPOSE

Despite the large number of osteoporosis patients in China, the diagnosis and treatment rates remain low. The Fracture Risk Assessment Tool (FRAX) can be used to effectively evaluate fracture risk. In this study, we explored the Chinese-specific thresholds of FRAX without the T-score.

METHODS

In all, 264 postmenopausal women aged > 50 years were randomly recruited from community-medical centers. All subjects completed self-reported questionnaires, BMD measurements, and spinal radiographs. The 10-year hip and major osteoporotic fracture risks were calculated by FRAX. A new threshold for both 10-year hip and major osteoporotic fracture risk was explored with receiver operating characteristic (ROC) curve analysis.

RESULTS

Overall, 92 subjects were diagnosed with osteoporosis. Among them, 14 participants with T-score > - 2.5 were diagnosed with osteoporosis based on clinical fractures. ROC analysis showed the cut-off value of the 10-year hip osteoporotic fracture for detecting osteoporosis was 0.95%, while that of 10-year major osteoporotic fracture was 4.95%. The sensitivity and specificity of the 10-year hip osteoporotic fracture probability for detecting osteoporosis were 0.86 and 0.59, respectively, while the guideline-recommended threshold had a sensitivity of 0.49 and specificity of 0.83. The sensitivity and specificity of the 10-year major osteoporotic fractures with the new threshold were 0.76 and 0.69, respectively, while the recommended threshold had a sensitivity of 0 and specificity of 1.

CONCLUSION

Current guideline-recommended FRAX thresholds without BMD showed low sensitivity. Therefore, 10-year osteoporotic hip fracture probability ≥ 0.95% and 10-year osteoporotic major fracture probability ≥ 4.95% are recommended as the new thresholds.

Evaluation of a Panel of MicroRNAs that Predicts Fragility Fracture Risk: A Pilot Study

The assessment of fragility fracture risk based on bone densitometry and FRAX°, although commonly used, has shown some limitations. MicroRNAs (miRNAs) are promising biomarkers known to regulate post-transcriptional gene expression. Many studies have already shown that microRNAs are involved in bone homeostasis by modulating osteoblast and osteoclast gene expression. In this pilot study, we investigated the ability of an miRNA panel (namely, the OsteomiR° score) to predict fragility fracture risk in older people. miRNAs were extracted from the sera of 17 persons who developed a fracture within 3 years of collecting the serum and 16 persons who did not experience fractures in the same period. Nineteen miRNAs known to be involved in bone homeostasis were assessed, and 10 miRNAs were employed to calculate the OsteomiR° score. We found a trend towards higher OsteomiR° scores in individuals who experienced fractures compared to control subjects. The most suitable cut-off that maximized sensitivity and specificity was determined by ROC curve analysis, and a positive predictive value of 68% and a sensitivity of 76% were obtained. The OsteomiR° score was higher in osteopenic and osteoporotic subjects compared to subjects with a normal T score. Additionally, the OsteomiR° score predicted more fracture events than the recommended "need-to-treat" thresholds based on FRAX° 10-year probability. miRNAs reflect impairments in bone homeostasis several years before the occurrence of a fracture. The OsteomiR° score seems to be a promising miRNA panel for fragility fracture risk prediction and might have added value compared to FRAX°. Given the limited cohort size, further studies should be dedicated to validating the OsteomiR° score.

Comparison of strategies for setting intervention thresholds for Chinese postmenopausal women using the FRAX model

PURPOSE

The two main strategies for managing osteoporosis using the Fracture Risk Assessment (FRAX®) are the fixed-probability threshold of the National Osteoporosis Foundation (NOF) and the age-dependent-probability threshold of the National Osteoporosis Guideline Group (NOGG), but there are no FRAX® Chinese-specific thresholds. This study examined the NOF and NOGG strategies for intervention thresholds using the Chinese FRAX® model for their appropriateness for Chinese postmenopausal women, and explored Chinese-specific thresholds.

METHODS

Postmenopausal women (N = 264) >50 years old from community-medical centers in China were randomly selected. They completed a self-report questionnaire and underwent bone mineral density measurements and spinal X-rays. The 10-year risks for a major osteoporosis fracture and hip fracture were calculated using the Chinese FRAX® model. Using an osteoporosis diagnosis as the gold standard, we compared the abilities of the NOF and NOGG thresholds to detect osteoporosis by analyzing their sensitivity, specificity, accuracy, and positive and negative likelihood ratios.

RESULTS

The 10-year risks for hip fracture and a major osteoporotic fracture increased with age. The NOF's accuracy in detecting osteoporosis was 83.33% and the NOGG's was 74.24%. The NOF thresholds showed higher accuracy and specificity than the NOGG thresholds.

CONCLUSION

NOF thresholds are more appropriate for Chinese menopausal women.

Revised FRAX®-based intervention thresholds for the management of osteoporosis among postmenopausal women in Sri Lanka

This paper revised the fixed intervention thresholds (ITs) based on the Sri Lankan fracture risk assessment tool (FRAX) published in 2013 and introduced new ITs, hybrid and two-tier, aiming to help clinicians in the management of postmenopausal osteoporosis. The hybrid and two-tier ITs have a better discriminatory power than age-dependent and revised fixed ITs.

INTRODUCTION

This study revised the Sri Lankan FRAX®-based intervention thresholds (ITs) previously published in 2013.

METHOD

Age-dependent ITs were estimated, from 50-80 years with 5-year intervals, using a Sri Lankan FRAX® algorithm for a woman with a BMI of 24.8 kg/m² and history of prior fragility fracture without other clinical risk factors. Data of 653 postmenopausal women were used in estimating fixed, hybrid, and two-tier ITs. ITs were determined using the ROC curve and partial Youden index. New ITs were validated using data of 356 postmenopausal women who underwent DXA and 62 women who had a recent fragility fracture. Women in the two groups (n = 653 and n = 356) came from the Southern Province and had undergone DXA in our state-owned tertiary care hospital as a part of their routine clinical assessment.

RESULTS

The mean (SD) age and BMI of the subjects (n = 653) were 62 (8) years and 24.8 (1.2) kg/m², respectively. Age-dependent ITs of major osteoporotic fracture risk (MOFR) and hip fracture risk (HFR) ranged from 2.7 to 18% and from 0.4 to 7.1%. The best fixed ITs for women aged 50-80 years were 9% for MOFR and 3% for HFR. In the hybrid method, MOFR of 6% and HFR of 2% were found appropriate for women aged < 70 years. These were combined with age-dependent ITs for women aged 70 years and above. In the two-tier system, two sets of ITs were calculated (ITs of MOFR/HFR for women aged < 70 years and ≥ 70 years were 6%/2% and 12%/5%, respectively). When age-dependent ITs were considered the reference standard, sensitivities of the fixed, hybrid, and two-tier ITs were 0.63, 0.73, and 0.74, respectively. The specificities were 0.76, 0.86, and 0.80 in the same order. Sensitivities of the age-dependent, fixed, hybrid, and two-tier ITs in identifying a woman with an incident fracture were 26%, 48%, 61%, and 61%, respectively.

CONCLUSIONS

The new fixed MOFR is slightly lower than the previous value and hybrid and two-tier ITs perform better than age-dependent and fixed ITs.

Fracture Risk Assessment Tool (FRAX®) Results Calculated With and Without Bone Mineral Density Values for the Evaluation of Fracture Risk in Postmenopausal Women With Osteopenia

The aim of this study was to evaluate the agreement between fracture risk predictions based on calculations made with and without bone mineral density (BMD) values using the Fracture Risk Assessment Tool (FRAX®) in Turkish postmenopausal women with osteopenia and to compare the treatment recommendations. This descriptive, cross-sectional study included postmenopausal women aged 50-79 yr with a diagnosis of osteoporosis who were not receiving any treatment. A questionnaire was administered to the participants face-to-face to obtain sociodemographic characteristics, medical history, and fracture history. Fracture risk was calculated with FRAX® separately with and without BMD. The study included 230 postmenopausal patients with osteopenia. The mean age of the patients was determined as 63.16 ± 7.59 yr, and the mean body mass index was 30.61 ± 5.02. The intraclass correlation coefficient values of the 10-yr major osteoporotic (MO) fracture and hip fracture score agreement with FRAX® with and without BMD were mean 0.486 and 0.462, respectively. The risk of MO fracture with an intervention threshold of ≥20 was determined in 227/230 patients (98.7%), and the risk of hip fracture with treatment recommendations of ≥3 was determined in 204/230 patients (88.7%). Treatment recommendations in patients with no fracture history and secondary osteoporosis were 100% for MO fracture and 94.7% (123/130) for hip fracture risk. The treatment recommendation rates of FRAX® with and without BMD were similar for the majority of postmenopausal women with osteopenia. The agreement between the values was of a moderate level. When patients with a fracture history and secondary osteoporosis were excluded, the agreement increased. Even though values with BMD are of basic importance for medical treatment in postmenopausal women, the use of measurements evaluating fracture risk, such as FRAX® without BMD, could be useful in postmenopausal women with osteopenia.

Individualized fracture risk assessment: State-of-the-art and room for improvement

Fragility fracture is a serious clinical event, because it is associated with increased risk of mortality and reduced quality of life. The risk of fracture is determined by multiple risk factors, and their effects may be interactional. Over the past 10 years, a number of predictive models (e.g., FRAX, Garvan Fracture Risk Calculator, and Qfracture) have been developed for individualized assessment of fracture risk. These models use different risk profiles to estimate the probability of fracture over 5- and 10-year period. The ability of these models to discriminate between those individuals who will and will not have a fracture (i.e., area under the receiver operating characteristic curve [AUC]) is generally acceptable-to-good (AUC, 0.6 to 0.8), and is highly variable between populations. The calibration of existing models is poor, particularly in Asian populations. There is a strong need for the development and validation of new prediction models based on Asian data for Asian populations. We propose approaches to improve the accuracy of existing predictive models by incorporating new markers such as genetic factors, bone turnover markers, trabecular bone score, and time-variant factors. New and more refined models for individualized fracture risk assessment will help identify those most likely to sustain a fracture, those most likely to benefit from treatment, and encouraging them to modify their risk profile to decrease risk.

The utility of dual-energy X-ray absorptiometry, calcaneal quantitative ultrasound, and fracture risk indices (FRAX® and Osteoporosis Risk Assessment Instrument) for the identification of women with distal forearm or hip fractures: A pilot study

PURPOSE

Dual-energy X-ray absorptiometry (DXA) is considered the "gold standard" in predicting osteoporotic fractures. Calcaneal quantitative ultrasound (QUS) variables are also known to predict fractures. Fracture risk assessment tools may also guide us for the detection of individuals at high risk for fractures. The aim of this case-control study was to evaluate the utility of DXA bone mineral density (BMD), calcaneal QUS parameters, FRAX® (Fracture Risk Assessment Tool), and Osteoporosis Risk Assessment Instrument (ORAI) for the discrimination of women with distal forearm or hip fractures.

MATERIALS AND METHODS

This case-control study included 20 women with a distal forearm fracture and 18 women with a hip fracture as cases and 76 age-matched women served as controls. BMD at the spine, proximal femur, and radius was measured using DXA and acoustic parameters of bone were obtained using a calcaneal QUS device. FRAX® 10-year probability of fracture and ORAI scores were also calculated in all participants. Receiver operating characteristic (ROC) analysis was used to assess fracture discriminatory power of all the tools.

RESULTS

While all DXA BMD, and QUS variables and FRAX® fracture probabilities demonstrated significant areas under the ROC curves for the discrimination of hip-fractured women and those without, only 33% radius BMD, broadband ultrasound attenuation (BUA), and FRAX® major osteoporotic fracture probability calculated without BMD showed significant discriminatory power for distal forearm fractures.

CONCLUSIONS

It can be concluded that QUS variables, particularly BUA, and FRAX® major osteoporotic fracture probability without BMD are good candidates for the identification of both hip and distal forearm fractures.

Is It Possible to Increase the Clinical Effectiveness of the Fracture Risk Assessment Tool in Osteopenia Patients by Taking Into Account Bone Mineral Density Values?

The study aimed to investigate the effectiveness of the clinical use of the Fracture Risk Assessment Tool (FRAX(®)) developed by the World Health Organization identifying patients at risk of osteoporotic fracture and to evaluate changes in osteoporotic fracture risk prediction according to bone mineral density (BMD) values. We identified the occurrence of osteoporotic fracture among patients whose BMD was measured in our hospital between April 2003 and March 2013. We then analyzed FRAX(®) scores obtained with or without BMD on the day before the occurrence of an osteoporotic fracture in actual osteoporotic fracture patients. According to the National Osteoporosis Foundation high-risk criteria, we identified the percentage of high-risk patients before the actual fracture. Among 445 osteoporotic fracture patients, when FRAX(®)-BMD was used, 281 patients (63%) were identified as high-risk before an actual osteoporotic fracture, and when FRAX(®) without BMD was used, 258 patients (58%) were identified (p = 0.115). In the 84 osteopenia patients, 39 patients (46.4%) were identified as high-risk when FRAX(®) without BMD was used, and 19 patients (22.6%) were identified when FRAX(®)-BMD was used (p = 0.001). The use of BMD in FRAX(®) does not seem to increase the clinical effectiveness of predicting osteoporotic fracture in osteopenia patients.

Screening for osteoporosis in Chinese post-menopausal women: a health economic modelling study

Screening and appropriate treatment for osteoporosis has been proven to be cost-effective in many populations; however, it is not clear in the Chinese population. Simulations using a validated health economics model suggest that screening for osteoporosis in Chinese women is cost-effective and may even be cost-saving in Chinese post-menopausal women.

INTRODUCTION

This study aimed at determining the cost-effectiveness of osteoporosis screening strategies in post-menopausal Chinese women.

METHODS

A validated state-transition microsimulation model with a lifetime horizon was used to evaluate the cost-effectiveness of different screening strategies with treatment of alendronate compared with current osteoporosis management in China. Osteoporosis screening strategies assessed were (1) universal screening with dual-energy X-ray absorptiometry (DXA) alone; (2) Osteoporosis Self-Assessment Tool for Asians (OSTA) + DXA; and (3) quantitative ultrasound (QUS) + DXA with rescreening at 2, 5 or 10-year intervals for patients screened negative by DXA. The study was performed from the Chinese healthcare payer's perspective. All model inputs were retrieved from publically available literature. Uncertainties were addressed by one-way and probabilistic sensitivity analysis.

RESULTS

Screening strategies all improved clinical outcomes at increased costs, and each were cost-effective compared with no screening in women aged 55 years given the Chinese willingness-to-pay threshold of USD 20,000 per quality-adjusted life year (QALY) gained. Pre-screening with QUS and subsequent DXA screening if the QUS T-score ≤ -0.5 with a 2-year rescreening interval was the most cost-effective strategy with the highest probability of being cost-effective across all non-dominated strategies. Screening strategies were cost-saving if screenings were initiated from age 65 years. One-way sensitivity analyses indicated that the results were robust.

CONCLUSIONS

Pre-screening with QUS with subsequent DXA screening if the QUS T-score ≤ -0.5 with a 2-year rescreening interval in the Chinese women starting at age 55 is the most cost-effective. In addition, screening and treatment strategies are cost-saving if the screening initiation age is greater than 65 years.

Correlation between osteoporotic fracture risk in Brazilian postmenopausal women calculated using the FRAX with and without the inclusion of bone densitometry data

The risks of fracture were calculated in 402 postmenopausal Brazilian women by FRAX with or without the inclusion of bone densitometry values. The correlation between the risk of major osteoporosis fracture or hip fracture calculated by FRAX with or without BMD was similar in this population, 0.76 and 0.64, respectively.

OBJECTIVE

The objective of this study is to evaluate the degree of agreement between the 10-year fracture risk in postmenopausal Brazilian women, calculated using the WHO Fracture Risk Assessment Tool (FRAX)-Brazil, with and without the inclusion of bone mineral density (BMD) values.

METHODS

A cross-sectional study was conducted with 402 postmenopausal women (≥40 years) who had undergone bone densitometry prior to initiating any pharmacological treatment for osteopenia or osteoporosis. The risks of a major osteoporosis fracture or hip fracture were calculated according to FRAX-Brazil either using clinical risk factors alone or with the inclusion of BMD value. The tests used were intraclass correlation coefficient, Mann-Whitney test, and univariate linear regression analysis.

RESULTS

When the patients were classified according to the cutoff point defined as determining a high risk of a major osteoporosis fracture (≥20 %), 0.75 % were defined as high risk when BMD values were included and 1 % when they were not. With respect to the hip, 5.22 % were defined as having a high risk of fracture (≥3 %) when BMD values were included and 11.44 % when they were not. Intraclass correlation coefficient between the FRAX-Brazil assessed risk with and without the inclusion of BMD values was 0.76 (95 % CI 0.716-0.799) for a major osteoporosis fracture and 0.64 (95 %CI 0.583-0.698) for a hip fracture.

CONCLUSION

The correlation found for the FRAX-Brazil score obtained with and without the inclusion of BMD values was good for the risk of a major osteoporosis fracture and moderate for the risk of a hip fracture. The fracture risk calculated was similar in this population irrespective of whether or not BMD values were included in the algorithm.

A non-invasive prevention program model for the assessment of osteoporosis in the early postmenopausal period: a pilot study on FRAX(®) and QUS tools advantages

OBJECTIVE

The study analyses the performances of FRAX algorithm and quantitative ultrasound (QUS) tool in relationship to the dual-energy X-ray absorptiometry (DXA) categorization to identify patients at risk of osteoporosis during menopause and to reach new thresholds for recommending the first DXA examination.

DESIGN

Retrospective cohort study.

PATIENTS AND MEASUREMENTS

Two hundred eighty-two postmenopausal patients filled out a questionnaire which determined their FRAX index and performed a bone evaluation by QUS of the calcaneus to determine their stiffness index (SI). Thereafter, they underwent assessments by the gold-standard DXA bone examination.

RESULTS

Statistically significant correlations were observed between FRAX (calculated without BMD) and both QUS and DXA diagnosis. FRAX mean indices of risk corresponding to the diagnosis of osteoporosis by QUS and DXA were similar. Receiver operating characteristic (ROC) curve analysis showed that both FRAX and QUS tests were sufficiently accurate in predicting the alteration of bone mineral composition. The ROC curves of QUS allowed us to identify, in our population, SI cutoff for normal patients (SI > 90.5) and for patients having osteoporosis (SI < 78.5). We selected a cutoff screening value from FRAX ROC curve for major clinical fracture (2.94). The following diagnostic algorithm demonstrated that the use of FRAX test alone has a sensitivity of 85.3 % and a specificity of 33.8 % while the use of QUS exam alone showed a sensitivity of 81.3 % and a specificity of 45.1 %. When considering the capacity of QUS exam in combination with FRAX test, the final algorithm showed a sensitivity of 69.4 % and a specificity of 57.7 %.

CONCLUSIONS

The use of QUS test with adjusted cutoffs offers a similar performance to the FRAX test alone in terms of sensitivity. The combined use of the tests reduces the sensibility but increases the specificity and adds clinical information related to the bone status of the patient.

Screening for and treatment of osteoporosis: construction and validation of a state-transition microsimulation cost-effectiveness model

This study aimed to document and validate a new cost-effectiveness model of osteoporosis screening and treatment strategies. The state-transition microsimulation model demonstrates strong internal and external validity. It is an important tool for researchers and policy makers to test the cost-effectiveness of osteoporosis screening and treatment strategies.

INTRODUCTION

The objective of this study was to document and validate a new cost-effectiveness model of screening for and treatment of osteoporosis.

METHODS

A state-transition microsimulation model using a lifetime horizon was constructed with seven Markov states (no history of fractures, hip fracture, vertebral fracture, wrist fracture, other fracture, postfracture state, and death) describing the most important clinical outcomes of osteoporotic fractures. Tracker variables were used to record patients' history, such as fracture events, duration of treatment, and time since last screening. The model was validated for Chinese postmenopausal women receiving screening and treatment versus no screening. Goodness-of-fit analyses were performed for internal and external validation. External validity was tested by comparing life expectancy, osteoporosis prevalence rate, and lifetime and 10-year fracture risks with published data not used in the model.

RESULTS

The model represents major clinical facets of osteoporosis-related conditions. Age-specific hip, vertebral, and wrist fracture incidence rates were accurately reproduced (the regression line slope was 0.996, R(2) = 0.99). The changes in costs, effectiveness, and cost-effectiveness were consistent with changes in both one-way and probabilistic sensitivity analysis. The model predicted life expectancy and 10-year any major osteoporotic fracture risk at the age of 65 of 19.01 years and 13.7%, respectively. The lifetime hip, clinical vertebral, and wrist fracture risks at age 50 were 7.9, 29.8, and 18.7% respectively, all consistent with reported data.

CONCLUSIONS

Our model demonstrated good internal and external validity, ensuring it can be confidently applied in economic evaluations of osteoporosis screening and treatment strategies.