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Vandenput L, Johansson H, McCloskey EV, Liu E, Schini M, Åkesson KE, Anderson FA, Azagra R, Bager CL, Beaudart C, Bischoff-Ferrari HA, Biver E, Bruyère O, Cauley JA, Center JR, Chapurlat R, Christiansen C, Cooper C, Crandall CJ, Cummings SR, da Silva JAP, Dawson-Hughes B, Diez-Perez A, Dufour AB, Eisman JA, Elders PJM, Ferrari S, Fujita Y, Fujiwara S, Glüer CC, Goldshtein I, Goltzman D, Gudnason V, Hall J, Hans D, Hoff M, Hollick RJ, Huisman M, Iki M, Ish-Shalom S, Jones G, Karlsson MK, Khosla S, Kiel DP, Koh WP, Koromani F, Kotowicz MA, Kröger H, Kwok T, Lamy O, Langhammer A, Larijani B, Lippuner K, McGuigan FEA, Mellström D, Merlijn T, Nguyen TV, Nordström A, Nordström P, O'Neill TW, Obermayer-Pietsch B, Ohlsson C, Orwoll ES, Pasco JA, Rivadeneira F, Schott AM, Shiroma EJ, Siggeirsdottir K, Simonsick EM, Sornay-Rendu E, Sund R, Swart KMA, Szulc P, Tamaki J, Torgerson DJ, van Schoor NM, van Staa TP, Vila J, Wareham NJ, Wright NC, Yoshimura N, Zillikens MC, Zwart M, Harvey NC, Lorentzon M, Leslie WD, Kanis JA. A meta-analysis of previous falls and subsequent fracture risk in cohort studies. Osteoporos Int 2024; 35:469-494. [PMID: 38228807 DOI: 10.1007/s00198-023-07012-1] [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: 09/24/2023] [Accepted: 12/27/2023] [Indexed: 01/18/2024]
Abstract
The relationship between self-reported falls and fracture risk was estimated in an international meta-analysis of individual-level data from 46 prospective cohorts. Previous falls were associated with an increased fracture risk in women and men and should be considered as an additional risk factor in the FRAX® algorithm. INTRODUCTION Previous falls are a well-documented risk factor for subsequent fracture but have not yet been incorporated into the FRAX algorithm. The aim of this study was to evaluate, in an international meta-analysis, the association between previous falls and subsequent fracture risk and its relation to sex, age, duration of follow-up, and bone mineral density (BMD). METHODS The resource comprised 906,359 women and men (66.9% female) from 46 prospective cohorts. Previous falls were uniformly defined as any fall occurring during the previous year in 43 cohorts; the remaining three cohorts had a different question construct. The association between previous falls and fracture risk (any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and hip fracture) was examined using an extension of the Poisson regression model in each cohort and each sex, followed by random-effects meta-analyses of the weighted beta coefficients. RESULTS Falls in the past year were reported in 21.4% of individuals. During a follow-up of 9,102,207 person-years, 87,352 fractures occurred of which 19,509 were hip fractures. A previous fall was associated with a significantly increased risk of any clinical fracture both in women (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33-1.51) and men (HR 1.53, 95% CI 1.41-1.67). The HRs were of similar magnitude for osteoporotic, major osteoporotic fracture, and hip fracture. Sex significantly modified the association between previous fall and fracture risk, with predictive values being higher in men than in women (e.g., for major osteoporotic fracture, HR 1.53 (95% CI 1.27-1.84) in men vs. HR 1.32 (95% CI 1.20-1.45) in women, P for interaction = 0.013). The HRs associated with previous falls decreased with age in women and with duration of follow-up in men and women for most fracture outcomes. There was no evidence of an interaction between falls and BMD for fracture risk. Subsequent risk for a major osteoporotic fracture increased with each additional previous fall in women and men. CONCLUSIONS A previous self-reported fall confers an increased risk of fracture that is largely independent of BMD. Previous falls should be considered as an additional risk factor in future iterations of FRAX to improve fracture risk prediction.
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Affiliation(s)
- Liesbeth Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Helena Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - Enwu Liu
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Marian Schini
- Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Kristina E Åkesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Fred A Anderson
- GLOW Coordinating Center, Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Rafael Azagra
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
- Health Centre Badia del Valles, Catalan Institute of Health, Barcelona, Spain
- GROIMAP (Research Group), Unitat de Suport a La Recerca Metropolitana Nord, Institut Universitari d'Investigació en Atenció Primària Jordi Gol, Cerdanyola del Vallès, Barcelona, Spain
- PRECIOSA-Fundación Para La Investigación, Barberà del Vallés, Barcelona, Spain
| | | | - Charlotte Beaudart
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Department of Health Services Research, University of Maastricht, Maastricht, The Netherlands
| | - Heike A Bischoff-Ferrari
- Department of Aging Medicine and Aging Research, University Hospital, Zurich, and University of Zurich, Zurich, Switzerland
- Centre On Aging and Mobility, University of Zurich and City Hospital, Zurich, Switzerland
| | - Emmanuel Biver
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Olivier Bruyère
- WHO Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - Jane A Cauley
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jacqueline R Center
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, School of Medicine and Health, University of New South Wales Sydney, Sydney, NSW, Australia
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Roland Chapurlat
- INSERM UMR 1033, Université Claude Bernard-Lyon1, Hôpital Edouard Herriot, Lyon, France
| | | | - Cyrus Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
| | - Carolyn J Crandall
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Steven R Cummings
- San Francisco Coordinating Center, California Pacific Medical Center Research Institute, San Francisco, CA, USA
| | - José A P da Silva
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Rheumatology Department, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | - Bess Dawson-Hughes
- Bone Metabolism Laboratory, Jean Mayer US Department of Agriculture Human Nutrition Research Center On Aging, Tufts University, Boston, MA, USA
| | - Adolfo Diez-Perez
- Department of Internal Medicine, Hospital del Mar and CIBERFES, Autonomous University of Barcelona, Barcelona, Spain
| | - Alyssa B Dufour
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - John A Eisman
- Skeletal Diseases Program, Garvan Institute of Medical Research, Sydney, NSW, Australia
- St Vincent's Clinical School, School of Medicine and Health, University of New South Wales Sydney, Sydney, NSW, Australia
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Petra J M Elders
- Department of General Practice, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Serge Ferrari
- Division of Bone Diseases, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Yuki Fujita
- Center for Medical Education and Clinical Training, Kindai University Faculty of Medicine, Osaka, Japan
| | - Saeko Fujiwara
- Department of Pharmacy, Yasuda Women's University, Hiroshima, Japan
| | - Claus-Christian Glüer
- Section Biomedical Imaging, Molecular Imaging North Competence Center, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein Kiel, Kiel University, Kiel, Germany
| | - Inbal Goldshtein
- Maccabitech Institute of Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Goltzman
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
| | - Vilmundur Gudnason
- Icelandic Heart Association, Kopavogur, Iceland
- University of Iceland, Reykjavik, Iceland
| | - Jill Hall
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Didier Hans
- Interdisciplinary Centre of Bone Diseases, Bone and Joint Department, Lausanne University Hospital (CHUV) & University of Lausanne, Lausanne, Switzerland
| | - Mari Hoff
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway
| | - Rosemary J Hollick
- Aberdeen Centre for Arthritis and Musculoskeletal Health, Epidemiology Group, University of Aberdeen, Aberdeen, UK
| | - Martijn Huisman
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- Department of Sociology, VU University, Amsterdam, The Netherlands
| | - Masayuki Iki
- Department of Public Health, Kindai University Faculty of Medicine, Osaka, Japan
| | | | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Orthopaedics, Skåne University Hospital, Malmö, Sweden
| | - Sundeep Khosla
- Robert and Arlene Kogod Center On Aging and Division of Endocrinology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Douglas P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Woon-Puay Koh
- Healthy Longevity Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR), Singapore, Singapore
| | - Fjorda Koromani
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mark A Kotowicz
- IMPACT (Institute for Mental and Physical Health and Clinical Translation), Deakin University, Geelong, VIC, Australia
- Barwon Health, Geelong, VIC, Australia
- Department of Medicine-Western Health, The University of Melbourne, St Albans, VIC, Australia
| | - Heikki Kröger
- Department of Orthopedics and Traumatology, Kuopio University Hospital, Kuopio, Finland
- Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland
| | - Timothy Kwok
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Jockey Club Centre for Osteoporosis Care and Control, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Olivier Lamy
- Centre of Bone Diseases, Lausanne University Hospital, Lausanne, Switzerland
- Service of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Arnulf Langhammer
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kurt Lippuner
- Department of Osteoporosis, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fiona E A McGuigan
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Dan Mellström
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital Mölndal, Mölndal, Sweden
| | - Thomas Merlijn
- Department of General Practice, Amsterdam UMC, Location AMC, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Tuan V Nguyen
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia
- School of Biomedical Engineering, University of Technology Sydney, Sydney, Australia
- School of Population Health, UNSW Medicine, UNSW Sydney, Kensington, Australia
| | - Anna Nordström
- School of Sport Sciences, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Health Sciences, Swedish Winter Sports Research Centre, Mid Sweden University, Östersund, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Nordström
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Terence W O'Neill
- National Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Barbara Obermayer-Pietsch
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University Graz, Graz, Austria
- Center for Biomarker Research in Medicine, Graz, Austria
| | - Claes Ohlsson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Drug Treatment, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Eric S Orwoll
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Julie A Pasco
- IMPACT (Institute for Mental and Physical Health and Clinical Translation), Deakin University, Geelong, VIC, Australia
- Barwon Health, Geelong, VIC, Australia
- Department of Medicine-Western Health, The University of Melbourne, St Albans, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Fernando Rivadeneira
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anne-Marie Schott
- Université Claude Bernard Lyon 1, U INSERM 1290 RESHAPE, Lyon, France
| | - Eric J Shiroma
- Laboratory of Epidemiology and Population Sciences, National Institute On Aging, Baltimore, MD, USA
| | | | - Eleanor M Simonsick
- Translational Gerontology Branch, National Institute On Aging Intramural Research Program, Baltimore, MD, USA
| | | | - Reijo Sund
- Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland
| | - Karin M A Swart
- Department of General Practice, Amsterdam UMC, Location VUmc, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
| | - Pawel Szulc
- INSERM UMR 1033, Université Claude Bernard-Lyon1, Hôpital Edouard Herriot, Lyon, France
| | - Junko Tamaki
- Department of Hygiene and Public Health, Faculty of Medicine, Educational Foundation of Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - David J Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Natasja M van Schoor
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Tjeerd P van Staa
- Centre for Health Informatics, Faculty of Biology, Medicine and Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Joan Vila
- Statistics Support Unit, Hospital del Mar Medical Research Institute, CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
| | | | - Nicole C Wright
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Noriko Yoshimura
- Department of Preventive Medicine for Locomotive Organ Disorders, The University of Tokyo Hospital, Tokyo, Japan
| | - MCarola Zillikens
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marta Zwart
- PRECIOSA-Fundación Para La Investigación, Barberà del Vallés, Barcelona, Spain
- Health Center Can Gibert del Plà, Catalan Institute of Health, Girona, Spain
- Department of Medical Sciences, University of Girona, Girona, Spain
- GROIMAP/GROICAP (Research Groups), Unitat de Suport a La Recerca Girona, Institut Universitari d'Investigació en Atenció Primària Jordi Gol, Girona, Spain
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Mattias Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - William D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - John A Kanis
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK.
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Wu Y, Chao J, Bao M, Zhang N. Predictive value of machine learning on fracture risk in osteoporosis: a systematic review and meta-analysis. BMJ Open 2023; 13:e071430. [PMID: 38070927 PMCID: PMC10728980 DOI: 10.1136/bmjopen-2022-071430] [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: 12/27/2022] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Early identification of fracture risk in patients with osteoporosis is essential. Machine learning (ML) has emerged as a promising technique to predict the risk, whereas its predictive performance remains controversial. Therefore, we conducted this systematic review and meta-analysis to explore the predictive efficiency of ML for the risk of fracture in patients with osteoporosis. METHODS Relevant studies were retrieved from four databases (PubMed, Embase, Cochrane Library and Web of Science) until 31 May 2023. A meta-analysis of the C-index was performed using a random-effects model, while a bivariate mixed-effects model was used for the meta-analysis of sensitivity and specificity. In addition, subgroup analysis was performed according to the types of ML models and fracture sites. RESULTS Fifty-three studies were included in our meta-analysis, involving 15 209 268 patients, 86 prediction models specifically developed for the osteoporosis population and 41 validation sets. The most commonly used predictors in these models encompassed age, BMI, past fracture history, bone mineral density T-score, history of falls, BMD, radiomics data, weight, height, gender and other chronic diseases. Overall, the pooled C-index of ML was 0.75 (95% CI: 0.72, 0.78) and 0.75 (95% CI: 0.71, 0.78) in the training set and validation set, respectively; the pooled sensitivity was 0.79 (95% CI: 0.72, 0.84) and 0.76 (95% CI: 0.80, 0.81) in the training set and validation set, respectively; and the pooled specificity was 0.81 (95% CI: 0.75, 0.86) and 0.83 (95% CI: 0.72, 0.90) in the training set and validation set, respectively. CONCLUSIONS ML has a favourable predictive performance for fracture risk in patients with osteoporosis. However, most current studies lack external validation. Thus, external validation is required to verify the reliability of ML models. PROSPERO REGISTRATION NUMBER CRD42022346896.
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Affiliation(s)
- Yanqian Wu
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Jianqian Chao
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Min Bao
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Na Zhang
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
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3
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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.
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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
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4
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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.
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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,
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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.
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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.
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Holloway-Kew KL, Zhang Y, Betson AG, Anderson KB, Hans D, Hyde NK, Nicholson GC, Pocock NA, Kotowicz MA, Pasco JA. How well do the FRAX (Australia) and Garvan calculators predict incident fractures? Data from the Geelong Osteoporosis Study. Osteoporos Int 2019; 30:2129-2139. [PMID: 31317250 DOI: 10.1007/s00198-019-05088-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 07/09/2019] [Indexed: 11/26/2022]
Abstract
UNLABELLED This study reports that both FRAX and Garvan calculators underestimated fractures in Australian men and women, particularly in those with osteopenia or osteoporosis. Major osteoporotic fractures were poorly predicted, while both calculators performed acceptably well for hip fractures. INTRODUCTION This study assessed the ability of the FRAX (Australia) and Garvan calculators to predict fractures in Australian women and men. METHODS Women (n = 809) and men (n = 821) aged 50-90 years, enrolled in the Geelong Osteoporosis Study, were included. Fracture risk was estimated using FRAX and Garvan calculators with and without femoral neck bone mineral density (BMD) (FRAXBMD, FRAXnoBMD, GarvanBMD, GarvannoBMD). Incident major osteoporotic (MOF), fragility, and hip fractures over the following 10 years were verified radiologically. Differences between observed and predicted numbers of fractures were assessed using a chi-squared test. Diagnostics indexes were calculated. RESULTS In women, 115 MOF, 184 fragility, and 42 hip fractures occurred. For men, there were 73, 109, and 17 fractures, respectively. FRAX underestimated MOFs, regardless of sex or inclusion of BMD. FRAX accurately predicted hip fractures, except in women with BMD (20 predicted, p = 0.004). Garvan underestimated fragility fractures except in men using BMD (88 predicted, p = 0.109). Garvan accurately predicted hip fractures except for women without BMD (12 predicted, p < 0.001). Fractures were underestimated primarily in the osteopenia and osteoporosis groups; MOFs in the normal BMD group were only underestimated by FRAXBMD and fragility fractures by GarvannoBMD, both in men. AUROCs were not different between scores with and without BMD, except for fragility fractures predicted by Garvan in women (0.696, 95% CI 0.652-0.739 and 0.668, 0.623-0.712, respectively, p = 0.008) and men, which almost reached significance (0.683, 0.631-0.734, and 0.667, 0.615-0.719, respectively, p = 0.051). Analyses of sensitivity and specificity showed overall that MOFs and fragility fractures were poorly predicted by both FRAX and Garvan, while hip fractures were acceptably predicted. CONCLUSIONS Overall, the FRAX and Garvan calculators underestimated MOF and fragility fractures, particularly in individuals with osteopenia or osteoporosis. Hip fractures were predicted better by both calculators. AUROC analyses suggest that GarvanBMD performed better than GarvannoBMD for prediction of fragility fractures.
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Affiliation(s)
| | - Y Zhang
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, St Albans, Australia
| | - A G Betson
- School of Medicine, Deakin University, Geelong, Australia
| | - K B Anderson
- School of Medicine, Deakin University, Geelong, Australia
| | - D Hans
- Center of Bone Diseases, Bone & Joint Department, Lausanne University Hospital, Lausanne, Switzerland
| | - N K Hyde
- School of Medicine, Deakin University, Geelong, Australia
| | - G C Nicholson
- Rural Clinical School, The University of Queensland, Toowoomba, QLD, Australia
| | - N A Pocock
- University of New South Wales, Sydney, NSW, Australia
| | - M A Kotowicz
- School of Medicine, Deakin University, Geelong, Australia
- Center of Bone Diseases, Bone & Joint Department, Lausanne University Hospital, Lausanne, Switzerland
- Barwon Health, Geelong, Australia
| | - J A Pasco
- School of Medicine, Deakin University, Geelong, Australia
- Center of Bone Diseases, Bone & Joint Department, Lausanne University Hospital, Lausanne, Switzerland
- Barwon Health, Geelong, Australia
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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.
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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
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Ryan P, Weiss M, Papanek P. A Substruction Approach to Assessing the Theoretical Validity of Measures. J Nurs Meas 2019; 27:126-145. [PMID: 31068496 DOI: 10.1891/1061-3749.27.1.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Validity is about the logic, meaningfulness, and evidence used to defend inferences made when interpreting results. Substruction is a heuristic or process that visually represent the hierarchical structure between theory and measures. PURPOSE To describe substruction as a method for assessing the toretical validity of research measures. METHODS Using Fawcett's Conceptual-Theoretical-Empirical Structure. an exemplar is presented of substruction from the Individual and Family Self-Management Theory to the Striving to be strong study concepts and empirical measures. RESULTS Substruction tables display evidence supporting theoretical validity of the instruments used in the study. CONCLUSION A high degree of congruence between theory and measure is critical to support the validity of the theory and to support attributions made about moderating, mediating, causal relationships, and intervention effects.
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Affiliation(s)
- Polly Ryan
- University of Wisconsin, Madison, School of Nursing, WI
| | | | - Paula Papanek
- Marquette University, College of Health Science, Milwaukee, WI
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9
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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: 125] [Impact Index Per Article: 20.8] [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.
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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
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Abstract
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.
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Affiliation(s)
- Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nariman Chamoun
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Dagan N, Cohen-Stavi C, Leventer-Roberts M, Balicer RD. External validation and comparison of three prediction tools for risk of osteoporotic fractures using data from population based electronic health records: retrospective cohort study. BMJ 2017; 356:i6755. [PMID: 28104610 PMCID: PMC5244817 DOI: 10.1136/bmj.i6755] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To directly compare the performance and externally validate the three most studied prediction tools for osteoporotic fractures-QFracture, FRAX, and Garvan-using data from electronic health records. DESIGN Retrospective cohort study. SETTING Payer provider healthcare organisation in Israel. PARTICIPANTS 1 054 815 members aged 50 to 90 years for comparison between tools and cohorts of different age ranges, corresponding to those in each tools' development study, for tool specific external validation. MAIN OUTCOME MEASURE First diagnosis of a major osteoporotic fracture (for QFracture and FRAX tools) and hip fractures (for all three tools) recorded in electronic health records from 2010 to 2014. Observed fracture rates were compared to probabilities predicted retrospectively as of 2010. RESULTS The observed five year hip fracture rate was 2.7% and the rate for major osteoporotic fractures was 7.7%. The areas under the receiver operating curve (AUC) for hip fracture prediction were 82.7% for QFracture, 81.5% for FRAX, and 77.8% for Garvan. For major osteoporotic fractures, AUCs were 71.2% for QFracture and 71.4% for FRAX. All the tools underestimated the fracture risk, but the average observed to predicted ratios and the calibration slopes of FRAX were closest to 1. Tool specific validation analyses yielded hip fracture prediction AUCs of 88.0% for QFracture (among those aged 30-100 years), 81.5% for FRAX (50-90 years), and 71.2% for Garvan (60-95 years). CONCLUSIONS Both QFracture and FRAX had high discriminatory power for hip fracture prediction, with QFracture performing slightly better. This performance gap was more pronounced in previous studies, likely because of broader age inclusion criteria for QFracture validations. The simpler FRAX performed almost as well as QFracture for hip fracture prediction, and may have advantages if some of the input data required for QFracture are not available. However, both tools require calibration before implementation.
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Affiliation(s)
- Noa Dagan
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
- Computer Science Department, Ben Gurion University of the Negev, Be'er Sheba, Israel
| | - Chandra Cohen-Stavi
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Maya Leventer-Roberts
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
- Department of Preventive Medicine and Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ran D Balicer
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
- Epidemiology Department, Ben Gurion University of the Negev, Be'er Sheba, Israel
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Crandall CJ. Risk Assessment Tools for Osteoporosis Screening in Postmenopausal Women: A Systematic Review. Curr Osteoporos Rep 2015; 13:287-301. [PMID: 26233285 DOI: 10.1007/s11914-015-0282-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Osteoporotic fractures are common in postmenopausal women. Tools are available to estimate the risk of low bone mineral density (BMD) or fracture. This systematic review retrieved articles that evaluated osteoporosis risk assessment tools among postmenopausal women in North America. For identifying BMD T-score ≤-2.5, most studies of the Simple Calculated Osteoporosis Risk Estimation tool (SCORE) and Osteoporosis Risk Assessment Instrument (ORAI) reported sensitivity ≥90 %. Area under the receiver operating characteristic curve (AUC) was usually <0.75 for SCORE and ≥0.75 for ORAI. Among women 50-64 years old, a Fracture Risk Assessment Tool (FRAX) threshold ≥9.3 % had a sensitivity of 33 % for identifying BMD T-score ≤-2.5 and 26 % for predicting major osteoporotic fracture (MOF). For predicting MOF, sensitivity was higher for SCORE and Osteoporosis Self-assessment Tool equation (OST), and higher in women ≥65 years old. For predicting BMD T-score ≤-2.5 in women ≥65 years old, the sensitivities of SCORE; ORAI; and Age, Body Size, No Estrogen (ABONE) were very high. No optimal osteoporosis risk assessment tool is available for identifying low BMD and MOF risk.
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Affiliation(s)
- Carolyn J Crandall
- David Geffen School of Medicine, University of California, Los Angeles, UCLA Medicine/GIM, 911 Broxton Ave., 1st floor, Los Angeles, CA, 90024, USA,
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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.
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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
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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.
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Leslie WD, Lix LM, Wu X. Competing mortality and fracture risk assessment. Osteoporos Int 2013; 24:681-8. [PMID: 22736068 DOI: 10.1007/s00198-012-2051-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 04/30/2012] [Indexed: 02/06/2023]
Abstract
SUMMARY Failure to account for competing mortality gave higher estimates of 10-year fracture probability than if appropriate adjustment is made for competing mortality, particularly among subgroups with higher mortality. A modified Kaplan-Meier method is easy to implement and provides an alternative approach to existing methods for competing mortality risk adjustment. INTRODUCTION A unique feature of FRAX(®) is that 10-year fracture probability accounts for mortality as a competing risk. We compared the effect of competing mortality adjustment on nonparametric and parametric methods of fracture probability estimation. METHODS The Manitoba Bone Mineral Density (BMD) database was used to identify men and women age ≥50 years with FRAX probabilities calculated using femoral neck BMD (N = 39,063). Fractures were assessed from administrative data (N = 2,543 with a major osteoporotic fracture, N = 549 with a hip fracture during mean 5.3 years follow-up). RESULTS The following subgroups with higher mortality were identified: men, age >80 years, high fracture probability, and presence of diabetes. Failure to account for competing mortality in these subgroups overestimated fracture probability by 16-56 % with the standard nonparametric (Kaplan-Meier) method and 15-29 % with the standard parametric (Cox) model. When the outcome was hip fractures, failure to account for competing mortality overestimated hip fracture probability by 18-36 % and 17-35 %, respectively. A simple modified Kaplan-Meier method showed very close agreement with methods that adjusted for competing mortality (within 2 %). CONCLUSIONS Failure to account for competing mortality risk gives considerably higher estimates of 10-year fracture probability than if adjustment is made for this competing risk.
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Affiliation(s)
- W D Leslie
- University of Manitoba, Winnipeg, MB, Canada.
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Middleton RG, Shabani F, Uzoigwe CE, Shoaib A, Moqsith M, Venkatesan M. FRAX and the assessment of the risk of developing a fragility fracture. ACTA ACUST UNITED AC 2012; 94:1313-20. [PMID: 23015554 DOI: 10.1302/0301-620x.94b10.28889] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Osteoporosis is common and the health and financial cost of fragility fractures is considerable. The burden of cardiovascular disease has been reduced dramatically by identifying and targeting those most at risk. A similar approach is potentially possible in the context of fragility fractures. The World Health Organization created and endorsed the use of FRAX, a fracture risk assessment tool, which uses selected risk factors to calculate a quantitative, patient-specific, ten-year risk of sustaining a fragility fracture. Treatment can thus be based on this as well as on measured bone mineral density. It may also be used to determine at-risk individuals, who should undergo bone densitometry. FRAX has been incorporated into the national osteoporosis guidelines of countries in the Americas, Europe, the Far East and Australasia. The United Kingdom National Institute for Health and Clinical Excellence also advocates its use in their guidance on the assessment of the risk of fragility fracture, and it may become an important tool to combat the health challenges posed by fragility fractures.
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Affiliation(s)
- R G Middleton
- Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire GL53 7AN, UK
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Pasco JA, Nicholson GC, Kotowicz MA. Cohort Profile: Geelong Osteoporosis Study. Int J Epidemiol 2011; 41:1565-75. [PMID: 23283714 DOI: 10.1093/ije/dyr148] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Julie A Pasco
- School of Medicine, Deakin University, Geelong, Victoria, Australia.
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