To the Editor A recent study by Dr Crandall and colleagues 1 found that both the Osteoporosis Self-Assessment Tool and the US version of the Fracture Risk Assessment Tool (US FRAX), which includes racial and ethnic categories, exhibited suboptimal performance in discriminating major osteoporotic fractures (MOFs) among younger postmenopausal women. Routine use of the US FRAX was not recommended for making screening decisions in younger postmenopausal women. However, we have certain concerns.First, the incorporation of race-based adjustments in clinical assessment tools has the potential to exacerbate health inequalities. In the case of the US FRAX, the calculator produces a lower fracture risk estimation for Asian (0.50), Black (0.43), and Hispanic (0.53) women compared with White women. 2 This raises concerns because it suggests that Asian, Black, and Hispanic women are perceived as half as likely to experience a MOF over a 10-year period, which could delay treatment for individuals who are not of White race. Although reliable data indicate that fracture risk differs among racial and ethnic groups-even when bone mineral density (BMD) is the same 3 -we believe that the inclusion of BMD information is crucial. However, the study by Dr Crandall and colleagues 1 mainly evaluated US FRAX without BMD information. We assert that a comprehensive approach should involve multiple clinical tools, such as BMD and FRAX, to identify high-risk patients and ensure appropriate treatment rather than labeling a single tool as suboptimal or recommending against its routine use.Second, the study 1 focused on incident MOFs as the primary end point. However, it is worth considering that outcomes may vary following MOFs, with racial and ethnic disparities being observed. A recent population-based study 4 that utilized Medicare claims data to analyze Black women and White women with MOFs revealed that the Black participants faced a statistically significant higher risk of mortality, disability, and poverty compared with the White participants for most types of fractures during the 1-year period after MOFs.Third, the equations used for the Osteoporosis Self-Assessment Tool calculations in the study 1 may be misleading. A more accurate representation of the equation should be 0.2 × (body weight in kilograms − age in years), 5 instead of 0.2 × body weight in kilograms − age in years.Lastly, despite its imperfections and limitations, the US FRAX provides quantitative estimates of fracture risk that are included in evidence-based clinical practice guidelines. When used in conjunction with other relevant clinical information, it can assist clinicians in making individualized treatment decisions that are fair and cost-effective.