Osteoporosis International

, Volume 19, Issue 4, pp 449–458 | Cite as

Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA

  • B. Dawson-Hughes
  • A. N. A. Tosteson
  • L. J. MeltonIII
  • S. Baim
  • M. J. Favus
  • S. Khosla
  • R. L. Lindsay
Special Position Paper



Application of the WHO fracture prediction algorithm in conjunction with an updated US economic analysis indicates that osteoporosis treatment is cost-effective in patients with fragility fractures or osteoporosis, in older individuals at average risk and in younger persons with additional clinical risk factors for fracture, supporting existing practice recommendations.


The new WHO fracture prediction algorithm was combined with an updated economic analysis to evaluate existing NOF guidance for osteoporosis prevention and treatment.


The WHO fracture prediction algorithm was calibrated to the US population using national age-, sex- and race-specific death rates and age- and sex-specific hip fracture incidence rates from the largely white population of Olmsted County, MN. Fracture incidence for other races was estimated by ratios to white women and men. The WHO algorithm estimated the probability (%) of a hip fracture (or a major osteoporotic fracture) over 10 years, given specific age, gender, race and clinical profiles. The updated economic model suggested that osteoporosis treatment was cost-effective when the 10-year probability of hip fracture reached 3%.


It is cost-effective to treat patients with a fragility fracture and those with osteoporosis by WHO criteria, as well as older individuals at average risk and osteopenic patients with additional risk factors. However, the estimated 10-year fracture probability was lower in men and nonwhite women compared to postmenopausal white women.


This analysis generally endorsed existing clinical practice recommendations, but specific treatment decisions must be individualized. An estimate of the patient’s 10-year fracture risk should facilitate shared decision-making.


Fracture prediction National Osteoporosis Foundation Osteoporosis Practice guidelines World Health Organization 


  1. 1.
    NOF (2005) National Osteoporosis Foundation: Physician Guide to Prevention and Treatment of Osteoporosis. www.nof.org/physguide/index.htm
  2. 2.
    Kanis JA, Melton LJ III, Christiansen C et al (1994) The diagnosis of osteoporosis. J Bone Miner Res 9:1137–1141PubMedCrossRefGoogle Scholar
  3. 3.
    Kanis JA, Johnell O, De Laet C et al (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382PubMedCrossRefGoogle Scholar
  4. 4.
    U. S. Preventive Services Task Force (2002) Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 137:526–528Google Scholar
  5. 5.
    Eddy D, Johnston CC, Cummings SR et al (1998) Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Osteoporos Int 8 Suppl 4:S7–80Google Scholar
  6. 6.
    Rossouw JE, Anderson GL, Prentice RL et al (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 288:321–333PubMedCrossRefGoogle Scholar
  7. 7.
    Anderson GL, Limacher M, Assaf AR et al (2004) Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women’s Health Initiative randomized controlled trial.[see comment]. JAMA 291:1701–1712PubMedCrossRefGoogle Scholar
  8. 8.
    Rosen CJ (2005) Clinical practice. Postmenopausal osteoporosis. N Engl J Med 353:595–603PubMedCrossRefGoogle Scholar
  9. 9.
    U.S.D.H.H.S. (2004) Chapter 4. The Frequency of Bone Disease. Bone Health and Osteoporosis: A Report of the Surgeon General. U.S. Department of Health and Human Services, Rockville, MD, pp 69–87Google Scholar
  10. 10.
    Burge R, Dawson-Hughes B, Solomon DH et al (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475PubMedCrossRefGoogle Scholar
  11. 11.
    Börgstrom F, Johnell O, Kanis JA et al (2006) At what hip fracture risk is it cost-effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int 17:1459–1471PubMedCrossRefGoogle Scholar
  12. 12.
    Kanis JA, Johnell O, Oden A et al. (2008) FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporos Int DOI 10.1007/s00198-007-0543-5
  13. 13.
    Tosteson AN (2008) Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int DOI 10.1007/s00198-007-0550-6
  14. 14.
    Murphy DJ, Gahm GJ, Santilli S et al (2002) Seniors’ preferences for cancer screening and medication use based on absolute risk reduction. J Gerontol A Biol Sci Med Sci 57A:M100–105Google Scholar
  15. 15.
    Leslie WD, Siminoski K, Brown JP (2007) Comparative effects of densitometric and absolute fracture risk classification systems on projected intervention rates in postmenopausal women. J Clin Densitom 10:124–131PubMedCrossRefGoogle Scholar
  16. 16.
    Bonjour P, Clark P, Cooper C et al. (2007) Assessment of Osteoporosis at the Primary Care Level. WHO Technical Report Series. WHO, GenevaGoogle Scholar
  17. 17.
    Oden A, Dawson A, Dere W et al (1998) Lifetime risk of hip fracture is underestimated. Osteoporos Int 8:599–603PubMedCrossRefGoogle Scholar
  18. 18.
    Looker AC, Wahner HW, Dunn WL et al (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8:468–489PubMedCrossRefGoogle Scholar
  19. 19.
    Kanis JA, Oden A, Johnell O et al (2007) The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18:1033–1046PubMedCrossRefGoogle Scholar
  20. 20.
    Arias E, Anderson RN, Kung HC et al (2003) Deaths: final data for 2001. Natl Vital Stat Rep 52:1–115PubMedGoogle Scholar
  21. 21.
    Melton LJ III, Crowson CS, O’Fallon WM (1999) Fracture incidence in Olmsted County, Minnesota: Comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int 9:29–37PubMedCrossRefGoogle Scholar
  22. 22.
    Arneson TJ, Melton LJ III, Lewallen DG et al (1988) Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965–1984. Clin Orthop 234:188–194PubMedGoogle Scholar
  23. 23.
    Bauer RL (1988) Ethnic differences in hip fracture: a reduced incidence in Mexican Americans. Am J Epidemiol 127:145–149PubMedGoogle Scholar
  24. 24.
    Silverman SL, Madison RE (1988) Decreased incidence of hip fracture in Hispanics, Asians, and blacks: California Hospital Discharge Data. Am J Public Health 78:1482–1483PubMedGoogle Scholar
  25. 25.
    Jacobsen SJ, Goldberg J, Miles TP et al (1990) Hip fracture incidence among the old and very old: a population-based study of 745,435 cases. Am J Public Health 80:871–873PubMedGoogle Scholar
  26. 26.
    Griffin MR, Ray WA, Fought RL et al (1992) Black-white differences in fracture rates. Am J Epidemiol 136:1378–1385PubMedGoogle Scholar
  27. 27.
    Baron JA, Barrett J, Malenka D et al (1994) Racial differences in fracture risk. Epidemiology 5:42–47PubMedCrossRefGoogle Scholar
  28. 28.
    Baron JA, Karagas M, Barrett J et al (1996) Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology 7:612–618PubMedCrossRefGoogle Scholar
  29. 29.
    Zingmond DS, Melton LJ 3rd, Silverman SL (2004) Increasing hip fracture incidence in California Hispanics, 1983 to 2000. Osteoporos Int 15:603–610PubMedCrossRefGoogle Scholar
  30. 30.
    Lauderdale DS, Jacobsen SJ, Furner SE et al (1998) Hip fracture incidence among elderly Hispanics. Am J Public Health 88:1245–1247PubMedCrossRefGoogle Scholar
  31. 31.
    Lauderdale DS, Jacobsen SJ, Furner SE et al (1997) Hip fracture incidence among elderly Asian-American populations. Am J Epidemiol 146:502–509PubMedGoogle Scholar
  32. 32.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767PubMedCrossRefGoogle Scholar
  33. 33.
    Kanis JA, Borgstrom F, De Laet C et al (2005) Assessment of fracture risk. Osteoporos Int 16:581–589PubMedCrossRefGoogle Scholar
  34. 34.
    Flegal KM, Carroll MD, Ogden CL et al (2002) Prevalence and trends in obesity among US adults, 1999–2000. JAMA 288:1723–1728PubMedCrossRefGoogle Scholar
  35. 35.
    Ogden CL, Fryar CD, Carroll MD et al (2004) Mean body weight, height, and body mass index, United States 1960–2002. Adv Data 347:1–17PubMedGoogle Scholar
  36. 36.
    Kanis JA, Black D, Cooper C et al (2002) A new approach to the development of assessment guidelines for osteoporosis. Osteoporos Int 13:527–536PubMedCrossRefGoogle Scholar
  37. 37.
    Delmas PD, Rizzoli R, Cooper C et al (2005) Treatment of patients with postmenopausal osteoporosis is worthwhile. The position of the International Osteoporosis Foundation. Osteoporos Int 16:1–5PubMedCrossRefGoogle Scholar
  38. 38.
    Lewiecki EM (2005) Review of guidelines for bone mineral density testing and treatment of osteoporosis. Curr Osteoporos Rep 3:75–83PubMedCrossRefGoogle Scholar
  39. 39.
    Kanis JA, Borgstrom F, Zethraeus N et al (2005) Intervention thresholds for osteoporosis in the UK. Bone 36:22–32PubMedCrossRefGoogle Scholar
  40. 40.
    Kanis JA, Johnell O, Oden A et al (2005) Intervention thresholds for osteoporosis in men and women: a study based on data from Sweden. Osteoporos Int 16:6–14PubMedCrossRefGoogle Scholar
  41. 41.
    Cummings SR (2006) A 55-year-old woman with osteopenia. JAMA 296:2601–2610PubMedCrossRefGoogle Scholar
  42. 42.
    Khosla S, Melton LJ III (2007) Osteopenia. N Engl J Med 356:2293–2300PubMedCrossRefGoogle Scholar
  43. 43.
    Siris ES, Chen YT, Abbott TA et al (2004) Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 164:1108–1112PubMedCrossRefGoogle Scholar
  44. 44.
    Pasco JA, Seeman E, Henry MJ et al (2006) The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int 17:1404–1409PubMedCrossRefGoogle Scholar
  45. 45.
    Sanders KM, Nicholson GC, Watts JJ et al (2006) Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost-effective? Bone 38:694–700PubMedCrossRefGoogle Scholar
  46. 46.
    Cummings SR, Black DM, Thompson DE et al (1998) Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 280:2077–2082PubMedCrossRefGoogle Scholar
  47. 47.
    De Laet C, Oden A, Johansson H et al (2005) The impact of the use of multiple risk indicators for fracture on case-finding strategies: a mathematical approach. Osteoporos Int 16:313–318PubMedCrossRefGoogle Scholar
  48. 48.
    Schousboe JT, Ensrud KE, Nyman JA et al (2005) Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women. J Am Geriatr Soc 53:1697–1704PubMedCrossRefGoogle Scholar
  49. 49.
    Kanis JA, Johansson H, Oden A et al (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19:893–899PubMedCrossRefGoogle Scholar
  50. 50.
    Anonymous (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis. Arthritis Rheum 44:1496–1503CrossRefGoogle Scholar
  51. 51.
    U.S.D.H.H.S. (2004) Chapter 3. Diseases of Bone. In Bone Health and Osteoporosis: A Report of the Surgeon General. U.S. Department of Health and Human Services, Office of the Surgeon General, Rockville, MD, pp 41–65Google Scholar
  52. 52.
    Alam NM, Archer JA, Lee E (2004) Osteoporotic fragility fractures in African Americans: under-recognized and undertreated. J Natl Med Assoc 96:1640–1645PubMedGoogle Scholar
  53. 53.
    Farley JF, Cline RR, Gupta K (2006) Racial variations in antiresorptive medication use: results from the 2000 Medical Expenditure Panel Survey (MEPS). Osteoporos Int 17:395–404PubMedCrossRefGoogle Scholar
  54. 54.
    Melton LJ III, Marquez MA, Achenbach SJ et al (2002) Variations in bone density among persons of African heritage. Osteoporos Int 13:551–559CrossRefGoogle Scholar
  55. 55.
    Barrett-Connor E, Siris ES, Wehren LE et al (2005) Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res 20:185–194PubMedCrossRefGoogle Scholar
  56. 56.
    Cauley JA, Lui LY, Ensrud KE et al (2005) Bone mineral density and the risk of incident nonspinal fractures in black and white women. JAMA 293:2102–2108PubMedCrossRefGoogle Scholar
  57. 57.
    Hanlon JT, Landerman LR, Fillenbaum GG et al (2002) Falls in African American and white community-dwelling elderly residents. J Gerontol: Med Sci 57A:M473–478Google Scholar
  58. 58.
    Melton LJ III, Cooper C (2001) Magnitude and impact of osteoporosis and fractures. In: Marcus R, Feldman D, Kelsey J (eds) Osteoporosis. Academic Press, San Diego, pp 557–567CrossRefGoogle Scholar
  59. 59.
    Stafford RS, Drieling RL, Hersh AL (2004) National trends in osteoporosis visits and osteoporosis treatment, 1988–2003. Arch Intern Med 164:1525–1530PubMedCrossRefGoogle Scholar
  60. 60.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936PubMedCrossRefGoogle Scholar
  61. 61.
    Schousboe JT, Nyman JA, Kane RL et al (2005) Cost-effectiveness of alendronate therapy for osteopenic postmenopausal women. Ann Intern Med 142:734–741PubMedGoogle Scholar
  62. 62.
    Elliot-Gibson V, Bogoch ER, Jamal SA et al (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778PubMedGoogle Scholar
  63. 63.
    Browner WS (2007) Predicting fracture risk: tougher than it looks. BoneKEy 4:226–230Google Scholar
  64. 64.
    Ettinger B, Hillier TA, Pressman A et al (2005) Simple computer model for calculating and reporting 5-year osteoporotic fracture risk in postmenopausal women. J Women’s Health 14:159–171CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2008

Authors and Affiliations

  • B. Dawson-Hughes
    • 1
  • A. N. A. Tosteson
    • 2
    • 8
  • L. J. MeltonIII
    • 3
  • S. Baim
    • 4
  • M. J. Favus
    • 5
  • S. Khosla
    • 6
  • R. L. Lindsay
    • 7
  1. 1.Bone Metabolism Laboratory, Jean Mayer USDA Human Nutrition Research Center on AgingTufts UniversityBostonUSA
  2. 2.Multidisciplinary Clinical Research Center in Musculoskeletal Diseases and The Dartmouth Institute for Health Policy and Clinical PracticeDartmouth Medical SchoolLebanonUSA
  3. 3.Division of Epidemiology, College of MedicineMayo ClinicRochesterUSA
  4. 4.The Medical College of WisconsinMilwaukeeUSA
  5. 5.Department of MedicineUniversity of ChicagoChicagoUSA
  6. 6.Division of Endocrinology, College of MedicineMayo ClinicRochesterUSA
  7. 7.Helen Hayes HospitalRegional Bone CenterWest HaverstrawUSA
  8. 8.HB7505 Clinical Research, Dartmouth Medical SchoolOne Medical Center DriveLebanonUSA

Personalised recommendations