The WHO Absolute Fracture Risk Models (FRAX): Do Clinical Risk Factors Improve Fracture Prediction in Older Women Without Osteoporosis?

摘要

Bone mineral density (BMD) is a strong predictor of fracture, yet most fractures occur in women without osteoporosis by BMD criteria. To improve fracture-risk prediction, the World Health Organization recently developed a country-specific fracture risk index of clinical risk factors (FRAX^®) that estimates 10-year probabilities of hip and major osteoporotic fracture. Within differing baseline BMD categories, we evaluated 6252 women age 65 and older in the Study of Osteoporotic Fractures using FRAX 10-year probabilities of hip and major osteoporotic fracture (hip, clinical spine, wrist, humerus) compared to incidence of fractures over 10 years of follow-up. Overall ability of FRAX to predict fracture risk based on initial BMD T-score categories (normal, low bone mass, and osteoporosis) was evaluated with receiver-operating-characteristic (ROC) analyses using area-under-the-curve (AUC). Over 10 years of follow-up, 368 women incurred a hip fracture, and 1011 a major osteoporotic fracture. Women with low bone mass represented the majority (n=3791; 61%); they developed many hip (n=176; 48%) and major osteoporotic fractures (n=569; 56%). Among women with normal and low bone mass, FRAX (including BMD) was an overall better predictor of hip fracture risk (AUC = 0.78 and 0.70, respectively) than major osteoporotic fractures (AUC = 0.64 and 0.62). Simpler models (e.g., age+prior fracture) had similar AUCs to FRAX, including among women for whom primary prevention is sought (no prior fracture or osteoporosis by BMD). The FRAX, and simpler models, predict 10-year risk of incident hip and major osteoporotic fractures in older U.S. women with normal or low bone mass.