Prognosis of fracture: evaluation of predictive accuracy of the FRAX™ algorithm and Garvan nomogram

Sandhu, S. K.; Nguyen, Nguyen D.; Pocock, N. A.; Eisman, John A.; Nguyen, Tuan V.

doi:10.1007/s00198-009-1026-7

Cited by 138 publications

(88 citation statements)

References 26 publications

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“…Noteworthy, other investigators reported the lack of sensitivity of FRAX in elderly women (27)(28)(29) and in some male populations. (30) We found that parity, which is not included in the FRAX algorithm, was a significant predictor of the risk of major OP fracture, independent of BMD and of the other CRFs. This risk factor may be more important with regard to fracture risk prediction in early postmenopausal women than in older women.…”

Section: Discussionmentioning

confidence: 67%

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: Sensitivity of the WHO FRAX tool

Trémollières

Pouillès

Drewniak

et al. 2010

Journal of Bone and Mineral Research

178

114

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The aim of this prospective study was (1) to identify significant and independent clinical risk factors (CRFs) for major osteoporotic (OP) fracture among peri-and early postmenopausal women, (2) to assess, in this population, the discriminatory capacity of FRAX and bone mineral density (BMD) for the identification of women at high risk of fracture, and (3) to assess whether adding risk factors to either FRAX or BMD would improve discriminatory capacity. The study population included 2651 peri-and early postmenopausal women [mean age (AE SD): 54 AE 4 years] with a mean follow-up period of 13.4 years (AE1.4 years). At baseline, a large set of CRFs was recorded, and vertebral BMD was measured (Lunar, DPX) in all women. Femoral neck BMD also was measured in 1399 women in addition to spine BMD. Women with current or past OP treatment for more than 3 months at baseline (n ¼ 454) were excluded from the analyses. Over the follow-up period, 415 women sustained a first low-energy fracture, including 145 major OP fractures (108 wrist, 44 spine, 20 proximal humerus, and 13 hip). In Cox multivariate regression models, only 3 CRFs were significant predictors of a major OP fracture independent of BMD and age: a personal history of fracture, three or more pregnancies, and current postmenopausal hormone therapy. In the subsample of women who had a hip BMD measurement and who were not receiving OP therapy (including hormone-replacement therapy) at baseline, mean FRAX value was 3.8% (AE2.4%). The overall discriminative value for fracture, as measured by the area under the Receiver Operating Characteristic (ROC) curve (AUC), was equal to 0.63 [95% confidence interval (CI) 0.56-0.69] and 0.66 (95% CI 0.60-0.73), respectively, for FRAX and hip BMD. Sensitivity of both tools was low (ie, around 50% for 30% of the women classified as the highest risk). Adding parity to the predictive model including FRAX or using a simple risk score based on the best predictive model in our population did not significantly improve the discriminatory capacity over BMD alone. Only a limited number of clinical risk factors were found associated with the risk of major OP fracture in peri-and early postmenopausal women. In this population, the FRAX tool, like other risk scores combining CRFs to either BMD or FRAX, had a poor sensitivity for fracture prediction and did not significantly improve the discriminatory value of hip BMD alone. ß

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Section: Discussionmentioning

confidence: 67%

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: Sensitivity of the WHO FRAX tool

Trémollières

Pouillès

Drewniak

et al. 2010

Journal of Bone and Mineral Research

178

114

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“…In a study from an independent cohort of Australian men and women, assessing the ability of the Garvan model (including age, sex, prior fractures, falls, and either femoral neck BMD or body weight) and the FRAX algorithm to predict OP fracture, the authors found that the Garvan model had good discriminatory performance for fracture prediction in both men and women, whereas discriminatory performances of the FRAX was better in women than in men. (27) In addition, even if the number of hip fracture during follow-up was of the same order as the probability given by the calculation of FRAX, it was too low to permit further interpretable analysis. Finally, some differences between predicted probability and observed incidence of major OP fractures may become significant with a bigger sample size.…”

Section: Discussionmentioning

confidence: 97%

The FRAX tool in French women: How well does it describe the real incidence of fracture in the OFELY cohort

Sornay‐Rendu

Munoz

Delmas

et al. 2010

Journal of Bone and Mineral Research

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The FRAX tool estimates an individual's fracture probability over 10 years from clinical risk factors with or without bone mineral density (BMD) measurement. The aim of our study was to compare the predicted fracture probabilities and the observed incidence of fracture in French women during a 10-year follow-up. The probabilities of fracture at four major sites (hip, clinical spine, shoulder, or wrist) and at the hip were calculated with the FRAX tool in 867 women aged 40 years and over from the Os des Femmes de Lyon (OFELY) cohort. The incidence of fracture was observed over 10 years. Thus 82 women sustained 95 incident major osteoporotic (OP) fractures including 17 fractures at the hip. In women aged at least 65 years (n ¼ 229), the 10-year predicted probabilities of fracture with BMD were 13% for major OP fractures and 5% for hip fractures, contrasting with 3.6% and 0.5% in women younger than 65 years ( p < .0001). The predicted probabilities of both major OP and hip fractures were significantly higher in women with osteoporosis (n ¼ 77, 18% and 10%) and osteopenia (n¼ 390, 6% and 2%) compared with women with normal BMD (n ¼ 208, 3% and <1%; p < .0001. The predicted probabilities of fracture were two and five times higher in women who sustained an incident major OP fracture and a hip fracture compared with women who did not ( p < .0001). Nevertheless, among women aged at least 65 years with low BMD values (T-score -1; n ¼ 199), the 10-year predicted probability of major OP fracture with BMD was 48% lower than the observed incidence of fractures ( p < .01). A 10-year probability of major OP fracture higher than 12% identified more women with incident fractures than did BMD in the osteoporotic range ( p < .05). In French women from the OFELY cohort, the observed incidence of fragility fractures over 10 years increased with age following a pattern similar to the predicted probabilities given by the FRAX tool. However, in women aged at least 65 years with low BMD, the observed incidence of fractures was substantially higher than the predicted probability. ß

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“…On the other hand, Garvan underestimates fracture risk in women with a parent history of hip fracture and in women with secondary osteoporosis. In spite of these differences, both approaches were reasonably accurate in women [Sandhu et al 2009].…”

Section: Therapeutic Advances In Musculoskeletal Disease 2 (2)mentioning

confidence: 91%

“…In the Women's Health Initiative (WHI) study, 11 factors predicted hip fracture within 5 years, of which two were related to fall risk (self-reported health and self-reported physical activity), independent of age, weight, height, race/ethnicity, history of fracture after age 54 years, parental hip fracture, current smoking, current corticosteroid use, and treated diabetes [Sandhu et al 2009].…”

Section: Therapeutic Advances In Musculoskeletal Disease 2 (2)mentioning

confidence: 99%

Can hip fracture prediction in women be estimated beyond bone mineral density measurement alone?

Geusens

Geel

Bergh

2010

Therapeutic Advances in Musculoskeletal

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The etiology of hip fractures is multifactorial and includes bone and fall-related factors. Low bone mineral density (BMD) and BMD-related and BMD-independent geometric components of bone strength, evaluated by hip strength analysis (HSA) and finite element analysis analyses on dual-energy X-ray absorptiometry (DXA) images, and ultrasound parameters are related to the presence and incidence of hip fracture. In addition, clinical risk factors contribute to the risk of hip fractures, independent of BMD. They are included in the fracture risk assessment tool (FRAX) case finding algorithm to estimate in the individual patient the 10-year risk of hip fracture, with and without BMD. Fall risks are not included in FRAX, but are included in other case finding tools, such as the Garvan algorithm, to predict the 5-and 10-year hip fracture risk. Hormones, cytokines, growth factors, markers of bone resorption and genetic background have been related to hip fracture risk. Vitamin D deficiency is endemic worldwide and low serum levels of 25-hydroxyvitamin D [25(OH)D] predict hip fracture risk. In the context of hip fracture prevention calculation of absolute fracture risk using clinical risks, BMD, bone geometry and fall-related risks is feasible, but needs further refinement by integrating bone and fall-related risk factors into a single case finding algorithm for clinical use.

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Prognosis of fracture: evaluation of predictive accuracy of the FRAX™ algorithm and Garvan nomogram

Abstract: In this analysis, although both approaches were reasonably accurate in women, FRAX discriminated fracture risk poorly in men. These data support the concept that all algorithms need external validation before clinical implementation.

Cited by 138 publications

References 26 publications

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: Sensitivity of the WHO FRAX tool

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: Sensitivity of the WHO FRAX tool

The FRAX tool in French women: How well does it describe the real incidence of fracture in the OFELY cohort

Can hip fracture prediction in women be estimated beyond bone mineral density measurement alone?

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