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Cheung CL. Enhancing osteoporosis management through risk assessment tools. Osteoporos Sarcopenia 2024; 10:45-46. [PMID: 39035226 PMCID: PMC11260003 DOI: 10.1016/j.afos.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 07/23/2024] Open
Affiliation(s)
- Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Laboratory of Data Discovery for Health Limited (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong Special Administrative Region, China
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Naseri A, Bakhshayeshkaram M, Salehi S, Heydari ST, Dabbaghmanesh MH, Dabbaghmanesh MM. FRAX-derived intervention and assessment thresholds for osteoporosis in ten Middle Eastern countries. Arch Osteoporos 2024; 19:41. [PMID: 38780743 DOI: 10.1007/s11657-024-01397-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
This study established FRAX-based age-specific assessment and intervention thresholds for ten Middle Eastern countries where FRAX is currently available, but the lack of specific thresholds has limited its usefulness. The intervention thresholds ranged from 0.6 (Saudi Arabia) to 36.0% (Syria) at the ages of 40 and 90 years, respectively. INTRODUCTION Developing fracture risk assessment tools allows physicians to select patients for therapy based on their absolute fracture risk instead of relying solely on bone mineral density (BMD). The most widely used tool is FRAX, currently available in ten Middle Eastern countries. This study aimed to set FRAX-derived assessment and intervention thresholds for individuals aged 40 or above in ten Middle Eastern countries. METHODS The age-specific 10-year probabilities of a major osteoporotic fracture (MOF) for a woman with a BMI of 25.0 kg/m2, without BMD and clinical risk factors except for prior fracture, were calculated as intervention Threshold (IT). The upper and lower assessment thresholds were set at 1.2 times the IT and an age-specific 10-year probability of a MOF in a woman with a BMI of 25.0 kg/m2, without BMD, prior fracture, and other clinical risk factors, respectively. IT is utilized to determine treatment or reassurance when BMD facilities are unavailable. However, with BMD facilities, assessment thresholds can offer treatment, reassurance, or bone densitometry based on MOF probability. RESULTS The age-specific IT varied from 0.9 to 11.0% in Abu Dhabi, 2.9 to 10% in Egypt, 2.7 to 14.0% in Iran, 1.0 to 28.0% in Jordan, 2.7 to 27.0% in Kuwait, 0.9 to 35.0% in Lebanon, 1.0 to 16.0% in Palestine, 4.1 to 14% in Qatar, 0.6 to 3.7% in Saudi Arabia, and 0.9 to 36.0% in Syria at the age of 40 and 90 years, respectively. CONCLUSIONS FRAX-based IT in Middle Eastern countries provides an opportunity to identify individuals with high fracture risk.
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Affiliation(s)
- Arzhang Naseri
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Marzieh Bakhshayeshkaram
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Salehi
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Taghi Heydari
- Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Dabbaghmanesh
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Shiraz University of Medical Sciences, Shiraz, Iran.
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Su Y, Zhou B, Kwok T. Fracture risk prediction in old Chinese people-a narrative review. Arch Osteoporos 2023; 19:3. [PMID: 38110842 DOI: 10.1007/s11657-023-01360-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/01/2023] [Indexed: 12/20/2023]
Abstract
With aging, the burden of osteoporotic fracture (OF) increases substantially, while China is expected to carry the greatest part in the future. The risk of fracture varies greatly across racial groups and geographic regions, and systematically organized evidence on the potential predictors for fracture risk is needed for Chinese. This review briefly introduces the epidemiology of OF and expands on the predictors and predictive tools for the risk of OF, as well as the challenges for their potential translation in the old Chinese population. There are regional differences of fracture incidence among China. The fracture incidences in Hong Kong and Taiwan have decreased in recent years, while it is still increasing in mainland China. Although the application of dual-energy X-ray absorptiometry (DXA) is limited among old Chinese in the mainland, bone mineral density (BMD) by DXA has a predictive value similar to that worldwide. Other non-DXA modalities, especially heel QUS, are helpful in assessing bone health. The fracture risk assessment tool (FRAX) has a good discrimination ability for OFs, especially the FRAX with BMD. And some clinical factors have added value to FRAX, which has been verified in old Chinese. In addition, although the application of the osteoporosis self-assessment tool for Asians (OSTA) in Chinese needs further validation, it may help identify high-risk populations in areas with limited resources. Moreover, the translation use of the muscle quality and genetic or serum biomarkers in fracture prediction needs further works. More applicable and targeted fracture risk predictors and tools are still needed for the old Chinese population.
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Affiliation(s)
- Yi Su
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, 410013, Hunan, China
| | - Bei Zhou
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, 410013, Hunan, China
| | - Timothy Kwok
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, SAR, China.
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Hong Kong, SAR, China.
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Wu Y, Chao J, Bao M, Zhang N. Predictive value of machine learning on fracture risk in osteoporosis: a systematic review and meta-analysis. BMJ Open 2023; 13:e071430. [PMID: 38070927 PMCID: PMC10728980 DOI: 10.1136/bmjopen-2022-071430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Early identification of fracture risk in patients with osteoporosis is essential. Machine learning (ML) has emerged as a promising technique to predict the risk, whereas its predictive performance remains controversial. Therefore, we conducted this systematic review and meta-analysis to explore the predictive efficiency of ML for the risk of fracture in patients with osteoporosis. METHODS Relevant studies were retrieved from four databases (PubMed, Embase, Cochrane Library and Web of Science) until 31 May 2023. A meta-analysis of the C-index was performed using a random-effects model, while a bivariate mixed-effects model was used for the meta-analysis of sensitivity and specificity. In addition, subgroup analysis was performed according to the types of ML models and fracture sites. RESULTS Fifty-three studies were included in our meta-analysis, involving 15 209 268 patients, 86 prediction models specifically developed for the osteoporosis population and 41 validation sets. The most commonly used predictors in these models encompassed age, BMI, past fracture history, bone mineral density T-score, history of falls, BMD, radiomics data, weight, height, gender and other chronic diseases. Overall, the pooled C-index of ML was 0.75 (95% CI: 0.72, 0.78) and 0.75 (95% CI: 0.71, 0.78) in the training set and validation set, respectively; the pooled sensitivity was 0.79 (95% CI: 0.72, 0.84) and 0.76 (95% CI: 0.80, 0.81) in the training set and validation set, respectively; and the pooled specificity was 0.81 (95% CI: 0.75, 0.86) and 0.83 (95% CI: 0.72, 0.90) in the training set and validation set, respectively. CONCLUSIONS ML has a favourable predictive performance for fracture risk in patients with osteoporosis. However, most current studies lack external validation. Thus, external validation is required to verify the reliability of ML models. PROSPERO REGISTRATION NUMBER CRD42022346896.
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Affiliation(s)
- Yanqian Wu
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Jianqian Chao
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Min Bao
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Na Zhang
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
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Cheung CL. Reply on "Identification of people with high risk of osteoporosis in Asia". Osteoporos Sarcopenia 2023; 9:113-114. [PMID: 37941534 PMCID: PMC10627865 DOI: 10.1016/j.afos.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/17/2023] [Accepted: 08/27/2023] [Indexed: 11/10/2023] Open
Affiliation(s)
- Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong
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Li GHY, Cheung CL, Tan KCB, Kung AWC, Kwok TCY, Lau WCY, Wong JSH, Hsu WW, Fang C, Wong ICK. Development and validation of sex-specific hip fracture prediction models using electronic health records: a retrospective, population-based cohort study. EClinicalMedicine 2023; 58:101876. [PMID: 36896245 PMCID: PMC9989633 DOI: 10.1016/j.eclinm.2023.101876] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Hip fracture is associated with immobility, morbidity, mortality, and high medical cost. Due to limited availability of dual-energy X-ray absorptiometry (DXA), hip fracture prediction models without using bone mineral density (BMD) data are essential. We aimed to develop and validate 10-year sex-specific hip fracture prediction models using electronic health records (EHR) without BMD. METHODS In this retrospective, population-based cohort study, anonymized medical records were retrieved from the Clinical Data Analysis and Reporting System for public healthcare service users in Hong Kong aged ≥60 years as of 31 December 2005. A total of 161,051 individuals (91,926 female; 69,125 male) with complete follow-up from 1 January 2006 till the study end date on 31 December 2015 were included in the derivation cohort. The sex-stratified derivation cohort was randomly divided into 80% training and 20% internal testing datasets. An independent validation cohort comprised 3046 community-dwelling participants aged ≥60 years as of 31 December 2005 from the Hong Kong Osteoporosis Study, a prospective cohort which recruited participants between 1995 and 2010. With 395 potential predictors (age, diagnosis, and drug prescription records from EHR), 10-year sex-specific hip fracture prediction models were developed using stepwise selection by logistic regression (LR) and four machine learning (ML) algorithms (gradient boosting machine, random forest, eXtreme gradient boosting, and single-layer neural networks) in the training cohort. Model performance was evaluated in both internal and independent validation cohorts. FINDINGS In female, the LR model had the highest AUC (0.815; 95% Confidence Interval [CI]: 0.805-0.825) and adequate calibration in internal validation. Reclassification metrics showed the LR model had better discrimination and classification performance than the ML algorithms. Similar performance was attained by the LR model in independent validation, with high AUC (0.841; 95% CI: 0.807-0.87) comparable to other ML algorithms. In internal validation for male, LR model had high AUC (0.818; 95% CI: 0.801-0.834) and it outperformed all ML models as indicated by reclassification metrics, with adequate calibration. In independent validation, the LR model had high AUC (0.898; 95% CI: 0.857-0.939) comparable to ML algorithms. Reclassification metrics demonstrated that LR model had the best discrimination performance. INTERPRETATION Even without using BMD data, the 10-year hip fracture prediction models developed by conventional LR had better discrimination performance than the models developed by ML algorithms. Upon further validation in independent cohorts, the LR models could be integrated into the routine clinical workflow, aiding the identification of people at high risk for DXA scan. FUNDING Health and Medical Research Fund, Health Bureau, Hong Kong SAR Government (reference: 17181381).
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Affiliation(s)
- Gloria Hoi-Yee Li
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- Corresponding author. Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong.
| | - Kathryn Choon-Beng Tan
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Annie Wai-Chee Kung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Timothy Chi-Yui Kwok
- Department of Medicine & Therapeutics and School of Public Health, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Janus Siu-Him Wong
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Warrington W.Q. Hsu
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian Chi-Kei Wong
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
- School of Pharmacy, University College London, London, UK
- Musketeers Foundation Institute of Data Science, The University of Hong, Hong Kong SAR, China
- Aston School of Pharmacy, Aston University, Birmingham B4 7ET, UK
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Cheung CL, Li GHY, Li HL, Mak C, Tan KCB, Kung AWC. Development and validation of the Chinese osteoporosis screening algorithm (COSA) in identification of people with high risk of osteoporosis. Osteoporos Sarcopenia 2023; 9:8-13. [PMID: 37082357 PMCID: PMC10111958 DOI: 10.1016/j.afos.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/05/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
Objectives To enhance the public awareness and facilitate diagnosis of osteoporosis, we aim to develop a new Chinese Osteoporosis Screening Algorithm (COSA) to identify people at high risk of osteoporosis. Methods A total of 4747 postmenopausal women and men aged ≥ 50 from the Hong Kong Osteoporosis Study were randomly split into a development (N = 2373) and an internal validation cohort (N = 2374). An external validation cohort comprising 1876 community-dwelling subjects was used to evaluate the positive predictive value (PPV). Results Among 11 predictors included, age, sex, weight, and history of fracture were significantly associated with osteoporosis after correction for multiple testing. Age- and sex-stratified models were developed due to the presence of significant sex and age interactions. The area under the curve of the COSA in the internal validation cohort was 0.761 (95% CI, 0.711-0.811), 0.822 (95% CI, 0.792-0.851), and 0.946 (95% CI, 0.908-0.984) for women aged < 65, women aged ≥ 65, and men, respectively. The COSA demonstrated improved reclassification performance when compared to Osteoporosis Self-Assessment Tool for Asians. In the external validation cohort, the PPV of COSA was 40.6%, 59.4%, and 19.4% for women aged < 65, women aged ≥ 65, and men, respectively. In addition, COSA > 0 was associated with an increased 10-year risk of hip fracture in women ≥ 65 (OR, 4.65; 95% CI, 2.24-9.65) and men (OR, 11.51; 95% CI, 4.16-31.81). Conclusions We have developed and validated a new osteoporosis screening algorithm, COSA, specific for Hong Kong Chinese.
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Affiliation(s)
- Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- Corresponding author. Department of Pharmacology and Pharmacy, The University of Hong Kong, Pokfulam, Hong Kong.
| | - Gloria HY. Li
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong
| | - Hang-Long Li
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Constance Mak
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Kathryn CB. Tan
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Annie WC. Kung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
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Chandran M, Brind'Amour K, Fujiwara S, Ha YC, Tang H, Hwang JS, Tinker J, Eisman JA. Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review. Osteoporos Int 2023; 34:1037-1053. [PMID: 36735053 DOI: 10.1007/s00198-022-06657-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 12/21/2022] [Indexed: 02/04/2023]
Abstract
UNLABELLED Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem. PURPOSE Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries. METHODS We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures. RESULTS All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women. CONCLUSION Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.
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Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | | | - Saeko Fujiwara
- Department of Pharmacy, Yasuda Women's University, Hiroshima, Japan
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Seoul Bumin Hospital, Seoul, South Korea
| | - Hai Tang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, Republic of China
| | - Jawl-Shan Hwang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | | | - John A Eisman
- UNSW Sydney and School of Medicine Sydney, Garvan Institute of Medical Research, St Vincent's Hospital, University of Notre Dame Australia, Sydney, NSW, Australia
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Corrao G, Biffi A, Porcu G, Ronco R, Adami G, Alvaro R, Bogini R, Caputi AP, Cianferotti L, Frediani B, Gatti D, Gonnelli S, Iolascon G, Lenzi A, Leone S, Michieli R, Migliaccio S, Nicoletti T, Paoletta M, Pennini A, Piccirilli E, Rossini M, Tarantino U, Brandi ML. Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021. Front Endocrinol (Lausanne) 2023; 14:1137671. [PMID: 37143730 PMCID: PMC10151776 DOI: 10.3389/fendo.2023.1137671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Background Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field. Purpose This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline. Methods The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations. Results Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively. Conclusions The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.
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Affiliation(s)
- Giovanni Corrao
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Raffaella Ronco
- National Centre for Healthcare Research and Pharmacoepidemiology, Laboratory of the University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology, and Public Health, University of Milano-Bicocca, Milan, Italy
| | | | - Rosaria Alvaro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Luisella Cianferotti
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Davide Gatti
- Rheumatology Unit, University of Verona, Verona, Italy
| | - Stefano Gonnelli
- Department of Medicine, Surgery and Neuroscience, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Andrea Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | - Salvatore Leone
- AMICI Onlus, Associazione Nazionale per le Malattie Infiammatorie Croniche dell’Intestino, Milan, Italy
| | - Raffaella Michieli
- Italian Society of General Medicine and Primary Care Società Italiana di Medicina Generale e delle cure primarie (SIMG), Florence, Italy
| | - Silvia Migliaccio
- Department of Movement, Human and Health Sciences, Foro Italico University, Rome, Italy
| | - Tiziana Nicoletti
- CnAMC, Coordinamento nazionale delle Associazioni dei Malati Cronici e rari di Cittadinanzattiva, Rome, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Annalisa Pennini
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Eleonora Piccirilli
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | | | - Umberto Tarantino
- Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
- Department of Orthopedics and Traumatology, “Policlinico Tor Vergata” Foundation, Rome, Italy
| | - Maria Luisa Brandi
- Italian Bone Disease Research Foundation, Fondazione Italiana Ricerca sulle Malattie dell’Osso (FIRMO), Florence, Italy
- *Correspondence: Giovanni Corrao, ; Maria Luisa Brandi,
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Sun X, Chen Y, Gao Y, Zhang Z, Qin L, Song J, Wang H, Wu IXY. Prediction Models for Osteoporotic Fractures Risk: A Systematic Review and Critical Appraisal. Aging Dis 2022; 13:1215-1238. [PMID: 35855348 PMCID: PMC9286920 DOI: 10.14336/ad.2021.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/01/2022] Open
Abstract
Osteoporotic fractures (OF) are a global public health problem currently. Many risk prediction models for OF have been developed, but their performance and methodological quality are unclear. We conducted this systematic review to summarize and critically appraise the OF risk prediction models. Three databases were searched until April 2021. Studies developing or validating multivariable models for OF risk prediction were considered eligible. Used the prediction model risk of bias assessment tool to appraise the risk of bias and applicability of included models. All results were narratively summarized and described. A total of 68 studies describing 70 newly developed prediction models and 138 external validations were included. Most models were explicitly developed (n=31, 44%) and validated (n=76, 55%) only for female. Only 22 developed models (31%) were externally validated. The most validated tool was Fracture Risk Assessment Tool. Overall, only a few models showed outstanding (n=3, 1%) or excellent (n=32, 15%) prediction discrimination. Calibration of developed models (n=25, 36%) or external validation models (n=33, 24%) were rarely assessed. No model was rated as low risk of bias, mostly because of an insufficient number of cases and inappropriate assessment of calibration. There are a certain number of OF risk prediction models. However, few models have been thoroughly internally validated or externally validated (with calibration being unassessed for most of the models), and all models showed methodological shortcomings. Instead of developing completely new models, future research is suggested to validate, improve, and analyze the impact of existing models.
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Affiliation(s)
- Xuemei Sun
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yancong Chen
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yinyan Gao
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Zixuan Zhang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Lang Qin
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Jinlu Song
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Huan Wang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Irene XY Wu
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha 410000, China
- Correspondence should be addressed to: Dr. IXY Wu, Xiangya School of Public health, Central South University, Xiangya School of Public health, Changsha 410000, Hunan, China.
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11
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Lam MT, Sing CW, Li GHY, Kung AWC, Tan KCB, Cheung CL. Development and Validation of a Risk Score to Predict the First Hip Fracture in the Oldest Old: A Retrospective Cohort Study. J Gerontol A Biol Sci Med Sci 2021; 75:980-986. [PMID: 31353417 DOI: 10.1093/gerona/glz178] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To evaluate whether the common risk factors and risk scores (FRAX, QFracture, and Garvan) can predict hip fracture in the oldest old (defined as people aged 80 and older) and to develop an oldest-old-specific 10-year hip fracture prediction risk algorithm. METHODS Subjects aged 80 years and older without history of hip fracture were studied. For the derivation cohort (N = 251, mean age = 83), participants were enrolled with a median follow-up time of 8.9 years. For the validation cohort (N = 599, mean age = 85), outpatients were enrolled with a median follow-up of 2.6 years. A five-factor risk score (the Hong Kong Osteoporosis Study [HKOS] score) for incident hip fracture was derived and validated, and its predictive accuracy was evaluated and compared with other risk scores. RESULTS In the derivation cohort, the C-statistics were .65, .61, .65, .76, and .78 for FRAX with bone mineral density (BMD), FRAX without BMD, QFracture, Garvan, and the HKOS score, respectively. The category-less net reclassification index and integrated discrimination improvement of the HKOS score showed a better reclassification of hip fracture than FRAX and QFracture (all p < .001) but not Garvan, while Garvan, but not HKOS score, showed a significant over-estimation in fracture risk (Hosmer-Lemeshow test p < .001). In the validation cohort, the HKOS score had a C-statistic of .81 and a considerable agreement between expected and observed fracture risk in calibration. CONCLUSION The HKOS score can predict 10-year incident hip fracture among the oldest old in Hong Kong. The score may be useful in identifying the oldest old patients at risk of hip fracture in both community-dwelling and hospital settings.
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Affiliation(s)
- Ming-Tuen Lam
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, China
| | - Chor-Wing Sing
- Department of Pharmacology and Pharmacy, The University of Hong Kong, China
| | - Gloria H Y Li
- Department of Pharmacology and Pharmacy, The University of Hong Kong, China
| | - Annie W C Kung
- Department of Medicine, The University of Hong Kong, China
| | | | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, The University of Hong Kong, China
- Department of Medicine, The University of Hong Kong, China
- Centre for Genomic Sciences, The University of Hong Kong, China
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12
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Kim H, Kim JH, Kim MJ, Hong AR, Choi H, Ku E, Lee JH, Shin CS, Cho NH. Low Predictive Value of FRAX Adjusted by Trabecular Bone Score for Osteoporotic Fractures in Korean Women: A Community-Based Cohort Study. Endocrinol Metab (Seoul) 2020; 35:359-366. [PMID: 32615720 PMCID: PMC7386105 DOI: 10.3803/enm.2020.35.2.359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/14/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The value of the Fracture Risk Assessment Tool (FRAX) and the trabecular bone score (TBS) for assessing osteoporotic fracture risk has not been fully elucidated in Koreans. We conducted this study to clarify the predictive value of FRAX adjusted by TBS for osteoporotic fractures in Korean women. METHODS After screening 7,192 eligible subjects from the Ansung cohort, 1,165 women aged 45 to 76 years with available bone mineral density (BMD) and TBS data were enrolled in this study. We assessed their clinical risk factors for osteoporotic fractures and evaluated the predictive value of FRAX with or without BMD and TBS. RESULTS During the mean follow-up period of 7.5 years, 99 (8.5%) women suffered major osteoporotic fractures (MOFs) and 28 (2.4%) experienced hip fractures. FRAX without BMD, BMD-adjusted FRAX, and TBS-adjusted FRAX were significantly associated with the risk of MOFs (hazard ratio [HR] per percent increase, 1.08; 95% confidence interval [CI], 1.03 to 1.14; HR, 1.09; 95% CI, 1.03 to 1.15; and HR, 1.07; 95% CI, 1.02 to 1.13, respectively). However, BMD-adjusted FRAX and TBS-adjusted FRAX did not predict MOFs better than FRAX without BMD based on the Harrell's C statistic. FRAX probabilities showed limited value for predicting hip fractures. The cut-off values of FRAX without BMD, FRAX with BMD, and FRAX with BMD adjusted by TBS for predicting MOFs were 7.2%, 5.0%, and 6.7%, respectively. CONCLUSION FRAX with BMD and TBS adjustment did not show better predictive value for osteoporotic fractures in this study than FRAX without adjustment. Moreover, the cut-off values of FRAX probabilities for treatment might be lower in Korean women than in other countries.
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Affiliation(s)
- Hana Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
- Department of Internal Medicine, Ilsan Cha Medical Center, Goyang,
Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Min Joo Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - A Ram Hong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - HyungJin Choi
- Department of Anatomy, Seoul National University College of Medicine, Seoul,
Korea
| | - EuJeong Ku
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju,
Korea
| | - Ji Hyun Lee
- Department of Internal Medicine, Veterans Health Service Medical Center, Seoul,
Korea
| | - Chan Soo Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Nam H. Cho
- Department of Preventive Medicine, Ajou University School of Medicine, Suwon,
Korea
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13
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Cui L, He T, Jiang Y, Li M, Wang O, Jiajue R, Chi Y, Xu Q, Xing X, Xia W. Predicting the intervention threshold for initiating osteoporosis treatment among postmenopausal women in China: a cost-effectiveness analysis based on real-world data. Osteoporos Int 2020; 31:307-316. [PMID: 31754756 PMCID: PMC7010623 DOI: 10.1007/s00198-019-05173-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 09/18/2019] [Indexed: 01/21/2023]
Abstract
UNLABELLED This study built a micro-simulation Markov model to determine the treatment threshold of osteoporosis in postmenopausal women in Mainland China. Treatment with zoledronate is cost-effective when FRAX-based (Fracture risk assessment tool) fracture probability is over 7%. INTRODUCTION The purpose of this study is to estimate FRAX-based fracture probabilities in Mainland China using real-world data, at which intervention could be cost-effective. METHODS We developed a micro-simulation Markov model to capture osteoporosis states and relevant morbidities including hip fracture, vertebral fracture, and wrist fracture. Baseline characteristics including incidences of osteoporosis and distribution of risk factors were derived from the Peking Vertebral Fracture study, the largest prospective cohort study of postmenopausal women in Mainland China. We projected incidences of fractures and deaths by age groups under two treatment scenarios: 1) no treatment, and 2) zoledronate. We also projected total quality-adjusted life-years (QALY) and total costs including fracture management and osteoporosis drugs for cost-effectiveness analysis. Cost-effective intervention thresholds were calculated based on the Chinese FRAX model. RESULTS Treatment with zoledronate was cost-effective when the 10-year probability of major osteoporotic fracture based on FRAX was above 7%. The FRAX threshold increased by age from 51 to 65 years old, and decreased in elder age groups, ranging from 4% to 9%. CONCLUSIONS Using real-world data, our model indicated that widespread use of zoledronate was of both clinical and economic benefit among Chinese postmenopausal women. Using a FRAX-based intervention threshold of 7% with zoledronate should permit cost-effective access to therapy to patients and contribute to reducing the disease burden of osteoporosis in Mainland China.
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Affiliation(s)
- L Cui
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - T He
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Y Jiang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - M Li
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - O Wang
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - R Jiajue
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Y Chi
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Q Xu
- Department of Orthopedics, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - X Xing
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - W Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, Ministry of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Lekamwasam S. The diversity of Fracture Risk Assessment Tool (FRAX)-based intervention thresholds in Asia. Osteoporos Sarcopenia 2019; 5:104-108. [PMID: 31938728 PMCID: PMC6953527 DOI: 10.1016/j.afos.2019.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/02/2019] [Accepted: 12/05/2019] [Indexed: 01/22/2023] Open
Abstract
Fracture Risk Assessment Tool (FRAX), introduced in 2008, is the most frequently used fracture risk calculator. Many Asian countries have developed own FRAX models to suit their country needs. Only a few Asian countries, however, have developed country-specific intervention thresholds to demarcate high-risk patients. A wide variation is seen in these intervention thresholds partly due to the different approaches used in developing the cutoff values. This paper discusses the diversity of the intervention thresholds in Asian countries and possible reasons. It also discusses the future directions for the countries in the Asian region.
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Affiliation(s)
- Sarath Lekamwasam
- Population Health Research Center, Department of Medicine, Faculty of Medicine, Galle, Sri Lanka
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15
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Cheung CL. FRAX-based intervention thresholds in Asia: Now and future. Osteoporos Sarcopenia 2019; 5:103. [PMID: 31938727 PMCID: PMC6953520 DOI: 10.1016/j.afos.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022] Open
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Beaudoin C, Moore L, Gagné M, Bessette L, Ste-Marie LG, Brown JP, Jean S. Performance of predictive tools to identify individuals at risk of non-traumatic fracture: a systematic review, meta-analysis, and meta-regression. Osteoporos Int 2019; 30:721-740. [PMID: 30877348 DOI: 10.1007/s00198-019-04919-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/26/2019] [Indexed: 01/28/2023]
Abstract
UNLABELLED There is no consensus on which tool is the most accurate to assess fracture risk. The results of this systematic review suggest that QFracture, Fracture Risk Assessment Tool (FRAX) with BMD, and Garvan with BMD are the tools with the best discriminative ability. More studies assessing the comparative performance of current tools are needed. INTRODUCTION Many tools exist to assess fracture risk. This review aims to determine which tools have the best predictive accuracy to identify individuals at high risk of non-traumatic fracture. METHODS Studies assessing the accuracy of tools for prediction of fracture were searched in MEDLINE, EMBASE, Evidence-Based Medicine Reviews, and Global Health. Studies were eligible if discrimination was assessed in a population independent of the derivation cohort. Meta-analyses and meta-regressions were performed on areas under the ROC curve (AUCs). Gender, mean age, age range, and study quality were used as adjustment variables. RESULTS We identified 53 validation studies assessing the discriminative ability of 14 tools. Given the small number of studies on some tools, only FRAX, Garvan, and QFracture were compared using meta-regression models. In the unadjusted analyses, QFracture had the best discriminative ability to predict hip fracture (AUC = 0.88). In the adjusted analysis, FRAX with BMD (AUC = 0.81) and Garvan with BMD (AUC = 0.79) had the highest AUCs. For prediction of major osteoporotic fracture, QFracture had the best discriminative ability (AUC = 0.77). For prediction of osteoporotic or any fracture, FRAX with BMD and Garvan with BMD had higher discriminative ability than their versions without BMD (FRAX: AUC = 0.72 vs 0.69, Garvan: AUC = 0.72 vs 0.65). A significant amount of heterogeneity was present in the analyses. CONCLUSIONS QFracture, FRAX with BMD, and Garvan with BMD have the highest discriminative performance for predicting fracture. Additional studies in which the performance of current tools is assessed in the same individuals may be performed to confirm this conclusion.
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Affiliation(s)
- C Beaudoin
- Department of Social and Preventive Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada.
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada.
- Bureau d'information et d'études en santé des populations, Institut National de Santé Publique du Québec, 945, Avenue Wolfe, Québec, G1V 5B3, Canada.
| | - L Moore
- Department of Social and Preventive Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
| | - M Gagné
- Bureau d'information et d'études en santé des populations, Institut National de Santé Publique du Québec, 945, Avenue Wolfe, Québec, G1V 5B3, Canada
| | - L Bessette
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
| | - L G Ste-Marie
- Department of Medicine, Medicine Faculty, University of Montréal, Montréal, QC, Canada
| | - J P Brown
- CHU de Québec-Université Laval Research Center, Québec, QC, Canada
- Department of Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
| | - S Jean
- Bureau d'information et d'études en santé des populations, Institut National de Santé Publique du Québec, 945, Avenue Wolfe, Québec, G1V 5B3, Canada
- Department of Medicine, Medicine Faculty, Laval University, Ferdinand Vandry Pavillon, 1050 Avenue de la Médecine, Quebec City, QC, G1V 0A6, Canada
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17
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Imerci A, Yalın Kılınç C, Aydogan NH, Karalezli MN, Savran A. Fracture Risk Assessment Tool (FRAX®) Results Calculated With and Without Bone Mineral Density Values for the Evaluation of Fracture Risk in Postmenopausal Women With Osteopenia. J Clin Densitom 2018; 21:464-471. [PMID: 28781230 DOI: 10.1016/j.jocd.2017.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 06/18/2017] [Accepted: 06/27/2017] [Indexed: 01/14/2023]
Abstract
The aim of this study was to evaluate the agreement between fracture risk predictions based on calculations made with and without bone mineral density (BMD) values using the Fracture Risk Assessment Tool (FRAX®) in Turkish postmenopausal women with osteopenia and to compare the treatment recommendations. This descriptive, cross-sectional study included postmenopausal women aged 50-79 yr with a diagnosis of osteoporosis who were not receiving any treatment. A questionnaire was administered to the participants face-to-face to obtain sociodemographic characteristics, medical history, and fracture history. Fracture risk was calculated with FRAX® separately with and without BMD. The study included 230 postmenopausal patients with osteopenia. The mean age of the patients was determined as 63.16 ± 7.59 yr, and the mean body mass index was 30.61 ± 5.02. The intraclass correlation coefficient values of the 10-yr major osteoporotic (MO) fracture and hip fracture score agreement with FRAX® with and without BMD were mean 0.486 and 0.462, respectively. The risk of MO fracture with an intervention threshold of ≥20 was determined in 227/230 patients (98.7%), and the risk of hip fracture with treatment recommendations of ≥3 was determined in 204/230 patients (88.7%). Treatment recommendations in patients with no fracture history and secondary osteoporosis were 100% for MO fracture and 94.7% (123/130) for hip fracture risk. The treatment recommendation rates of FRAX® with and without BMD were similar for the majority of postmenopausal women with osteopenia. The agreement between the values was of a moderate level. When patients with a fracture history and secondary osteoporosis were excluded, the agreement increased. Even though values with BMD are of basic importance for medical treatment in postmenopausal women, the use of measurements evaluating fracture risk, such as FRAX® without BMD, could be useful in postmenopausal women with osteopenia.
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Affiliation(s)
- Ahmet Imerci
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey.
| | - Cem Yalın Kılınç
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Nevres Hurriyet Aydogan
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Mustafa Nazım Karalezli
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Ahmet Savran
- Department of Hand Surgery, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
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Viswanathan M, Reddy S, Berkman N, Cullen K, Middleton JC, Nicholson WK, Kahwati LC. Screening to Prevent Osteoporotic Fractures: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018; 319:2532-2551. [PMID: 29946734 DOI: 10.1001/jama.2018.6537] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Osteoporotic fractures cause significant morbidity and mortality. OBJECTIVE To update the evidence on screening and treatment to prevent osteoporotic fractures for the US Preventive Services Task Force. DATA SOURCES PubMed, the Cochrane Library, EMBASE, and trial registries (November 1, 2009, through October 1, 2016) and surveillance of the literature (through March 23, 2018); bibliographies from articles. STUDY SELECTION Adults 40 years and older; screening cohorts without prevalent low-trauma fractures or treatment cohorts with increased fracture risk; studies assessing screening, bone measurement tests or clinical risk assessments, pharmacologic treatment. DATA EXTRACTION AND SYNTHESIS Dual, independent review of titles/abstracts and full-text articles; study quality rating; random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Incident fractures and related morbidity and mortality, diagnostic and predictive accuracy, harms of screening or treatment. RESULTS One hundred sixty-eight fair- or good-quality articles were included. One randomized clinical trial (RCT) (n = 12 483) comparing screening with no screening reported fewer hip fractures (2.6% vs 3.5%; hazard ratio [HR], 0.72 [95% CI, 0.59-0.89]) but no other statistically significant benefits or harms. The accuracy of bone measurement tests to identify osteoporosis varied (area under the curve [AUC], 0.32-0.89). The pooled accuracy of clinical risk assessments for identifying osteoporosis ranged from AUC of 0.65 to 0.76 in women and from 0.76 to 0.80 in men; the accuracy for predicting fractures was similar. For women, bisphosphonates, parathyroid hormone, raloxifene, and denosumab were associated with a lower risk of vertebral fractures (9 trials [n = 23 690]; relative risks [RRs] from 0.32-0.64). Bisphosphonates (8 RCTs [n = 16 438]; pooled RR, 0.84 [95% CI, 0.76-0.92]) and denosumab (1 RCT [n = 7868]; RR, 0.80 [95% CI, 0.67-0.95]) were associated with a lower risk of nonvertebral fractures. Denosumab reduced the risk of hip fracture (1 RCT [n = 7868]; RR, 0.60 [95% CI, 0.37-0.97]), but bisphosphonates did not have a statistically significant association (3 RCTs [n = 8988]; pooled RR, 0.70 [95% CI, 0.44-1.11]). Evidence was limited for men: zoledronic acid reduced the risk of radiographic vertebral fractures (1 RCT [n = 1199]; RR, 0.33 [95% CI, 0.16-0.70]); no studies demonstrated reductions in clinical or hip fractures. Bisphosphonates were not consistently associated with reported harms other than deep vein thrombosis (raloxifene vs placebo; 3 RCTs [n = 5839]; RR, 2.14 [95% CI, 0.99-4.66]). CONCLUSIONS AND RELEVANCE In women, screening to prevent osteoporotic fractures may reduce hip fractures, and treatment reduced the risk of vertebral and nonvertebral fractures; there was not consistent evidence of treatment harms. The accuracy of bone measurement tests or clinical risk assessments for identifying osteoporosis or predicting fractures varied from very poor to good.
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Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Shivani Reddy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Nancy Berkman
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Katie Cullen
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International, Research Triangle Park, North Carolina
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Wanda K Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill
| | - Leila C Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
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Marques A, Lucas R, Simões E, Verstappen SMM, Jacobs JWG, da Silva JAP. Do we need bone mineral density to estimate osteoporotic fracture risk? A 10-year prospective multicentre validation study. RMD Open 2017; 3:e000509. [PMID: 29018567 PMCID: PMC5623321 DOI: 10.1136/rmdopen-2017-000509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/30/2017] [Accepted: 08/25/2017] [Indexed: 02/01/2023] Open
Abstract
Objective Evaluate the performance of FRAX®, with and without bone mineral densitometry (BMD), in predicting the occurrence of fragility fractures over 10 years. Methods Participants aged ≥40 years at baseline, with a complete set of data and a minimum of 8.5 years of follow-up were identified from three cohorts (n=2626). Ten-year fracture risk at baseline were estimated with FRAX® and assessed by comparison with observed fractures and receiver operating characteristic analysis. Results During a mean (SD) follow-up of 9.12 (1.5) years, 178 participants suffered a major osteoporotic (MOP) fracture and 28 sustained a hip fracture. The predictive performance of FRAX® was superior to that of BMD alone for both MOP and hip fractures. The area under the curve (AUC) of FRAX® without BMD was 0.76 (95% CI 0.72 to 0.79) for MOP fractures and 0.78 (95% CI 0.69 to 0.86) for hip fractures. No significant improvements were found when BMD was added to clinical variables to predict either MOP (0.78, 95% CI 0.74 to 0.82, p=0.25) or hip fractures (0.79, 95% CI 0.69 to 0.89, p=0.72). AUCs for FRAX® (with and without BMD) were greater for men than for women. FRAX®, with and without BMD, tended to underestimate the number of MOP fractures and to overestimate the number of hip fractures in females. In men, the number of observed fractures were within the 95% CI of the number predicted, both with and without BMD. Conclusion FRAX® without BMD provided good fracture prediction. Adding BMD to FRAX® did not improve the performance of the tool in the general population.
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Affiliation(s)
- Andréa Marques
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal.,Coimbra Nursing School, Esenfc, Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Raquel Lucas
- EPIUnit - Institute of Public Health and Porto Medical School, University of Porto, Porto, Portugal
| | | | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Johannes W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands
| | - Jose A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal
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20
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Epidemiology of fractures in Armenia: development of a country-specific FRAX model and comparison to its surrogate. Arch Osteoporos 2017; 12:98. [PMID: 29116417 PMCID: PMC5676826 DOI: 10.1007/s11657-017-0392-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/15/2017] [Indexed: 02/03/2023]
Abstract
UNLABELLED Fracture probabilities derived from the surrogate FRAX model for Armenia were compared to those from the model based on regional estimates of the incidence of hip fracture. Disparities between the surrogate and authentic FRAX models indicate the importance of developing country-specific FRAX models. Despite large differences between models, differences in the rank order of fracture probabilities were minimal. OBJECTIVE Armenia has relied on a surrogate FRAX model based on the fracture epidemiology of Romania. This paper describes the epidemiology of fragility fractures in Armenia used to create an Armenia-specific FRAX model with an aim of comparing this new model with the surrogate model. METHODS We carried out a population-based study in two regions of Armenia (Ararat and Vayots Dzor representing approximately 11% of the country's population). We aimed to identify all low-energy fractures: retrospectively from hospital registers in 2011-2012 and prospectively in 2013 with the inclusion of primary care sources. RESULTS The differences in incidence between the surveys with and without data from primary care suggested that 44% of patients sustaining a hip fracture did not receive specialized medical care. A similar proportion of forearm and humeral fractures did not come to hospital attention (48 and 49%, respectively). Only 57.7% of patients sustaining a hip fracture were hospitalized. In 2013, hip fracture incidence at the age of 50 years or more was 201/100,000 for women and 136/100,000 for men, and age- and sex-specific rates were incorporated into the new "authentic" FRAX model for Armenia. Compared to the surrogate model, the authentic model gave lower 10-year fracture probabilities in men and women aged less than 70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the surrogate and authentic models (> 0.99) so that the revisions had little impact on the rank order of risk. CONCLUSION A substantial proportion of major osteoporotic fractures in Armenia do not come to hospital attention. The disparities between surrogate and authentic FRAX models indicate the importance of developing country-specific FRAX models. Despite large differences between models, differences in the rank order of fracture probabilities were minimal.
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Relationship between the FRAX ® score and falls in community-dwelling middle-aged and elderly people. Osteoporos Sarcopenia 2016; 2:221-227. [PMID: 30775490 PMCID: PMC6372775 DOI: 10.1016/j.afos.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Falls is a risk factor for fracture. The FRAX® predicts fractures. Whether the FRAX® is associated with fall in both gender is inconclusive. The aim of our study is to evaluate the association between FRAX scores and falls. METHODS The cross-sectional study set from 2009 to 2010 included 1200 community-dwelling people who were systematically sampled in central Taiwan. The 1200 participants (men: 524; women: 676; ≥40 years old) completed questionnaires about socioeconomic status; lifestyle; medical and fall history were completed. FRAX scores with and without bone mineral density (BMD) were calculated by using the Taiwan calculator. RESULTS A total of 19.8% participants fell down. Binary regression models showed that diabetes mellitus history (OR: 1.61; 95% CI: 1.03-2.52), the FRAX without BMD in a continuous major score (OR: 1.06; 95% CI: 1.03-1.09), continuous hip score (OR: 1.11; 95% CI: 1.05-1.16), categorical major score ≥ 10% (OR: 1.81; 95% CI: 1.25-2.61), and categorical hip score ≥ 3% (OR: 1.80; 95% CI: 1.30-2.50) were independent risk factors for falls. FRAX with BMD in a continuous major score (OR: 1.04; 95% CI: 1.02-1.06), continuous hip score (OR: 1.06; 95% CI: 1.02-1.09), categorical major score ≥ 10% (OR: 1.52; 95% CI: 1.09-2.12), and categorical hip score ≥ 3% (OR: 1.53; 95% CI: 1.13-2.09) were also independent risk factors. CONCLUSIONS We concluded that FRAX® scores with and without BMD were unanimously correlated with falls in community-dwelling middle-aged and elderly males and females.
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Cheung EY, Tan KC, Cheung CL, Kung AW. Osteoporosis in East Asia: Current issues in assessment and management. Osteoporos Sarcopenia 2016; 2:118-133. [PMID: 30775478 PMCID: PMC6372753 DOI: 10.1016/j.afos.2016.07.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 06/27/2016] [Accepted: 07/01/2016] [Indexed: 12/31/2022] Open
Abstract
The greatest burden of hip fractures around the world is expected to occur in East Asia, especially China. However, there is a relative paucity of information on the epidemiology and burden of fractures in East Asia. Osteoporosis is greatly under-diagnosed and under-treated, even among the highest-risk subjects who have already suffered fractures. The accessibility to bone densitometry, the awareness of the disease by professionals and the public, and the use and reimbursement of drugs are some of the areas which need improvement especially. Cost-effective analysis on screening strategy and intervention thresholds based on local epidemiology data and economic status are available only in Japan. In addition, clinical risk factor models for the assessment of fracture probability may be ethnic specific. Further research is needed to develop a cost-effective risk assessment strategy to identify high-risk individuals for screening and treatment based on local data. Moreover, inadequate calcium and vitamin D intake is still an issue faced by this region.
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Affiliation(s)
- Elaine Y.N. Cheung
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong, China
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kathryn C.B. Tan
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Ching-Lung Cheung
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
- Centre for Genomic Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Annie W.C. Kung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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Lin J, Yang Y, Fei Q, Zhang X, Ma Z, Wang Q, Li J, Li D, Meng Q, Wang B. Validation of three tools for identifying painful new osteoporotic vertebral fractures in older Chinese men: bone mineral density, Osteoporosis Self-Assessment Tool for Asians, and fracture risk assessment tool. Clin Interv Aging 2016; 11:461-9. [PMID: 27217730 PMCID: PMC4853018 DOI: 10.2147/cia.s101078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This cross-sectional study compared three tools for predicting painful new osteoporotic vertebral fractures (PNOVFs) in older Chinese men: bone mineral density (BMD), the Osteoporosis Self-Assessment Tool for Asians (OSTA), and the World Health Organization fracture risk assessment tool (FRAX) (without BMD). METHODS Men aged ≥50 years were apportioned to a group for men with fractures who had undergone percutaneous vertebroplasty (n=111), or a control group of healthy men (n=385). Fractures were verified on X-ray and magnetic resonance imaging. BMD T-scores were determined by dual energy X-ray absorptiometry. Diagnosis of osteoporosis was determined by a BMD T-score of ≤2.5 standard deviations below the average for a young adult at peak bone density at the femoral neck, total hip, or L1-L4. Demographic and clinical risk factor data were self-reported through a questionnaire. BMD, OSTA, and FRAX scores were assessed for identifying PNOVFs via receiver-operating characteristic (ROC) curves. Optimal cutoff points, sensitivity, specificity, and areas under the ROC curves (AUCs) were determined. RESULTS Between the men with fractures and the control group, there were significant differences in BMD T-scores (at femoral neck, total hip, and L1-L4), and OSTA and FRAX scores. In those with fractures, only 53.15% satisfied the criteria for osteoporosis. Compared to BMD or OSTA, the FRAX score had the best predictive value for PNOVFs: the AUC of the FRAX score (cutoff =2.9%) was 0.738, and the sensitivity and specificity were 82% and 62%, respectively. CONCLUSION FRAX may be a valuable tool for identifying PNOVFs in older Chinese men.
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Affiliation(s)
- JiSheng Lin
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Qi Fei, Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Yongan Road 95#, Xicheng District, Beijing 100050, People’s Republic of China, Tel +86 10 6313 8353, Fax +86 10 8391 1029, Email
| | - XiaoDong Zhang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zhao Ma
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Qi Wang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - JinJun Li
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dong Li
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Qian Meng
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - BingQiang Wang
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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Liu LK, Lee WJ, Chen LY, Hwang AC, Lin MH, Peng LN, Chen LK. Association between Frailty, Osteoporosis, Falls and Hip Fractures among Community-Dwelling People Aged 50 Years and Older in Taiwan: Results from I-Lan Longitudinal Aging Study. PLoS One 2015; 10:e0136968. [PMID: 26348034 PMCID: PMC4562637 DOI: 10.1371/journal.pone.0136968] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 08/11/2015] [Indexed: 12/25/2022] Open
Abstract
Background Association of frailty with adverse clinical outcomes has been reported in Western countries, but data from the Asian population are scarce. This study aimed to evaluate the epidemiology of frailty among community-dwelling middle-aged and elderly population and to explore its association with musculoskeletal health in Taiwan. Methods I-Lan Longitudinal Aging Study (ILAS) data were retrieved for this study. Frailty was defined by the Fried’s criteria; a comparison of demographic characteristics, physical performance, and body composition, including skeletal muscle mass and bone mineral density (BMD), as well as recent falls, history of hip fractures and the functional status of subjects with different frailty statuses were accomplished. Results Overall, the data of 1,839 participants (mean age: 63.9±9.3 years, male 47.5%) were obtained for analysis. The prevalence of pre-frailty was 42.3% in men and 38.8% in women, whereas the prevalence of frailty was 6.9% and 6.7% in men and women, respectively. Frailty was significantly associated with older age, the male gender, larger waist circumference, lower skeletal muscle index, lower hip BMD, poorer physical function, poorer nutritional status, and poorer cognitive function. Also, frailty was significantly associated with osteoporosis (OR: 7.73, 95% CI: 5.01–11.90, p<0.001), history of hip fractures (OR: 8.66, 95% CI: 2.47–30.40, p = 0.001), and recent falls (O.R: 2.53, 95% CI: 1.35–4.76, p = 0.004). Conclusions Frailty and pre-frailty, in Taiwan, was closely associated with recent falls, history of hip fractures and osteoporosis among community-dwelling people 50 years of age and older. Furthermore, frailty intervention programs should take an integrated approach towards strengthening both and muscle mass, as well as prevention of falls.
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Affiliation(s)
- Li-Kuo Liu
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ju Lee
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming University, Taipei, Taiwan
- Department of Family Medicine, Taipei Veterans General Hospital Yuanshan Branch, I-Lan County, Taiwan
| | - Liang-Yu Chen
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - An-Chun Hwang
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Hsien Lin
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Ning Peng
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Institute of Public Health, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
- * E-mail:
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Marques A, Ferreira RJO, Santos E, Loza E, Carmona L, da Silva JAP. The accuracy of osteoporotic fracture risk prediction tools: a systematic review and meta-analysis. Ann Rheum Dis 2015; 74:1958-67. [PMID: 26248637 DOI: 10.1136/annrheumdis-2015-207907] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 07/14/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To identify and synthesise the best available evidence on the accuracy of the currently available tools for predicting fracture risk. METHODS We systematically searched PubMed MEDLINE, Embase and Cochrane databases to 2014. Two reviewers independently selected articles, collected data from studies, and carried out a hand search of the references of the included studies. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) checklist was used, and the primary outcome was the area under the curve (AUC) and 95% CIs, obtained from receiver operating characteristic (ROC) analyses. We excluded tools if they had not been externally validated or were designed for specific disease populations. Random effects meta-analyses were performed with the selected tools. RESULTS Forty-five studies met inclusion criteria, corresponding to 13 different tools. Only three tools had been tested more than once in a population-based setting: FRAX (26 studies in 9 countries), GARVAN (6 studies in 3 countries) and QFracture (3 studies in the UK, 1 also including Irish participants). Twenty studies with these three tools were included in a total of 17 meta-analyses (for hip or major osteoporotic fractures; men or women; with or without bone mineral density). CONCLUSIONS Most of the 13 tools are feasible in clinical practice. FRAX has the largest number of externally validated and independent studies. The overall accuracy of the different tools is satisfactory (>0.70), with QFracture reaching 0.89 (95% CI 0.88 to 0.89). Significant methodological limitations were observed in many studies, suggesting caution when comparing tools based solely on the AUC.
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Affiliation(s)
- Andréa Marques
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Eduardo Santos
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
| | - Estíbaliz Loza
- Instituto de Salud Musculoesquelética-InMusc, Madrid, Spain
| | - Loreto Carmona
- Instituto de Salud Musculoesquelética-InMusc, Madrid, Spain
| | - José António Pereira da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal Faculty of Medicine, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal
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Blain H, Rolland Y, Beauchet O, Annweiler C, Benhamou CL, Benetos A, Berrut G, Audran M, Bendavid S, Bousson V, Briot K, Brazier M, Breuil V, Chapuis L, Chapurlat R, Cohen-Solal M, Cortet B, Dargent P, Fardellone P, Feron JM, Gauvain JB, Guggenbuhl P, Hanon O, Laroche M, Kolta S, Lespessailles É, Letombe B, Mallet É, Marcelli C, Orcel P, Puisieux F, Seret P, Souberbielle JC, Sutter B, Trémollières F, Weryha G, Roux C, Thomas T. Usefulness of bone density measurement in fallers. Joint Bone Spine 2014; 81:403-8. [DOI: 10.1016/j.jbspin.2014.01.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2014] [Indexed: 10/25/2022]
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Cheung CL, Lam KSL, Wong ICK, Cheung BMY. Non-invasive score identifies ultrasonography-diagnosed non-alcoholic fatty liver disease and predicts mortality in the USA. BMC Med 2014; 12:154. [PMID: 25204761 PMCID: PMC4207316 DOI: 10.1186/s12916-014-0154-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 08/15/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Several non-invasive prediction scores for non-alcoholic fatty liver disease (NAFLD) have been developed, but their performance has not been compared and validated in the same population, and whether these prediction scores can predict clinical outcomes remains unknown. In this study, we aimed to validate and compare the performance of four NAFLD prediction scores: fatty liver index, hepatic steatosis index, lipid accumulation product, and NAFLD liver fat score (LFS), and to evaluate the ability of the best NAFLD prediction score to predict mortality. METHODS We analyzed data from the National Health and Nutrition Examination Survey conducted in 1988 to 1994, and subsequent follow-up data for mortality up to December 31, 2006. NAFLD was defined by ultrasonographic detection of hepatic steatosis in the absence of other known liver diseases. RESULTS In a group of 5,184 participants, LFS consistently showed the highest area under the curve for predicting the presence of NAFLD. During a median follow-up of 14.7 years (range 0.1 to 18.2 years) and 83,830.5 person-years, participants in the high LFS group (LFS ≥1.257) had a higher cardiovascular and liver-related mortality than participants in the low (LFS ≤ -1.413; cardiovascular hazard ratio (HR) = 2.24, 95% CI 1.03 to 4.88; liver HR = 31.25, 95% CI 3.13 to 333.33) or intermediate (-1.413 < LFS < 1.257; cardiovascular HR = 2.3, 95% CI 1.19 to 4.48; liver HR = 30.3, 95% CI 4 to 250) LFS groups in the fully adjusted model. Similar results were obtained when LFS was treated as a continuous variable. CONCLUSIONS LFS is the best non-invasive prediction score for NAFLD, and people with a high LFS score have an increased risk for cardiovascular and liver-related mortality.
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Cheung E, Cheung CL, Kung AWC, Tan KCB. Possible FRAX-based intervention thresholds for a cohort of Chinese postmenopausal women. Osteoporos Int 2014; 25:1017-23. [PMID: 24196720 DOI: 10.1007/s00198-013-2553-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 09/16/2013] [Indexed: 11/28/2022]
Abstract
SUMMARY A total of 2,266 postmenopausal Chinese women were followed for 4.5 years to determine the incidence of new fractures. The positive predictive value, negative predictive value, sensitivity and specificity of different treatment strategies were compared. Using a fixed optimal threshold calculated from receiver operating characteristics (ROC) curve had the highest sensitivity but lowest specificity. INTRODUCTION There is no specific intervention threshold based on FRAX to guide treatment for Asian populations. This prospective study sought to determine the impact of applying different intervention thresholds to a cohort of Chinese postmenopausal women. METHODS This study was part of the Hong Kong Osteoporosis Study. A total of 2,266 treatment-naïve postmenopausal women underwent clinical risk factor and BMD assessments. The subjects were followed to assess fractures. We calculated the FRAX probability of major osteoporotic fractures corresponding to women with prior fractures but no other clinical risk factors. Different treatment strategies which include treating women with prior fractures, women with age-specific FRAX probability corresponding to those with prior fractures, women with osteoporosis as well as women with FRAX probability above a fixed cut-off based on optimizing sensitivity and specificity on the ROC curve were compared. RESULTS The mean age at baseline was 62.1 ± 8.5 years, and the mean follow-up time was 4.5 ± 2.8 years. One hundred six new major osteoporotic fractures were reported. An optimal (FRAX, with BMD) cut-off point of 9.95 % was identified. All strategies had negative predictive value of >90 %. Using a fixed cut-off had the highest sensitivity (62.3 %) but lowest specificity (73.5 %) and positive predictive value (10.3 %). Using a fixed cut-off would direct treatment from younger women with lower absolute risk to elderly women with higher absolute risk. CONCLUSION Targeting only women with prior fractures is unlikely to reduce fracture burden. Other treatment strategies with higher sensitivity need to be considered but they have different shortcomings.
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Affiliation(s)
- E Cheung
- Department of Medicine, United Christian Hospital, Hong Kong, China,
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Chen XF, Li XL, Zhang H, Liu GJ. Were you identified to be at high fracture risk by FRAX® before your osteoporotic fracture occurred? Clin Rheumatol 2014; 33:693-8. [DOI: 10.1007/s10067-014-2533-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 02/06/2014] [Accepted: 02/09/2014] [Indexed: 10/25/2022]
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Cheung E, Kung AWC, Tan KCB. Outcomes of applying the NOF, NOGG and Taiwanese guidelines to a cohort of Chinese early postmenopausal women. Clin Endocrinol (Oxf) 2014; 80:200-7. [PMID: 24010883 DOI: 10.1111/cen.12322] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 02/23/2013] [Accepted: 09/01/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We applied the NOF (National Osteoporosis Foundation, USA), NOGG (National Osteoporosis Guideline Group, UK) and Taiwanese guidelines to a cohort of postmenopausal women and compared the effectiveness in fracture prevention according to these guidelines. DESIGN This study is part of the Hong Kong Osteoporosis Study in which postmenopausal women underwent regular assessment and followed up for fracture outcome. SUBJECTS We studied 2266 treatment-naïve postmenopausal women with mean age of 62·1 years and mean follow-up of 4·5 years. MEASUREMENT The treatment recommendations based on different guidelines were compared. The women were followed up to determine the rate of fracture occurrence. RESULTS A total of 106 new major osteoporotic fractures (MOF) were reported, of which 21 were hip fractures (HF). Application of the NOF, NOGG and Taiwanese guidelines resulted in bone mineral density (BMD) screening of 40·7%, 1·3% and 31·8% and treatment of 26·8%, 15·5% and 25·4% of the cohort, respectively. 85·7%, 52·4% and 85·7% of the subjects who sustained HFs would be offered treatment according to the NOF, NOGG and Taiwanese guidelines, respectively. Likewise, 58·5%, 34% and 59·4% of the subjects who sustained MOF would be offered treatment according to the 3 guidelines, respectively. The clinical utility indexes for the 3 guidelines based on the occurrence of MOF during follow-up were 0·0597, 0·0345 and 0·0651, respectively. The corresponding numbers for HFs were even lower. CONCLUSION The clinical utility for these three guidelines is low for this postmenopausal cohort. Specific guidelines should be needed to guide BMD screening and treatment in our society.
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Affiliation(s)
- Elaine Cheung
- Department of Medicine, United Christian Hospital, Hong Kong, China
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Nayak S, Edwards DL, Saleh AA, Greenspan SL. Performance of risk assessment instruments for predicting osteoporotic fracture risk: a systematic review. Osteoporos Int 2014; 25:23-49. [PMID: 24105431 PMCID: PMC3962543 DOI: 10.1007/s00198-013-2504-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 08/19/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED We systematically reviewed the literature on the performance of osteoporosis absolute fracture risk assessment instruments. Relatively few studies have evaluated the calibration of instruments in populations separate from their development cohorts, and findings are mixed. Many studies had methodological limitations making susceptibility to bias a concern. INTRODUCTION The aim of this study was to systematically review the literature on the performance of osteoporosis clinical fracture risk assessment instruments for predicting absolute fracture risk, or calibration, in populations other than their derivation cohorts. METHODS We performed a systematic review, and MEDLINE, Embase, Cochrane Library, and multiple other literature sources were searched. Inclusion and exclusion criteria were applied and data extracted, including information about study participants, study design, potential sources of bias, and predicted and observed fracture probabilities. RESULTS A total of 19,949 unique records were identified for review. Fourteen studies met inclusion criteria. There was substantial heterogeneity among included studies. Six studies assessed the WHO's Fracture Risk Assessment (FRAX) instrument in five separate cohorts, and a variety of risk assessment instruments were evaluated in the remainder of the studies. Approximately half found good instrument calibration, with observed fracture probabilities being close to predicted probabilities for different risk categories. Studies that assessed the calibration of FRAX found mixed performance in different populations. A similar proportion of studies that evaluated simple risk assessment instruments (≤5 variables) found good calibration when compared with studies that assessed complex instruments (>5 variables). Many studies had methodological features making them susceptible to bias. CONCLUSIONS Few studies have evaluated the performance or calibration of osteoporosis fracture risk assessment instruments in populations separate from their development cohorts. Findings are mixed, and many studies had methodological limitations making susceptibility to bias a possibility, raising concerns about use of these tools outside of the original derivation cohorts. Further studies are needed to assess the calibration of instruments in different populations prior to widespread use.
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Affiliation(s)
- S Nayak
- Swedish Center for Research and Innovation, Swedish Health Services, Swedish Medical Center, 747 Broadway, Seattle, WA, 98122-4307, USA,
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Rubin KH, Friis-Holmberg T, Hermann AP, Abrahamsen B, Brixen K. Risk assessment tools to identify women with increased risk of osteoporotic fracture: complexity or simplicity? A systematic review. J Bone Miner Res 2013; 28:1701-17. [PMID: 23592255 DOI: 10.1002/jbmr.1956] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 03/26/2013] [Accepted: 03/27/2013] [Indexed: 01/03/2023]
Abstract
A huge number of risk assessment tools have been developed. Far from all have been validated in external studies, more of them have absence of methodological and transparent evidence, and few are integrated in national guidelines. Therefore, we performed a systematic review to provide an overview of existing valid and reliable risk assessment tools for prediction of osteoporotic fractures. Additionally, we aimed to determine if the performance of each tool was sufficient for practical use, and last, to examine whether the complexity of the tools influenced their discriminative power. We searched PubMed, Embase, and Cochrane databases for papers and evaluated these with respect to methodological quality using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) checklist. A total of 48 tools were identified; 20 had been externally validated, however, only six tools had been tested more than once in a population-based setting with acceptable methodological quality. None of the tools performed consistently better than the others and simple tools (i.e., the Osteoporosis Self-assessment Tool [OST], Osteoporosis Risk Assessment Instrument [ORAI], and Garvan Fracture Risk Calculator [Garvan]) often did as well or better than more complex tools (i.e., Simple Calculated Risk Estimation Score [SCORE], WHO Fracture Risk Assessment Tool [FRAX], and Qfracture). No studies determined the effectiveness of tools in selecting patients for therapy and thus improving fracture outcomes. High-quality studies in randomized design with population-based cohorts with different case mixes are needed.
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Affiliation(s)
- Katrine Hass Rubin
- Institute of Clinical Research, University of Southern Denmark, Odense University Hospital, DK-Odense C, Denmark.
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Stepan JJ, Vaculik J, Pavelka K, Zofka J, Johansson H, Kanis JA. Hip fracture incidence from 1981 to 2009 in the Czech Republic as a basis of the country-specific FRAX model. Calcif Tissue Int 2012; 90:365-72. [PMID: 22399225 DOI: 10.1007/s00223-012-9582-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 02/10/2012] [Indexed: 10/28/2022]
Abstract
The aim of this study was to calculate rates of hospitalization for hip fracture and the incidence of hip fractures in the Czech Republic over a period of 29 years. A second aim was to use the most recent data to populate a FRAX(®) model for the assessment of fracture probability in individual patients. Data on hospitalizations for hip fracture (1981-2009) and number of women and men with hip fractures (2000-2009) were obtained, and incidences were computed for the entire population ≥50 years of age. Incidence of hospitalization for hip fracture in the Czech population aged ≥50 years increased progressively by calendar year. Age-standardized incidence of hip fractures increased to 2004 but leveled off thereafter and decreased after 2005. Data for hip fracture risk in 2008 and 2009 and the death hazard were used to populate a Czech-specific FRAX model for the computation of 10-year fracture probability. The customized FRAX model, using the verified epidemiological data, will be used to identify patients at increased fracture risk.
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Affiliation(s)
- Jan J Stepan
- Institute of Rheumatology, Prague, and Department of Rheumatology, Charles University, Prague, Czech Republic.
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