1
|
Jain RK, Weiner M, Polley E, Iwamaye A, Huang E, Vokes T. Electronic Health Records (EHRs) Can Identify Patients at High Risk of Fracture but Require Substantial Race Adjustments to Currently Available Fracture Risk Calculators. J Gen Intern Med 2023; 38:3451-3459. [PMID: 37715097 PMCID: PMC10713897 DOI: 10.1007/s11606-023-08347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/21/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Osteoporotic fracture prediction calculators are poorly utilized in primary care, leading to underdiagnosis and undertreatment of those at risk for fracture. The use of these calculators could be improved if predictions were automated using the electronic health record (EHR). However, this approach is not well validated in multi-ethnic populations, and it is not clear if the adjustments for race or ethnicity made by calculators are appropriate. OBJECTIVE To investigate EHR-generated fracture predictions in a multi-ethnic population. DESIGN Retrospective cohort study using data from the EHR. SETTING An urban, academic medical center in Philadelphia, PA. PARTICIPANTS 12,758 White, 7,844 Black, and 3,587 Hispanic patients seeking routine care from 2010 to 2018 with mean 3.8 years follow-up. INTERVENTIONS None. MEASUREMENTS FRAX and QFracture, two of the most used fracture prediction tools, were studied. Risk for major osteoporotic fracture (MOF) and hip fracture were calculated using data from the EHR at baseline and compared to the number of fractures that occurred during follow-up. RESULTS MOF rates varied from 3.2 per 1000 patient-years in Black men to 7.6 in White women. FRAX and QFracture had similar discrimination for MOF prediction (area under the curve, AUC, 0.69 vs. 0.70, p=0.08) and for hip fracture prediction (AUC 0.77 vs 0.79, p=0.21) and were similar by race or ethnicity. FRAX had superior calibration than QFracture (calibration-in-the-large for FRAX 0.97 versus QFracture 2.02). The adjustment factors used in MOF prediction were generally accurate in Black women, but underestimated risk in Black men, Hispanic women, and Hispanic men. LIMITATIONS Single center design. CONCLUSIONS Fracture predictions using only EHR inputs can discriminate between high and low risk patients, even in Black and Hispanic patients, and could help primary care physicians identify patients who need screening or treatment. However, further refinements to the calculators may better adjust for race-ethnicity.
Collapse
Affiliation(s)
- Rajesh K Jain
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, The University of Chicago, 5841 South Maryland Ave, MC 1027, Chicago, IL, 60637, USA.
| | - Mark Weiner
- Weill Cornell Medicine, Clinical Population Health Sciences, New York, USA
| | - Eric Polley
- Department of Public Health Sciences, The University of Chicago, Chicago, USA
| | - Amy Iwamaye
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Elbert Huang
- Department of Medicine and Department of Public Health Sciences, The University of Chicago, Chicago, USA
| | - Tamara Vokes
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, The University of Chicago, 5841 South Maryland Ave, MC 1027, Chicago, IL, 60637, USA
| |
Collapse
|
2
|
Adami G, Biffi A, Porcu G, Ronco R, Alvaro R, Bogini R, Caputi AP, Cianferotti L, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Tarantino U, Brandi ML, Corrao G, Rossini M, Michieli R. A systematic review on the performance of fracture risk assessment tools: FRAX, DeFRA, FRA-HS. J Endocrinol Invest 2023; 46:2287-2297. [PMID: 37031450 PMCID: PMC10558377 DOI: 10.1007/s40618-023-02082-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/27/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Preventing fragility fractures by treating osteoporosis may reduce disability and mortality worldwide. Algorithms combining clinical risk factors with bone mineral density have been developed to better estimate fracture risk and possible treatment thresholds. This systematic review supported panel members of the Italian Fragility Fracture Guidelines in recommending the use of best-performant tool. The clinical performance of the three most used fracture risk assessment tools (DeFRA, FRAX, and FRA-HS) was assessed in at-risk patients. METHODS PubMed, Embase, and Cochrane Library were searched till December 2020 for studies investigating risk assessment tools for predicting major osteoporotic or hip fractures in patients with osteoporosis or fragility fractures. Sensitivity (Sn), specificity (Sp), and areas under the curve (AUCs) were evaluated for all tools at different thresholds. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2; certainty of evidence (CoE) was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Forty-three articles were considered (40, 1, and 2 for FRAX, FRA-HS, and DeFRA, respectively), with the CoE ranging from very low to high quality. A reduction of Sn and increase of Sp for major osteoporotic fractures were observed among women and the entire population with cut-off augmentation. No significant differences were found on comparing FRAX to DeFRA in women (AUC 59-88% vs. 74%) and diabetics (AUC 73% vs. 89%). FRAX demonstrated non-significantly better discriminatory power than FRA-HS among men. CONCLUSION The task force formulated appropriate recommendations on the use of any fracture risk assessment tools in patients with or at risk of fragility fractures, since no statistically significant differences emerged across different prediction tools.
Collapse
Affiliation(s)
- G Adami
- Rheumatology Unit, University of Verona, Verona, Italy
| | - A Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - G Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - R Ronco
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - R Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - R Bogini
- Local Health Unit (USL) Umbria, Perugia, Italy
| | - A P Caputi
- Department of Pharmacology, School of Medicine, University of Messina, Messina, Italy
| | - L Cianferotti
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - B Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - D Gatti
- Rheumatology Unit, University of Verona, Verona, Italy.
| | - S Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - G Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - S Leone
- AMICI Onlus, Associazione Nazionale per le Malattie Infiammatorie Croniche dell'Intestino, Milan, Italy
| | - S Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - T Nicoletti
- Coordinamento Nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, CnAMC, Rome, Italy
| | - M Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - A Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - E Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - U Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy
- Department of Orthopedics and Traumatology, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - M L Brandi
- Italian Bone Disease Research Foundation (FIRMO), Florence, Italy
| | - G Corrao
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - M Rossini
- Rheumatology Unit, University of Verona, Verona, Italy
| | - R Michieli
- Italian Society of General Medicine and Primary Care (SIMG), Florence, Italy
| |
Collapse
|
3
|
Gates M, Pillay J, Nuspl M, Wingert A, Vandermeer B, Hartling L. Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools. Syst Rev 2023; 12:51. [PMID: 36945065 PMCID: PMC10029308 DOI: 10.1186/s13643-023-02181-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/02/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care. METHODS For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach. RESULTS We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I2 = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I2 = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I2 = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I2 = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated. CONCLUSION An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragility fracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.
Collapse
Affiliation(s)
- Michelle Gates
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Jennifer Pillay
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada.
| | - Megan Nuspl
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Aireen Wingert
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Ben Vandermeer
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| |
Collapse
|
4
|
Corrao G, Biffi A, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Cianferotti L, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML. Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021. Front Endocrinol (Lausanne) 2023; 14:1137671. [PMID: 37143730 PMCID: PMC10151776 DOI: 10.3389/fendo.2023.1137671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field. Purpose This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline. Methods The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations. Results Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively. Conclusions The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.
Collapse
Affiliation(s)
- Giovanni Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Raffaella Ronco
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Luisella Cianferotti
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Davide Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Salvatore Leone
- AMICI Onlus, Associazione Nazionale per le Malattie Infiammatorie Croniche dell’Intestino, Milan, Italy
| | - Raffaella Michieli
- Italian Society of General Medicine and Primary Care Società Italiana di Medicina Generale e delle cure primarie (SIMG), Florence, Italy
| | - Silvia Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - Tiziana Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | | | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | - Maria Luisa Brandi
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
| |
Collapse
|
5
|
Tebé C, Pallarès N, Reyes C, Carbonell-Abella C, Montero-Corominas D, Martín-Merino E, Nogués X, Diez-Perez A, Prieto-Alhambra D, Martínez-Laguna D. Development and external validation of a 1- and 5-year fracture prediction tool based on electronic medical records data: The EPIC risk algorithm. Bone 2022; 162:116469. [PMID: 35691583 DOI: 10.1016/j.bone.2022.116469] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We aimed to develop and validate a fracture risk algorithm for the automatic identification of subjects at high risk of imminent and long-term fracture risk. RESEARCH, DESIGN, AND METHODS A cohort of subjects aged 50-85, between 2007 and 2017, was extracted from the Catalan information system for the development of research in primary care database (SIDIAP). Participants were followed until the earliest of death, transfer out, fracture, or 12/31/2017. Potential risk factors were obtained based on the existing literature. Cox regression was used to model 1 and 5-year risk of hip and major fracture. The original cohort was randomly split in 80:20 for development and internal validation purposes respectively. External validation was explored in a cohort extracted from the Spanish database for pharmaco-epidemiological research in primary care. RESULTS A total of 1.76 million people were included from SIDIAP (50.7 % women with mean age of 65.4 years). Hip and major fracture incidence rates were 3.57 [95%CI 3.53 to 3.60] and 11.61 [95%CI 11.54 to 11.68] per 1000 person-years, respectively. The derived model included 19 risk factors. Internal validity showed good results on calibration and discrimination. The 1-year C-statistic for hip and major fracture were 0.851 (95%CI 0.853 to 0.864), and 0.717 (95%CI 0.742 to 0.749) respectively. The 5-year C-statistic for hip and major fracture were 0.849 (95%CI 0.847 to 0.852) and 0.724 (95%CI 0.721 to 0.727) respectively. External validation showed good performance for hip and major fracture risk prediction. CONCLUSIONS We have developed and validated a clinical prediction tool for 1- and 5-year hip and major osteoporotic fracture risks using electronic primary care data. The proposed algorithm can be automatically estimated at the population level using the available primary care records. Future work is needed on the cost-effectiveness of its use for population-based screening and targeted prevention of osteoporotic fractures.
Collapse
Affiliation(s)
- Cristian Tebé
- Biostatistics Unit, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Spain; Department of Clinical Sciences, Universitat de Barcelona
| | - Natalia Pallarès
- Biostatistics Unit, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Spain; Department of Clinical Sciences, Universitat de Barcelona
| | - Carlen Reyes
- IDIAP Jordi Gol Primary Care Research Institute; Ambit Barcelona, Primary Care Department, Institut Catala de la Salut; GREMPAL Research Group
| | | | - Dolores Montero-Corominas
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency of Medicines and Medical Devices (AEMPS)
| | - Elisa Martín-Merino
- Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency of Medicines and Medical Devices (AEMPS)
| | - Xavier Nogués
- GREMPAL Research Group; Musculoskeletal Research Unit, IMIM-Hospital del Mar, Barcelona, Spain; CIBER of Healthy Ageing and Frailty Research (CIBERFes), Instituto de Salud Carlos III
| | - Adolfo Diez-Perez
- GREMPAL Research Group; Musculoskeletal Research Unit, IMIM-Hospital del Mar, Barcelona, Spain; CIBER of Healthy Ageing and Frailty Research (CIBERFes), Instituto de Salud Carlos III
| | - Daniel Prieto-Alhambra
- GREMPAL Research Group; CIBER of Healthy Ageing and Frailty Research (CIBERFes), Instituto de Salud Carlos III; Centre for Statistics in Medicine (CSM), Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford.
| | - Daniel Martínez-Laguna
- IDIAP Jordi Gol Primary Care Research Institute; Ambit Barcelona, Primary Care Department, Institut Catala de la Salut; GREMPAL Research Group; CIBER of Healthy Ageing and Frailty Research (CIBERFes), Instituto de Salud Carlos III
| |
Collapse
|
6
|
García-Sempere A, Hurtado I, Peiró S, Sánchez-Sáez F, Santaana Y, Rodríguez-Bernal C, Sanfélix-Gimeno G, Sanfélix-Genovés J. Predictive Performance of the FRAX Tool Calibrated for Spain vs. an Age and Sex Model: Prospective Cohort Study with 9082 Women and Men Followed for up to 8 Years. J Clin Med 2022; 11:jcm11092409. [PMID: 35566539 PMCID: PMC9101808 DOI: 10.3390/jcm11092409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
In Spain, the Fracture Risk Assessment Tool (FRAX) was adapted using studies with a small number of patients, and there are only a few external validation studies that present limitations. In this prospective cohort study, we compared the performance of FRAX and a simple age and sex model. We used data from the ESOSVAL cohort, a cohort composed of a Mediterranean population of 11,035 women and men aged 50 years and over, followed for up to 8 years, to compare the discrimination, calibration, and reclassification of FRAX calibrated for Spain and a logistic model including only age and sex as variables. We found virtually identical AUC, 83.55% for FRAX (CI 95%: 80.46, 86.63) and 84.10% for the age and sex model (CI 95%: 80.91, 87.29), and there were similar observed-to-predicted ratios. In the reclassification analyses, patients with a hip fracture that were reclassified correctly as high risk by FRAX, compared to the age and sex model, were −2.86%, using either the 3% threshold or the observed incidence, 1.54% (95%CI: −8.44, 2.72 for the 3% threshold; 95%CI: −7.68, 1.97 for the incidence threshold). Remarkably simple and inexpensive tools that are easily transferable into electronic medical record environments may offer a comparable predictive ability to that of FRAX.
Collapse
Affiliation(s)
- Aníbal García-Sempere
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Isabel Hurtado
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Salvador Peiró
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Francisco Sánchez-Sáez
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
| | - Yared Santaana
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
| | - Clara Rodríguez-Bernal
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
- Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain
- Correspondence:
| | - José Sanfélix-Genovés
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain; (A.G.-S.); (I.H.); (S.P.); (F.S.-S.); (Y.S.); (C.R.-B.); (J.S.-G.)
| |
Collapse
|
7
|
Validation of the Taiwan FRAX® calculator for the prediction of fracture risk. Arch Osteoporos 2022; 17:27. [PMID: 35094177 DOI: 10.1007/s11657-022-01068-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/20/2022] [Indexed: 02/03/2023]
Abstract
The Taiwan FRAX® calculator was validated to predict incident fractures preliminarily. Cutoffs of FRAX probability for predicting major osteoporotic fracture and hip fracture were proposed as 9.5% and 4% in Taiwanese individuals. PURPOSE FRAX® is an algorithm used to calculate fracture probabilities based on clinical risk factors (CRFs) and bone mineral density (BMD). The country-specific Taiwan FRAX calculator has not been validated since its establishment in 2010. The aim of the present study is to evaluate the predictive performance of the Taiwan FRAX calculator using longitudinal fracture data. METHODS A total of 1975 subjects, aged ≧ 40 years old, from Yunlin and Tianliao cohorts in Taiwan during the period 2009-2010, were identified and completely connected with the 2008-2016 National Health Insurance Research Database. RESULTS During the average 6.8 ± 1.1 years of follow-up, 160 incident major osteoporotic fractures (MOFs) were identified. The predictive ability assessing based on the observed to expected fractures (O/E) ratio calculated with the FRAX probability adjusted for 6.8 years were 1.19 (95%CI 1.02-1.39) for MOF, and 1.07 (95%CI 0.82-1.39) for hip fractures. In the discriminative statistics, the AUC for prediction of major osteoporotic fractures using FRAX was 0.75 without and 0.77 with BMD (AUC for hip fracture was 0.75 without and 0.77 with BMD). The optimal cutoff value was 9.5% of the FRAX score with BMD for all major osteoporotic fractures, with good sensitivity (76.9%) and specificity (65.3%). For hip fractures, the optimal cutoff point for the FRAX probability with BMD was 4.0%, and the sensitivity and specificity were 74.4% and 68.3%, respectively. CONCLUSION The Taiwan FRAX® calculator was validated to predict incident fractures preliminarily. Cutoffs are proposed for predicting fracture risk in Taiwanese individuals.
Collapse
|
8
|
Sun X, Chen Y, Gao Y, Zhang Z, Qin L, Song J, Wang H, Wu IXY. Prediction Models for Osteoporotic Fractures Risk: A Systematic Review and Critical Appraisal. Aging Dis 2022; 13:1215-1238. [PMID: 35855348 PMCID: PMC9286920 DOI: 10.14336/ad.2021.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/01/2022] Open
Abstract
Osteoporotic fractures (OF) are a global public health problem currently. Many risk prediction models for OF have been developed, but their performance and methodological quality are unclear. We conducted this systematic review to summarize and critically appraise the OF risk prediction models. Three databases were searched until April 2021. Studies developing or validating multivariable models for OF risk prediction were considered eligible. Used the prediction model risk of bias assessment tool to appraise the risk of bias and applicability of included models. All results were narratively summarized and described. A total of 68 studies describing 70 newly developed prediction models and 138 external validations were included. Most models were explicitly developed (n=31, 44%) and validated (n=76, 55%) only for female. Only 22 developed models (31%) were externally validated. The most validated tool was Fracture Risk Assessment Tool. Overall, only a few models showed outstanding (n=3, 1%) or excellent (n=32, 15%) prediction discrimination. Calibration of developed models (n=25, 36%) or external validation models (n=33, 24%) were rarely assessed. No model was rated as low risk of bias, mostly because of an insufficient number of cases and inappropriate assessment of calibration. There are a certain number of OF risk prediction models. However, few models have been thoroughly internally validated or externally validated (with calibration being unassessed for most of the models), and all models showed methodological shortcomings. Instead of developing completely new models, future research is suggested to validate, improve, and analyze the impact of existing models.
Collapse
Affiliation(s)
- Xuemei Sun
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yancong Chen
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yinyan Gao
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Zixuan Zhang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Lang Qin
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Jinlu Song
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Huan Wang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Irene XY Wu
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha 410000, China
- Correspondence should be addressed to: Dr. IXY Wu, Xiangya School of Public health, Central South University, Xiangya School of Public health, Changsha 410000, Hunan, China.
| |
Collapse
|
9
|
Fracture risk assessment in the general population in Spain by FRAX® algorithm. EPISER2016 study. Med Clin (Barc) 2020; 154:163-170. [PMID: 31780217 DOI: 10.1016/j.medcli.2019.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/09/2019] [Accepted: 05/16/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To analyse the risk of fracture calculated by FRAX® and the frequency of high risk of fracture in the general population in Spain. METHODS EPISER2016 is a multicentre cross-sectional population-based study of the prevalence of rheumatic diseases in the adult population in Spain. 3,154 subjects aged ≥40 years (1,184 men and 1,970 women) were selected by stratified random sampling. The questions related to fracture risk factors were asked by telephone survey. The risk of major osteoporotic fracture (MOFR) and hip fracture (HFR) were calculated with the Spanish version of the FRAX® tool, without the inclusion of bone mineral density. To define high fracture risk, the MOFR≥20%, MOFR≥10%, MOFR≥7.5% and HFR≥3% thresholds were used. RESULTS The median (interquartile range) of the MOFR was 2.61% (1.55-6.34%) in women and 1.67% (1.15-2.87%) in men, whereas that of the HFR was 0.39% (0.14-1.86%) and 0.18% (0.07-0.77%); 3.83% of women and no men had a MOFR≥20%; 15.71% and 1.14% had a MOFR≥10%; 20.62% and 2.21%, a MOFR≥7.5%; and 19.27% and 8.05%, an HFR≥3%. In women aged 65 and over, the HFR was high in 58.09%. CONCLUSIONS EPISER2016 enabled us to establish the risk of fracture calculated by FRAX® and the prevalence of high risk of fracture in the general population according to the different thresholds used in Spain.
Collapse
|
10
|
Chen JF, Yu SF, Hsu CY, Chiu WC, Wu CH, Lai HM, Chen YC, Su YJ, Chen JF, Cheng TT. 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). Arch Osteoporos 2019; 14:101. [PMID: 31650396 DOI: 10.1007/s11657-019-0653-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/16/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED 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.
Collapse
Affiliation(s)
- Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Han-Ming Lai
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Yu-Jih Su
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC.
| |
Collapse
|
11
|
Palomeras-Vilches A, Viñals-Mayolas E, Bou-Mias C, Jordà-Castro M, Agüero-Martínez M, Busquets-Barceló M, Pujol-Busquets G, Carrion C, Bosque-Prous M, Serra-Majem L, Bach-Faig A. Adherence to the Mediterranean Diet and Bone Fracture Risk in Middle-Aged Women: A Case Control Study. Nutrients 2019; 11:E2508. [PMID: 31635237 PMCID: PMC6835915 DOI: 10.3390/nu11102508] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/06/2019] [Accepted: 10/10/2019] [Indexed: 12/21/2022] Open
Abstract
The prevention of bone mass loss and related complications associated with osteoporosis is a significant public health issue. The Mediterranean diet (MD) is favorably associated with bone health, a potentially modifiable risk factor. The objective of this research was to determine MD adherence in a sample of women with and without osteoporosis. In this observational case-control study of 139 women (64 women with and 75 without osteoporosis) conducted in a primary-care health center in Girona (Spain), MD adherence, lifestyle, physical exercise, tobacco and alcohol consumption, pathological antecedents, and FRAX index scores were analyzed. Logistic multilinear regression modeling to explore the relationship between the MD and bone fracture risk indicated that better MD adherence was associated with a lower bone risk fracture. Non-pharmacological preventive strategies to reduce bone fracture risk were also reviewed to explore the role of lifestyle and diet in bone mass maintenance and bone fracture prevention.
Collapse
Affiliation(s)
- Anna Palomeras-Vilches
- Medicina Familiar i Comunitària (MFiC), Institut Català de la Salut, EAP Santa Clara, 17001 Girona, Spain.
| | | | - Concepció Bou-Mias
- Medicina Familiar i Comunitària (MFiC), Institut Català de la Salut, EAP Santa Clara, 17001 Girona, Spain.
| | | | | | | | - Georgina Pujol-Busquets
- Faculty of Health Sciences, Universitat Oberta de Catalunya (Open University of Catalonia, UOC), 08018 Barcelona, Spain.
- Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, 7725 Cape Town, South Africa.
| | - Carme Carrion
- UOC eHealth Center (eHC), Universitat Oberta de Catalunya (UOC), 08018 Barcelona, Spain.
- eHealth Lab Research Group, Faculty of Health Sciences, Universitat Oberta de Catalunya (UOC), 08018 Barcelona, Spain.
| | - Marina Bosque-Prous
- Faculty of Health Sciences, Universitat Oberta de Catalunya (Open University of Catalonia, UOC), 08018 Barcelona, Spain.
| | - Lluís Serra-Majem
- CIBER de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Research Institute of Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, 35001 Las Palmas de Gran Canaria, Spain.
| | - Anna Bach-Faig
- FoodLab Research Group (2017SGR 83), Faculty of Health Sciences, Universitat Oberta de Catalunya (Open University of Catalonia, UOC), 08018 Barcelona, Spain.
- Food and Nutrition Area, Barcelona Official College of Pharmacists, 08009 Barcelona, Spain.
| |
Collapse
|
12
|
Martin-Sanchez M, Comas M, Posso M, Louro J, Domingo L, Tebé C, Castells X, Espallargues M. Cost-Effectiveness of the Screening for the Primary Prevention of Fragility Hip Fracture in Spain Using FRAX ®. Calcif Tissue Int 2019; 105:263-270. [PMID: 31172231 DOI: 10.1007/s00223-019-00570-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/30/2019] [Indexed: 12/17/2022]
Abstract
To assess the cost-effectiveness of the primary prevention of fragility hip fractures through opportunistic risk-based screening using FRAX® among women aged 70 to 89 years, and the subsequent treatment with alendronate in women at high-risk, from the Spanish national health system perspective. We performed a discrete-event simulation model. Women were categorized in low, intermediate and high-risk of fragility hip fracture through screening based on the FRAX® risk assessment tool score (Spanish version). Low-risk women received lifestyle recommendations whereas the high-risk group was assigned to alendronate treatment. For women at intermediate-risk, treatment decision was based on a recalculated score considering bone mineral density (BMD). The cost-effectiveness analysis tested six scenarios defined by different FRAX® cut-off values assessing the incremental costs per averted fracture in 20 years. Deterministic sensitivity analysis was performed. We included a random sample of 5146 women obtained from a Spanish cohort of women referred for BMD. The most cost-effective intervention had an Incremental Cost-effectiveness Ratio (ICER) of 57,390 € per averted hip fracture and consisted of using the FRAX® score without BMD and treating women with a score higher than 5%. The ICER exceeded the acceptability threshold of 25,000 € in all the scenarios. Sensitivity analysis based on time to fracture, treatment efficacy, adherence to treatment and cost of dependence resulted in ICERs ranging from 39,216 € to 254,400 €. An ICER of 24,970 € was obtained when alendronate cost was reduced to 1.13 € per month. The use of FRAX® as screening tool followed by alendronate treatment is not cost-effective in senior women in Spain. Other primary preventions strategies are advisable.
Collapse
Affiliation(s)
- Mario Martin-Sanchez
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Preventive Medicine and Public Health Training Unit PSMAR-UPF-ASPB (Parc de Salut Mar - Pompeu Fabra University-Public Health Agency of Barcelona), Barcelona, Spain
| | - Mercè Comas
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain.
| | - Margarita Posso
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
| | - Javier Louro
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
| | - Laia Domingo
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
| | - Cristian Tebé
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Xavier Castells
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
| | - Mireia Espallargues
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Barcelona, Spain
- Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), Barcelona, Spain
| |
Collapse
|
13
|
Beaudoin C, Moore L, Gagné M, Bessette L, Ste-Marie LG, Brown JP, Jean S. Performance of predictive tools to identify individuals at risk of non-traumatic fracture: a systematic review, meta-analysis, and meta-regression. Osteoporos Int 2019; 30:721-740. [PMID: 30877348 DOI: 10.1007/s00198-019-04919-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/26/2019] [Indexed: 01/28/2023]
Abstract
UNLABELLED There is no consensus on which tool is the most accurate to assess fracture risk. The results of this systematic review suggest that QFracture, Fracture Risk Assessment Tool (FRAX) with BMD, and Garvan with BMD are the tools with the best discriminative ability. More studies assessing the comparative performance of current tools are needed. INTRODUCTION Many tools exist to assess fracture risk. This review aims to determine which tools have the best predictive accuracy to identify individuals at high risk of non-traumatic fracture. METHODS Studies assessing the accuracy of tools for prediction of fracture were searched in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Global Health. Studies were eligible if discrimination was assessed in a population independent of the derivation cohort. Meta-analyses and meta-regressions were performed on areas under the ROC curve (AUCs). Gender, mean age, age range, and study quality were used as adjustment variables. RESULTS We identified 53 validation studies assessing the discriminative ability of 14 tools. Given the small number of studies on some tools, only FRAX, Garvan, and QFracture were compared using meta-regression models. In the unadjusted analyses, QFracture had the best discriminative ability to predict hip fracture (AUC = 0.88). In the adjusted analysis, FRAX with BMD (AUC = 0.81) and Garvan with BMD (AUC = 0.79) had the highest AUCs. For prediction of major osteoporotic fracture, QFracture had the best discriminative ability (AUC = 0.77). For prediction of osteoporotic or any fracture, FRAX with BMD and Garvan with BMD had higher discriminative ability than their versions without BMD (FRAX: AUC = 0.72 vs 0.69, Garvan: AUC = 0.72 vs 0.65). A significant amount of heterogeneity was present in the analyses. CONCLUSIONS QFracture, FRAX with BMD, and Garvan with BMD have the highest discriminative performance for predicting fracture. Additional studies in which the performance of current tools is assessed in the same individuals may be performed to confirm this conclusion.
Collapse
Affiliation(s)
- C Beaudoin
- Department of Social and Preventive Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada.
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada.
- Bureau d'information et d'études en santé des populations, Institut National de Santé Publique du Québec, 945, Avenue Wolfe, Québec, G1V 5B3, Canada.
| | - L Moore
- Department of Social and Preventive Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
| | - M Gagné
- Bureau d'information et d'études en santé des populations, Institut National de Santé Publique du Québec, 945, Avenue Wolfe, Québec, G1V 5B3, Canada
| | - L Bessette
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
| | - L G Ste-Marie
- Department of Medicine, Medicine Faculty, University of Montréal, Montréal, QC, Canada
| | - J P Brown
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
| | - S Jean
- Bureau d'information et d'études en santé des populations, Institut National de Santé Publique du Québec, 945, Avenue Wolfe, Québec, G1V 5B3, Canada
- Department of Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
| |
Collapse
|
14
|
Viswanathan M, Reddy S, Berkman N, Cullen K, Middleton JC, Nicholson WK, Kahwati LC. Screening to Prevent Osteoporotic Fractures: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 319:2532-2551. [PMID: 29946734 DOI: 10.1001/jama.2018.6537] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Osteoporotic fractures cause significant morbidity and mortality. OBJECTIVE To update the evidence on screening and treatment to prevent osteoporotic fractures for the US Preventive Services Task Force. DATA SOURCES PubMed, the Cochrane Library, EMBASE, and trial registries (November 1, 2009, through October 1, 2016) and surveillance of the literature (through March 23, 2018); bibliographies from articles. STUDY SELECTION Adults 40 years and older; screening cohorts without prevalent low-trauma fractures or treatment cohorts with increased fracture risk; studies assessing screening, bone measurement tests or clinical risk assessments, pharmacologic treatment. DATA EXTRACTION AND SYNTHESIS Dual, independent review of titles/abstracts and full-text articles; study quality rating; random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Incident fractures and related morbidity and mortality, diagnostic and predictive accuracy, harms of screening or treatment. RESULTS One hundred sixty-eight fair- or good-quality articles were included. One randomized clinical trial (RCT) (n = 12 483) comparing screening with no screening reported fewer hip fractures (2.6% vs 3.5%; hazard ratio [HR], 0.72 [95% CI, 0.59-0.89]) but no other statistically significant benefits or harms. The accuracy of bone measurement tests to identify osteoporosis varied (area under the curve [AUC], 0.32-0.89). The pooled accuracy of clinical risk assessments for identifying osteoporosis ranged from AUC of 0.65 to 0.76 in women and from 0.76 to 0.80 in men; the accuracy for predicting fractures was similar. For women, bisphosphonates, parathyroid hormone, raloxifene, and denosumab were associated with a lower risk of vertebral fractures (9 trials [n = 23 690]; relative risks [RRs] from 0.32-0.64). Bisphosphonates (8 RCTs [n = 16 438]; pooled RR, 0.84 [95% CI, 0.76-0.92]) and denosumab (1 RCT [n = 7868]; RR, 0.80 [95% CI, 0.67-0.95]) were associated with a lower risk of nonvertebral fractures. Denosumab reduced the risk of hip fracture (1 RCT [n = 7868]; RR, 0.60 [95% CI, 0.37-0.97]), but bisphosphonates did not have a statistically significant association (3 RCTs [n = 8988]; pooled RR, 0.70 [95% CI, 0.44-1.11]). Evidence was limited for men: zoledronic acid reduced the risk of radiographic vertebral fractures (1 RCT [n = 1199]; RR, 0.33 [95% CI, 0.16-0.70]); no studies demonstrated reductions in clinical or hip fractures. Bisphosphonates were not consistently associated with reported harms other than deep vein thrombosis (raloxifene vs placebo; 3 RCTs [n = 5839]; RR, 2.14 [95% CI, 0.99-4.66]). CONCLUSIONS AND RELEVANCE In women, screening to prevent osteoporotic fractures may reduce hip fractures, and treatment reduced the risk of vertebral and nonvertebral fractures; there was not consistent evidence of treatment harms. The accuracy of bone measurement tests or clinical risk assessments for identifying osteoporosis or predicting fractures varied from very poor to good.
Collapse
Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shivani Reddy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Nancy Berkman
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Katie Cullen
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International, Research Triangle Park, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Wanda K Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| |
Collapse
|
15
|
Park JS, Lee J, Park YS. 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? J Clin Densitom 2016; 19:340-5. [PMID: 26822485 DOI: 10.1016/j.jocd.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/11/2015] [Accepted: 12/16/2015] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jin-Sung Park
- Department of Orthopaedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, South Korea
| | - Jaewon Lee
- Department of Orthopaedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, South Korea
| | - Ye-Soo Park
- Department of Orthopaedic Surgery, Guri Hospital, Hanyang University College of Medicine, Guri, South Korea.
| |
Collapse
|
16
|
Azagra R, Zwart M, Encabo G, Aguyé A, Martin-Sánchez JC, Puchol-Ruiz N, Gabriel-Escoda P, Ortiz-Alinque S, Gené E, Iglesias M, Moriña D, Diaz-Herrera MA, Utzet M, Manresa JM. Rationale of the Spanish FRAX model in decision-making for predicting osteoporotic fractures: an update of FRIDEX cohort of Spanish women. BMC Musculoskelet Disord 2016; 17:262. [PMID: 27317560 PMCID: PMC4912785 DOI: 10.1186/s12891-016-1096-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/24/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The FRAX® tool estimates the risk of a fragility fracture among the population and many countries have been evaluating its performance among their populations since its creation in 2007. The purpose of this study is to update the first FRIDEX cohort analysis comparing FRAX with the bone mineral density (BMD) model, and its predictive abilities. METHODS The discriminatory ability of the FRAX was assessed using the 'area under curve' of the receiver operating characteristic (AUC-ROC). Predictive ability was assessed by comparing estimated risk fractures with incidence fractures after a 10-year follow up period. RESULTS One thousand three hundred eight women ≥ 40 and ≤ 90 years followed up during a 10-year period. The AUC for major osteoporotic fractures using FRAX without DXA was 0.686 (95 % CI 0.630-0.742) and using FN T-score of DXA 0.714 (95 % CI 0.661-0.767). Using only the traditional parameters of DXA (FN T-score), the AUC was 0.706 (95 % CI 0.652-0.760). The AUC for hip osteoporotic fracture was 0.883 (95 % CI 0.827-0.938), 0.857 (95 % CI 0.773-0.941), and 0.814 (95 % CI 0.712-0.916) respectively. For major osteoporotic fractures, the overall predictive value using the ratio Observed fractures/Expected fractures calculated with FRAX without T-score of DXA was 2.29 and for hip fractures 2.28 and with the inclusion of the T-score 2.01 and 1.83 respectively. However, for hip fracture in women < 65 years was 1.53 and 1.24 respectively. CONCLUSIONS The FRAX tool has been found to show a good discriminatory capacity for detecting women at high risk of fragility fracture, and is better for hip fracture than major fracture. The test of sensibility shows that it is, at least, not inferior than when using BMD model alone. The predictive capacity of FRAX tool needs some adjustment. This capacity is better for hip fracture prediction and better for women < 65 years. Further studies in Catalonia and other regions of Spain are needed to fine tune the FRAX tool's predictive capability.
Collapse
Affiliation(s)
- Rafael Azagra
- Department of Medicine, Universitat Autònoma de Barcelona, ps/Vall de Hebron 119, 08135, Barcelona, Spain.,Health Center Badia del Valles, Institut Català de la Salut, GROIMAP-USR MN-IDIAP Jordi Gol, c/Bética s/n, 08214, Badia del Vallés, Barcelona, Spain.,QuironSalud-Hospital General de Catalunya, Universitat Internacional de Catalunya, c/Josep Trueta s/n, 08195, Sant Cugat del Vallès, Barcelona, Spain
| | - Marta Zwart
- Department of Medicine, Universitat Autònoma de Barcelona, ps/Vall de Hebron 119, 08135, Barcelona, Spain. .,Health Center Can Gibert del Plà (ICS), Institut Català de la Salut, GROIMAP-USR Girona-IDIAP Jordi Gol, c/San Sebastian 9, 17005, Girona, Spain.
| | - Gloria Encabo
- Department of Nuclear Medicine, Valle de Hebron Hospital, Institut Català de la Salut, Ps/Valle de Hebron 119-129, 08035, Barcelona, Spain
| | - Amada Aguyé
- Health Center Granollers-Centre, Institut Català de la Salut, c/Museu 19, 08400, Granollers, Barcelona, Spain
| | - Juan Carlos Martin-Sánchez
- Department of Basic Sciences, Biostatistics Unit, Universitat Internacional de Catalunya, c/Josep Trueta s/n, 08195, Sant Cugat del Valles, Barcelona, Spain
| | - Nuria Puchol-Ruiz
- Health Center Badia del Valles, Institut Català de la Salut, GROIMAP-USR MN-IDIAP Jordi Gol, c/Bética s/n, 08214, Badia del Vallés, Barcelona, Spain
| | - Paula Gabriel-Escoda
- Health Center Barberà del Vallès, Institut Català de la Salut, GROIMAP-USR MN-IDIAP Jordi Gol, c/Verge de l'Assumpció s/n, 08210, Barberà del Vallès, Barcelona, Spain
| | - Sergio Ortiz-Alinque
- Health Center Canaletes, Institut Català de la Salut, GROIMAP-USR MN-IDIAP Jordi Gol, c/Ps d'Horta 17, 08290, Cerdanyola del Vallès, Barcelona, Spain
| | - Emilio Gené
- Department of Medicine, Universitat Autònoma de Barcelona, ps/Vall de Hebron 119, 08135, Barcelona, Spain.,Department of Medicine, Universitat Internacional de Catalunya, c/Josep Trueta s/n, 08195, Sant Cugat del Valles, Barcelona, Spain.,Urgencies Service, Hospital of Sabadell, Corporació Sanitaria i Universitaria Parc Tauli, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - Milagros Iglesias
- Health Center Badia del Valles, Institut Català de la Salut, GROIMAP-USR MN-IDIAP Jordi Gol, c/Bética s/n, 08214, Badia del Vallés, Barcelona, Spain
| | - David Moriña
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Program (CERP), Catalan Institute of Oncology (ICO)-IDIBELL, Av Gran Via, 199-203, 08908, L'Hospitalet de Llobregat, Barcelona, Spain.,Departament d'Economia i Història Econòmica, Grups de Recerca d'Àfrica i Amèrica Llatines (GRAAL), Unitat de Fonaments de l'Anàlisi Econòmica, Universitat Autònoma de Barcelona, c/Emprius 2, 08202, Sabadell, Barcelona, Spain
| | - Miguel Angel Diaz-Herrera
- Health Center Cornellà 2 (Sant Ildefons), Institut Català de la Salut, GROIMAP-USR MN-IDIAP Jordi Gol, c/Republica Argentina s/n, 08940, Cornellá, Barcelona, Spain
| | - Mireia Utzet
- Biostatistics Unit, CUPESSE European Project, Universitat Pompeu Fabra, Ed Jaume I-Campus Ciutadella, 08003, Barcelona, Spain
| | - Josep Maria Manresa
- Unitat Supor Recerca Metropolitana Nord, IDIAP Jordi Gol, ctra de Barcelona 473, 08204, Sabadell, Barcelona, Spain.,Department of Nursing, Universitat Autònoma de Barcelona, avda Can Domenech s/n, 08193, Cerdanyola del Valles, Barcelona, Spain
| | | |
Collapse
|
17
|
Azagra R, Zwart M, Aguyé A, Martín-Sánchez J, Casado E, Díaz-Herrera M, Moriña D, Cooper C, Díez-Pérez A, Dennison E. Fracture experience among participants from the FROCAT study: what thresholding is appropriate using the FRAX tool? Maturitas 2016; 83:65-71. [DOI: 10.1016/j.maturitas.2015.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/04/2015] [Accepted: 10/02/2015] [Indexed: 12/15/2022]
|
18
|
Pluskiewicz W, Adamczyk P, Czekajło A, Grzeszczak W, Drozdzowska B. High fracture probability predicts fractures in a 4-year follow-up in women from the RAC-OST-POL study. Osteoporos Int 2015; 26:2811-20. [PMID: 26168766 DOI: 10.1007/s00198-015-3196-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 05/28/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED In 770 postmenopausal women, the fracture incidence during a 4-year follow-up was analyzed in relation to the fracture probability (FRAX risk assessment tool) and risk (Garvan risk calculator) predicted at baseline. Incident fractures occurred in 62 subjects with a higher prevalence in high-risk subgroups. Prior fracture, rheumatoid arthritis, femoral neck T-score and falls increased independent of fracture incidence. INTRODUCTION The aim of the study was to analyze the incidence of fractures during a 4-year follow-up in relation to the baseline fracture probability and risk. METHODS Enrolled in the study were 770 postmenopausal women with a mean age of 65.7 ± 7.3 years. Bone mineral density (BMD) at the proximal femur, clinical data, and fracture probability using the FRAX tool and risk using the Garvan calculator were determined. Each subject was asked yearly by phone call about the incidence of fracture during the follow-up period. RESULTS Of the 770 women, 62 had a fracture during follow-up, and 46 had a major fracture. At baseline, BMD was significantly lower, and fracture probability and fracture risk were significantly higher in women who had a fracture. Among women with a major fracture, the percentage with a high baseline fracture probability (>10 %) was significantly higher than among those without a fracture (p < 0.01). Fracture incidence during follow-up was significantly higher among women with a high baseline fracture probability (12.7 % vs. 5.2 %) and a high fracture risk (9.2 vs. 5.3 %) so that the "fracture-free survival" curves were significantly different (p < 0.05). The number of clinical risk factors noted at baseline was significantly associated with fracture incidence (chi-squared = 20.82, p < 0.01). Prior fracture, rheumatoid arthritis, and femoral neck T-score were identified as significant risk factors for major fractures (for any fractures, the influence of falls was also significant). CONCLUSIONS During follow-up, fracture incidence was predicted by baseline fracture probability (FRAX risk assessment tool) and risk (Garvan risk calculator). A number of clinical risk factors and a prior fracture, rheumatoid arthritis, femoral neck T-score, and falls were independently associated with an increased incidence of fractures. [Corrected]
Collapse
Affiliation(s)
- W Pluskiewicz
- School of Medicine with the Division of Dentistry, Metabolic Bone Diseases Unit, Department and Clinic of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia in Katowice, 3-Maja 13/15 street, 41-800, Zabrze, Poland.
| | - P Adamczyk
- School of Medicine with the Division of Dentistry, Department and Clinic of Pediatrics, Medical University of Silesia in Katowice, Zabrze, Poland
| | - A Czekajło
- Department of Nephrology, Wodzisław, Poland
| | - W Grzeszczak
- School of Medicine with the Division of Dentistry, Department and Clinic of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia in Katowice, Zabrze, Poland
| | - B Drozdzowska
- School of Medicine with the Division of Dentistry, Department of Pathomorphology, Medical University of Silesia in Katowice, Zabrze, Poland
| |
Collapse
|
19
|
SECOT-GEIOS guidelines in osteoporosis and fragility fracture. An update. Rev Esp Cir Ortop Traumatol (Engl Ed) 2015. [DOI: 10.1016/j.recote.2015.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
20
|
Puigoriol E, Rodríguez J, Luchetti G, Kanterewicz E. El FRAX® español se ajusta más en la predicción de las fracturas femorales que en el resto de fracturas osteoporóticas. Resultados preliminares del estudio FRODOS. Rev Clin Esp 2015; 215:476-8. [DOI: 10.1016/j.rce.2015.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/24/2015] [Accepted: 04/26/2015] [Indexed: 11/16/2022]
|
21
|
Marques A, Ferreira RJO, Santos E, Loza E, Carmona L, da Silva JAP. The accuracy of osteoporotic fracture risk prediction tools: a systematic review and meta-analysis. Ann Rheum Dis 2015; 74:1958-67. [PMID: 26248637 DOI: 10.1136/annrheumdis-2015-207907] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 07/14/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To identify and synthesise the best available evidence on the accuracy of the currently available tools for predicting fracture risk. METHODS We systematically searched PubMed MEDLINE, Embase and Cochrane databases to 2014. Two reviewers independently selected articles, collected data from studies, and carried out a hand search of the references of the included studies. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) checklist was used, and the primary outcome was the area under the curve (AUC) and 95% CIs, obtained from receiver operating characteristic (ROC) analyses. We excluded tools if they had not been externally validated or were designed for specific disease populations. Random effects meta-analyses were performed with the selected tools. RESULTS Forty-five studies met inclusion criteria, corresponding to 13 different tools. Only three tools had been tested more than once in a population-based setting: FRAX (26 studies in 9 countries), GARVAN (6 studies in 3 countries) and QFracture (3 studies in the UK, 1 also including Irish participants). Twenty studies with these three tools were included in a total of 17 meta-analyses (for hip or major osteoporotic fractures; men or women; with or without bone mineral density). CONCLUSIONS Most of the 13 tools are feasible in clinical practice. FRAX has the largest number of externally validated and independent studies. The overall accuracy of the different tools is satisfactory (>0.70), with QFracture reaching 0.89 (95% CI 0.88 to 0.89). Significant methodological limitations were observed in many studies, suggesting caution when comparing tools based solely on the AUC.
Collapse
Affiliation(s)
- Andréa Marques
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Eduardo Santos
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Estíbaliz Loza
- Instituto de Salud Musculoesquelética-InMusc, Madrid, Spain
| | - Loreto Carmona
- Instituto de Salud Musculoesquelética-InMusc, Madrid, Spain
| | - José António Pereira da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Faculty of Medicine, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal
| |
Collapse
|
22
|
Etxebarria-Foronda I, Caeiro-Rey JR, Larrainzar-Garijo R, Vaquero-Cervino E, Roca-Ruiz L, Mesa-Ramos M, Merino Pérez J, Carpintero-Benitez P, Fernández Cebrián A, Gil-Garay E. [SECOT-GEIOS guidelines in osteoporosis and fragility fracture. An update]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2015; 59:373-93. [PMID: 26233814 DOI: 10.1016/j.recot.2015.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 05/13/2015] [Accepted: 05/29/2015] [Indexed: 12/12/2022] Open
Affiliation(s)
- I Etxebarria-Foronda
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Hospital Alto Deba, Arrasate-Mondragón, Gipuzkoa, España.
| | - J R Caeiro-Rey
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Complexo Hospitalario Universitario Santiago Compostela, Santiago de Compostela, A Coruña, España
| | - R Larrainzar-Garijo
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Infanta Leonor, Madrid, España
| | - E Vaquero-Cervino
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Complexo Hospitalario Pontevedra, Pontevedra, España
| | - L Roca-Ruiz
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - M Mesa-Ramos
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Unidad de Gestión Clínica del Aparato Locomotor, Área Sanitaria Norte de Córdoba, Pozoblanco, Córdoba, España
| | - J Merino Pérez
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario de Cruces, Barakaldo, Bizkaia, España
| | - P Carpintero-Benitez
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Cátedra de Cirugía Ortopédica y Traumatología, Facultad de Medicina, Córdoba, España
| | - A Fernández Cebrián
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Complejo Hospitalario de Ourense, Ourense, España
| | - E Gil-Garay
- Grupo de Estudio e Investigación de la Osteoporosis y la Fractura Osteoporótica de la Sociedad Española de Cirugía Ortopédica y Traumatología (GEIOS-SECOT), España; Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Paz, Madrid, España
| |
Collapse
|
23
|
Azagra R, Zwart M, Martín-Sánchez JC, Aguyé A. La herramienta FRAX® en la prevención de fracturas asociadas al tratamiento de privación androgénica en el cáncer de próstata. Med Clin (Barc) 2014; 142:231-2. [PMID: 24018248 DOI: 10.1016/j.medcli.2013.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 05/30/2013] [Accepted: 06/06/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Rafael Azagra
- Equip d'Atenció Primària Badia del Vallès, Servei d'Atenció Primària Vallès Occidental-Institut Català de la Salut, Unitat de Suport a la Recerca Metropolitana Nord, Institut d'Investigació en Atenció Primària Jordi Gol, Barcelona, España; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, España; Departamento de Medicina, Universitat Internacional de Catalunya, Barcelona, España.
| | - Marta Zwart
- Equip d'Atenció Primària Girona-2, Institut Català de la Salut, Unitat de Suport a la Recerca-Girona, Intitut d'Investigació en Atenció Primària Jordi Gol, Girona, España
| | - Juan Carlos Martín-Sánchez
- Bioestadística, Departamento de Ciencias Básicas, Facultad de Medicina, Campus Sant Cugat, Universitat Internacional de Catalunya, Barcelona, España
| | - Amada Aguyé
- Equip d'Atenció Primària Vallès Oriental-Granollers Centre, Servei d'Atenció Primària Vallès Oriental-Institut Catalá de la Salut, Barcelona, España
| |
Collapse
|
24
|
Chen XF, Li XL, Zhang H, Liu GJ. Were you identified to be at high fracture risk by FRAX® before your osteoporotic fracture occurred? Clin Rheumatol 2014; 33:693-8. [DOI: 10.1007/s10067-014-2533-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
|
25
|
Leslie WD, Lix LM. Comparison between various fracture risk assessment tools. Osteoporos Int 2014; 25:1-21. [PMID: 23797847 DOI: 10.1007/s00198-013-2409-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 05/24/2013] [Indexed: 11/28/2022]
Abstract
The suboptimal performance of bone mineral density as the sole predictor of fracture risk and treatment decision making has led to the development of risk prediction algorithms that estimate fracture probability using multiple risk factors for fracture, such as demographic and physical characteristics, personal and family history, other health conditions, and medication use. We review theoretical aspects for developing and validating risk assessment tools, and illustrate how these principles apply to the best studied fracture probability tools: the World Health Organization FRAX®, the Garvan Fracture Risk Calculator, and the QResearch Database's QFractureScores. Model development should follow a systematic and rigorous methodology around variable selection, model fit evaluation, performance evaluation, and internal and external validation. Consideration must always be given to how risk prediction tools are integrated into clinical practice guidelines to support better clinical decision making and improved patient outcomes. Accurate fracture risk assessment can guide clinicians and individuals in understanding the risk of having an osteoporosis-related fracture and inform their decision making to mitigate these risks.
Collapse
|
26
|
Prieto-Alhambra D, Díez-Pérez A. Do we need to fine-tune the Spanish version of the FRAX predictive tool? J Clin Densitom 2013; 16:133-4. [PMID: 22921774 DOI: 10.1016/j.jocd.2012.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 06/11/2012] [Indexed: 11/22/2022]
|