Osteoporosis International

, Volume 21, Issue 12, pp 2135–2142

Validation of a 5-year risk score of hip fracture in postmenopausal women. The Danish Nurse Cohort Study

  • Y. A. Hundrup
  • R. K. Jacobsen
  • A. H. Andreasen
  • M. Davidsen
  • E. B. Obel
  • B. Abrahamsen
Original Article

Abstract

Summary

We evaluated the Women’s Health Initiative (WHI) hip fracture risk score in 15,648 postmenopausal Danish nurses. The algorithm was well calibrated for Denmark. However, the sensitivity was poor at common decision making thresholds. Obtaining sensitivity better than 80% led to a low specificity of 61.4%.

Introduction

A new score based on data from the WHI has been designed to predict 5-year risk of hip fracture in postmenopausal women. The performance of the algorithm has not been validated in populations with different lifestyle characteristics and ethnicity. The aim of this study was to test the clinical performance of the algorithm in a large Danish cohort of postmenopausal Caucasian women against hip fracture.

Methods

The Danish Nurse Cohort is a prospective risk factor and hormone therapy (HT) study established in 1993. Participants in the present analysis were 15,648 postmenopausal nurses. The calibration and diagnostic performance of the WHI algorithm was evaluated using fracture events captured in the Danish National Hospital Registry.

Results

During 5 years of follow-up, 122 participants suffered a hip fracture (1.8/1,000 person years). The WHI algorithm predicted that 107 hip fractures would occur, indicating an underestimation of the number of fractures by 12%. To obtain sensitivity better than 80%, the cut-off value for 5-year risk was set to 0.5%, which was accompanied by a low positive predictive value of 1.9% and a low specificity of 61.4%. The algorithm predicted too many fractures in HT-users (12 observed, 22 expected) and too few in non HT-users (107 observed, 81 expected).

Conclusions

While the WHI algorithm was well calibrated on the Danish population, the clinical utility of the WHI algorithm in Danish postmenopausal women was limited by poor sensitivity at common decision-making thresholds and suboptimal in non-HT-users.

Keywords

Cohort study Hip fracture risk score Osteoporosis Postmenopausal women Validation study 

References

  1. 1.
    Study Group WHO (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis 843:1–129Google Scholar
  2. 2.
    Gullberg B, Johnell O, Kanis JA (1997) Worldwide projections for hip fracture. Osteoporos Int 7:407–413CrossRefPubMedGoogle Scholar
  3. 3.
    Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17:1237–1244CrossRefPubMedGoogle Scholar
  4. 4.
    Vestergaard P, Rejnmark L, Mosekilde L (2008) Strongly increasing incidence of hip fractures in Denmark from 1977 to 1999. Ugeskr Laeger 170:621–623PubMedGoogle Scholar
  5. 5.
    Cummings SR, Nevitt MC, Browner WS, Stone K, Fox CS, Ensrud K, Cauley JA, Black D, Voght TM (1995) Risk factors for hip fracture in white women. N Engl J Med 332:767–773CrossRefPubMedGoogle Scholar
  6. 6.
    Lane NE (2006) Epidemiology, etiology, and diagnosis of osteoporosis. Am J Obstet Gynecol 194:S3–S11CrossRefPubMedGoogle Scholar
  7. 7.
    Cauley JA, Wu LL, Wampler NS, Barnhart JM, Alison M, Chen Z, Jackson R, Robbins J (2007) Clinical risk factors for fractures in multi-ethnic women: the women’s health initiative. J Bone Miner Res 22:1816–1826CrossRefPubMedGoogle Scholar
  8. 8.
    Hannan MT, Felson DT, Dawson-Hughes B, Tucker KL, Cupples LA, Wilson PWF, Kiel DP (2000) Risk factors for longitudinal bone loss in elderly men and women: the Framingham Osteoporosis Study. J Bone Miner Res 15:710–720CrossRefPubMedGoogle Scholar
  9. 9.
    Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS, Johnell O (2001) An assessment tool for predicting fracture risk in postmenopausal women. Osteoporosis Int 12:519–528CrossRefGoogle Scholar
  10. 10.
    Buist DS, Lacroix A, Manfredonia D, Abbott T (2002) Identifying postmenopausal women at high risk of fracture in populations: a comparison of three strategies. J Am Geriatr Soc 50:1031–1038CrossRefPubMedGoogle Scholar
  11. 11.
    Cadarette SM, Jaglal SB, Murray TM, Mclsaac WJ, Joseph L, Brown JP, Canadian Multicentre Osteoporosis Study (CaMos) (2001) Evaluation of decision rules for referring women for bone densitometry by dual-energy X-ray absorptiometry. JAMA 286:57–63CrossRefPubMedGoogle Scholar
  12. 12.
    McGrother CW, Donaldson MMK, Clayton D, Abrams KR, Clarke M (2002) Evaluation of a hip fracture risk score for assessing elderly women: the Melton Osteoporotic Fracture (MOF) Study. Osteoporos Int 13:89–96CrossRefPubMedGoogle Scholar
  13. 13.
    Miller PD, Barlas S, Brenneman SK, Abott TA, Chen Y, Barrett-Connor EL, Siris ES (2004) An approach to identifying osteopenic women at increased short-term risk of fracture. Arch Intern Med 164:1113–1120CrossRefPubMedGoogle Scholar
  14. 14.
    Schott AM, Ganne C, Hans D, Monnier G, Gauchoux R, Krieg MA, Delmas PD, Meunier PJ, Colin C (2007) Which screening strategy using BMD measurements would be most cost effective for hip fracture prevention in elderly women? Osteoporos Int 18:143–151CrossRefPubMedGoogle Scholar
  15. 15.
    Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanik ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J, Writing Group for the Women’s Health Initiative Investigators (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the women’s health initiative. Randomized controlled trial. JAMA 288:321–333CrossRefPubMedGoogle Scholar
  16. 16.
    Robbins J, Aragaki AK, Kooperberg C, Watts N, Wactawski-Wende J, Jackson RD, LeBoff MS, Lewis CE, Chen Z, Stefanick ML, Cauley JA (2007) Factors associated with 5-year risk of hip fracture in postmenopausal women. JAMA 298:2389–2398CrossRefPubMedGoogle Scholar
  17. 17.
    Hundrup YA, Høidrup S, Ekholm O, Davidsen M, Obel EB (2004) Risk of low-energy hip, wrist, and upper arm fractures among current and previous users of hormone replacement therapy. The Danish Nurse Cohort Study. Eur J Epidemiol 19:1089–1095CrossRefPubMedGoogle Scholar
  18. 18.
    Hundrup YA, Ekholm O, Høidrup S, Davidsen M, Obel EB (2005) Risk factors for hip fracture and a possible effect modification by hormone replacement therapy. The Danish Nurse Cohort Study. Eur J Epidemiol 19:1089–1095CrossRefGoogle Scholar
  19. 19.
    Miller ME, Hui S, Tierney WM (1991) Validation techniques for logistic regression models. Stat Med 10:1213–1226CrossRefPubMedGoogle Scholar
  20. 20.
    Black D, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosatio-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings S, The Horizon Pivotal Fracture Trial (2007) Once yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 356:1809–1821CrossRefPubMedGoogle Scholar
  21. 21.
    van Staa T-P, Kanis JP, Geussens P, Boonen A, Leufkens HGM, Cooper C (2007) The cost-effectiveness of bisphosphonates in postmenopausal women based on individual long-term fracture risks. Value Health 10:348–357CrossRefPubMedGoogle Scholar
  22. 22.
    Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, Burckardt P, Cooper C, Christiansen C, Cummings S, Eisman JA, Fujiwara S, Glüer C, Goltzman D, Hans D, Krieg MA, Lacroix A, McCloskey E, Mellstrom D, Melton LJ III, Pols H, Reeve J, Sanders K, Schott A-M, Silman A, Torgerson D, van Staa T-P, Watts NB, Yoshimura N (2007) The use of clinical risk factors enhances the performance of BMD in prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18:1046CrossRefGoogle Scholar
  23. 23.
    Seeman E, Devogelaer J-P, Lorence R, Spector T, Brixen K, Balogh A, Stucki G, Reginster J-Y (2008) Strontium ranelate reduces the risk of vertebral fractures in patients with osteopenia. J Bone Miner Res 23:433–438CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2010

Authors and Affiliations

  • Y. A. Hundrup
    • 1
  • R. K. Jacobsen
    • 1
  • A. H. Andreasen
    • 1
  • M. Davidsen
    • 2
  • E. B. Obel
    • 3
  • B. Abrahamsen
    • 4
    • 5
  1. 1.Research Centre for Prevention and Health, The Capital Region of DenmarkGlostrup University HospitalGlostrupDenmark
  2. 2.National Institute of Public HealthUniversity of Southern DenmarkCopenhagenDenmark
  3. 3.Department of GynaecologyHillerød HospitalHillerødDenmark
  4. 4.Department of Medicine and EndocrinologyCopenhagen University Hospital GentofteHellerupDenmark
  5. 5.Institute of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark

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