Osteoporosis International

, Volume 22, Issue 3, pp 829–837

Fracture prediction and calibration of a Canadian FRAX® tool: a population-based report from CaMos

  • L.-A. Fraser
  • L. Langsetmo
  • C. Berger
  • G. Ioannidis
  • D. Goltzman
  • J. D. Adachi
  • A. Papaioannou
  • R. Josse
  • C. S. Kovacs
  • W. P. Olszynski
  • T. Towheed
  • D. A. Hanley
  • S. M. Kaiser
  • J. Prior
  • S. Jamal
  • N. Kreiger
  • J. P. Brown
  • H. Johansson
  • A. Oden
  • E. McCloskey
  • J. A. Kanis
  • W. D. Leslie
  • CaMos Research Group
Original Article

Abstract

Summary

A new Canadian WHO fracture risk assessment (FRAX®) tool to predict 10-year fracture probability was compared with observed 10-year fracture outcomes in a large Canadian population-based study (CaMos). The Canadian FRAX tool showed good calibration and discrimination for both hip and major osteoporotic fractures.

Introduction

The purpose of this study was to validate a new Canadian WHO fracture risk assessment (FRAX®) tool in a prospective, population-based cohort, the Canadian Multicentre Osteoporosis Study (CaMos).

Methods

A FRAX tool calibrated to the Canadian population was developed by the WHO Collaborating Centre for Metabolic Bone Diseases using national hip fracture and mortality data. Ten-year FRAX probabilities with and without bone mineral density (BMD) were derived for CaMos women (N = 4,778) and men (N = 1,919) and compared with observed fracture outcomes to 10 years (Kaplan–Meier method). Cox proportional hazard models were used to investigate the contribution of individual FRAX variables.

Results

Mean overall 10-year FRAX probability with BMD for major osteoporotic fractures was not significantly different from the observed value in men [predicted 5.4% vs. observed 6.4% (95%CI 5.2–7.5%)] and only slightly lower in women [predicted 10.8% vs. observed 12.0% (95%CI 11.0–12.9%)]. FRAX was well calibrated for hip fracture assessment in women [predicted 2.7% vs. observed 2.7% (95%CI 2.2–3.2%)] but underestimated risk in men [predicted 1.3% vs. observed 2.4% (95%CI 1.7–3.1%)]. FRAX with BMD showed better fracture discrimination than FRAX without BMD or BMD alone. Age, body mass index, prior fragility fracture and femoral neck BMD were significant independent predictors of major osteoporotic fractures; sex, age, prior fragility fracture and femoral neck BMD were significant independent predictors of hip fractures.

Conclusion

The Canadian FRAX tool provides predictions consistent with observed fracture rates in Canadian women and men, thereby providing a valuable tool for Canadian clinicians assessing patients at risk of fracture.

Keywords

Canada Fracture Fracture prediction FRAX Osteoporosis 

References

  1. 1.
    Berger C, Goltzman D, Langsetmo L, Joseph L, Kreiger N, Tenenhouse A, Davison KS, Josse R, Prior J, Hanley D, CaMos Research Group (2010) Peak bone mass from longitudinal data: implications for the prevalence, pathophysiology, and diagnosis of osteoporosis. J Bone Miner Res 25:1948–1957CrossRefPubMedGoogle Scholar
  2. 2.
    Hanley DA, Josse RG (1996) Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 1. Introduction. CMAJ 155(7):921–923PubMedGoogle Scholar
  3. 3.
    Jaglal SB, Sherry PG, Schatzker J (1996) The impact and consequences of hip fracture in Ontario. Can J Surg 39(2):105–111PubMedGoogle Scholar
  4. 4.
    Melton LJ III (2003) Epidemiology worldwide. Endocrinol Metab Clin North Am 32(1):1–13, vCrossRefPubMedGoogle Scholar
  5. 5.
    Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17(12):1726–1733CrossRefPubMedGoogle Scholar
  6. 6.
    Ioannidis G, Papaioannou A, Hopman WM, khtar-Danesh N, Anastassiades T, Pickard L, Kennedy CC, Prior JC, Olszynski WP, Davison KS, Goltzman D, Thabane L, Gafni A, Papadimitropoulos EA, Brown JP, Josse RG, Hanley DA, Adachi JD (2009) Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ 181(5):265–271PubMedGoogle Scholar
  7. 7.
    Adachi JD, Ioannidis G, Berger C, Joseph L, Papaioannou A, Pickard L, Papadimitropoulos EA, Hopman W, Poliquin S, Prior JC, Hanley DA, Olszynski WP, Anastassiades T, Brown JP, Murray T, Jackson SA, Tenenhouse A (2001) The influence of osteoporotic fractures on health-related quality of life in community-dwelling men and women across Canada. Osteoporos Int 12(11):903–908CrossRefPubMedGoogle Scholar
  8. 8.
    Hallberg I, Rosenqvist AM, Kartous L, Lofman O, Wahlstrom O, Toss G (2004) Health-related quality of life after osteoporotic fractures. Osteoporos Int 15(10):834–841CrossRefPubMedGoogle Scholar
  9. 9.
    Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, Chesnut CH III, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD (1999) Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA 282(14):1344–1352CrossRefPubMedGoogle Scholar
  10. 10.
    Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C (2002) Meta-analyses of therapies for postmenopausal osteoporosis. IX: summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev 23(4):570–578CrossRefPubMedGoogle Scholar
  11. 11.
    Goeree R, Blackhouse G, Adachi J (2006) Cost-effectiveness of alternative treatments for women with osteoporosis in Canada. Curr Med Res Opin 22(7):1425–1436CrossRefPubMedGoogle Scholar
  12. 12.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312(7041):1254–1259PubMedGoogle Scholar
  13. 13.
    Cranney A, Jamal SA, Tsang JF, Josse RG, Leslie WD (2007) Low bone mineral density and fracture burden in postmenopausal women. CMAJ 177(6):575–580PubMedGoogle Scholar
  14. 14.
    Langsetmo L, Goltzman D, Kovacs CS, Adachi JD, Hanley DA, Kreiger N, Josse R, Papaioannou A, Olszynski WP, Jamal SA (2009) Repeat low-trauma fractures occur frequently among men and women who have osteopenic bone mineral density. J Bone Miner Res 24(9):1515–1522CrossRefPubMedGoogle Scholar
  15. 15.
    Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19(4):385–397CrossRefPubMedGoogle Scholar
  16. 16.
    Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, Burckhardt P, Cooper C, Christiansen C, Cummings S, Eisman JA, Fujiwara S, Gluer C, Goltzman D, Hans D, Krieg MA, La CA, McCloskey E, Mellstrom D, Melton LJ III, Pols H, Reeve J, Sanders K, Schott AM, Silman A, Torgerson D, van ST W, NB YN (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(8):1033–1046CrossRefPubMedGoogle Scholar
  17. 17.
    Leslie WD, O'Donnell S, Lagace C, Walsh P, Bancej C, Jean S, Siminoski K, Kaiser S, Kendler DL, Jaglal S (2009) Population-based Canadian hip fracture rates with international comparisons. Osteoporos Int 21:1317–1322CrossRefPubMedGoogle Scholar
  18. 18.
    Ettinger B, Black DM, wson-Hughes B, Pressman AR, Melton LJ III (2010) Updated fracture incidence rates for the US version of FRAX. Osteoporos Int 21(1):25–33CrossRefPubMedGoogle Scholar
  19. 19.
    Kreiger N, Tenenhouse A, Joseph L, MacKenzie T, Poliquin S, Brown JP, Prior JC, Rittmaster (1999) Research notes: the Canadian Multicentre Osteoporosis Study (CaMos)—background, rationale, methods. Can J Aging 18:376–387CrossRefGoogle Scholar
  20. 20.
    Lu Y, Fuerst T, Hui S, Genant HK (2001) Standardization of bone mineral density at femoral neck, trochanter and Ward’s triangle. Osteoporos Int 12(6):438–444CrossRefPubMedGoogle Scholar
  21. 21.
    Genant HK (1995) Universal standardization for dual X-ray absorptiometry: patient and phantom cross-calibration results. J Bone Miner Res 10(6):997–998CrossRefPubMedGoogle Scholar
  22. 22.
    Berger C, Langsetmo L, Joseph L, Hanley D, Davison KS, Josse RG, Kreiger N, Tenenhouse A, Goltzman D (2008) Change in bone mineral density as a function of age in women and men and association with the use of antiresorptive agents. Can Med Assoc J 178(13):1660–1668CrossRefGoogle Scholar
  23. 23.
    Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA (2010) Independent clinical validation of a Canadian FRAX® tool: fracture prediction and model calibration. J Bone Miner Res. doi:10.1002/jbmr.123
  24. 24.
    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(7):1237–1244CrossRefPubMedGoogle Scholar
  25. 25.
    Kanis JA, Oden A, Johansson H, Borgstrom F, Strom O, McCloskey E (2009) FRAX and its applications to clinical practice. Bone 44(5):734–743CrossRefPubMedGoogle Scholar
  26. 26.
    Fujiwara S, Nakamura T, Orimo H, Hosoi T, Gorai I, Oden A, Johansson H, Kanis JA (2008) Development and application of a Japanese model of the WHO fracture risk assessment tool (FRAX). Osteoporos Int 19(4):429–435CrossRefPubMedGoogle Scholar
  27. 27.
    Dawson-Hughes B, Tosteson AN, Melton LJ III, Baim S, Favus MJ, Khosla S, Lindsay RL (2008) Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int 19(4):449–458CrossRefPubMedGoogle Scholar
  28. 28.
    Lippuner K, Johansson H, Kanis JA, Rizzoli R (2010) FRAX assessment of osteoporotic fracture probability in Switzerland. Osteoporos Int 21(3):381–389CrossRefPubMedGoogle Scholar
  29. 29.
    Siminoski K, Leslie WD, Frame H, Hodsman A, Josse RG, Khan A, Lentle BC, Levesque J, Lyons DJ, Tarulli G, Brown JP (2005) Recommendations for bone mineral density reporting in Canada. Can Assoc Radiol J 56(3):178–188PubMedGoogle Scholar
  30. 30.
    Richards JB, Leslie WD, Joseph L, Siminoski K, Hanley DA, Adachi JD, Brown JP, Morin S, Papaioannou A, Josse RG, Prior JC, Davison KS, Tenenhouse A, Goltzman D (2007) Changes to osteoporosis prevalence according to method of risk assessment. J Bone Miner Res 22(2):228–234CrossRefPubMedGoogle Scholar
  31. 31.
    Leslie WD, Tsang JF, Lix LM (2009) Simplified system for absolute fracture risk assessment: clinical validation in Canadian women. J Bone Miner Res 24(2):353–360CrossRefPubMedGoogle Scholar
  32. 32.
    Chen P, Krege JH, Adachi JD, Prior JC, Tenenhouse A, Brown JP, Papadimitropoulos E, Kreiger N, Olszynski WP, Josse RG, Goltzman D (2009) Vertebral fracture status and the World Health Organization risk factors for predicting osteoporotic fracture risk. J Bone Miner Res 24(3):495–502CrossRefPubMedGoogle Scholar
  33. 33.
    Johansson H, Kanis JA, Oden A, Johnell O, McCloskey E (2009) BMD, clinical risk factors and their combination for hip fracture prevention. Osteoporos Int 20(10):1675–1682CrossRefPubMedGoogle Scholar
  34. 34.
    Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA, Fujiwara S, Kroger H, Mellstrom D, Meunier PJ, Melton LJ III, O’Neill T, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20(7):1185–1194CrossRefPubMedGoogle Scholar
  35. 35.
    Leslie WD, Metge C, Ward L (2003) Contribution of clinical risk factors to bone density-based absolute fracture risk assessment in postmenopausal women. Osteoporos Int 14(4):334–338CrossRefPubMedGoogle Scholar
  36. 36.
    Schuit SC, van der Klift M, Weel AE, de Laet CE, Burger H, Seeman E, Hofman A, Uitterlinden AG, van Leeuwen JP, Pols HA (2004) Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 34(1):195–202CrossRefPubMedGoogle Scholar
  37. 37.
    Siris ES, Chen YT, Abbott TA, Barrett-Connor E, Miller PD, Wehren LE, Berger ML (2004) Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 164(10):1108–1112CrossRefPubMedGoogle Scholar
  38. 38.
    Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, Nevitt MC, Cummings SR (2003) BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res 18(11):1947–1954CrossRefPubMedGoogle Scholar
  39. 39.
    De Laet C, Kanis JA, Oden A, Johanson H, Johnell O, Delmas P, Eisman JA, Kroger H, Fujiwara S, Garnero P, McCloskey EV, Mellstrom D, Melton LJ III, Meunier PJ, Pols HA, Reeve J, Silman A, Tenenhouse A (2005) Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int 16(11):1330–1338CrossRefPubMedGoogle Scholar
  40. 40.
    Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Eisman JA, McCloskey EV, Mellstrom D, Melton LJ III, Pols HA, Reeve J, Silman AJ, Tenenhouse A (2004) A family history of fracture and fracture risk: a meta-analysis. Bone 35(5):1029–1037CrossRefPubMedGoogle Scholar
  41. 41.
    Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35(2):375–382CrossRefPubMedGoogle Scholar
  42. 42.
    Kanis JA, Johansson H, Oden A, Johnell O, de LC M, LJ III, Tenenhouse A, Reeve J, Silman AJ, Pols HA, Eisman JA, McCloskey EV, Mellstrom D (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19(6):893–899CrossRefPubMedGoogle Scholar
  43. 43.
    Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A (2005) Alcohol intake as a risk factor for fracture. Osteoporos Int 16(7):737–742CrossRefPubMedGoogle Scholar
  44. 44.
    Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Smoking and fracture risk: a meta-analysis. Osteoporos Int 16(2):155–162CrossRefPubMedGoogle Scholar
  45. 45.
    Borgstrom F, Johnell O, Kanis JA, Jonsson B, Rehnberg C (2006) At what hip fracture risk is it cost-effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int 17(10):1459–1471CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2010

Authors and Affiliations

  • L.-A. Fraser
    • 1
  • L. Langsetmo
    • 2
  • C. Berger
    • 2
  • G. Ioannidis
    • 1
  • D. Goltzman
    • 2
  • J. D. Adachi
    • 1
  • A. Papaioannou
    • 1
  • R. Josse
    • 3
  • C. S. Kovacs
    • 4
  • W. P. Olszynski
    • 5
  • T. Towheed
    • 6
  • D. A. Hanley
    • 7
  • S. M. Kaiser
    • 8
  • J. Prior
    • 9
  • S. Jamal
    • 3
  • N. Kreiger
    • 11
  • J. P. Brown
    • 10
  • H. Johansson
    • 12
  • A. Oden
    • 12
  • E. McCloskey
    • 13
  • J. A. Kanis
    • 14
  • W. D. Leslie
    • 15
  • CaMos Research Group
  1. 1.Departments of Clinical Epidemiology and Biostatistics and MedicineMcMaster UniversityHamiltonCanada
  2. 2.CaMos National Coordinating CenterMcGill UniversityMontrealCanada
  3. 3.Department of MedicineUniversity of TorontoTorontoCanada
  4. 4.Faculty of MedicineMemorial University of NewfoundlandSt. John’s NewfoundlandCanada
  5. 5.Department of MedicineUniversity of SaskatchewanSaskatoonCanada
  6. 6.Department of MedicineQueen’s UniversityKingstonCanada
  7. 7.Department of MedicineUniversity of CalgaryCalgaryCanada
  8. 8.Department of MedicineDalhousie UniversityHalifaxCanada
  9. 9.Department of MedicineUniversity of British ColumbiaVancouverCanada
  10. 10.Department of MedicineLaval UniversityQuebec CityCanada
  11. 11.Department of EpidemiologyUniversity of Toronto Cancer Care OntarioTorontoCanada
  12. 12.GothenburgSweden
  13. 13.Osteoporosis CentreNorthern General HospitalSheffieldUK
  14. 14.WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
  15. 15.Department of Medicine (C5121)University of Manitoba St. Boniface General HospitalWinnipegCanada

Personalised recommendations