Skip to main content

Advertisement

SpringerLink
Log in

Evaluation of the FRAX Model for Hip Fracture Predictions in the Population-based Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE)

  • Original Research
  • Published:
Calcified Tissue International Aims and scope Submit manuscript

    We’re sorry, something doesn't seem to be working properly.

    Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Abstract

Calibration of the Finnish FRAX model was evaluated using a locally derived population-based cohort of postmenopausal women (n = 13,917). Hip fractures were observed from national register-based data and verified from radiological records. For a subpopulation of 11,182 women, there were enough data to calculate the fracture probabilities using the Finnish FRAX tool (without bone mineral density). A 10-year period prevalence of hip fractures to this subpopulation was 0.66 %. The expected numbers of hip fractures were significantly higher than the self reported ones (O/E ratio 0.46; 95 % CI 0.33–0.63), had a tendency to be greater than the observed ones (O/E ratio 0.83; 95 % CI 0.65–1.04), and calibration in terms of goodness-of-fit of absolute probabilities was questionable (P = 0.015). Strikingly, the 10-year period prevalence of hip fractures to the whole cohort was higher (0.84 %) than for the women with FRAX measurements (0.66 %). This was mainly the result of difference between people who had and who had not responded to postal enquiries (0.71 vs. 1.77 %, P < 0.0001). Self-reports missed to capture 38 % of all hip fractures in those who responded and about 45 % of hip fractures in women who had a FRAX estimate. The Finnish FRAX tool seems to provide appropriate discrimination for hip fracture risk, but caution is required in the interpretation of absolute risk, especially if used for population that may not be representing general population per se. Our study also showed that patients with no response had significantly higher hip fracture risk and that the use of purely self-reported hip fractures in calculations results in biased incidence and period prevalence estimates. Such important biases may remain unnoticed if there are no data from other sources available.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N (1994) The diagnosis of osteoporosis. J Bone Miner Res 9:1137–1141

    Article  CAS  PubMed  Google Scholar 

  2. Kanis JA, Gluer CC (2000) An update on the diagnosis and assessment of osteoporosis with densitometry. Osteoporos Int 11:192–202

    Article  CAS  PubMed  Google Scholar 

  3. World Health Organization (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Technical Report Series 843. World Health Organization, Geneva

  4. Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D, European Foundation for Osteoporosis and Bone Disease (1997) Guidelines for diagnosis and management of osteoporosis. Osteoporos Int 7:390–406

    Article  CAS  PubMed  Google Scholar 

  5. National Osteoporosis Foundation (NOF) (2003) Physician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington, DC

    Google Scholar 

  6. Kanis JA, Johnell O, Odén A, Johansson H, McCloskey EV (2008) FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–397

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  7. Kanis JA, Johnell O, De Laet C, Jonnson B, Odén A, Ogelsby AK (2002) International variations in hip fracture probability: implications for risk assessment. J Bone Miner Res 17:1237–1244

    Article  PubMed  Google Scholar 

  8. Kanis JA, Odén A, McCloskey EV, Johansson H, Wahl DA, Cooper C, IOF Working Group on Epidemiology and Quality of Life (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23:2239–2256

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  9. Honkanen R, Kröger H, Tuppurainen M, Alhava E, Saarikoski S (1995) Fractures and low axial bone density in perimenopausal women. J Clin Epidemiol 48:881–888

    Article  CAS  PubMed  Google Scholar 

  10. Honkanen R, Tuppurainen M, Kröger H, Alhava E, Saarikoski S (1998) Relationship between risk factors and fracture differ by type of fracture: a population-based study of 12,191 perimenopausal women. Osteoporos Int 8:25–31

    Article  CAS  PubMed  Google Scholar 

  11. Sund R (2007) Utilization of routinely collected administrative data in monitoring of aging-dependent hip fracture incidence. Epidemiol Perspect Innov 4:2

    Article  PubMed Central  PubMed  Google Scholar 

  12. Hand DJ (2010) Evaluating diagnostic tests: the area under the ROC curve and the balance of errors. Stat Med 29:1502–1510

    PubMed  Google Scholar 

  13. 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, Glüer C, Goltzman D, Hans D, Krieg MA, La Croix A, McCloskey E, Mellstrom D, Melton LJ 3rd, Pols H, Reeve J, Sanders K, Schott AM, Silman A, Torgerson D, van Staa T, Watts NB, Yoshimura N (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 18:1033–1046

    Article  CAS  PubMed  Google Scholar 

  14. Sund R (2006) Hip fracture incidence in Finland, 1998–2002. Duodecim 122(9):1085–1091

    PubMed  Google Scholar 

  15. Honkanen K, Honkanen R, Heikkinen L, Kröger H, Saarikoski S (1999) Validity of self-reports of fractures in perimenopausal women. Am J Epidemiol 150:511–516

    Article  CAS  PubMed  Google Scholar 

  16. Sund R (2012) Quality of the Finnish Hospital Discharge Register: a systematic review. Scand J Public Health 40:505–515

    Article  PubMed  Google Scholar 

  17. Sund R, Nurmi-Lüthje I, Lüthje P, Tanninen S, Narinen A, Keskimäki I (2007) Comparing properties of audit data and routinely collected register data in case of performance assessment of hip fracture treatment in Finland. Methods Inf Med 46:558–566

    CAS  PubMed  Google Scholar 

  18. Schousboe JT, Paudel ML, Taylor BC, Virnig BA, Cauley JA, Curtis JR, Ensrud KE (2013) Magnitude and consequences of misclassification of incident hip fractures in large cohort studies: the Study of Osteoporotic Fractures and Medicare claims data. Osteoporos Int 24:801–810

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  19. Nurmi-Lüthje I, Sund R, Juntunen M, Lüthje P (2011) Post-hip fracture use of prescribed calcium plus vitamin D or vitamin D supplements and anti-osteoporotic drugs are associated with lower mortality. A nationwide study in Finland. J Bone Miner Res 26:1845–1853

    Article  PubMed  Google Scholar 

  20. Kanis JA, Hans D, Cooper C, Baim S, Bilezikian JP, Binkley N, Cauley JA, Compston JE, Dawson-Hughes B, El-Hajj Fuleihan G, Johansson H, Leslie WD, Lewiecki EM, Luckey M, Oden A, Papapoulos SE, Poiana C, Rizzoli R, Wahl DA, McCloskey EV (2011) Interpretation and use of FRAX in clinical practice. Osteoporos Int 22:395–411

    Google Scholar 

  21. Kanis JA, Odén A, Johansson H, McCloskey E (2012) Pitfalls in the external validation of FRAX. Osteoporos Int 23:423–431

    Article  CAS  PubMed  Google Scholar 

  22. Honkanen R, Sund R, Tuppurainen M, Koivumaa-Honkanen H, Kröger H (2012) 20-year mortality of non-respondents in a population-based cohort (OSTPRE) study. Poster presented at: ASBMR annual meeting, Minneapolis, MN

  23. Kanis JA, Johansson H, Odén A, Dawson-Hughes B, Melton LJ 3rd, McCloskey EV (2010) The effects of a FRAX((R)) revision for the USA. Osteoporos Int 21:35–40

    Article  CAS  PubMed  Google Scholar 

  24. Binkley N, Kiebzak GM, Lewiecki EM, Krueger D, Gangnon RE, Miller PD, Shepherd JA, Drezner MK (2005) Recalculation of the NHANES Database SD improves T-score agreement and reduces osteoporosis prevalence. J Bone Miner Res 20:195–201

    Article  PubMed  Google Scholar 

Download references

Acknowledgment

Liisa Ollikainen (Lic.Sc., RN) had a significant role in obtaining the radiology reports for potential hip fractures identified in the register.

Conflict of interest

Reijo Sund, Risto Honkanen, Helena Johansson, Anders Odén and Heikki Kröger declare that they have no conflict of interest. Eugene McCloskey received speaker fees and/or unrestricted research grants from Novartis, Amgen, AstraZeneca, Pfizer, Bayer, Warner-Chilcott/Procter & Gamble, Lilly, Roche, Servier, Hologic, and GSK. John Kanis received grants from Industry: Amgen, USA, Switzerland and Belgium; D3A, France; Gador, Argentina; General Electric, USA; GSK, UK, USA; Hologic, Belgium and USA; Kissei, Japan; Lilly, USA, Canada, Japan, Australia, and UK; Merck Research Labs, USA; Merlin Ventures, UK; Novartis, Switzerland and USA; Novo Nordisk, Denmark; Nycomed, Norway; Ono, UK and Japan; Pfizer USA; Pharmexa, Denmark; ProStrakan, UK; Roche, Germany, Australia, Switzerland, and USA; Rotta Research, Italy; Sanofi-Aventis, USA; Servier, France and UK; Shire, UK; Solvay, France and Germany; Tethys, USA; Teijan, Japan; Teva, Israel; UBS, Belgium; Unigene, USA; Warburg-Pincus, UK; and from governmental and nongovernment organizations: National Institute for Health and Clinical Excellence (NICE), UK; International Osteoporosis Foundation; National Osteoporosis Guideline Group (NOGG), UK; INSERM, France; Ministry of Public Health, China; Ministry of Health, Australia; National Osteoporosis Society, UK; and World Health Organization.

Human and Animal Rights and Informed Consent

The study was approved by the Ethics Committee of the University Hospital of Kuopio, and all participants gave informed consent. Permissions to use register-based data were separately obtained from the register authorities as required in the Finnish legislation.

Author information

Authors and Affiliations

  1. Bone and Cartilage Research Unit (BCRU), University of Eastern Finland, Kuopio, Finland

    Reijo Sund, Risto Honkanen & Heikki Kröger

  2. Service Systems Research Unit, National Institute for Health and Welfare, Helsinki, Finland

    Reijo Sund

  3. Department of Social Research, Centre for Research Methods, University of Helsinki, Helsinki, Finland

    Reijo Sund

  4. Lapland Hospital District, Rovaniemi, Finland

    Risto Honkanen

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

    Helena Johansson, Anders Odén, Eugene McCloskey & John Kanis

  6. Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland

    Heikki Kröger

Authors
  1. Reijo Sund
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Risto Honkanen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Helena Johansson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Anders Odén
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Eugene McCloskey
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. John Kanis
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Heikki Kröger
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Reijo Sund.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sund, R., Honkanen, R., Johansson, H. et al. Evaluation of the FRAX Model for Hip Fracture Predictions in the Population-based Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE). Calcif Tissue Int 95, 39–45 (2014). https://doi.org/10.1007/s00223-014-9860-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00223-014-9860-9

Keywords

Search

Navigation