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Osteoporosis International
Published in: Osteoporosis International 1/2021

01-01-2021 | Osteoporosis | Original Article

Fracture prediction from FRAX for Canadian ethnic groups: a registry-based cohort study

Authors: W. D. Leslie, S.N. Morin, L.M. Lix, E.V. McCloskey, H. Johansson, N.C. Harvey, J.A. Kanis

Published in: Osteoporosis International | Issue 1/2021

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Abstract

Summary

We identified large between-ethnicity calibration differences in the Canadian FRAX® tool which substantially overestimated the major osteoporotic fracture (MOF) risk in Asian women and Black women, and overestimated hip fracture risk in Asian women.

Purpose

FRAX® is calibrated using population-specific fracture and mortality data. The need for FRAX to accommodate ethnic diversity within a country is uncertain. We addressed this question using the population-based Manitoba Bone Mineral Density (BMD) Program registry and self-reported ethnicity.

Methods

The study population was women aged 40 years or older with baseline FRAX assessments (Canadian and other ethnic calculators), fracture outcomes, and self-reported ethnicity (White N = 68,907 [referent], Asian N = 1910, Black N = 356). Adjusted hazard ratios (HR) with 95% confidence intervals (CI) for time to MOF and hip fracture were estimated. We examined candidate variables from DXA that might contribute to ethnic differences including skeletal size, hip axis length (HAL), trabecular bone score (TBS), and estimated body composition.

Results

Adjusted for baseline risk using the Canadian FRAX tool with BMD, Asian women compared with White women were at much lower risk for MOF (HR 0.46, 95% CI 0.35–0.59) and hip fracture (0.16, 95% CI 0.08–0.34). Black women were also at lower MOF risk (HR 0.58, 95% CI 0.32–1.00); there were no hip fractures. The US ethnic-specific FRAX calculators accounted for most of the between-ethnicity differences in MOF risk (86% for Asian, 92% for Black) but only partially accounted for lower hip fracture risk in Asian women (40%). The candidate variables explained only a minority of the effect of ethnicity. Gradient of risk in analyses was similar (p-interactions ethnicity*FRAX non-significant).

Conclusions

We identified significant ethnic differences in performance of the Canadian FRAX tool with fracture probability overestimated among Asian and Black women. The US ethnic calculators helped to address this discrepancy for MOF risk assessment, but not for hip fracture risk among Asian women.
Appendix
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Literature
1.
Kanis JA, Harvey NC, Cooper C, Johansson H, Oden A, McCloskey EV et al (2016) A systematic review of intervention thresholds based on FRAX : a report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 11(1):25CrossRef
2.
3.
Cauley JA, El-Hajj Fuleihan G, Arabi A, Fujiwara S, Ragi-Eis S, Calderon A et al (2011) Official positions for FRAX(R) clinical regarding international differences 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):240–262CrossRef
4.
Cauley JA, El-Hajj Fuleihan G, Luckey MM, Members FPDC (2011) FRAX(R) International Task Force of the 2010 Joint International Society for Clinical Densitometry & International Osteoporosis Foundation Position Development Conference. J Clin Densitom 14(3):237–239CrossRef
5.
Hippisley-Cox J, Coupland C (2012) Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study. BMJ. 344:e3427CrossRef
6.
Johansson H, Oden A, Lorentzon M, McCloskey E, Kanis JA, Harvey NC et al (2015) Is the Swedish FRAX model appropriate for Swedish immigrants? Osteoporos Int 26(11):2617–2622CrossRef
7.
8.
Leslie WD, Metge C (2003) Establishing a regional bone density program: lessons from the Manitoba experience. J Clin Densitom 6(3):275–282CrossRef
9.
Leslie WD, Caetano PA, Macwilliam LR, Finlayson GS (2005) Construction and validation of a population-based bone densitometry database. J Clin Densitom 8(1):25–30CrossRef
10.
11.
Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston Jr CC, Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8(5):468–489CrossRef
12.
Kanis JA, Oden A, Johansson H, Borgstrom F, Strom O, McCloskey E (2009) FRAX and its applications to clinical practice. Bone. 44(5):734–743CrossRef
13.
Leslie WD, Lix LM, Langsetmo L, Berger C, Goltzman D, Hanley DA, Adachi JD, Johansson H, Oden A, McCloskey E, Kanis JA (2011) Construction of a FRAX(R) model for the assessment of fracture probability in Canada and implications for treatment. Osteoporos Int 22(3):817–827CrossRef
14.
Bisson EJ, Finlayson ML, Ekuma O, Marrie RA, Leslie WD (2019) Accuracy of FRAX(R) in people with multiple sclerosis. J Bone Miner Res 34:1095–1100CrossRef
15.
Leslie WD, Morin SN, Lix LM, Niraula S, McCloskey EV, Johansson H et al (2019) Performance of FRAX in women with breast cancer initiating aromatase inhibitor therapy: a registry-based cohort study. J Bone Miner Res 34(8):1428–1435CrossRef
16.
Peschken CA, Hitchon CA, Garland A, Bernstein CN, Chen H, Fransoo R, Marrie RA (2016) A population-based study of intensive care unit admissions in rheumatoid arthritis. J Rheumatol 43(1):26–33CrossRef
17.
Yang S, Leslie WD, Yan L, Walld R, Roos LL, Morin SN, Majumdar SR, Lix LM (2016) Objectively verified parental hip fracture is an independent risk factor for fracture: a linkage analysis of 478,792 parents and 261,705 offspring. J Bone Miner Res 31(9):1753–1759CrossRef
18.
Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA, Manitoba Bone Density Program (2010) Independent clinical validation of a Canadian FRAX tool: fracture prediction and model calibration. J Bone Miner Res 25(11):2350–2358CrossRef
19.
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):829–837CrossRef
20.
Metge C, Black C, Peterson S, Kozyrskyj AL (1999) The population’s use of pharmaceuticals. Med Care 37(6 Suppl):JS42–JS59PubMed
21.
Reid RJ, Roos NP, MacWilliam L, Frohlich N, Black C (2002) Assessing population health care need using a claims-based ACG morbidity measure: a validation analysis in the province of Manitoba. Health Serv Res 37(5):1345–1364CrossRef
22.
Khokhar B, Jette N, Metcalfe A, Cunningham CT, Quan H, Kaplan GG, Butalia S, Rabi D (2016) Systematic review of validated case definitions for diabetes in ICD-9-coded and ICD-10-coded data in adult populations. BMJ Open 6(8):e009952CrossRef
23.
Blanchard JF, Ludwig S, Wajda A, Dean H, Anderson K, Kendall O, Depew N (1996) Incidence and prevalence of diabetes in Manitoba, 1986-1991. Diabetes Care 19(8):807–811CrossRef
24.
Fazli GS, Moineddin R, Bierman AS, Booth GL (2019) Ethnic differences in prediabetes incidence among immigrants to Canada: a population-based cohort study. BMC Med 17(1)
25.
26.
27.
Leslie WD, Lix LM, Morin SN, Johansson H, Oden A, McCloskey EV et al (2015) Hip axis length is a FRAX- and bone density-independent risk factor for hip fracture in women. J Clin Endocrinol Metab 100(5):2063–2070CrossRef
28.
Leslie WD, Lix LM, Majumdar SR, Morin SN, Johansson H, Oden A et al (2017) Total hip bone area affects fracture prediction with FRAX(R) in Canadian white women. J Clin Endocrinol Metab 102:4242–4249CrossRef
29.
Christensen AM, Leslie WD, Baim S (2014) Ancestral differences in femoral neck axis length: possible implications for forensic anthropological analyses. Forensic Sci Int 236:193 e1–193 e4CrossRef
30.
Clark P, Tesoriero LJ, Morton DJ, Talavera JO, Karlamangla A, Schneider DL, Wooten WJ, Barrett-Connor E (2008) Hip axis length variation: its correlation with anthropometric measurements in women from three ethnic groups. Osteoporos Int 19(9):1301–1306CrossRef
31.
Hans D, Goertzen AL, Krieg MA, Leslie WD (2011) Bone microarchitecture assessed by TBS predicts osteoporotic fractures independent of bone density: the Manitoba study. J Bone Miner Res 26(11):2762–2769CrossRef
32.
Looker AC, Sarafrazi Isfahani N, Fan B, Shepherd JA (2016) Trabecular bone scores and lumbar spine bone mineral density of US adults: comparison of relationships with demographic and body size variables. Osteoporos Int 27(8):2467–2475CrossRef
33.
Leslie WD, Orwoll ES, Nielson CM, Morin SN, Majumdar SR, Johansson H, Odén A, McCloskey EV, Kanis JA (2014) Estimated lean mass and fat mass differentially affect femoral bone density and strength index but are not FRAX independent risk factors for fracture. J Bone Miner Res 29(11):2511–2519CrossRef
34.
Leslie WD, Morin SN, Lix LM, Martineau P, Bryanton M, McCloskey EV et al (2019) Fracture prediction from self-reported falls in routine clinical practice: a registry-based cohort study. Osteoporos Int 30(11):2195–2203CrossRef
35.
Lix LM, Azimaee M, Osman BA, Caetano P, Morin S, Metge C, Goltzman D, Kreiger N, Prior J, Leslie WD (2012) Osteoporosis-related fracture case definitions for population-based administrative data. BMC Public Health 12:301CrossRef
36.
Epp R, Alhrbi M, Ward L, Leslie WD (2018) Radiological validation of fracture definitions from administrative data. J Bone Miner Res 33(Supp 1):S275
37.
Kanis JA, Oden A, McCloskey EV, Johansson H, Wahl DA, Cooper C et al (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23(9):2239–2256CrossRef
38.
Metadata
Title
Fracture prediction from FRAX for Canadian ethnic groups: a registry-based cohort study
Authors
W. D. Leslie
S.N. Morin
L.M. Lix
E.V. McCloskey
H. Johansson
N.C. Harvey
J.A. Kanis
Publication date
01-01-2021
Publisher
Springer London
Published in
Osteoporosis International / Issue 1/2021
Print ISSN: 0937-941X
Electronic ISSN: 1433-2965
DOI
https://doi.org/10.1007/s00198-020-05594-8

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