A Comparison of Prediction Models for Fractures in Older Women Is More Better?

Department of Medicine, Minneapolis Veterans Affairs Medical Center, MN 55417, USA.
Archives of internal medicine (Impact Factor: 17.33). 12/2009; 169(22):2087-94. DOI: 10.1001/archinternmed.2009.404
Source: PubMed


A Web-based risk assessment tool (FRAX) using clinical risk factors with and without femoral neck bone mineral density (BMD) has been incorporated into clinical guidelines regarding treatment to prevent fractures. However, it is uncertain whether prediction with FRAX models is superior to that based on parsimonious models.
We conducted a prospective cohort study in 6252 women 65 years or older to compare the value of FRAX models that include BMD with that of parsimonious models based on age and BMD alone for prediction of fractures. We also compared FRAX models without BMD with simple models based on age and fracture history alone. Fractures (hip, major osteoporotic [hip, clinical vertebral, wrist, or humerus], and any clinical fracture) were ascertained during 10 years of follow-up. Area under the curve (AUC) statistics from receiver operating characteristic curve analysis were compared between FRAX models and simple models.
The AUC comparisons showed no differences between FRAX models with BMD and simple models with age and BMD alone in discriminating hip (AUC, 0.75 for the FRAX model and 0.76 for the simple model; P = .26), major osteoporotic (AUC, 0.68 for the FRAX model and 0.69 for the simple model; P = .51), and clinical fracture (AUC, 0.64 for the FRAX model and 0.63 for the simple model; P = .16). Similarly, performance of parsimonious models containing age and fracture history alone was nearly identical to that of FRAX models without BMD. The proportion of women in each quartile of predicted risk who actually experienced a fracture outcome did not differ between FRAX and simple models (P > or = .16).
Simple models based on age and BMD alone or age and fracture history alone predicted 10-year risk of hip, major osteoporotic, and clinical fracture as well as more complex FRAX models.

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    • "Optionally, Bone Mineral Density (BMD) of the femoral neck can be included for risk calculation. Other studies have questioned the effectiveness of FRAX ® as a tool for predicting fracture risk [21] [22]. "
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    ABSTRACT: Osteoporotic vertebral fractures represent major cause of disability, loss of quality of life and even mortality among the elderly population. Decisions on drug therapy are based on the assessment of risk factors for fracture, from bone mineral density measurements. The combination of biomechanical models with clinical studies could better estimate bone strength and support the specialists in their decision. A model to assess the probability of fracture, based on the Damage and Fracture Mechanics has been developed, evaluating the mechanical magnitudes involved in the fracture process from clinical bone mineral density measurements. The model is intended for simulating the degenerative process in the skeleton, with the consequent lost of bone mass and hence the decrease of its mechanical resistance which enables the fracture due to different traumatisms. Clinical studies were chosen, both in non-treatment conditions and receiving drug therapy, and fitted to specific patients according their actual bone mineral density measures. The predictive model is applied in a finite element simulation of the lumbar spine. The fracture zone would be determined according loading scenario (fall, impact, accidental loads, etc.), using the mechanical properties of bone obtained from the evolutionary model corresponding to the considered time. Bone mineral density evolution in untreated patients and in those under different
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    • "The performance characteristics of the FRAX® tool have been validated in independent cohorts from various countries [24] with over a million of person-years of observation. Previous studies conducted in population with past/current osteoporotic treatment [30], [38], [39] and without such treatment [26], [40] reported the prediction of FRAX® in elderly women [30], [38], [39], [40] and in peri- and early postmenopausal women [26]. Using data of the SOF (Study of Osteoporotic Study) study, a cohort of older community-dwelling women (n =  6252, mean age of 71.3 years), Ensrud et al showed that a simple model based on age and BMD predicted 10-year risk of hip, major osteoporotic, and any clinical fracture as well as FRAX® models with BMD [30]. "
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    ABSTRACT: The aim of this study was to analyse how well FRAX® predicts the risk of major osteoporotic and vertebral fractures over 6 years in postmenopausal women from general population. The OPUS study was conducted in European women aged above 55 years, recruited in 5 centers from random population samples and followed over 6 years. The population for this study consisted of 1748 women (mean age 74.2 years) with information on incident fractures. 742 (43.1%) had a prevalent fracture; 769 (44%) and 155 (8.9%) of them received an antiosteoporotic treatment before and during the study respectively. We compared FRAX® performance with and without bone mineral density (BMD) using receiver operator characteristic (ROC) c-statistical analysis with ORs and areas under receiver operating characteristics curves (AUCs) and net reclassification improvement (NRI). 85 (4.9%) patients had incident major fractures over 6 years. FRAX® with and without BMD predicted these fractures with an AUC of 0.66 and 0.62 respectively. The AUC were 0.60, 0.66, 0.69 for history of low trauma fracture alone, age and femoral neck (FN) BMD and combination of the 3 clinical risk factors, respectively. FRAX® with and without BMD predicted incident radiographic vertebral fracture (n = 65) with an AUC of 0.67 and 0.65 respectively. NRI analysis showed a significant improvement in risk assignment when BMD is added to FRAX®. This study shows that FRAX® with BMD and to a lesser extent also without FN BMD predict major osteoporotic and vertebral fractures in the general population.
    Full-text · Article · Dec 2013 · PLoS ONE
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    • "Most of these studies have included age in the construction of new models. Ensrud et al. [35] included models based on age and BMD or fracture history in comparison with FRAX® in a cohort study of 6652 women with 10-years of follow-up. They concluded that the simple models based on age and BMD or age and fracture history alone predicted the 10-year probability of fractures as well as the more complex FRAX® model. "
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    ABSTRACT: PURPOSE: To compare the power of FRAX® without Bone Mineral Density (BMD) and simpler screening tools (OST, ORAI, OSIRIS, SCORE and age alone) in predicting fractures. METHODS: This study was a prospective, population-based study performed in Denmark comprising 3,614 women aged 40-90 years, who returned a questionnaire concerning items on risk factors for osteoporosis. Fracture risk was calculated using the different screening tools (FRAX®, OST, ORAI, OSIRIS and SCORE) for each woman. The women were followed using the Danish National Register registering new major osteoporotic fractures during 3 years, counting only the first fracture per person. Area under the receiver operating characteristic curve (ROC) and statistics and Harrell´s index were calculated. Agreement between the tools was calculated by kappa statistics. RESULTS: A total of 4% of the women experienced a new major osteoporotic fracture during the follow-up period. There were no differences in the area under the curve (AUC) values between FRAX® and the simpler tools; AUC values between 0.703 and 0.722 (p=0.86). Also, Harrell´s C values were very similar between the tools. Agreement between the tools was modest. CONCLUSION: During 3 years follow-up FRAX® did not perform better in the fracture risk prediction compared with simpler tools such as OST, ORAI, OSIRIS, SCORE or age alone in a screening scenario where BMD was not measured. These findings suggest that simpler models based on fewer risk factors, which would be easier to use in clinical practice by the GP or the patient herself, could just as well as FRAX be used to identify women with increased risk of fracture. SUMMARY: Comparison of FRAX® and simpler screening tools (OST, ORAI, OSIRIS, SCORE) in predicting fractures indicate that FRAX® did not perform better in fracture risk prediction compared with the simpler tools or even age alone in a screening scenario without Bone Mineral Density assessment.
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