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Open Access 01-12-2023 | Osteoporosis | Original Article

Ireland DXA-FRAX may differ significantly and substantially to Web-FRAX

Authors: Lan Yang, Mary Dempsey, Attracta Brennan, Bryan Whelan, E. Erjiang, Tingyan Wang, Rebecca Egan, Kelly Gorham, Fiona Heaney, Catherine Armstrong, Guadalupe Morote Ibarrola, Amina Gsel, Ming Yu, John J. Carey, the DXA MAP Group

Published in: Archives of Osteoporosis | Issue 1/2023

Abstract

Summary

Appropriate use of FRAX reduces the number of people requiring DXA scans, while contemporaneously determining those most at risk. We compared the results of FRAX with and without inclusion of BMD. It suggests clinicians to carefully consider the importance of BMD inclusion in fracture risk estimation or interpretation in individual patients.

Purpose

FRAX is a widely accepted tool to estimate the 10-year risk of hip and major osteoporotic fracture in adults. Prior calibration studies suggest this works similarly with or without the inclusion of bone mineral density (BMD). The purpose of the study is to compare within-subject differences between FRAX estimations derived using DXA and Web software with and without the inclusion of BMD.

Method

A convenience cohort was used for this cross-sectional study, consisting of 1254 men and women aged between 40 and 90 years who had a DXA scan and complete validated data available for analysis. FRAX 10-year estimations for hip and major osteoporotic fracture were calculated using DXA software (DXA-FRAX) and the Web tool (Web-FRAX), with and without BMD. Agreements between estimates within each individual subject were examined using Bland–Altman plots. We performed exploratory analyses of the characteristics of those with very discordant results.

Results

Overall median DXA-FRAX and Web-FRAX 10-year hip and major osteoporotic fracture risk estimations which include BMD are very similar: 2.9% vs. 2.8% and 11.0% vs. 11% respectively. However, both are significantly lower than those obtained without BMD: 4.9% and 14% respectively, P < 0.001. Within-subject differences between hip fracture estimates with and without BMD were < 3% in 57% of cases, between 3 and 6% in 19% of cases, and > 6% in 24% of cases, while for major osteoporotic fractures such differences are < 10% in 82% of cases, between 10 and 20% in 15% of cases, and > 20% in 3% of cases.

Conclusions

Although there is excellent agreement between the Web-FRAX and DXA-FRAX tools when BMD is incorporated, sometimes there are very large differences for individuals between results obtained with and without BMD. Clinicians should carefully consider the importance of BMD inclusion in FRAX estimations when assessing individual patients.

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Compston JE, McClung MR, Leslie WD (2019) Osteoporosis. Lancet 393(10169):364–376. https://doi.org/10.1016/S0140-6736(18)32112-3CrossRefPubMed

Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S et al (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25(10):2359–2381. https://doi.org/10.1007/s00198-014-2794-2CrossRefPubMedPubMedCentral

Kanis JA, Norton N, Harvey NC, Jacobson T, Johansson H, Lorentzon M et al (2021) SCOPE 2021: a new scorecard for osteoporosis in Europe. Arch Osteoporos 16(1):82. https://doi.org/10.1007/s11657-020-00871-9CrossRefPubMedPubMedCentral

McGowan B, Kanis JA, Johansson H, Silke C, Whelan B (2013) Development and application of FRAX in the management of osteoporosis in Ireland. Arch Osteoporos 8:146. https://doi.org/10.1007/s11657-013-0146-zCrossRefPubMed

Executive HS. Strategy to prevent falls and fractures in Ireland’s ageing population. . HSE Website: Health Service Executive2008 June 2008. Report No.: ISBN 978–1–906218–12–6

Kelly MA, McCabe E, Bergin D, Kearns SR, McCabe JP, Armstrong C et al (2020) Osteoporotic vertebral fractures are common in hip fracture patients and are under-recognized. J Clin Densitom. https://doi.org/10.1016/j.jocd.2020.05.007CrossRefPubMed

Kelly MA, McGowan B, McKenna MJ, Bennett K, Carey JJ, Whelan B et al (2018) Emerging trends in hospitalisation for fragility fractures in Ireland. Ir J Med Sci 187(3):601–608. https://doi.org/10.1007/s11845-018-1743-zCrossRefPubMed

Dockery F, Glynn A, Franks K, Carey JJ, O’Gradaigh D, Kenny P et al (2022) Fracture liaison services in Ireland-how do we compare to international standards? Osteoporos Int 33(5):1089–1096. https://doi.org/10.1007/s00198-021-06251-4CrossRefPubMed

Walsh ME, Ferris H, Coughlan T, Hurson C, Ahern E, Sorensen J et al (2021) Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database. Osteoporos Int 32(4):727–736. https://doi.org/10.1007/s00198-020-05636-1CrossRefPubMed

10.

Walsh ME, Nerdrum M, Fahey T, Moriarty F (2021) Factors associated with initiation of bone-health medication among older adults in primary care in Ireland. Age Ageing 50(5):1649–1656. https://doi.org/10.1093/ageing/afab033CrossRefPubMedPubMedCentral

11.

Aziziyeh R, Amin M, Habib M, Perlaza JG, McTavish RK, Ludke A et al (2019) A scorecard for osteoporosis in four Latin American countries: Brazil, Mexico, Colombia, and Argentina. Arch Osteoporos 14(1):69. https://doi.org/10.1007/s11657-019-0622-1CrossRefPubMed

12.

Chandran M, Ebeling PR, Mitchell PJ, Nguyen TV, Executive Committee of the Asia Pacific Consortium on O (2022) Harmonization of osteoporosis guidelines: paving the way for disrupting the status quo in osteoporosis management in the Asia Pacific. J Bone Miner Res 37(4):608–15. https://doi.org/10.1002/jbmr.4544CrossRefPubMed

13.

Jones AR, Herath M, Ebeling PR, Teede H, Vincent AJ (2021) Models of care for osteoporosis: a systematic scoping review of efficacy and implementation characteristics. EClinicalMedicine 38:101022. https://doi.org/10.1016/j.eclinm.2021.101022CrossRefPubMedPubMedCentral

14.

Maeda SS, Da Silva LLibre R, Arantes HP, de Souza GC, Molina FFC, Wiluzanski D et al (2021) Challenges and opportunities for quality densitometry in Latin America. Arch Osteoporos 16(1):23. https://doi.org/10.1007/s11657-021-00892-yCrossRefPubMed

15.

Lewiecki EM, Binkley N, Clark P, Kim S, Leslie WD, Morin SN (2020) Core principles for fracture prevention: North American Consensus from the National Osteoporosis Foundation, Osteoporosis Canada, and Academia Nacional de Medicina de Mexico. Osteoporos Int 31(11):2073–2076. https://doi.org/10.1007/s00198-020-05541-7CrossRefPubMed

16.

Lewiecki EM, Binkley N, Morgan SL, Shuhart CR, Camargos BM, Carey JJ et al (2016) Best practices for dual-energy X-ray absorptiometry measurement and reporting: International Society for Clinical Densitometry Guidance. J Clin Densitom 19(2):127–140. https://doi.org/10.1016/j.jocd.2016.03.003CrossRefPubMed

17.

McCloskey E, Rathi J, Heijmans S, Blagden M, Cortet B, Czerwinski E et al (2020) The osteoporosis treatment gap in patients at risk of fracture in European primary care: a multi-country cross-sectional observational study. Osteoporos Int. https://doi.org/10.1007/s00198-020-05557-zCrossRefPubMedPubMedCentral

18.

Rubin KH, Friis-Holmberg T, Hermann AP, Abrahamsen B, Brixen K (2013) Risk assessment tools to identify women with increased risk of osteoporotic fracture: complexity or simplicity? A systematic review. J Bone Miner Res 28(8):1701–1717. https://doi.org/10.1002/jbmr.1956CrossRefPubMed

19.

Marques A, Ferreira RJ, Santos E, Loza E, Carmona L, da Silva JA (2015) The accuracy of osteoporotic fracture risk prediction tools: a systematic review and meta-analysis. Ann Rheum Dis 74(11):1958–1967. https://doi.org/10.1136/annrheumdis-2015-207907CrossRefPubMed

20.

Leslie WD, Crandall CJ (2019) Population-based osteoporosis primary prevention and screening for quality of care in osteoporosis, Current Osteoporosis Reports. Curr Osteoporos Rep 17(6):483–490. https://doi.org/10.1007/s11914-019-00542-wCrossRefPubMed

21.

Crandall CJ, Ensrud KE (2020) Osteoporosis screening in younger postmenopausal women. JAMA 323(4):367–368. https://doi.org/10.1001/jama.2019.18343CrossRefPubMed

22.

Nayak S, Edwards DL, Saleh AA, Greenspan SL (2015) Systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for osteoporosis or low bone density. Osteoporos Int 26(5):1543–1554. https://doi.org/10.1007/s00198-015-3025-1CrossRefPubMedPubMedCentral

23.

Subramaniam S, Ima-Nirwana S, Chin KY (2018) Performance of osteoporosis self-assessment tool (OST) in predicting osteoporosis-a review. Int J Environ Res Public Health 15(7). https://doi.org/10.3390/ijerph15071445

24.

Diem SJ, Peters KW, Gourlay ML, Schousboe JT, Taylor BC, Orwoll ES et al (2017) Screening for osteoporosis in older men: operating characteristics of proposed strategies for selecting men for BMD testing. J Gen Intern Med 32(11):1235–1241. https://doi.org/10.1007/s11606-017-4153-4CrossRefPubMedPubMedCentral

25.

Erjiang E, Wang T, Yang L, Dempsey M, Brennan A, Yu M et al (2021) Utility of osteoporosis self-assessment tool as a screening tool for osteoporosis in Irish men and women: results of the DXA-HIP project. J Clin Densitom 24(4):516–26. https://doi.org/10.1016/j.jocd.2021.03.003CrossRef

26.

McCloskey EV, Harvey NC, Johansson H, Lorentzon M, Liu E, Vandenput L et al (2022) Fracture risk assessment by the FRAX model. Climacteric 25(1):22–28. https://doi.org/10.1080/13697137.2021.1945027CrossRefPubMed

27.

Kanis JA, Cooper C, Rizzoli R, Reginster JY, Reginster JY, Scientific Advisory Board of the European Society for C, Economic Aspects of O et al (2019) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 30(1):3–44. https://doi.org/10.1007/s00198-018-4704-5CrossRefPubMed

28.

Lewiecki EM, Compston JE, Miller PD, Adachi JD, Adams JE, Leslie WD et al (2011) Official Positions for FRAX(R) Bone Mineral Density and FRAX(R) simplification from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(R). J Clin Densitom 14(3):226–236. https://doi.org/10.1016/j.jocd.2011.05.017CrossRefPubMed

29.

Hans DB, Kanis JA, Baim S, Bilezikian JP, Binkley N, Cauley JA et al (2011) Joint Official Positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX((R)). Executive summary of the 2010 Position Development Conference on interpretation and use of FRAX(R) in clinical practice. J Clin Densitom 14(3):171–80. https://doi.org/10.1016/j.jocd.2011.05.007CrossRefPubMed

30.

Mohammad A, Aamir MU, Mooney S, Coughlan RJ, Carey JJ (2014) Appropriateness of referrals to a tertiary referral centre for bone mineral density testing. Ir J Med Sci 183(4):533–537. https://doi.org/10.1007/s11845-013-1044-5CrossRefPubMed

31.

European Union (Basic safety standards for protection against dangers arising from medical exposure to ionising radiation) Regulations, S.I. No. 256/2022 (2018)

32.

Erjiang E, Wang T, Yang L, Dempsey M, Brennan A, Yu M et al (2020) The Irish dual-energy X-ray absorptiometry (DXA) Health Informatics Prediction (HIP) for Osteoporosis Project. BMJ Open 10(12):e040488. https://doi.org/10.1136/bmjopen-2020-040488CrossRef

33.

Brewer L, Mellon L, Duggan J (2013) Ability of fracture risk assessment tool and national osteoporosis guideline group guidance to stratify people appropriately before fracture. J Am Geriatr Soc 61(9):1633–1634. https://doi.org/10.1111/jgs.12435CrossRefPubMed

34.

Haroon M, Khan K, Thong L, Ali K, Janjua F (2019) High prevalence of risk factors for low bone mineral density and estimated fracture and fall risk among elderly medical inpatients: a missed opportunity. Ir J Med Sci 188(2):531–536. https://doi.org/10.1007/s11845-018-1882-2CrossRefPubMed

35.

Erjiang E, Wang T, Yang L, Dempsey M, Brennan A, Yu M et al (2021) How does proximal femur BMD of healthy Irish adults compare to NHANES III? Results of the DXA-HIP Project. Arch Osteoporos 16(1):170. https://doi.org/10.1007/s11657-021-01034-0CrossRef

36.

Carey JJ, Yang L, Erjiang E, Wang T, Gorham K, Egan R et al (2021) Vertebral Fractures in Ireland: a sub-analysis of the DXA HIP Project. Calcif Tissue Int 109(5):534–543. https://doi.org/10.1007/s00223-021-00868-7CrossRefPubMedPubMedCentral

37.

Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J et al (2007) The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18(8):1033–1046. https://doi.org/10.1007/s00198-007-0343-yCrossRefPubMed

38.

Compston JE, Drake MT (2020) Defining very high fracture risk: is FRAX fit for purpose? J Bone Miner Res 35(8):1399–1403. https://doi.org/10.1002/jbmr.4134CrossRefPubMed

39.

McCloskey E, Harvey N, Johansson H, Lorentzon M, Liu E, Vandenput L et al (2022) Fracture risk assessment by the FRAX model. Climacteric 25(1):22–28CrossRefPubMed

40.

Kanis JA, Johansson H, Harvey NC, McCloskey EV (2018) A brief history of FRAX. Arch Osteoporos 13(1):1–16CrossRef

41.

Xu G, Yamamoto N, Hayashi K, Takeuchi A, Miwa S, Igarashi K et al (2020) The accuracy of different FRAX tools in predicting fracture risk in Japan: a comparison study. J Orthop Surg (Hong Kong) 28(2):2309499020917276. https://doi.org/10.1177/2309499020917276CrossRefPubMed

42.

Kanis JA, Harvey NC, Johansson H, Lorentzon M, Liu E, Leslie WD et al (2022) FRAX. In: Pape HC, Kates SL, Hierholzer C, Bischoff-Ferrari HA (eds) Senior Trauma Patients. Springer, Cham, pp 89–99. https://doi.org/10.1007/978-3-030-91483-7_10

43.

Dhiman P, Andersen S, Vestergaard P, Masud T, Qureshi N (2018) Does bone mineral density improve the predictive accuracy of fracture risk assessment? A prospective cohort study in Northern Denmark. BMJ Open 8(4):e018898. https://doi.org/10.1136/bmjopen-2017-018898CrossRefPubMedPubMedCentral

44.

Fraser LA, Langsetmo L, Berger C, Ioannidis G, Goltzman D, Adachi JD et al (2011) Fracture prediction and calibration of a Canadian FRAX(R) tool: a population-based report from CaMos. Osteoporos Int 22(3):829–837. https://doi.org/10.1007/s00198-010-1465-1CrossRefPubMed

45.

Hillier TA, Cauley JA, Rizzo JH, Pedula KL, Ensrud KE, Bauer DC et al (2011) WHO absolute fracture risk models (FRAX): do clinical risk factors improve fracture prediction in older women without osteoporosis? J Bone Miner Res 26(8):1774–1782. https://doi.org/10.1002/jbmr.372CrossRefPubMed

46.

Gourlay ML, Ritter VS, Fine JP, Overman RA, Schousboe JT, Cawthon PM et al (2017) Comparison of fracture risk assessment tools in older men without prior hip or spine fracture: the MrOS study. Arch Osteoporos 12(1):91. https://doi.org/10.1007/s11657-017-0389-1CrossRefPubMedPubMedCentral

47.

Hamdy RC, Seier E, Whalen K, Clark WA, Hicks K, Piggee TB (2018) FRAX calculated without BMD does not correctly identify Caucasian men with densitometric evidence of osteoporosis. Osteoporos Int 29(4):947–952. https://doi.org/10.1007/s00198-017-4368-6CrossRefPubMed

48.

Tremollieres FA, Pouilles JM, Drewniak N, Laparra J, Ribot CA, Dargent-Molina P (2010) Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool. J Bone Miner Res 25(5):1002–1009. https://doi.org/10.1002/jbmr.12CrossRefPubMed

49.

Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA et al (2010) Independent clinical validation of a Canadian FRAX tool: fracture prediction and model calibration. J Bone Miner Res 25(11):2350–2358. https://doi.org/10.1002/jbmr.123CrossRefPubMed

50.

Crandall CJ, Larson J, Cauley JA, Schousboe JT, LaCroix AZ, Robbins JA et al (2019) Do additional clinical risk factors improve the performance of fracture risk assessment tool (FRAX) among postmenopausal women? Findings from the women’s health initiative observational study and clinical trials. JBMR Plus 3(12):e10239. https://doi.org/10.1002/jbm4.10239CrossRefPubMedPubMedCentral

51.

Holloway-Kew KL, Zhang Y, Betson AG, Anderson KB, Hans D, Hyde NK et al (2019) How well do the FRAX (Australia) and Garvan calculators predict incident fractures? Data from the Geelong Osteoporosis Study. Osteoporos Int 30(10):2129–2139. https://doi.org/10.1007/s00198-019-05088-2CrossRefPubMed

52.

Sambrook PN, Flahive J, Hooven FH, Boonen S, Chapurlat R, Lindsay R et al (2011) Predicting fractures in an international cohort using risk factor algorithms without BMD. J Bone Miner Res 26(11):2770–2777. https://doi.org/10.1002/jbmr.503CrossRefPubMed

53.

Cook NR (2007) Use and misuse of the receiver operating characteristic curve in risk prediction. Circulation 115(7):928–935. https://doi.org/10.1161/CIRCULATIONAHA.106.672402CrossRefPubMed

54.

Obuchowski NA (2005) ROC analysis. AJR Am J Roentgenol 184(2):364–372. https://doi.org/10.2214/ajr.184.2.01840364CrossRefPubMed

55.

Makin TR, Orban de Xivry JJ (2019) Ten common statistical mistakes to watch out for when writing or reviewing a manuscript. Elife 8. https://doi.org/10.7554/eLife.48175

56.

Bland JM, Altman DG (1999) Measuring agreement in method comparison studies. Stat Methods Med Res 8(2):135–160. https://doi.org/10.1177/096228029900800204CrossRefPubMed

Title: Ireland DXA-FRAX may differ significantly and substantially to Web-FRAX
Authors: Lan Yang
Mary Dempsey
Attracta Brennan
Bryan Whelan
E. Erjiang
Tingyan Wang
Rebecca Egan
Kelly Gorham
Fiona Heaney
Catherine Armstrong
Guadalupe Morote Ibarrola
Amina Gsel
Ming Yu
John J. Carey
the DXA MAP Group
Publication date: 01-12-2023
Publisher: Springer London
Keywords: Osteoporosis
Osteoporosis
Published in: Archives of Osteoporosis / Issue 1/2023
Print ISSN: 1862-3522
Electronic ISSN: 1862-3514
DOI: https://doi.org/10.1007/s11657-023-01232-y

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Ireland DXA-FRAX may differ significantly and substantially to Web-FRAX

Abstract

Summary

Purpose

Method

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Summary

Purpose

Method

Results

Conclusions

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