FRAX Calculator Research Articles

FRAX prognostic and intervention thresholds in the management of major bone fractures in hemodialysis patients: A two-year prospective multicenter cohort study.

The usefulness of FRAX in predicting major bone fractures in patients with end-stage kidney disease on maintenance hemodialysis treatment has been confirmed in previous studies. For meaningful clinical use, the prognostic and intervention FRAX thresholds need to be established. The primary aim of our study was to calculate the optimal cut-off point of FRAX for the best prediction of an increased bone fracture risk in dialysis patients and additionally, to propose its intervention threshold, indicating the need for antifracture pharmacological treatment. The study included 718 hemodialysis patients, who were followed up for two years. Thirty low-energy major bone fractures were diagnosed during the study period. We used the Polish version of FRAX (without the DXA examination) and some particular variables of the FRAX calculator. The optimal cut-off point for prediction of an increased major bone fracture risk was based on the analysis of the sensitivity and specificity curves of FRAX. The analysis revealed FRAX >5% (sensitivity of 70.0%, specificity of 69.8%) as the prognostic threshold for major bone fractures. Its sensitivity for bone fracture prediction was significantly higher, but specificity lower than those of FRAX ≥10%, used in general Polish population. The reason for this can be an underestimation of bone fracture risk with FRAX in dialysis patients. We conclude that the FRAX prognostic threshold for identification of an increased risk of major bone fractures in hemodialysis patients is >5%. We propose to use this specific value of FRAX as an intervention threshold for pharmacological antifracture treatment in hemodialysis patients.

Pilot study of 10-year absolute fracture risk assessment tool (FRAX®) introduction into the structure of undegraduate practical training "physician assistant” course

Background: high fracture rates throughout the Eastern Europe and Central Asia region have been reported. Major fractures rate increasing, primary care physicians need to be aware of risk assessment and prevention tools.
 Aims: The aim of this pilot study was to assess main issues of FRAX tool introduction into undergraduate medical education.
 Material and methods: Russian version of the IOF approved presentation on FRAX application procedure, results assessment and interpretation as well as Russian Association for Osteoporosis clinical guidelines and reference to www.osteoporoz.ru site have been provided to 248 undergraduate medical students. To increase osteoporosis related issues study motivation the students were asked to apply the Russian version of on-line FRAX calculator to assess risk fracture in their close relatives of appropriate age. Also the students were asked to create a FRAX assessment based patient management program.
 Results: 207 FRAX assessment reports were received as feedback. Derived intervention threshold was reached in 41 cases (19.8%), while in 45 reports (21.7%) body mass index (BMI) value was mistaken for a 10-year fracture risk. There were 123 cases of the students’ parents assessments. These subjects appeared to be quite young (median 48, range 42 – 62) and relatively healthy to report no fracture risk factors. The students’ grandparents or great-grandparents (68 cases) were assessed on rare occasions due to lack of information or absence of personal contacts between students and their relatives. The students reported appreciable difficulties in decision making. Lifestyle and diet modification were not included in 165 of recommendations, while calcium and vitamin D prescriptions were severely biased by TV advertising. The students reported that it was quite difficult for them to give the patients recommendations regarding the choice of drug and administration timeframe.
 Conclusion: pilot study of FRAX introduction into undergraduate medical education helped to ascertain several gaps in teaching of osteoporosis diagnosis, prevention and treatment to be covered during undergraduate medical education

FRAX (Australia) scores in women with impaired fasting glucose and diabetes

BackgroundDiabetes is associated with higher fracture risk despite higher bone mineral density (BMD), with FRAX® underestimating risk. This study aimed to investigate FRAX score with and without BMD for women with normoglycaemia, impaired fasting glucose (IFG) and diabetes. MethodsAmong 566 women, aged 40–90 years, enrolled in the Geelong Osteoporosis Study, IFG was defined as fasting plasma glucose (FPG) ≥5.5 mmol/L and diabetes as FPG ≥ 7.0 mmol/L, use of antihyperglycaemic medication and/or self-report. FRAX (Australia) 10-year probabilities of major osteoporotic (MOF) and hip fracture were calculated, with and without BMD, producing four FRAX scores per participant. Kruskal-Wallis test for non-parametric data was used to examine differences between the three glycaemia groups. Fractures over 10 years were ascertained using radiological reports. The number of fractures predicted by FRAX was compared with the number of fractures observed using Chi-square tests. ResultsFor MOF FRAX calculated without BMD, women with diabetes (n = 67) tended to have a higher median score 7.1 (IQR 2.7–12.0) than normoglycaemia (n = 252) (4.3 (IQR 1.9–9.9) and IFG (n = 247) (5.1 (IQR 2.2–9.6)). For hip FRAX without BMD, diabetes tended to have a higher score (2.5 (IQR 06–4.3)) than normoglycaemia (1.2 (IQR 0.3–4.1)) and IFG (1.3 (IQR 0.3–4.1)). In the normoglycaemia and IFG groups, MOFs were underestimated; 15 predicted vs 28 observed, p = 0.038; and 16 predicted vs 31 observed, p = 0.021, respectively. Fractures were accurately estimated in all other groups.When including BMD, the association with diabetes was non-significant for both MOF FRAX (normoglycaemia 3.7 (IQR 1.9–8.0), IFG 4.3 (IQR 2.2–8.1) and diabetes 5.3 (IQR 2.7–9.4)) and hip FRAX scores (normoglycaemia 0.6 (IQR 0.2–2.5), IFG 0.8 (IQR 0.2–2.7) and diabetes 1.0 (IQR 0.3–3.0)). For normoglycaemia and IFG, MOFs were underestimated (normoglycaemia: 13 predicted vs 28 observed and IFG: 13 vs 31). For diabetes, both MOFs and hip fractures tended to be underestimated by FRAX with BMD (MOF: 4 predicted vs 11 observed, p = 0.055, hip: 1 predicted vs 6 observed, p = 0.052). Hip fractures were accurately estimated in the normoglycaemia and IFG groups. ConclusionsCompared with women who had normoglycaemia or IFG, women with diabetes tended to have a higher FRAX score for both MOF and hip fractures when BMD was not included. When BMD was included, there was no difference. Fractures in diabetes tended to be underestimated by FRAX with BMD. This suggests that FRAX calculations including BMD may not be accurate for estimating fractures in those with diabetes.

How well do the FRAX (Australia) and Garvan calculators predict incident fractures? Data from the Geelong Osteoporosis Study.

This study assessed the ability of the FRAX (Australia) and Garvan calculators to predict fractures in Australian women and men. Women (n = 809) and men (n = 821) aged 50-90years, enrolled in the Geelong Osteoporosis Study, were included. Fracture risk was estimated using FRAX and Garvan calculators with and without femoral neck bone mineral density (BMD) (FRAXBMD, FRAXnoBMD, GarvanBMD, GarvannoBMD). Incident major osteoporotic (MOF), fragility, and hip fractures over the following 10years were verified radiologically. Differences between observed and predicted numbers of fractures were assessed using a chi-squared test. Diagnostics indexes were calculated. In women, 115 MOF, 184 fragility, and 42 hip fractures occurred. For men, there were 73, 109, and 17 fractures, respectively. FRAX underestimated MOFs, regardless of sex or inclusion of BMD. FRAX accurately predicted hip fractures, except in women with BMD (20 predicted, p = 0.004). Garvan underestimated fragility fractures except in men using BMD (88 predicted, p = 0.109). Garvan accurately predicted hip fractures except for women without BMD (12 predicted, p < 0.001). Fractures were underestimated primarily in the osteopenia and osteoporosis groups; MOFs in the normal BMD group were only underestimated by FRAXBMD and fragility fractures by GarvannoBMD, both in men. AUROCs were not different between scores with and without BMD, except for fragility fractures predicted by Garvan in women (0.696, 95% CI 0.652-0.739 and 0.668, 0.623-0.712, respectively, p = 0.008) and men, which almost reached significance (0.683, 0.631-0.734, and 0.667, 0.615-0.719, respectively, p = 0.051). Analyses of sensitivity and specificity showed overall that MOFs and fragility fractures were poorly predicted by both FRAX and Garvan, while hip fractures were acceptably predicted. Overall, the FRAX and Garvan calculators underestimated MOF and fragility fractures, particularly in individuals with osteopenia or osteoporosis. Hip fractures were predicted better by both calculators. AUROC analyses suggest that GarvanBMD performed better than GarvannoBMD for prediction of fragility fractures.

Implications of the Fracture Risk Assessment Algorithm for the assessment and improvement of bone health in patients with prostate cancer: A comprehensive review.

Maintaining the optimum bone health is one of the important concerns in patients with prostate cancer, but it usually remains neglected. Failure to screen these patients is detrimental to both the length and the quality of life. The estimation of bone mineral density (BMD) and more recently the World Health Organization's fracture risk assessment (FRAX) algorithm in appropriate patients is recommended by several specialty organizations/associations at the time of instituting androgen deprivation therapy (ADT) for metastatic and high-risk individuals. It provides a 10-year risk evaluation of hip and major osteoporotic fractures (MOF). Using this web-based new investigating tool, candidates at high risk of fractures can be predicted more accurately according to clinical risk factors (CRF) alone or in combination with the femoral neck BMD. The FRAX application for senile osteoporosis has been studied and reviewed extensively, but no systematic review has ever been conducted for assessing the implication of FRAX in prostate cancer. This review article will give insight about the validity, role, and utility of this investigating tool in clinical practice for fracture risk assessment in these individuals. This systematic review was carried out as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and Cochrane review principles. We searched the PubMed, Cochrane database of systematic reviews, and the EMBASE electronic database until December 2018 using the medical subject heading terms prostate cancer and FRAX. A total of nine studies meet the inclusion criteria and were included in the review. These studies enrolled a total of 3704 patients (sample size range, 78-1220) of localized, metastatic, castration resistant prostate cancer with or without ADT and/or on photon or radiotherapy. The factors that influenced FRAX included age, ethnicity, baseline BMD, duration of ADT, presence of CRF, and measurement methods (CRF, with/without BMD, computed tomography based). An advanced age and duration of ADT were the most robust risk factors. A 10-year MOF and hip fracture risk estimation was higher when the femoral neck BMD was not incorporated in the FRAX measurement. Despite several well-known strengths of using FRAX in the fracture risk assessment of suitable candidates with prostate cancer, several risk factors such as the mode/duration of ADT, mode of radiotherapy, Vitamin D levels, bone remodeling markers, and recent/recurrent fractures need to be incorporated in the FRAX calculator for improving the predictive ability. In contrast to senile osteoporosis with a longer life expectancy, the fracture risk in patients with prostate cancer need to be measured more frequently and for a shorter time. Therefore, models like Garvan calculator with both 5- and 10-year risk estimates have to be developed for these patients. Additionally, its utilization is of limited value in the presence of recurrent fractures or falls. The FRAX algorithm is beneficial in identifying patients who require early intervention or bone-directed therapy as an early step to decrease skeletal-related events and other morbidity. Several risk factors need to be added for improving the FRAX predictive value. This model is still underutilized in the clinical practice and increasing the awareness among treating physicians will help in optimizing the bone health and the quality of life of this important population subgroup.

The Impact of GE Lunar vs ICMR Database in Diagnosis of Osteoporosis among South Indian Subjects.

Objective:To study the effect of choosing ICMR reference values on the classification of bone mineral density in Indian patients.Design:Retrospective analysis of Dual Energy X-ray absorptiometry (DEXA) and clinical data.Patients:Totally, 316 patients aged more than 65 years attending a tertiary care hospital in South India who underwent DEXA scan were included in the study.Measurements:DEXA scan at femoral neck and lumbar spine.Results:A total of 316 patients were studied. The mean age was 61.98 ± 7.66 years. There were 46.84% females and 53.16% males. The average BMI was 26.37 ± 4.51. Of these patients, 46 had history of hip fracture (14.55%). The adoption of the ICMR normative data resulted in a significant increase in T scores in both the hip (+0.51, P < 0.05) and the spine (+1.64, P < 0.01). The adoption of ICMR normative values, resulted in reduction of osteoporosis prevalence from 26.58% to 5.06%.Conclusions:There is a clinically significant reduction in diagnosis of osteoporosis with the adoption of ICMR reference standard. Clinicians should be recommended to use raw BMD values in gm/cm2 in FRAX calculation and avoid the use of T scores, to avoid overestimation of fracture risk. If our results are replicated, the implications are enormous – Osteoporosis is currently being over diagnosed.

Prevalence of Osteoporosis and Risk of Developing Fragility Fracture in Post-Menopausal Women

Introduction: Osteoporosis and fragility fracture pose major health concern and cause significant financial burdens in healthcare system. The objectives of this study were to determine the prevalence of osteoporosis among post-menopausal women and to predict the risk of having the major osteoporotic and hip fracture in 10 years using the WHO Fracture Risk Assessment Tool. Materials and Methods: This was a cross-sectional study spanning over a two-year period (from June 2015 to June 2017) investigating post-menopausal women who did their Bone Mass Density (BMD) test at Hospital Melaka. Collected BMD data and parameters were used for analysif of the prevalence of osteoporosis among the study population and FRAX calculation was used to predict the average risk of fragility fracture in 10 years. Statistical analysis was done using SPSS statistical package. Results: Prevalence of osteoporosis among 388 post-menopausal women age 45 to 90 years old was 29.9%. More than half of patients had osteoporosis were Chinese (51%) followed by Malay (43%), Indian (5%) and others (1%). The 10 years average percentage of developing major osteoporosis was 10.81 ± 9.55 %, while the average percentage of developing hip fracture was 4.20 ± 6.53. Conclusion: Prevalence of the post-menopausal women who were osteoporotic was about 30% which is comparable to other countries (Japan, Egypt, Australia, Mexico, Argentina and India). The 10 years average percentage of developing major osteoporosis and hip fracture in our study is quite high, approximately around 20% and 10%, respectively.

Effect of Vertebral Body Exclusion on TBS and FRAX Calculations

Spinal degenerative changes are common and elevate DXA-measured BMD. However, existing data suggest trabecular bone score (TBS) is relatively unaffected by degenerative changes. Clinically, we observed patients in whom spinal degenerative changes appeared to substantially elevate not only BMD, but also TBS. The purpose of this study was to explore the hypothesis that vertebral body exclusion impacts TBS results and subsequently TBS-adjusted FRAX scores. The reports of DXA scans interpreted by one clinician (NB) over a 4-month time span were reviewed. Vertebral body exclusion was performed following ISCD recommendations. Data collected from those scans with vertebral body exclusion included the L1-4 BMD/TBS and lumbar spine BMD/TBS following vertebral exclusion. FRAX calculations were performed using L1-4 TBS and post-exclusion TBS values and the effect of vertebral exclusion was assessed by T-test. This study was determined exempt by the local IRB. Of 302 patients with TBS, 62 evaluable scans (57 female, 5 male) had vertebral bodies excluded. Patient mean (SD) age, BMI, and lowest T-score, were 71.9 (10.0) years, 24.7 (4.4) kg/m2 and -2.9 (1.1) respectively. Compared to L1-4, mean lumbar spine BMD and TBS declined by 10% and 3.6% respectively with vertebral exclusion (p<0.0001). TBS adjusted FRAX 10-year risk increased by 1% and 0.2% for mean osteoporotic fracture (MOF) and hip fracture respectively (p<0.0001). After vertebral body exclusion 37% of patients shifted into lower TBS categories. Lumbar spine BMD and TBS decline when excluding vertebral bodies per ISCD recommendations. This leads to higher fracture risk estimates using TBS adjusted FRAX. Additionally, a substantial number of patients move into lower TBS categories after exclusion. This study is limited by small sample size; however, these data suggest that vertebral body exclusion may be appropriate with TBS. Further research to determine if vertebral exclusion improves fracture risk prediction is needed.

Effect of vertebral exclusion on TBS and FRAX calculations.

Spinal degenerative changes elevate DXA-measured BMD, but reports find trabecular bone score (TBS) relatively unaffected. However, we observed patients where degenerative changes elevated both. Consequently, this study explored whether vertebral exclusion impacts TBS and subsequently TBS-adjusted FRAX risk. Clinical DXA interpretations of one physician were reviewed; those with vertebrae excluded per ISCD guidance were included in this study. BMD and TBS at L1-4 and from post-exclusion vertebrae were collected and used to adjust fracture risk (FRAX). Of the patients, 102 had vertebrae excluded; their mean (SD) age, BMI, and lowest T-score were 71.6 (9.5)years, 25.4 (4.5)kg/m2, and - 2.8 (1.0), respectively. Compared to L1-4, vertebral exclusion lowered (p < 0.0001) mean spine BMD and TBS by 9.5 and 3.1%, respectively. Vertebral exclusion decreased TBS by 0.040, being lower in 83%. In those with lower TBS, the mean adjusted 10-year fracture risk increased (p < 0.0001) by 0.94 and 0.32% for major osteoporotic (MOF) and hip fracture, respectively, in some risk increased by up to 4%. In those with higher TBS, adjusted risk was reduced, MOF - 0.49% and hip - 0.1%. Vertebral exclusion following ISCD recommendations generally, but not always, lowers TBS. Consequently, the impact on TBS adjusted FRAX risk is variable. In most patients, vertebral exclusion lowers TBS; in some, this could result in a relevant change in calculated fracture risk. It seems reasonable to use TBS values from evaluable vertebrae to adjust FRAX. Further research to determine if vertebral exclusion improves fracture risk prediction is needed.

Relation between FRAX index and ACPA serum level in premenopausal rheumatoid arthritis patients

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis in adults and is characterized by synovial inflammation and hyperplasia, autoantibody production: rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA), cartilage and bone destruction, and systemic features, including cardiovascular, pulmonary, psychological, and skeletal disorders. Fracture Risk Assessment Tool (FRAX) is a computer-based algorithm developed by the World Health Organization (WHO) Collaborating Centre for metabolic bone diseases and first released in 2008. The outputs of FRAX are the 10-year probability of a major osteoporotic fracture (hip, spine, humerus or wrist fracture) and the 10-year probability of hip fracture. The study included 25 premenopausal RA patients and 20 healthy subjects. The serum ACPA level was assessed by ELISA technique, RF using Rose Waaler test in IU/mL was measured as well. BMD in (g/cm 2 ) has been measured for all subjects enrolled in the study by a Lunar Prodigy Advanced DEXA scanner system and were carried out by the same technician. FRAX index was calculated for all members in both groups by using online FRAX calculator. Femoral neck BMD was added to enhance fracture risk prediction. The range of ACPA in the patients group ranged between 11.40–525.0 U/mL. Eighty percent of our patients were ACPA positive. While RF range was from 8.30 to 648.0 IU/mL. Strong statistically significant difference between both groups was found where FRAX index was significantly higher in patients group compared to control group as regards major osteoporotic and hip fractures ( P < 0.001). Serum ACPA and RF level showed insignificant correlation with FRAX index in premenopausal RA patients. FRAX index was found to be high in RA patients but it was not correlated to ACPA nor RF serum level.

Cortical Thickness Index of the Proximal Femur: A Radiographic Parameter for Preliminary Assessment of Bone Mineral Density and Osteoporosis Status in the Age 50 Years and Over Population.

BackgroundBone mineral density (BMD) is the indicator of bone quality in at-risk individuals. Along with the fracture risk assessment tool (FRAX), a quick assessment of BMD from routine radiographs may be useful in the case of lacking X-ray absorptiometry data. This study aimed to investigate the correlation of cortical thickness index (CTI) and canal flare index (CFI) with BMD and FRAX and to evaluate their ability to predict femoral neck BMD (nBMD) and FRAX in the general elderly population.MethodsA total of 560 volunteers (age ≥ 50 years) who underwent hip-spine X-ray, BMD scanning and FRAX calculation were retrospectively reviewed. CTI and CFI were measured on anteroposterior radiographs and analyzed for their correlation with BMD and FRAX and for their ability to predict nBMD. The ability of CTI to predict osteoporosis status (OPS) and fracture risk status (FRS) was also investigated and the threshold values were calculated. All the analyses were performed separately on male and female subjects.ResultsSignificant differences in CTI, CFI, nBMD and FRAX between males and females were observed. CTI and CFI demonstrated significant positive correlation with nBMD and FRAX (all p < 0.001) in both males and females. CTI, height, and weight significantly predicted nBMD. CTI statistically predicted OPS and FRS, and the values of 0.56 and 0.62 were computed as CTI thresholds for males and females, respectively.ConclusionsCTI was significantly correlated with nBMD and it predicted nBMD at good prediction levels. Therefore, CTI may be used as a supportive tool in the assessment of OPS and FRS besides BMD and FRAX in clinical practice.

FRAX predictior with and without BMD for assessment of osteoporotic fracture risk in the Himalayan state of India: A comparative study

Objective: BMD (bone mineral density) testing facilities are not available in every places in India. We compare the predictive ability of FRAX with BMD and FRAX without BMD for major osteoporotic and hip fracture in Himalayan population. Materials and methods: a hospital based cross sectional study was conducted on patients attending the outpatient Department of orthopaedics of SGRRIMHS, and others for a period of 2 years from Aug 2015 to July 2017. A total no. of 125 patients (104 F+ 21M) in the age group 40 -90 years were selected randomly for study. Exclusion criteria were age less than 40 and more than 90 years, confirmed cases of osteoporosis, patients on antiresorptive treatment, cases of surgically removed ovary and uterus, bone metastasis. Dual Energy X-ray Absorptiometry (DXA) scans were obtained to assess presence of low BMD. FRAX calculations with and without addition of femoral neck BMD were done in all patients. Statistical Package for Social Sciences (SPSS) version 20 was used for statistical analysis. Results: Hip fracture probabilities (6.00±10.47% 5.03±10.26%) and MO fracture probabilities (11.34±12.85% 11.89±12.87%) were similar with or without inclusion of BMD in FRAX tool respectively. Conclusion: FRAX may be used to assess for 10 year hip and major osteoporotic fracture probabilities status in the absence of DXA facilities or avoiding unnecessary DXA scanning.

FRAX Score Can Be Used to Avoid Superfluous DXA Scans in Detecting Osteoporosis in Celiac Disease: Accuracy of the FRAX Score in Celiac Patients

The Fracture Risk Assessment (FRAX) tool has been developed to estimate patients' 10-yr probability of fracture, thus establishing which patients should undergo dual-energy X-ray Absorptiometry (DXA) scan. This study aimed to evaluate if the FRAX tool can replace or optimize the use of DXA scan in celiac disease (CD). We prospectively enrolled all CD patients aged over 40 yr diagnosed at our third-level unit. At time of CD diagnosis, all patients underwent FRAX score calculation for risk of major osteoporotic and hip fractures and DXA scan (used as gold standard) to assess the accuracy of the FRAX score. The FRAX score calculation was based on the following 10 variables: age (>40 yr), sex (M/F), body mass index, history of previous fracture (yes/no), parent fractured hip (yes/no), current smoking (yes/no), use of steroids (yes/no), rheumatoid arthritis (yes/no), secondary osteoporosis (yes/no), and alcohol ≥3 units/d (yes/no). DXA assessment was performed within 1 week from FRAX calculation. The FRAX score was dichotomized as normal or pathologic in accordance with the National Osteoporosis Guideline Group. A total of 160 CD patients were enrolled (M/F = 20/140; mean age 48.7 yr). A pathologic FRAX score was evident in 14 out of 160 patients (8.7%), whereas osteoporosis based on DXA scan was found in 10 patients (6%) (κ = 0.6); 3 patients with osteoporosis (1.9%) showed a 10-yr risk of major fracture >10% according to the National Osteoporosis Guideline Group criteria. With regard to diagnostic accuracy, the FRAX score showed sensitivity of 0%, specificity of 91%, positive predictive value of 0%, and negative predictive value of 94%. The prevalence of osteoporosis in adult CD appears to be quite low and only a small proportion of patients would require a DXA investigation. The FRAX score could be an effective tool to avoid useless DXA scans in CD patients in view of its high negative predictive value.

Annals for Educators - 6 June 2017

Annals for Educators - 6 June 2017

Access to fracture risk assessment by FRAX and linked National Osteoporosis Guideline Group (NOGG) guidance in the UK-an analysis of anonymous website activity.

In the UK, guidance on assessment of osteoporosis and fracture risk is provided by the National Osteoporosis Guideline Group ( www.shef.ac.uk/NOGG ). We wished to determine access to this guidance by exploring website activity. We undertook an analysis of FRAX and NOGG website usage for the year between 1st July 2013 and 30th June 2014 using Google Analytics software. During this period, there was a total of 1,774,812 sessions (a user interaction with the website) on the FRAX website with 348,964 of these from UK-based users; 253,530 sessions were recorded on the NOGG website. Of the latter, two-thirds were returning visitors, with the vast majority (208,766; 82%) arising from sites within the UK. The remainder of sessions were from other countries demonstrating that some users of FRAX in other countries make use of the NOGG guidance. Of the UK-sourced sessions, the majority was from England, but the session rate (adjusted for population) was the highest for Scotland. Almost all (95.7%) of the UK sessions arose from calculations being passed through from the FRAX tool ( www.shef.ac.uk/FRAX ) to the NOGG website, comprising FRAX calculations in patients without a bone mineral density (BMD) measurement (74.5%) or FRAX calculations with a BMD result (21.2%). National Health Service (NHS) sites were identified as the major source of visits to the NOGG website, comprising 79.9% of the identifiable visiting locations, but this is an underestimate as many sites from within the NHS are not classified as such. The study shows that the facilitated interaction between web-based fracture risk assessment and clinical guidelines is widely used in the UK. The approach could usefully be adopted in other countries for which a FRAX model is available.

Evaluation of the validity of treatment decisions based on surrogate country models before introduction of the Polish FRAX and recommendations in comparison to current practice.

IntroductionPatients diagnosed before the Polish FRAX was introduced may require re-evaluation and treatment changes if the diagnosis was established according to a surrogate country FRAX score. The aim of the study was to evaluate the validity of treatment decisions based on the surrogate country model before introduction of the Polish FRAX and to provide recommendations based on the current practice.Material and methodsWe evaluated a group of 142 postmenopausal women (70.7 ±8.9 years) who underwent bone mineral density measurements. We used 22 country-specific FRAX models and compared these to the Polish model.ResultsThe mean risk values for hip and major osteoporotic fractures within 10 years were 4.575 (from 0.82 to 8.46) and 12.47% (from 2.18 to 21.65), respectively. In the case of a major fracture, 94.4% of women would receive lifestyle advice, and 5.6% would receive treatment according to the Polish FRAX using the guidelines of the National Osteoporosis Foundation (NOF). Polish treatment thresholds would implement pharmacotherapy in 32.4% of the study group. In the case of hip fractures, 45% of women according to the NOF would require pharmacotherapy but only 9.8% of women would qualify according to Polish guidelines. Nearly all surrogate FRAX calculator scores proved significantly different form Polish (p > 0.05).ConclusionsMore patients might have received antiresorptive medication before the Polish FRAX. This study recommends re-evaluation of patients who received medical therapy before the Polish FRAX was introduced and a review of the recommendations, considering the side effects of antiresorptive medication.

How to predict the risk of fracture in HIV?

Skeletal fractures are more common in HIV, and impact the medical, functional and economic status of frequently vulnerable patients. Identifying asymptomatic patients with low bone mineral density (BMD)/osteoporosis requiring intervention can be expected to reduce fracture risk and complications. Clinical tools are available to determine fracture risk in the general population and are being evaluated in HIV patients. The FRAX calculator, incorporating demographics and risk factors for osteoporosis, with or without BMD results, has been investigated most often in HIV patients. The few published studies that have calculated the 10-year FRAX risk for both major osteoporosis and hip fractures without BMD generally show limited precision in predicting the presence of osteoporosis severe enough to initiate treatment. It remains uncertain whether using HIV as a secondary risk factor and adding dual X-ray absorptiometry (DXA)-BMD information improves case-finding compared with using DXA results only. Not incorporating risks relevant to aging HIV patients such as antiretroviral exposure, hepatitis C virus coinfection and history of falls is other potential limitation. Accurate screening tools using clinical risk factors alone to determine fracture risk in HIV are not yet available. Further research and validation studies are necessary.

Evaluation of Automated Fracture Risk Assessment Based on the Canadian Association of Radiologists and Osteoporosis Canada Assessment Tool

Fracture risk assessments are not always clearly communicated on bone mineral density (BMD) reports; evidence suggests that structured reporting (SR) tools may improve report clarity. The aim of this study is to compare fracture risk assessments automatically assigned by SR software in accordance with Canadian Association of Radiologists and Osteoporosis Canada (CAROC) recommendations to assessments from experts on narrative BMD reports. Charts for 500 adult patients who recently received a BMD exam were sampled from across University of Toronto's Joint Department of Medical Imaging. BMD measures and clinical details were manually abstracted from charts and were used to create structured reports with assessments generated by a software implementation of CAROC recommendations. CAROC calculations were statistically compared to experts' original assessments using percentage agreement (PA) and Krippendorff's alpha. Canadian FRAX calculations were also compared to experts', where possible. A total of 25 (5.0%) reported assessments did not conform to categorizations recommended by Canadian guidelines. Across the remainder, the Krippendorff's alpha relating software assigned assessments to physicians was high at 0.918; PA was 94.3%. Lower agreement was associated with reports for patients with documented modifying factors (alpha = 0.860, PA = 90.2%). Similar patterns of agreement related expert assessments to FRAX calculations, although statistics of agreement were lower. Categories of disagreement were defined by (1) gray areas in current guidelines, (2) margins of assessment categorizations, (3) dictation/transcription errors, (4) patients on low doses of steroids, and (5) ambiguous documentation of modifying factors. Results suggest that SR software can produce fracture risk assessments that agree with experts on most routine, adult BMD exams. Results also highlight situations where experts tend to diverge from guidelines and illustrate the potential for SR software to (1) reduce variability in, (2) ameliorate errors in, and (3) improve clarity of routine adult BMD exam reports.

A multi-study cost-effectiveness comparison of the QFracture and FRAX fracture risk algorithms

BACKGROUND: The FRAX and QFracture risk calculators have previously been validated but their relative performance with respect to cost-effectiveness has yet to be evaluated. METHODS: The relative costs of implementing these two fracture risk calculators were assessed in two scenarios, firstly in a case-control group of 584 post-menopausal women using the National Osteoporosis Guideline Group (NOGG) guidelines, and then using the QResearch database, which contains over 8 million patient-years of prospective data. RESULTS: QFracture was more cost-effective in the first scenario while the underlying cost drivers were different for each algorithm; however, the cost per fracture prevented could not be estimated. The incremental cost-effectiveness ratio of FRAX was £516.22 per hip fracture saved compared with QFracture in the second scenario. LIMITATIONS: The comparison yielded virtually identical false negative rates for both calculators. In cases where these rates are significantly different, an all-encompassing cost comparison would be a challenge. CONCLUSIONS: FRAX was more cost-effective per fracture prevented when the same risk assessment cost was used for the two algorithms; a key factor in assessing the relative cost-effectiveness of these algorithms is the cost of the risk assessment process. QFracture considers more risk factors than FRAX and has been developed to incorporate additional risk factors in the future. This makes QFracture costly, however, this calculator may benefit from automated systems to reduce its cost of implementation.

The WHO FRAX Calculator with and without BMD as an Indicator of Low BMD in Pakistani Women

The WHO FRAX Calculator with and without BMD as an Indicator of Low BMD in Pakistani Women