Osteoporosis International

, Volume 24, Issue 2, pp 681–688

Competing mortality and fracture risk assessment

  • W. D. Leslie
  • L. M. Lix
  • X. Wu
  • On behalf of the Manitoba Bone Density Program
Original Article

DOI: 10.1007/s00198-012-2051-5

Cite this article as:
Leslie, W.D., Lix, L.M., Wu, X. et al. Osteoporos Int (2013) 24: 681. doi:10.1007/s00198-012-2051-5



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.


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.


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).


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 %).


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.


Fracture prediction FRAX® Mortality Osteoporosis Survival analysis 

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2012

Authors and Affiliations

  • W. D. Leslie
    • 1
    • 3
  • L. M. Lix
    • 2
  • X. Wu
    • 2
  • On behalf of the Manitoba Bone Density Program
  1. 1.University of ManitobaWinnipegCanada
  2. 2.University of SaskatchewanSaskatoonCanada
  3. 3.Department of MedicineSt. Boniface General HospitalWinnipegCanada