National Osteoporosis Risk Assessment Research Articles

Diagnostics and fracture risk prediction

Diagnostics in osteoporosis and fracture risk prediction should never rely on bone mineral density (BMD) measurements alone. Data from the National Osteoporosis Risk Assessment (NORA) in the USA revealed some 15 years ago that only 6.4% of postmenopausal women with new fragility fractures had T-scores of −2.5 or less (WHO definition of osteoporosis) in BMD tests performed one year before the event. The majority of fractures occurs in patients with osteopenia or normal BMD. Many of them are middle-aged women, 40 to 65 years old, an age group not much attended to in most studies on osteoporosis. A study on 100.000 women treated in a specialized Viennese menopause and osteoporosis clinic showed that 66.8% of patients with non-vertebral fractures were less than 65 years of age. Such results point to the urgent need of moving away from the preoccupation with BMD alone to a multi-causal risk-of-fracture approach for improving identification of women at risk. Fracture risk assessment tools as FRAX® may be of great help to ease the handling of anamnestic information, weight clinical risk factors and spot secondary causes of osteoporosis. Beside the medical history and physical examination of patients more attention should be paid to x-ray imaging of the spine for detection of vertebral fractures, which otherwise are overlooked to a great extent, to measuring muscle mass and -strength for diagnosing sarcopenia, and to laboratory tests for evaluating the impact of a wide array of diseases and functional disorders on the bone and mineral metabolism. Both, primary fracture prevention by identification of women at risk as early as age 40, and secondary prevention in patients with preexisting fractures, preferably by fracture liaison services, will be of crucial importance to avoid detrimental sequelae for the affected patients and associated costs to the health-care system.

Rib fracture as a predictor of future fractures in young and older postmenopausal women: National Osteoporosis Risk Assessment (NORA)

A rib fracture history after age 45 was associated with a 5.4-fold increase in new rib fracture risk and a 2.4-fold increase in risk of any new clinical fracture in 155,031 postmenopausal women. A rib fracture history suggests osteoporosis and should be considered when evaluating patients for interventions to prevent fractures. Until recently, little attention was paid to rib fracture as an osteoporosis marker. Emerging evidence suggests rib fracture may be an osteoporotic fracture in men and women. We report the 5-year independent association between baseline rib fracture histories and self-reported future fractures by age (decade) in the NORA cohort (155,031 postmenopausal women, 50-99 years). Participants reported fracture history and responded to follow-up surveys at years 1, 3, or 6. Women with a baseline rib fracture history without other fractures were compared with women with no fracture. At baseline, 4,758 (3.07%) women reported a rib fracture history without other fractures; 6,300 women reported 6,830 new clinical fractures, including wrist (2,271), rib (1,891), spine (1,136), hip (941), and forearm (591). Adjusted relative risk (ARR) values (95% confidence interval [CI]) for future fractures in women with rib fracture history versus women with no fracture history were 5.4 (4.8-6.1) at the rib, 2.1 (1.7-2.6) at the spine, and 1.4 (1.1-1.7) at the wrist, and not significant for forearm or hip fractures. Future fracture risk was at least doubled in women with a rib fracture history in all ages: ARR (95% CI) 3.4 (2.8-4.0) for ages 50-59, 2.5 (2.1-3.0) for ages 60-69, 2.0 (1.7-2.3) for ages 70-79, and 2.0 (1.6-2.6) for ages >80. Rib fracture, the second most common clinical fracture in women (after wrist fracture), predicted future fractures of the rib, wrist, and spine at all ages. Women presenting with rib fractures should be evaluated for appropriate management to prevent future fractures.

Predictors of falls among postmenopausal women: results from the National Osteoporosis Risk Assessment (NORA)

Using data from 66,134 postmenopausal women enrolled in the National Osteoporosis Risk Assessment (NORA) study, more than half of whom were less than age 65, we identified 18 risk factors that independently predicted a significantly increased risk of falling and observed a graded increase in risk with an increasing number of risk factors. This study was designed to identify predictors of falls in a large prospective study of community-dwelling, postmenopausal women, 58% of whom were less than 65 years old at baseline. We exclusively used survey data from 66,134 NORA participants who completed the baseline survey and three follow-up surveys over 6 years. Stepwise logistic regression was used to select potential fall predictors. A simple fall risk index was created by giving one point to each significant independent risk factor. More than one third (38.2%) of participants reported at least one fall since baseline. The largest predictor of fall risk was history of falls (odds ratio [OR] = 2.7). In the multivariate analysis, 17 additional risk factors were significantly associated with incident falls (but with smaller OR), including age, college education, poor hearing, diabetes, personal or family history of fracture, hypothyroidism, and height loss. Of the 3,346 women with zero fall risk factors, 22.6% reported falling compared to 84.3% of the 51 women with >or=11 risk factors. This large cohort had sufficient power to identify 18 risk factors that independently predicted a significantly increased risk of falling with a graded increase in risk with increasing number of risk factors.

Wrist fracture as a predictor of future fractures in younger versus older postmenopausal women: results from the National Osteoporosis Risk Assessment (NORA)

The short-term association between wrist-fracture history and future fracture has not been simultaneously compared between younger and older postmenopausal women. This 3-year follow-up study of 158,940 women showed a similar future fracture risk in younger and older women with wrist-fracture history. We examined the association between prior wrist fracture and future osteoporosis-related fractures within 3 years in younger and older postmenopausal women. In the National Osteoporosis Risk Assessment (NORA) study, 158,940 postmenopausal women, aged 50-98 (median 63) years, provided information on fracture history since age 45, and responded to follow-up surveys 1 or 3 years later when new fractures were queried. Cox regression models were used to obtain relative risk (RR) and 95% confidence interval (CI) estimates. Of the 158,940 participants, 8,665 reported a history of wrist fracture at baseline; 4,316 women reported at least one new fracture within three years. The RR for any subsequent clinical fracture, adjusted for covariates and baseline BMD T-score, was 2.4 (2.0, 2.9) for younger and 2.1 (1.9, 2.3) for older women. A prior wrist fracture increased the risk of a future wrist fracture about 3-fold and doubled the risk of any osteoporotic fracture. Prior wrist fracture strongly predicts three-year risk of any future osteoporotic fracture for older and younger postmenopausal women, independent of baseline BMD and common osteoporosis risk factors. More consideration should be given to evaluating and managing osteoporosis in younger and older women with a history of wrist fracture, independent of their BMD.

Calcium and vitamin D intake influence bone mass, but not short-term fracture risk, in Caucasian postmenopausal women from the National Osteoporosis Risk Assessment (NORA) study

The impact of calcium and vitamin D intake on bone density and one-year fracture risk was assessed in 76,507 postmenopausal Caucasian women. Adequate calcium with or without vitamin D significantly reduced the odds of osteoporosis but not the risk of fracture in these Caucasian women. Calcium and vitamin D intake may be important for bone health; however, studies have produced mixed results. The impact of calcium and vitamin D intake on bone mineral density (BMD) and one-year fracture incidence was assessed in 76,507 postmenopausal Caucasian women who completed a dietary questionnaire that included childhood, adult, and current consumption of dairy products. Current vitamin D intake was calculated from milk, fish, supplements and sunlight exposure. BMD was measured at the forearm, finger or heel. Approximately 3 years later, 36,209 participants returned a questionnaire about new fractures. The impact of calcium and vitamin D on risk of osteoporosis and fracture was evaluated by logistic regression adjusted for multiple covariates. Higher lifetime calcium intake was associated with reduced odds of osteoporosis (peripheral BMD T-score < or =-2.5; OR = 0.80; 95% CI 0.72, 0.88), as was a higher current calcium (OR = 0.75; (0.68, 0.82)) or vitamin D intake (OR = 0.73; 95% CI 0.0.66, 0.81). Women reported 2,205 new osteoporosis-related fractures. The 3-year risk of any fracture combined or separately was not associated with intake of calcium or vitamin D. Thus, higher calcium and vitamin D intakes significantly reduced the odds of osteoporosis but not the 3-year risk of fracture in these Caucasian women.

Osteoporosis practice patterns in 2006 among primary care physicians participating in the NORA study

This study investigated osteoporosis management trends from 1998 to 2006 among 808 primary care physicians involved in the US-based NORA (National Osteoporosis Risk Assessment) study. These results suggest some significant improvements in osteoporosis management over the past eight years. The purpose of this study was to investigate osteoporosis management trends among a large cohort of primary care physicians (PCPs) involved in the US-based NORA (National Osteoporosis Risk Assessment) study. In 2006, we undertook a resurvey of the 2,836 NORA PCPs who completed a baseline survey in 1998. Of the 2,199 PCPs for whom we had current contact information and who were still practicing, we collected usable surveys from 808 (37% response rate). From 1998 to 2006, more than double the percentage of NORA PCPs reported using BMDs "often" (35% vs. 87%). There was a doubling of the percentage of NORA PCPs who reported that a T-score of < or = -2.5 was the threshold indicating the presence of osteoporosis (34% vs. 67%). The percentage of NORA PCPs who reported using bone turnover markers to screen, diagnosis, or monitor osteoporosis almost tripled (19% vs. 55%). The percentage of patients prescribed or recommended hormone therapy dropped sixfold (67% to 11%), and the percentage of patients prescribed bisphosphonates increased fourfold from 15% to 59%. These results suggest some significant improvements in osteoporosis management over the past eight years.

An approach for identifying postmenopausal women age 50–64 years at increased short-term risk for osteoporotic fracture

Using data from NORA, we used 18 potential risk factors in a classification and regression tree analysis to build two algorithms. These algorithms correctly identified postmenopausal women between the ages of 50 and 64 years who were at the highest risk of osteoporotic fracture within 36 months. The objective was to develop algorithms that best predict short-term fracture risk (3 years) in postmenopausal women 50-64 years old. Data were from 91,652 women who responded to follow-up surveys as part of National Osteoporosis Risk Assessment (NORA) study. Peripheral bone mineral density (BMD) and risk factors obtained at baseline; incident osteoporotic fractures obtained from follow-up surveys. Eighteen risk factors were entered into a classification and regression tree analysis to build two algorithms, one with and one without BMD. Two thousand and seven (2.2%) women reported new osteoporotic fractures. Prior fracture, a peripheral BMD T-score <or= -1.1, and self-reported fair/poor health status were the most important determinants for short-term fracture and were associated, respectively, with 7.2%, 3.1%, and 2.4% fracture risk within 3 years. This algorithm with three risk factors correctly classified 65% of the women who experienced an incident fracture and 59% of the women who did not experience an incident fracture. Without BMD T-score, the most important determinants for fracture prediction were previous fracture, self-reported fair/poor health status, and no current use of postmenopausal hormone therapy. NORA-based algorithms may be useful for health care providers to guide further assessment and management decisions to prevent fractures in younger postmenopausal women.

Impact of Recent Fracture on Health-Related Quality of Life in Postmenopausal Women

The effect of fractures other than hip and spine on HRQoL in younger and older women has not been extensively studied. In a cohort of 86,128 postmenopausal women, we found the impact of recent osteoporosis-related fractures on HRQoL to be similar between women < 65 compared with those > or = 65 years of age. The impact of spine, hip, or rib fractures was greater than that of wrist fractures in both age groups. Health-related quality of life (HRQoL) after vertebral and hip fractures has been well studied. Less is known about HRQoL after fractures at other sites. We studied the effect of recent clinical fractures on HRQoL, using Short Form-12 (SF-12). This study included 86,128 postmenopausal participants in the National Osteoporosis Risk Assessment (NORA) who responded to two follow-up surveys during a 2-year interval. At each survey, they completed the SF-12 HRQoL questionnaire and reported new fractures of the hip, spine, wrist, and rib. The effect of recent fracture on HRQoL was assessed by comparing Physical Component Score (PCS) and Mental Component Score (MCS) means for women with and without new fractures at the second survey. Analyses were by fracture type and by age group (50-64 and 65-99) and were adjusted for PCS and MCS at the first survey. New fractures (320 hip, 445 vertebral, 657 rib, 835 wrist) occurring during the interval between the first and second follow-up surveys were reported by 2257 women. The PCS was poorer in both older and younger women who had fractured the hip, spine, or rib (p < or = 0.001). Wrist fractures had an impact on PCS in women < or = 65 years of age (p < 0.001), but not older women (p > 0.10). These differences in PCS by fracture status were similar to those reported for other chronic diseases such as asthma, chronic obstructive pulmonary disease (COPD), and osteoarthritis. MCS was less consistently changed by fracture status, but younger and older women with vertebral fracture (p < 0.004), older women with hip fracture (p < 0.004), and younger women with rib fracture (p < 0.004) had poorer MCS compared with those who did not fracture within their age cohort. Recent osteoporosis-related fractures have significant impact on HRQoL as measured by SF-12. The impact of recent fracture on HRQoL was similar for older and younger postmenopausal women. Fracture prevention and postfracture interventions that target the subsequent symptoms are needed for postmenopausal women of any age.

Selecting patients for osteoporosis therapy: the new WHO paradigm

‘It has become clear that bone density, while valuable, may not be sufficient information to identify all patients at higher risk.’ With the development of a diverse therapeutic menu in osteoporosis, there is an increasing need to develop strategies for fracture risk assessment. This is to enable us to target treatments more effectively for those who need it and avoid unnecessary treatment for individuals at low risk of fracture. In 1994, the WHO developed bone density diagnostic criteria, based on dual energy x-ray (DXA) measurements, using the concept of T scores; the number of standard deviations (SDs) above or below the average peak bone density in young adults. A T score between -1 and -2.5 was classified as osteopenia, -2.5 or lower was osteoporosis and -2.5 or lower with a fragility fracture was considered severe, established osteoporosis. Although only designed to be diagnostic criteria, T scores were interpreted by third-party payers and others to also be intervention thresholds. For fracture prediction, DXA gives measurements that predict fracture with an increase in fracture risk of approximately 1.5–2 per SD decrease in bone mineral density (BMD) (the socalled gradient of risk) [1]. It has become clear that bone density, while valuable, may not be sufficient information to identify patients at higher risk. Recent studies have shown that up to half of the patients in the community with fractures have a baseline BMD above the WHO diagnostic threshold [2,3]. In the National Osteoporosis Risk Assessment (NORA), using peripheral bone density measurements, approximately half the osteoporotic fractures in the community occurred in women without osteoporosis. Although the relative risk of fractures in NORA was greater in

The effect of age and bone mineral density on the absolute, excess, and relative risk of fracture in postmenopausal women aged 50–99: results from the National Osteoporosis Risk Assessment (NORA)

This study evaluates the effect of age and bone mineral density (BMD) on the absolute, excess, and relative risk for osteoporotic fractures at the hip, wrist, forearm, spine, and rib within 3 years of peripheral BMD testing in postmenopausal women over a wide range of postmenopausal ages. Data were obtained from 170,083 women, aged 50-99 years, enrolled in the National Osteoporosis Risk Assessment (NORA) following recruitment from their primary care physicians' offices across the United States. Risk factors for fracture and peripheral BMD T-scores at the heel, forearm, or finger were obtained at baseline. Self-reported new fractures at the hip, spine, rib, wrist, and forearm were obtained from questionnaires at 1- and 3-year follow-ups. Absolute, excess (attributable to low BMD), and unadjusted and adjusted relative risks of fracture were calculated. At follow-up, 5312 women reported 5676 fractures (868 hip, 2420 wrist/forearm, 1531 rib, and 857 spine). Absolute risk of fracture increased with age for all fracture sites. This age-effect was most evident for hip fracture--both the incidence and the excess risk of hip fracture for women with low BMD increased at least twofold for each decade increase in age. The relative risk for any fracture per 1 SD decrease in BMD was similar across age groups (p>0.07). Women with low BMD (T-score <-1.0) had a similar relative risk for fracture regardless of age. At any given BMD, not only the absolute fracture risk but also the excess fracture risk increased with advancing age. Relative risk of fracture for low bone mass was consistent across all age groups from 50 to 99 years.

Evidence-Based Guidelines Needed for Osteoporosis Screening and Treatment

WHEN A 40-YEAR-OLD WOMAN has an annual examination, she can expect her physician to recommend she begin having regular mammograms. When that same woman reaches age 65, it is far less likely that her physician will advise that she be screened for osteoporosis. Even if a woman has had a fracture, she may not receive treatment. “There is still a big gap out there between what many people think is appropriate and what is actually happening,” said Ethel S. Siris, MD, director of the Toni Stabile Center for the Prevention and Treatment of Osteoporosis at Columbia-Presbyterian Medical Center in New York City. Siris, president-elect of the National Osteoporosis Foundation (NOF), would like to see osteoporosis screening, including bone mineral density measurements or a risk assessment, become part of the standard of care for older women. Siris also is leading the National Osteoporosis Risk Assessment (NORA), a longitudinal observational study of 200 160 postmenopausal women not previously diagnosed with osteoporosis (Siris et al. JAMA. 2001;286:2815-2822). JAMA: Besides bone mineral density measurements, what kind of risk assessment is appropriate for older women? Dr Siris: On your 65 birthday you should automatically be asked, “Have you ever had a fracture, did your mother ever fracture, are you a smoker, what do you weigh, did you take estrogen after menopause?” JAMA: Why aren’t more physicians screening for osteoporosis and treating patients with the disease? Dr Siris: We’ve really only been able to deal with osteoporosis in the past 10 years in an effective manner in terms of having diagnostic tools and an armamentarium of treatments. It seems to be taking time to get the primary care physicians and physicians who treat fractures to learn what we can do and should be doing. Following a fracture

Bone Mineral Density Thresholds for Pharmacologic Intervention to Prevent Fractures

This study, based on data from the National Osteoporosis Risk Assessment, examined the effects of different treatment thresholds on fracture risk within a year after a measurement of bone mineral density (BMD). BMD is the single most important predictor of osteoporotic fractures in postmenopausal women having no previous fractures. The study population included 149,524 white postmenopausal women 50 to 104 years of age. At baseline, BMD was measured by peripheral bone densitometry at the heel, finger, or forearm. Fracture risk was followed over the next 12 months. A total of 2340 new osteoporotic fractures were reported by 2259 women. Hip fractures made up 17% of the total. As shown in Figure 1, lower baseline BMD values were associated with higher fracture rates (the number of women with fracture per 1000 person-years of follow up). Fracture rates were highest in women with the lowest T scores. More than 80% of women who reported having a fracture within 12 months had peripheral T scores higher than −2.5, and two thirds had T scores exceeding −2.0. Fracture rates were highest in these women but they occurred in only 18% of osteoporotic fractures and 26% of hip fractures. According to treatment guidelines formulated by the National Osteoporosis Foundation, 22.6% of women had T scores of 2.0 or less or −1.5 or less accompanied by 1 or more clinical risk factors. Fracture rates were lower in these women, but they constituted 45% of all osteoporotic fractures and 53% of hip fractures. It seems unlikely that a substantial reduction of osteoporotic fractures in postmenopausal women could be achieved solely by treating women with T scores of −2.5 or less. More attention must be given to women with moderate loss of bone mass who are nevertheless at increased risk of future fracture. The authors believe that nonpharmacologic measures such as weight-bearing exercise, strength training, and a healthy diet with adequate calcium should be tried as an initial measure.Fig. 1: Bone mineral density (BMD), osteoporotic fracture rate, and number of women with fractures. Reproduced with permission from Arch Intern Med 2004;164:1108–1112. Copyright© 2004, American Medical Association. All rights reserved.

An Approach to Identifying Osteopenic Women at Increased Short-term Risk of Fracture

Attempts to prevent fractures in postmenopausal women often are limited to those having T scores less than -2.5. Many fractures, however, occur in women having higher T scores. The investigators attempted to develop an algorithm that would identify women with T scores between [minus2.5 and -1.0 who were at increased short-term risk of fracture. Information on new fractures was gathered in the 57,421 participants after 12 months. All subjects were postmenopausal women whose baseline peripheral T scores ranged from to -2.5 to -1.0. Data were gathered from women participating in the National Osteoporosis Risk Assessment. New fractures occurred during the 12-month follow-up period in 1130 women. Among 32 potential predictors, 4 were the most important determinants of fracture in the short term (Fig. 1): previous fracture, a peripheral-site T score of -1.8 or less, self-rated poor health, and poor mobility. Previous fracture was the strongest predictor of fracture in the coming 12 months. More than half the women (55%) were considered to be at increased risk of fracture. The risk for women with past fracture, regardless of the T score, was 4.1%; for women with T scores of - 1.8 or less or with self-rated poor health, 2.2%; and for women with impaired mobility, 1.9%. The algorithm correctly identified approximately three fourths of women having fracture, regardless of age. Although these findings remain to be validated, the present results suggest that postmenopausal women having T scores greater than -2.5 and who are at increased risk of fracture in the ensuing 12 months can be identified.

Predictive value of low BMD for 1-year fracture outcomes is similar for postmenopausal women ages 50-64 and 65 and Older: results from the National Osteoporosis Risk Assessment (NORA).

The relationship of low bone mass and fracture in younger postmenopausal women has not been extensively studied. In a large cohort of postmenopausal women > or =50 years of age, we found the relationship of BMD measured at peripheral sites and subsequent 1-year fracture risk to be similar between women <65 and those > or =65 years of age. Low bone mass and fractures are prevalent in older postmenopausal women. However, the frequency of low bone mass and fracture in younger postmenopausal women has not been studied extensively. There are very limited data regarding the association between BMD measurements and fractures in postmenopausal women who are between the ages of 50 and 64. In the National Osteoporosis Risk Assessment (NORA) we studied the frequency of low bone mass and its association with fracture in women 50-64 years of age in comparison with women > or =65 of age. NORA enrolled 200,160 postmenopausal women > or =50 years of age who had no prior diagnosis of osteoporosis. Baseline BMD was measured at the heel, forearm, or finger. A 1-year follow-up survey requesting incident fractures since baseline was completed by 163,935 women, 87,594 (53%) of whom were 50-64 years of age. The association between BMD and fracture was assessed using logistic regression, adjusted for important covariates. Thirty-one percent of women 50-64 years of age had low bone mass (T scores < or = -1.0) compared to 62% of women > or =65 years of age. During the first year of follow-up, 2440 women reported fractures of wrist/forearm, rib, spine, or hip, including 440 hip fractures. Nine hundred four women 50-64 years of age reported fractures, including 86 hip fractures, accounting for 37% of fractures and 20% of hip fractures reported in the entire NORA cohort. Relative risk for osteoporotic fracture was 1.5 for each SD decrease in BMD for both the younger and older groups of women. Low BMD in younger postmenopausal women 50-64 years of age showed a 1-year relative risk of fracture similar to that found in women > or =65 years of age.

Bone mineral density thresholds for pharmacological intervention to prevent fractures.

Treatment intervention thresholds for prevention of osteoporotic fractures can be derived from reports from the World Health Organization (diagnostic criteria) and National Osteoporosis Foundation (treatment criteria). It is not known how well these thresholds work to identify women who will fracture and are therefore candidates for treatment interventions. We used data from the National Osteoporosis Risk Assessment (NORA) to examine the effect of different treatment thresholds on fracture incidence and numbers of women with fractures within the year following bone mineral density measurement. The study comprised 149 524 white postmenopausal women aged 50 to 104 years (mean age, 64.5 years). At baseline, bone mineral density was assessed by peripheral bone densitometry at the heel, finger, or forearm. New fractures during the next 12 months were self-reported. New fractures were reported by 2259 women, including 393 hip fractures; only 6.4% had baseline T scores of -2.5 or less (World Health Organization definition for osteoporosis). Although fracture rates were highest in these women, they experienced only 18% of the osteoporotic fractures and 26% of the hip fractures. By National Osteoporosis Foundation treatment guidelines, 22.6% of the women had T scores of 2.0 or less, or -1.5 or less with 1 or more clinical risk factors. Fracture rates were lower, but 45% of osteoporotic fractures and 53% of hip fractures occurred in these women. Using peripheral measurement devices, 82% of postmenopausal women with fractures had T scores better than -2.5. A strategy to reduce overall fracture incidence will likely require lifestyle changes and a targeted effort to identify and develop treatment protocols for women with less severe low bone mass who are nonetheless at increased risk for future fractures.

Rapid loss of hip fracture protection after estrogen cessation: evidence from the National Osteoporosis Risk Assessment.

Since the findings from the Women's Health Initiative became available in July 2002, millions of women have discontinued postmenopausal hormone therapy (HT). The objective of this study was to evaluate the association between HT cessation and hip fracture risk. Women who participated in the National Osteoporosis Risk Assessment and completed the 12-month follow-up survey were studied. All participants were aged at least 50 years, were postmenopausal, and had no previous diagnosis of osteoporosis. Baseline and 12-month follow-up questionnaires assessed use of HT and incident fractures. Of the 140,584 women in this study, 269 reported an incident hip fracture. A logistic regression model was used to assess association between HT use and incident hip fracture, controlling for potential confounders. Consistent with the Women's Health Initiative, women in National Osteoporosis Risk Assessment who were currently on HT had a 40% lower incidence of hip fractures compared with those who never used HT. Women who stopped using HT more than 5 years earlier had similar hip fracture risk to never users, as expected. However, surprisingly, women who had discontinued HT within the previous 5 years had an increased hip fracture odds ratio of 1.65 (95% confidence interval 1.05, 2.59) relative to never users of HT. Postmenopausal women who have discontinued HT within the past 5 years have a risk for hip fracture that is at least as high as that in women who have never used HT. II-2

Prediction of Fracture Risk in Postmenopausal White Women With Peripheral Bone Densitometry: Evidence From the National Osteoporosis Risk Assessment

Low bone mineral density (BMD) is a risk factor for fracture. Although the current "gold standard" test is DXA of the hip and spine, this method is not universally available. No large studies have evaluated the ability of new, less expensive peripheral technologies to predict fracture. We studied the association between BMD measurements at peripheral sites and subsequent fracture risk at the hip, wrist/forearm, spine, and rib in 149,524 postmenopausal white women, without prior diagnosis of osteoporosis. At enrollment, each participant completed a risk assessment questionnaire and had BMD testing at the heel, forearm, or finger. Main outcomes were new fractures of the hip, wrist/forearm, spine, or rib within the first 12 months after testing. After 1 year, 2259 women reported 2340 new fractures. Based on manufacturers' normative data and multivariable adjusted analyses, women who had T scores < or = -2.5 SD were 2.15 (finger) to 3.94 (heel ultrasound [US]) times more likely to fracture than women with normal BMD. All measurement sites/devices predicted fracture equally well, and risk prediction was similar whether calculated from the manufacturers' young normal values (T scores) or using SDs from the mean age of the National Osteoporosis Risk Assessment (NORA) population. The areas under receiver operating characteristic (ROC) curves for hip fracture were comparable with those published using measurements at hip sites. We conclude that low BMD found by peripheral technologies, regardless of the site measured, is associated with at least a twofold increased risk of fracture within 1 year, even at skeletal sites other than the one measured.

Identification and Fracture Outcomes of Undiagnosed Low Bone Mineral Density in Postmenopausal Women: Results From the National Osteoporosis Risk Assessment

Siris, Ethel S.; Miller, Paul D.; Barrett-Connor, Elizabeth; Faulkner, Kenneth G.; Wehren, Lois E.; Abbott, Thomas A.; Berger, Marc L.; Santora, Arthur C.; Sherwood, Louis M.

Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment.

Large segments of the population at risk for osteoporosis and fracture have not been evaluated, and the usefulness of peripheral measurements for short-term prediction of fracture risk is uncertain. To describe the occurrence of low bone mineral density (BMD) in postmenopausal women, its risk factors, and fracture incidence during short-term follow-up. The National Osteoporosis Risk Assessment, a longitudinal observational study initiated September 1997 to March 1999, with approximately 12 months of subsequent follow-up. A total of 200 160 ambulatory postmenopausal women aged 50 years or older with no previous osteoporosis diagnosis, derived from 4236 primary care practices in 34 states. Baseline BMD T scores, obtained from peripheral bone densitometry performed at the heel, finger, or forearm; risk factors for low BMD, derived from questionnaire responses; and clinical fracture rates at 12-month follow-up. Using World Health Organization criteria, 39.6% had osteopenia (T score of -1 to -2.49) and 7.2% had osteoporosis (T score </=-2.5). Age, personal or family history of fracture, Asian or Hispanic heritage, smoking, and cortisone use were associated with significantly increased likelihood of osteoporosis; higher body mass index, African American heritage, estrogen or diuretic use, exercise, and alcohol consumption significantly decreased the likelihood. Among the 163 979 participants with follow-up information, osteoporosis was associated with a fracture rate approximately 4 times that of normal BMD (rate ratio, 4.03; 95% confidence interval [CI], 3.59-4.53) and osteopenia was associated with a 1.8-fold higher rate (95% CI, 1.49-2.18). Almost half of this population had previously undetected low BMD, including 7% with osteoporosis. Peripheral BMD results were highly predictive of fracture risk. Given the economic and social costs of osteoporotic fractures, strategies to identify and manage osteoporosis in the primary care setting need to be established and implemented.

Utility of peripheral densitometry in assessment of patients in primary care

Objective: To evaluate peripheral bone mineral density (BMD) in postemenopausal Caucasian women with no previous diagnosis of osteoporosis. Methods: Data was collected from 179,471 women participating in the National Osteoporosis Risk Assessment (NORA) study, who had BMD measured at heel, forearm, or finger. BMD t scores were classified as normal, osteopenic (–1.0 to –2.49), or osteoporotic (–2.5 or lower). New fractures (forearm, spine, hip, rib, wrist, or other) were reported approximately 7 months after baseline. Results: Heel BMD (X-ray or ultrasonography) was measured on 104,796 women, forearm on 61,412, and finger on 13,263. Nearly half of the women had a t score of –1.0 or lower; 7% had osteoporosis. Within 7 months, 2% of respondents had suffered a fracture. Low BMD was associated with increased fracture risk for all peripheral measurement methods. Conclusion: All of the peripheral BMD measurements used in this study successfully identified women at risk for osteoporotic fracture.