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Risk-equivalent T-score adjustment for using lumbar spine trabecular bone score (TBS): the Manitoba BMD registry

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Abstract

Summary

Lumbar spine trabecular bone score (TBS) can be used to modify the output from the fracture risk assessment tool, FRAX, to enhance fracture prediction. An alternative approach for using TBS in clinical practice, based upon an adjustment to the bone mineral density (BMD) T-score, may be helpful in regions where intervention guidelines and/or reimbursement are primarily based on BMD T-score.

Introduction

The aim of this study is to develop an approach for using TBS in clinical practice based upon a “risk-equivalent” adjustment to the BMD T-score.

Methods

We identified 45,185 women age 40 years and older with baseline spine and hip DXA, TBS, and FRAX probabilities including femoral neck BMD. Incident major osteoporotic fractures (MOF, n = 3925) were identified from population-based health services data (mean follow-up 7.4 years comprising 335,910 person-years). Cox proportional hazards models adjusted for age and BMI were first used to estimate the risk for MOF from BMD T-score alone, then after including TBS and a multiplicative age interaction term. From the parameter estimates, we developed a TBS offset to the BMD T-score based upon change in TBS that would give the same risk as a unit change in BMD T-score for the femoral neck, total hip, and lumbar spine.

Results

All BMD measurements, TBS, and the age interaction term independently predicted MOF (p < 0.001). Measures of risk stratification and model fit were improved for the TBS-adjusted BMD T-score versus the unadjusted BMD T-score (p < 0.001). There was a high level of agreement between MOF probability estimated from TBS-adjusted MOF FRAX probability and FRAX probability using the “risk-equivalent” femoral BMD T-score: MOF probability r2 = 0.98, slope = 1.02, intercept = − 0.3; hip probability r2 = 0.95, slope = 1.07, intercept = 0.0.

Conclusions

The BMD-independent effect of lumbar spine TBS on fracture risk can be estimated as a simple offset to the BMD T-score.

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Acknowledgments

The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository (HIPC 2012/2013-18). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Healthy Living, and Seniors, 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.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, University of Manitoba, (C5121) 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada

    W. D. Leslie

  2. Bone and Joint Department, Lausanne University Hospital, Lausanne, Switzerland

    E. Shevroja & D. Hans

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

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

  4. Institute for Health and Aging, Catholic University of Australia, Melbourne, Australia

    H. Johansson & J. A. Kanis

  5. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

    N. C. Harvey

  6. NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK

    N. C. Harvey

Authors
  1. W. D. Leslie
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  2. E. Shevroja
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  3. H. Johansson
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  4. E. V. McCloskey
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  5. N. C. Harvey
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  6. J. A. Kanis
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  7. D. Hans
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Contributions

Conception, design, and analysis (WDL); interpretation of data (all authors); drafting the article (ES); critically revising the article for important intellectual content (all authors); final approval of the version to be published (all authors); and agreement to be accountable for all aspects of the work (all authors). WDL had full access to all the data in the study and takes the responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to W. D. Leslie.

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Conflicts of interest

Eugene McCloskey: Nothing to declare for FRAX and the context of this paper, but numerous ad hoc consultancies/speaking honoraria and/or research funding from Amgen, Bayer, General Electric, GSK, Hologic, Lilly, Merck Research Labs, Novartis, Novo Nordisk, Nycomed, Ono, Pfizer, ProStrakan, Roche, Sanofi-Aventis, Servier, Tethys, UBS, and Warner-Chilcott.

Didier Hans: Co-ownership in the TBS patent. Stock options or royalties: Med-Imaps. Research grants: Amgen, Radius Pharma, Agnovos, GE Healthcare.

Nicholas Harvey: Nothing to declare for FRAX and the context of this paper but has received consultancy, lecture fees, and honoraria from Alliance for Better Bone Health, AMGEN, MSD, Eli Lilly, Servier, Shire, UCB, Radius, Consilient Healthcare, and Internis Pharma.

John A. Kanis: Grants from Amgen, grants from Lilly, non-financial support from Medimaps, grants from Unigene, nonfinancial support from Asahi, grants from Radius Health, outside the submitted work; and Dr. Kanis is the architect of FRAX but has no financial interest. Governmental and NGOs: National Institute for health and clinical Excellence (NICE), UK; International Osteoporosis Foundation; INSERM, France; Ministry of Public Health, China; Ministry of Health, Australia; Ministry of Health, Abu Dhabi; National Osteoporosis Guideline Group, UK; WHO.

Appendix

Appendix

Mean-centered age (AgeC) is calculated as age − 63.5; mean-centered age-normalized TBS (TBSCAN) is calculated as TBSCAN = (TBS − 1.32) + AgeC × 0.00413, where 1.32 is the mean TBS of the study population, 63.5 is the mean age, and 0.00413 is the β-coefficient of age in the linear regression with TBS.

Relative gradients were calculated as the ratios of the Cox model parameter estimates of BMD T-score alone versus the parameter estimate of TBSCAN, or versus the parameter estimate of AgeC × TBSCAN interaction term. From Table 2, the relative gradients for TBSCAN for the femoral neck (FN), total hip (TH), and lumbar spine (LS) regions were 0.28, 0.29, and 0.13, respectively, and for the AgeN × TBSCAN interaction term were − 7.63, − 6.89, and − 3.26, respectively. The calculation of TBS-adjusted BMD T-scores for the three regions is as follows:

  • TBS-adjusted FN BMD T-score = FN BMD T-score + TBSCAN/0.28 − AgeC × TBSCAN/7.63

  • TBS-adjusted hip BMD T-score = hip BMD T-score + TBSCAN/0.29 − AgeC × TBSCAN/6.89

  • TBS-adjusted LS BMD T-score = LS BMD T-score + TBSCAN/0.13 − AgeC × TBSCAN/3.26

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Leslie, W.D., Shevroja, E., Johansson, H. et al. Risk-equivalent T-score adjustment for using lumbar spine trabecular bone score (TBS): the Manitoba BMD registry. Osteoporos Int 29, 751–758 (2018). https://doi.org/10.1007/s00198-018-4405-0

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