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Direct comparison of FRAXR and a simplified fracture risk assessment tool in routine clinical practice: a registry-based cohort study

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Abstract

Summary

FRAXR incrementally improved prediction of incident major osteoporotic fractures compared with the simplified Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool.

Introduction

There is debate over the value of seemingly more complex fracture prediction tools over simpler fracture prediction tools. FRAXR and the simplified CAROC tool are both widely used in Canada for estimating 10-year probability of major osteoporotic fractures. We compared the performance of these tools for predicting fracture outcomes.

Methods

Using a bone densitometry registry for Manitoba, Canada, we identified 34,060 individuals age ≥50 years not receiving anti-osteoporosis therapy. Fracture Risk Assessment (FRAX) and CAROC were used to classify 10-year fracture risk as low (<10 %), moderate (10–20 %) and high (>20 %). Net reclassification improvement (NRI) was used to quantify the performance of FRAX versus CAROC.

Results

During mean 9.8 years of follow-up, 3905 individuals sustained fractures. There were 10 (of 35 total) situations where observed fracture risk fell outside of the predicted range, and all 10 discordances favoured FRAX. NRI among incident fracture cases was not significantly changed, but there was a significant improvement in risk categorization for those who remained fracture-free (+1.7 %, P < 0.001) resulting in overall improvement (NRI overall +0.028, P < 0.001). Within nine pre-specified subgroups, there was no case of significant worsening in NRI when using FRAX instead of CAROC. In absolute terms, only 36 individuals would need to be assessed using FRAX instead of CAROC to yield an improvement in prediction (8 among individuals with prior fracture and 4 among those with prolonged glucocorticoid use).

Conclusions

FRAX provides improvement in fracture risk prediction compared with the simplified CAROC tool in individuals referred for osteoporosis screening, supporting the use of FRAX as the international reference tool for fracture risk assessment.

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Acknowledgments

The authors acknowledge the Manitoba Centre for Health Policy (MCHP) for use of data contained in the Population Health Research Data Repository (HIPC Project Number 2011/2012-31). The results and conclusions are those of the authors, and no official endorsement by the MCHP, Manitoba Health or other data providers is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.

LML is supported by a Manitoba Research Chair. SRM holds the Endowed Chair in Patient Health Management (Faculties of Medicine and Dentistry and Pharmacy and Pharmaceutical Sciences, University of Alberta).

Author information

Authors and Affiliations

  1. University of Manitoba, Winnipeg, Canada

    W. D. Leslie & L. M. Lix

  2. Department of Medicine (C5121), St. Boniface Hospital, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada

    W. D. Leslie

  3. University of Alberta, Edmonton, Canada

    S. R. Majumdar

  4. University of Toronto, Toronto, Canada

    R. G. Josse

  5. Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK

    H. Johansson, A. Oden, E. V. McCloskey & J. A. Kanis

Authors
  1. W. D. Leslie
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  2. S. R. Majumdar
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  3. L. M. Lix
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  4. R. G. Josse
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  5. H. Johansson
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  6. A. Oden
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  7. E. V. McCloskey
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  8. J. A. Kanis
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Corresponding author

Correspondence to W. D. Leslie.

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Conflicts of interest

None.

Financial activities outside the submitted work (last 3 years): WDL: Speaker fees Amgen, Eli Lily and Novartis and research grants Amgen (all paid to institution). RGJ: Consultancy fees and speaker honoraria: Amgen, Merck and Lilly and research grant Amgen. EVM: Consultancy fees, research funding and/or speaker fees from ActiveSignal, Amgen, AstraZeneca, Consilient Healthcare, GSK, Hologic, Internis, Lilly, Medtronic, Merck, Novartis, Pfizer, Roche, Sanofi-Aventis, Servier, Synexus, Tethys, UCB and Warner Chilcott and research support from ARUK, I3 Innovus, MRC, IOF and Unilever. JAK: Ad hoc consulting AgNovos Healthcare, Amgen, D3A, Lilly and Medimaps; research support Asahi, GSK, Lilly, Medtronic, Novartis, Pfizer, Radius Health, Roche, Sanofi-Aventis, Servier and Warner-Chilcott; and speaker’s fees Amgen, Pfizer, Servier and Takeda.

SRM, LML, HJ and AO have nothing to disclose.

Personal non-pecuniary interests: WDL: Director of the Manitoba Bone Mineral Density Program and President of the International Society for Clinical Densitometry. JAK: Architect of FRAX and President, International Osteoporosis Foundation.

Funding

No funding support was received for this research.

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Leslie, W.D., Majumdar, S.R., Lix, L.M. et al. Direct comparison of FRAXR and a simplified fracture risk assessment tool in routine clinical practice: a registry-based cohort study. Osteoporos Int 27, 2689–2695 (2016). https://doi.org/10.1007/s00198-016-3613-8

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  • DOI: https://doi.org/10.1007/s00198-016-3613-8

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