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Original article
Do we need bone mineral density to estimate osteoporotic fracture risk? A 10-year prospective multicentre validation study
  1. Andréa Marques1,2,
  2. Raquel Lucas3,
  3. Eugénia Simões4,
  4. Suzanne M M Verstappen5,7,
  5. Johannes W G Jacobs6 and
  6. Jose A P da Silva1
  1. 1 Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal
  2. 2 Coimbra Nursing School, Esenfc, Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
  3. 3 EPIUnit – Institute of Public Health and Porto Medical School, University of Porto, Porto, Portugal
  4. 4 Instituto Português de Reumatologia, Lisboa, Portugal
  5. 5 Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
  6. 6 Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands
  7. 7 NIHR Manchester Biomedical Research Centre, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
  1. Correspondence to Professor Jose A P da Silva; jdasilva{at}ci.uc.pt

Abstract

Objective Evaluate the performance of FRAX®, with and without bone mineral densitometry (BMD), in predicting the occurrence of fragility fractures over 10 years.

Methods Participants aged ≥40 years at baseline, with a complete set of data and a minimum of 8.5 years of follow-up were identified from three cohorts (n=2626). Ten-year fracture risk at baseline were estimated with FRAX® and assessed by comparison with observed fractures and receiver operating characteristic analysis.

Results During a mean (SD) follow-up of 9.12 (1.5) years, 178 participants suffered a major osteoporotic (MOP) fracture and 28 sustained a hip fracture. The predictive performance of FRAX® was superior to that of BMD alone for both MOP and hip fractures. The area under the curve (AUC) of FRAX® without BMD was 0.76 (95% CI 0.72 to 0.79) for MOP fractures and 0.78 (95% CI 0.69 to 0.86) for hip fractures. No significant improvements were found when BMD was added to clinical variables to predict either MOP (0.78, 95% CI 0.74 to 0.82, p=0.25) or hip fractures (0.79, 95% CI 0.69 to 0.89, p=0.72).

AUCs for FRAX® (with and without BMD) were greater for men than for women. FRAX®, with and without BMD, tended to underestimate the number of MOP fractures and to overestimate the number of hip fractures in females. In men, the number of observed fractures were within the 95% CI of the number predicted, both with and without BMD.

Conclusion FRAX® without BMD provided good fracture prediction. Adding BMD to FRAX® did not improve the performance of the tool in the general population.

  • osteoporosis
  • epidemiology
  • outcomes research

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Footnotes

  • Contributors AM and JAPS were responsible for conceiving the project. AM and RL were responsible for data collection. AM performed the data management and statistical analysis in collaboration with RL, SMMV, JJ and JAPS. AM wrote the paper in collaboration with all coauthors. All coauthors read the report and made suggestions about its content.

  • Funding This study was supported by unrestricted grants from the Direção Geral da Saúde and Amgen, which had no role in the design of the study, the writing or review of the paper.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The Research Ethics Board of Faculty of Medicine of Coimbra University approved the current analysis. All participants gave informed consent before taking part.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.