Validation of the Cummings’ risk score; how well does it identify women with high risk of hip fracture: The Tromsø Study

Association between self-rated health and the risk of hip fracture and mortality in a cohort of older women during a 10-year follow-up

Fragility fracture of the hip is associated with reduced functional status and mortality. Poor self-rated health (SRH) might be such an indicator. Our aim was to study if SRH was associated with hip fractures and all-cause mortality within the next 10 years in community-dwelling older women. A population-based sample of 350 women aged between 69 and 79 years (median 72.4) assessed their SRH by answering the question "How would you rate your health right now" by putting a mark on a visual-analogue scale (0-100 mm). Information on hip fracture and mortality over the next 10 years was retrieved from health care registers. The association between SRH and hip fracture and all-cause mortality was tested with a Cox proportional hazards regression model. SRH was divided into low, intermediate, and high (reference) assessed SRH. During the study, 40 hip fractures and 72 deaths occurred. The median value of SRH was 62 mm (IQR 50-81 mm). The age-adjusted hazard ratio (HR) for hip fracture was significantly higher in the group with low and intermediate SRH; HR: 3.17 (95% CI 1.25-8.01), and HR: 2.75 (95% CI 1.08-7.04), compared with high SRH. Adding bone mineral density (at the femoral neck) gave even greater risk. We did not find the hypothesized association between SRH and mortality. In our study, SRH indicated a higher risk of future hip fracture in older women. SRH might be a marker that could add information about the risk of hip fracture independently of bone mineral density.

The accuracy of osteoporotic fracture risk prediction tools: a systematic review and meta-analysis

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.

Performance of risk assessment instruments for predicting osteoporotic fracture risk: a systematic review

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.

Risk assessment tools to identify women with increased risk of osteoporotic fracture: complexity or simplicity? A systematic review

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.

Excess mortality after hip fracture among elderly women in Norway. The HUNT study

We wanted to study mortality after hip fractures among elderly women in Norway. We found that excess mortality was highest short time after hip fracture, but persisted for several years after the fracture. The excess mortality was not explained by pre-fracture medical conditions.

INTRODUCTION

The purpose of the present study was to investigate short and long term mortality after hip fracture, and to evaluate how comorbidity, bone mineral density, and lifestyle factors affect the survival after hip fractures.

METHODS

The study cohort emerges from a population-based health survey in the county of Nord-Trøndelag, Norway. Women aged 65 or more at participation at the health survey who sustained a hip fracture after attending the health survey are cases in this study (n = 781). A comparison cohort was constructed based on participants at HUNT 2 with no history of hip fractures (n = 3, 142). Kaplan-Meier survival curves were used to evaluate crude survival, and Cox regression analyses were used to study age-adjusted hazard ratios for mortality and for multivariable analyses involving relevant covariates.

RESULTS

Mean length of follow-up after fracture was 2.8 years. Within the first 3 months of follow-up, 78 (10.0%) of the hip fracture patients died, compared to only 39 (1.7%) in the control group. HR for mortality 3 months after hip fracture was 6.5 (95% CI 4.2-9.6). For the entire follow-up period women who sustained a hip fracture had an HR for mortality of 1.9 (95% CI 1.6-2.3), compared with women without a hip fracture.

CONCLUSIONS

We found that elderly women who sustained a hip fracture had increased mortality risk. The excess mortality was highest short time after the fracture, but persisted for several years after the fracture, and was not explained by pre-fracture medical conditions.

Clinical value of prognostic instruments to identify patients with an increased risk for osteoporotic fractures: systematic review

Background

With the broad availability of effective medications, identifying individuals bearing a higher risk for osteoporotic fractures has become an issue of major concern in modern medicine. In recent years various prognostic instruments have become available showing conflicting results regarding estimated risks for individual patients.

Objective

To provide an overview of current evidence and of opportunities for further research.

Methodology/Principal Findings

Systematic Review: We identified studies describing the development of instruments and all subsequent validations in electronic databases and reference lists of included studies. We screened for inclusion, read full papers and extracted data on salient clinical features, performance characteristics and quality in duplicate. Searches retrieved 5,275 records of which full texts of 167 papers were obtained after screening titles and abstract. We included 35 studies enrolling a total of 609,969 patients (median 2546) reporting on 31 derivations and 12 validations after assessing full texts. Median follow-up time was 4.1 years (IQR 3 to 7.7). Only four studies validated an instrument that was developed by another group. None of the existing instruments was validated more than once. The five most frequent included variables in the final model were age, body mass index, bone mass index, past history of falls, and maternal history of fractures. The methodological quality of the studies was moderate.

Conclusion

There is a plethora of evidence available studying the association of risk profiles and the development of osteoporotic fractures. The small number of out-of-sample validations, the large variety of study characteristics, outcomes and follow-up periods impedes from deriving robust summaries and from conclusions regarding the clinical performance of many tools. First and foremost, future activity in this field should aim at reaching a consensus among clinical experts in respect to the existing instruments. Then we call for careful validations and expedient adaptations for local circumstances of the most promising candidates.

Impact of systematic implementation of a clinical case finding strategy on diagnosis and therapy of postmenopausal osteoporosis

INTRODUCTION

Case finding for osteoporosis in postmenopausal women is advocated in guidelines of osteoporosis, but implementation is unsatisfactory. We studied, in daily practice, the impact of systematic implementation of a previously validated clinical decision rule and fracture history on referral for bone densitometry (DXA) and drug prescription for osteoporosis.

MATERIALS AND METHODS

Before-after impact analysis in 41,478 consecutive consulting postmenopausal women, included by 1080 general practitioners (GPs) during 2 mo, using the osteoporosis self-assessment (OST) index (based on age and weight, indicating women at low [LR], moderate [MR], and high risk [HR] for having osteoporosis [T-score < -2.5 in spine and/or hip]) and fracture history. Relative risks (RRs) and 95% CIs were calculated between referrals before (n = 6580) and after intervention (n = 10,379) and between risk subgroups.

RESULTS

Post-intervention RR for referral for DXA was 1.9 (95% CI, 1.8-2.0). Compared with LR women with prior DXA, the RR was 6.3 (95% CI, 6.0-6.6) in MR and 10.7 (95% CI, 10.0-11.4) in HR women without fracture, but similar in MR and HR women with fracture (11.4 and 11.6, respectively). New cases of osteoporosis were diagnosed in 3811 women, 96% of whom were prescribed drug treatment. Of HR women, 79% were referred for DXA. The sensitivity of a low OST index to predict osteoporosis was 92% and specificity was 16%.

CONCLUSIONS

The impact of temporary systematic implementation of this case finding strategy on GP practice was high: it nearly tripled referrals for DXA, and 96% of patients found to have osteoporosis had treatment. The impact depended on OST index and fracture history. Only 79% of HR women were referred for DXA. Specificity of a low OST index to predict osteoporosis was low. This indicates the need in the GP population for case finding strategies with fewer barriers for referral for DXA and with higher accuracy for predicting osteoporosis.

Measured height loss predicts fractures in middle-aged and older men and women: the EPIC-Norfolk prospective population study

In this large population-based prospective study among middle-aged and older men and women, we found that height loss of >2 cm over a period of 4 yr is a significant predictor of future fractures. Serial measurement of height is, therefore, recommended among the elderly people.

INTRODUCTION

Height change can be easily measured and may contribute to fracture risk prediction. We assessed measured height loss and fracture incidence in a prospective population study.

MATERIALS AND METHODS

Height was measured in participants in the Norfolk cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk) between 1993 and 1997 and repeated between 1997 and 2000. Incident fractures to 2006 were ascertained by hospital record linkage.

RESULTS

In 14,921 men and women 42-82 yr of age, during a mean follow-up period of 7.1 yr, there were 390 fractures, including 122 hip fractures. Prior annual height loss in those who had an incident fracture (1.8 +/- 0.3 [SD] mm) was significantly greater than other participants (0.9 +/- 0.2 mm; p < 0.001). Participants with annual height loss >0.5 cm had an age- and sex-adjusted hazard ratio of any fracture of 1.76 (95% CI, 1.16-2.67) and of hip fracture of 2.08 (95% CI, 1.07-4.05) compared with those with no height loss. Each 1 cm/yr height loss was associated with a hazard ratio of 1.86 (95% CI, 1.28-2.72) for all fractures and 2.24 (95% CI, 1.23-4.09) for hip fracture after adjustment for age, sex, past history of fracture, smoking, body mass index, alcohol intake, and heel ultrasound measures. Annual height loss of 1 cm was comparable to having a past history of fracture and equivalent to being approximately 14 yr older in chronological age in terms of the magnitude of relationship with fracture risk.

CONCLUSIONS

Middle-aged and older men and women with annual height loss >0.5 cm are at increased risk of hip and any fracture. Serial height measurements can contribute to fracture risk prediction.