The impact of a FRAX-based intervention threshold in Turkey: the FRAX-TURK study

The association of FRAX with predictors of falls in the assessment of postmenopausal osteoporosis in Turkey: the fracture study of Turkey (FRACT study)

Although FRAX is used for fracture risk evaluation, this tool does not include balance and fall risk. The association between the predictors of falls and high FRAX scores we found in this study suggests that risk indicators for falls may add substantial value to FRAX by improving fracture risk prediction.

PURPOSE

This observational, descriptive, and cross-sectional study aimed to assess the fall risk predictors and explore their association with FRAX in Turkish patients with postmenopausal osteoporosis.

METHODS

Two hundred and nine (209) women with postmenopausal osteoporosis referred to the Fracture Liaison Service (FLS) at Istanbul University-Cerrahpaşa were enrolled in the FRACT study (The Fracture Study of Turkey). Clinical risk factors were assessed using the FRAX tool. Tandem stance, Tandem walking, Timed up and go (TUG), and Chair stand tests were performed to assess balance and fall risk.

RESULTS

Among patients with a mean age of 67.6 (± 9.7) years, 66 patients (31.6%) had osteoporosis without fractures and 143 patients (68.4%) had fragility fractures. The proportion of patients with poor performance of fall prediction tests was significantly higher in patients with a fragility fracture than those with osteoporosis alone. There was an inverse relationship between dynamic balance tests and the reported number of prior falls in the past year. FRAX score was higher in patients with impaired Tandem stance, Tandem walking, and TUG tests (p = 0.008, p = 0.035, p = 0.001, respectively).

CONCLUSION

Assessment of fall risk predictors should be one of the major pillars in the physical evaluation of osteoporotic patients in the FLS setting. FRAX is a useful tool to determine the fracture risk of patients with both static and dynamic balance impairments. Combining balance assessment with FRAX may be an important step to optimize osteoporosis risk assessment.

"A natural consequence of aging in women?": a mixed-method exploration on osteoporosis self-efficacy in Turkey

The perception of osteoporosis self-efficacy is an important factor in coping with osteoporosis. Being older, not exercising regularly, inadequate consumption of milk and dairy products, inadequate exposure to sunlight, knowledge gaps, negative disease perceptions, and barriers to osteoporosis treatment adherence negatively affect osteoporosis self-efficacy levels of women (p < 0.001).

PURPOSE

The purpose of this study to determine the osteoporosis-related self-efficacy levels of women with osteoporosis and investigate the relationship between the characteristics of these women and their osteoporosis self-efficacy.

METHODS

The study was conducted in Siirt province in the Southeastern Anatolia Region of Turkey. A mixed-method approach was selected. Data were collected with 280 surveys and 30 participants' interviews.

RESULTS

The mean total OSES score of the participants was 649.82 ± 221.09. Aging, not exercising regularly, inadequate consumption of milk and dairy products, and inadequate exposure to sunlight were significant predictors of low osteoporosis self-efficacy (p < 0.001), explaining 23.4% of the total variance. Knowledge gaps, disease perceptions, facilitators of treatment adherence, and barriers to treatment adherence affected the osteoporosis self-efficacy of the participants.

CONCLUSION

The osteoporosis-related self-efficacy levels of the participants of this study were low. The results suggest that a strategy to organize routine health education programs should be established in order to create a higher perception of osteoporosis self-efficacy in women with osteoporosis and to reduce knowledge gaps and barriers.

The effect of health belief model-based short interviews in women in the postmenopausal period on the prevention of osteoporosis: A randomized controlled trial

AIM

This study was conducted to investigate the effect of health belief model-based short interviews on preventive behaviours for osteoporosis in postmenopausal women.

DESIGN AND METHODS

A randomized pretest, posttest and follow-up design was used. The study was conducted between June 2016 and June 2017 with an intervention (n = 41) and a control group (n = 41). The intervention group applied the Short Interviews Model for 12 weeks as a short interview programme that was created based on the health belief model. The study data were collected by the researcher using a descriptive information form, the Osteoporosis Health Belief Scale, the Osteoporosis Self-efficacy Scale and the Osteoporosis Knowledge Test.

RESULTS

In the posttest and follow-up measurements, the mean scores of the intervention group on the total Osteoporosis Health Belief Scale and its self-efficacy and exercise sub-dimensions and the total Osteoporosis Knowledge Test and its sub-dimensions were significantly higher than those of the control group.

CONCLUSION

The short interviews held in this study provided evidence to guide women and nurses in the prevention of osteoporosis in postmenopausal women. It is recommended that the prevention of osteoporosis should be integrated into women's health programmes at the primary health-care level.

Low bone density, vertebral fracture and FRAX score in kidney transplant recipients: A cross-sectional cohort study

Background

Kidney transplantation (KT) recipients are at increased risk of low bone density (LBD) and fractures. In this retrospective study, we investigated bone mineral density (BMD), vertebral fractures, calculated risk for major osteoporotic fractures (MOF), and hip fractures in the KT recipients.

Patients-method

Patients who completed at least one year after KT were included in the analysis. Demographic, clinical, and laboratory data were recorded. Measurements of BMD were performed by dual-energy X-ray absorptiometry. Vertebral fractures were assessed using semi-quantitative criteria with conventional radiography. The ten-year risk for MOF and hip fracture were calculated using the FRAX@ tool with BMD.

Results

One hundred fifty-three KT recipients were included in the study. The population included 77 women. The mean age at evaluation was 46,5±11,9 years. Seventy-eight (50.9%) patients had normal femoral neck BMD while osteoporosis and osteopenia at the femoral neck were present in 12 (7.8%) and 63 (41.1%) of the patients, respectively. Age at evaluation was the risk factor for LBD (OR 1.057; 95% CI 1.024–1.091; p = 0.001). In female KT recipients, LBD was principally affected by menopausal status whereas in males, mammalian target of rapamycin (mTOR) inhibitor use and lower BMI levels were the risk factors. The prevalent vertebral fracture was found in 43.4% of patients. In multivariate analysis, only steroid use (OR 0.121; 95% CI 0.015–0.988; p = 0.049) was found to be associated with prevalent fracture. Among all KT recipients, 1.9% had a high MOF probability (≥20% risk of fracture), and 23.5% had high hip fracture probability (≥3% risk of hip fracture) according to FRAX.

Conclusion

Exploring the prevalence of LBD and vertebral fracture and the risk factors would help clinicians to modify long-term follow-up strategies. Furthermore, the high hip fracture risk probability in our cohort suggested that there is a need for longitudinal studies to confirm the validity of the FRAX tool in the transplant population.

Evaluation of pain, quality of life, and patient satisfaction in parenterally treated patients with postmenopausal osteoporosis

Objectives

This study aims to evaluate pain, quality of life, and patient satisfaction in parenterally treated patients with postmenopausal osteoporosis (OP).

Patients and methods

Between May 2016 and January 2018, a total of 138 patients (mean age 63.78 years; range, 50 to 70 years) with postmenopausal OP were retrospectively analyzed. All patients were previously treated with denosumab (DEN) and parenteral forms of bisphosphonates such as zoledronic acid (ZOL) and ibandronate (IBN). The pain severity was evaluated using the Visual Analog Scale (VAS) and Brief Pain Inventory-Short Form (BPI-SF). The quality of life was evaluated using the Quality of Life Questionnaire of the European Foundation for Osteoporosis (Qualeffo-41). For the evaluation of patient satisfaction, a three-item questionnaire including satisfaction with the medication, route, and frequency of administration was applied.

Results

Of the patients, 50 received DEN, 48 received ZOL, and 40 received IBN treatment. There was no significant difference in any of the pain parameters. All domains of the Qualeffo-41 were similar among the three groups. The patients in the DEN group were more satisfied with their medication (DEN: 88%, ZOL: 43.75%, and IBN: 52.5%), its administration route (DEN: 84%, ZOL: 43.8%, and IBN: 57.5%), and the frequency of its administration (DEN: 84%, ZOL: 56.25%, and IBN: 52.5%) (p=0.0001).

Conclusion

Neither of the medication showed a superior effect on quality of life. However, patients were more satisfied with medications used in a six-month interval and applied subcutaneously. Of these three treatment options, DEN seems to be a step ahead in terms of patient satisfaction.

Updated approach for the management of osteoporosis in Turkey: a consensus report

As a result of the current demographics, increased projections of osteoporosis (OP) and prevalence of the disease in Turkey, a panel of multidisciplinary experts developed a thorough review to assist clinicians in identifying OP and associated fracture risk patients, diagnosing the disease with the appropriate available diagnostic methods, classifying the disease, and initiating appropriate treatment. The panel expects to increase the awareness of this prevalent disease, decrease consequences of OP with corresponding cost savings and, ultimately, decrease the overall burden of OP and related fractures in Turkey.

BACKGROUND

OP is not officially accepted as a chronic disease in Turkey despite the high prevalence and predicted increase in the following years. However, there are areas where the country is performing well, such as having a country-specific fracture risk assessment model, DXA access, and the uptake of FRAX. Additional efforts are required to decrease the existing treatment gap estimating 75-90% of patients do not receive pharmacological intervention for secondary prevention, and the diagnosis rate is around 25%.

METHODS

A selected panel of Turkish experts in fields related to osteoporosis was provided with a series of relevant questions to address prior to the multi-day conference. Within this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion until a consensus was achieved. Represented in the panel were a number of societies including The Turkish Osteoporosis Society, The Society of Endocrinology and Metabolism of Turkey (SEMT), and The Turkish Society of Physical Medicine and Rehabilitation.

RESULTS

Standardized general guidelines to identify OP and related fractures and at-risk population in Turkey, which will enable clinicians to accurately and effectively diagnose the disease, treat the appropriate patients with available pharmacological and non-pharmacological treatments and decrease the burden of the disease.

CONCLUSIONS

This manuscript provides a review of the current state of OP and related fractures in Turkey. Moreover, this manuscript reviews current international guidelines and national studies and proposes a number of helpful country-specific classifications that can be used by healthcare providers caring for the at-risk population. Additionally, the panel proposes practical recommendations that should be implemented nationally in order to decrease the burden of OP and related fractures and effectively preventing the burden in future generations.

The burden of osteoporosis in Turkey: a scorecard and economic model

The burden of osteoporosis in Turkey is not well characterized. Our results indicate that osteoporosis is undertreated in Turkey with 1.35 million fractures predicted to occur from 2019 to 2023 at an associated cost of 2.42 billion USD. Interventions are needed to close the treatment gap and minimize the economic burden.

PURPOSE

The number of osteoporotic fractures is expected to increase as populations age, posing a major risk to health systems and patients. We created a scorecard summarizing the burden of disease, policy framework, service provision, and service uptake for osteoporosis in Turkey and estimated the economic burden of osteoporotic fractures in Turkey.

METHODS

A systematic review of osteoporosis in Turkey was performed. Gaps in the literature were supplemented by surveys with osteoporosis experts. The findings were used to populate a scorecard and burden of illness model focused on adults aged 50 to 89 years in Turkey. The scorecard provided a visual representation of osteoporosis burden and management using a traffic light color coding system. The model quantified osteoporosis-related fracture costs (2019 USD) including hospitalizations, dual-energy x-ray absorptiometry testing, hip fracture surgery, prescription drugs, and patient productivity losses.

RESULTS

The scorecard showed that osteoporosis is undertreated in Turkey. Despite timely access to diagnosis, > 75% of high-risk patients fail to initiate on appropriate therapies. In 2019, the economic model predicted that 255,183 osteoporosis-related fractures would occur in Turkey with an associated annual cost of approximately 455 million USD and an average burden per 1000 at risk of 23,987 USD. The cumulative 5-year cost of 1,354,817 fractures was 2.42 billion USD.

CONCLUSIONS

Approximately 1.35 million fragility fractures are predicted to occur in Turkey during the next 5 years with costs of 2.42 billion USD. Closing the treatment gap will be imperative for preventing these fractures and minimizing the burden of osteoporosis in Turkey.

Evaluation of the effects of β1-selective beta-blockers on bone mineral density and fracture risk in postmenopausal women

Background/aim

β1-selective beta-blockers (BBs) are sympatholytic agents, and discerning their effects on bone health would be of great importance. This study aimed to investigate the influence of β1-selective BBs on bone mineral density (BMD) and fracture risk.

Materials and methods

This study included postmenopausal women who used β1-selective BBs (BB group) and control group. Sociodemographic characteristics, BMD and previous fragility fractures were recorded. Additionally, the 10-year probability of a major osteoporotic and hip fracture was calculated using the fracture risk assessment tool (FRAX).

Results

A total of 60 participants were included in the study. L1-4 and L2-4 BMD values were significantly higher in BB group than control group (P = 0.015 and P = 0.025, respectively). Moreover, T-scores of lumbar and femur total were significantly higher in the BB group. Two patients in BB and 6 patients in control group had previous fragility fracture. No statistically significant intergroup difference was noted regarding FRAX.

Conclusion

Based on our results, β1-selective BB usage was associated with higher BMD at the lumbar region in postmenopausal women.

Epidemiology of hip fractures in Bulgaria: development of a country-specific FRAX model

A retrospective population-based survey was undertaken in a region of Bulgaria to determine the incidence of hip fracture. The estimated number of hip fractures nationwide for 2015 was 9322 and is predicted to increase to 11,398 in 2050. The hip fracture rates were used to create a FRAX model.

OBJECTIVE

To describe the epidemiology of hip fractures in Bulgaria, which was then used to develop the country-specific fracture prediction FRAX® tool.

METHODS

We carried out a retrospective population-based survey in Stara Zagora, Bulgaria, representing approximately 4.6% of the country's population. We identified hip fractures occurring in 2015, 2016 and 2017 from hospital registers and primary care sources held by the regional health insurance agency. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Bulgaria. Fracture probabilities were compared with those from neighbouring countries having FRAX models.

RESULTS

The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 9322 and is predicted to increase to 11,398 in 2050. FRAX-based probabilities were higher in Bulgaria than those in Serbia or Romania, lower than those in Turkey and similar to those in Greece.

CONCLUSION

The FRAX model should enhance accuracy of determining fracture probability among the Bulgarian population and help guide decisions about treatment.

Hypovitaminosis D, Low Bone Mineral Density, and Diabetes Mellitus as Probable Risk Factors for Benign Paroxysmal Positional Vertigo in the Elderly

Introduction  Studies have found that elderly patients with benign paroxysmal positional vertigo (BPPV) may present low levels of vitamin D (25 (OH) D), changes in bone mineral density, and diabetes mellitus (DM).

Objective : To investigate the possible association between BPPV, bone mineral density, hypovitaminosis D, 25 (OH) D and DM.

Methods  The sample consisted of 109 elderly subjects. The BPPV was verified by a standardized questionnaire and the Dix-Hallpike maneuver. Blood samples were collected for the investigation of 25 (OH) D serum levels. The bone mineral density was evaluated by means of a densitometer. Diabetes mellitus verification was performed using a self-reported questionnaire.

Results  Of the 109 participants, 17 had BPPV. There was a statistically significant difference between BPPV and gender ( p  = 0.027, phi = 0.222), with female representing 88.2% of those with BPPV. In the group with BPPV, there was a statistically significant difference for the amount of vitamin D found ( p  = 0.001) and for age ( p  = 0.001). In the elderly group with DM and BPPV, a difference was found for the standard deviation of the femur ( p  = 0.022) with posthoc Dunn, identifying the difference between diabetics with and without BPPV ( p  = 0.047).

Conclusion  Although no association was found (25 (OH) D levels) with BPPV in the general population of this study, it was observed that there was an association with bone mineral density in the elderly group with DM and BPPV, and, in the group with BPPV, there was an association between the amount of vitamin D and age.

The role of bone mineral density in therapeutic decision-making using the Fracture Risk Assessment Tool (FRAX): a sub-study of the Taiwan OsteoPorosis Survey (TOPS)

Fracture Risk Assessment Tool (FRAX)-based intervention threshold (IT) is widely applied for treatment decision-making; however, an IT based on FRAX without the measurement of bone mass density (BMD) has not been validated. The study demonstrated that estimates of fracture risk by FRAX without BMD were higher than those by FRAX with BMD in women with old age.

INTRODUCTION

BMD is an integral component for bone strength assessment, but age-specific impacts of BMD on fracture risk assessment and therapeutic decision-making remained unclear. We aimed to investigate whether using BMD measurement changed the interpretation of the FRAX-based fracture probability assessment and treatment decision.

METHODOLOGY

The database was provided by the Taiwanese Osteoporosis Association (TOA) which conducted a nationwide survey of BMD. We calculated the 10-year major and hip fracture probabilities using the FRAX for each participant, either with (FRAX + BMD) or without BMD (FRAX - BMD). Age-specific individual intervention thresholds (IITs) were established using the FRAX-based fracture risk, equivalent to a woman with a prior fracture. Participants whose FRAX scores of major fracture were greater than or equal to their IITs were deemed suitable for therapeutic intervention.

RESULTS

A total of 14,007 postmenopausal women were enrolled. Compared with FRAX + BMD, FRAX - BMD predicted lower FRAX scores in major and hip fractures in subjects aged 40-60 years; however, FRAX - BMD estimated higher risks for those aged 61-90 years. The therapeutic decision using FRAX - BMD was concordant to that using FRAX + BMD in 90.5% of the subjects, especially in the younger age group (40-70 years). FRAX - BMD identified more treatment candidates (7.7-16.4%) among those aged 71-90 years.

CONCLUSIONS

The FRAX scores are influenced by age, irrespective of the consideration of BMD. FRAX - BMD is able to identify more subjects for therapeutic intervention in the elderly population. We should reconsider the role of BMD at different ages for therapeutic decision-making.

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.

A brief history of FRAX

This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008.

INTRODUCTION

Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments.

METHODS

The method used in this paper is literature review.

RESULTS

FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population.

CONCLUSION

FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.

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.

Agreement between the Turkey Guidelines and the Fracture Risk Assessment Tool®-based Intervention Threshold

BACKGROUND

The aim of this study was to evaluate the agreement between the fracture-risk assessment tool (FRAX®)-based intervention strategy in Turkey and the recommendations published in the Healthcare Practices Statement (HPS).

METHODS

This descriptive cross-sectional study included individuals aged 40 to 90 years who were previously diagnosed as having osteoporosis but had not received any treatment. The intervention thresholds recommended by the National Osteoporosis Foundation for treatment were used. The criteria necessary for the start of administration of pharmacological agents in osteoporosis treatment were evaluated on the basis of the HPS guidelines.

RESULTS

Of the 1,255 patients evaluated, 161 (12.8%) were male and 1,094 (87.2%) were female. In the evaluation, according to HPS, treatment was recommended for 783 patients (62.4%; HPS+) and not recommended for 472 (37.6%; HPS-). Of the 783 HPS+ patients, 391 (49.9%) were FRAX+, and of the 472 HPS- patients, 449 (95.1%) were FRAX-. A statistically significant difference was observed between the treatment recommendations of HPS and FRAX® (P<0.001). In the age group of 75 to 90 years, excellent agreement was found between the two strategies (Gwet's agreement coefficient 1=0.94). As age increased, the agreement between the two treatment strategies also increased.

CONCLUSIONS

The FRAX® model has different treatment recommendation rates from the HPS. The agreement between the two is at a minimal level. However, as age increased, so did the agreement between the FRAX® and the HPS treatment recommendations. In the recommendation to start pharmacological treatment primarily based on age, non-medical interventions that preserve bone density should be evaluated.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

Evaluation of three risk assessment tools in discriminating fracture status among Chinese patients undergoing hemodialysis

We evaluated three risk assessment tools, including bone mineral density (BMD) measurement by dual energy X-ray absorptiometry (DXA), osteoporosis self-assessment tool for Asians (OSTA), and fracture risk assessment tool (FRAX), for the prediction of fracture status among Chinese patients undergoing hemodialysis. All of the three assessment tools have a reasonable capability in discriminating fractures.

INTRODUCTION

Fractures are common in hemodialysis patients however insufficiently assessed. Our study aimed to assess the ability of three widely used tools [BMD, OSTA, and FRAX] to discriminate fracture status in patients with renal failure undergoing hemodialysis.

METHODS

We enrolled 136 hemodialysis patients in a tertiary teaching hospital setting. BMD was measured using DXA at the lumbar spine and the hip region. OSTA was calculated from weight and age. FRAX score was calculated based upon online availability. Discriminative abilities of BMD, OSTA, and FRAX in fracture status were analyzed by receiver operator characteristic (ROC) curves.

RESULTS

There were total 16 fractures (11.76 %) identified in 136 hemodialysis patients. BMD at any site (lumbar spine L1-L4, femoral neck, and total hip) was independently associated with fracture. Areas under the curves (AUC) of BMD (lumbar spine L1-L4, femoral neck, total hip), OSTA, FRAX1 (non-BMD model), and FRAX2 (BMD model) were 0.669 (95 % CI 0.583, 0.747), 0.708 ( 95 % CI 0.624, 0.783), 0.736 (95 % CI 0.654, 0.808), 0.686 (95 % CI 0.601, 0.763), 0.715 (95 % CI 0.631, 0.789), and 0.697 (95 % CI 0.613, 0.773), respectively. The differences of their performance were not significant.

CONCLUSIONS

All of the three risk assessment tools had the ability to discriminate fracture status among hemodialysis patients; FRAX BMD model did not improve the discriminative ability of BMD or FRAX non-BMD model alone.

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.

Establishing and evaluating FRAX® probability thresholds in Taiwan

BACKGROUND/PURPOSE

The Taiwanese FRAX^® calculator was launched in 2010. However, cost-effectiveness thresholds for the prescription of antiosteoporosis medications were not established. This study aims to establish and evaluate FRAX^®-based probability thresholds in Taiwan.

METHODS

Using previous data from Taiwan and literature, we determined cost-effectiveness thresholds for prevention of osteoporotic fractures by alendronate with a Markov model, as well as using two other translational approaches. Sensitivity analysis was applied using different alendronate prices. A clinical sample was used to test these Taiwan-specific thresholds by determining the percentages of high-risk patients who would be qualified for current National Health Insurance reimbursement.

RESULTS

With the Markov model, the intervention threshold for hip fracture was 7% for women and 6% for men; for major osteoporotic fracture, it was 15% for women and 12.5% for men. Both translational approach models were cost effective only for certain age groups. However, if branded alendronate was reimbursed at 60% of the current price, they became cost effective in almost all age groups. This clinical screening study showed that the National Health Insurance Administration model identified the highest proportion (44%) of patients qualified for National Health Insurance reimbursements, followed by the Markov model (30%), and the United States model (22%).

CONCLUSION

Three FRAX^®-based models of alendronate use were established in Taiwan to help optimize treatment strategies. The government is encouraged to incorporate FRAX^®-based approaches into the reimbursement policy for antiosteoporosis medicines.

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.

FRAX-based assessment and intervention thresholds--an exploration of thresholds in women aged 50 years and older in the UK

Under current guidelines, based on prior fracture probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold (a fixed threshold from the age of 70 years) reduces this disparity, increases treatment access and decreases the need for bone densitometry.

INTRODUCTION

Several international guidelines set age-specific intervention thresholds at the 10-year probability of fracture equivalent to a woman of average BMI with a prior fracture. At older ages (≥70 years), women with prior fracture selected for treatment are at lower average absolute risk than those selected for treatment in the absence of prior fracture, prompting consideration of alternative thresholds in this age group.

METHODS

Using a simulated population of 50,633 women aged 50-90 years in the UK, with a distribution of risk factors similar to that in the European FRAX derivation cohorts and a UK-matched age distribution, the current NOGG intervention and assessment thresholds were compared to one where the thresholds remained constant from 70 years upwards.

RESULTS

Under current thresholds, 45.1% of women aged ≥70 years would be eligible for therapy, comprising 37.5% with prior fracture, 2.2% with high risk but no prior fracture and 5.4% selected for treatment after bone mineral density (BMD) measurement. Mean hip fracture probability was 11.3, 23.3 and 17.6%, respectively, in these groups. Under the alternative thresholds, the overall proportion of women treated increased from 45.1 to 52.9%, with 8.4% at high risk but no prior fracture and 7.0% selected for treatment after BMD measurement. In the latter group, the mean probability of hip fracture was identical to that observed in women with prior fracture (11.3%). The alternative threshold also reduced the need for BMD measurement, particularly at older ages (>80 years).

CONCLUSIONS

The alternative thresholds equilibrate fracture risk, particularly hip fracture risk, in those with or without prior fracture selected for treatment and reduce BMD usage at older ages.

Agreement between FRAX scores calculated with and without bone mineral density in women with osteopenia in Turkey

This study aimed to analyze the agreement between FRAX scores calculated with and without femoral neck (FN) bone mineral density (BMD) and to investigate the resultant treatment recommendations in women with osteopenia. A cross-sectional review of postmenopausal women who were referred for DXA evaluation was conducted. One hundred twenty-nine postmenopausal women aged 40 years and older with osteopenia [FN T-score between -1 and (-2.5)] were recruited for the study. Absolute agreement between FRAX scores calculated with and without BMD was analyzed by intraclass correlation analysis (ICC). Thresholds recommended by National Osteoporosis Foundation were used for treatment recommendations. Correlation between demographic factors and the difference in BMD+ and BMD- FRAX scores was analyzed by Spearman correlation test. Agreement levels and treatment recommendations were also analyzed in 112/129 patients without previous fracture. Agreement between BMD+ and BMD- MO and hip FRAX scores was good (ICC 0.867) and fair to good (ICC 0.641), respectively. In patients without previous fracture, agreement between MO and hip fracture probabilities was good (ICC = 0.838 and ICC = 0.778, respectively). Treatment recommendations with respect to treatment threshold of ≥3 for hip fracture probabilities were identical in 120/129 (93 %) cases. Difference between BMD+ and BMD- fracture probabilities was correlated with age and FN BMD. In most cases, FRAX without BMD provided the same treatment recommendations as FRAX with BMD in postmenopausal women with osteopenia. Exclusion of patients with previous fracture yielded better agreement levels.