Abstract
Summary
A procedure for creating a simplified version of fracture risk assessment tool (FRAX®) is described. Calibration, fracture prediction, and concordance were compared with the full FRAX tool using two large, complementary Canadian datasets.
Introduction
The Canadian Association of Radiologists and Osteoporosis Canada (CAROC) system for fracture risk assessment is based upon sex, age, bone mineral density (BMD), prior fragility fracture, and glucocorticoid use. CAROC does not require computer or web access, and categorizes 10-year major osteoporotic fracture risk as low (<10%), moderate (10–20%), or high (>20%).
Methods
Basal CAROC fracture risk tables (by age, sex, and femoral neck BMD) were constructed from Canadian FRAX probabilities for major osteoporotic fractures (adjusted for prevalent clinical risk factors). We assessed categorization and fracture prediction with the updated CAROC system in the CaMos and Manitoba BMD cohorts.
Results
The new CAROC system demonstrated high concordance with the Canadian FRAX tool for risk category in both the CaMos and Manitoba cohorts (89% and 88%). Ten-year fracture outcomes in CaMos and Manitoba BMD cohorts showed good discrimination and calibration for both CAROC (6.1–6.5% in low-risk, 13.5–14.6% in moderate-risk, and 22.3–29.1% in high-risk individuals) and FRAX (6.1–6.6% in low-risk, 14.4–16.1% in moderate-risk, and 23.4–31.0% in high-risk individuals). Reclassification from the CAROC risk category to a different risk category under FRAX occurred in <5% for low-risk, 20–24% for moderate-risk, and 27–30% for high-risk individuals. Reclassified individuals had 10-year fracture outcomes that were still within or close to the original nominal-risk range..
Conclusion
The new CAROC system is well calibrated to the Canadian population and shows a high degree of concordance with the Canadian FRAX tool. The CAROC system provides s a simple alternative when it is not feasible to use the full Canadian FRAX tool.
Similar content being viewed by others
References
Kanis JA, Melton LJ III, Christiansen C et al (1994) The diagnosis of osteoporosis [see comments]. J Bone Miner Res 9:1137–41
Looker AC, Wahner HW, Dunn WL et al (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8:468–89
Kanis JA, McCloskey EV, Johansson H et al (2008) A reference standard for the description of osteoporosis. Bone 42:467–75
Siris ES, Chen YT, Abbott TA et al (2004) Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 164:1108–12
Cranney A, Jamal SA, Tsang JF et al (2007) Low bone mineral density and fracture burden in postmenopausal women. CMAJ 177:575–80
Langsetmo L, Goltzman D, Kovacs CS et al (2009) Repeat low-trauma fractures occur frequently among men and women who have osteopenic BMD. J Bone Miner Res 24:1515–22
Siminoski K, Leslie WD, Frame H et al (2007) Recommendations for bone mineral density reporting in Canada: a shift to absolute fracture risk assessment. J Clin Densitom 10:120–3
Kanis JA, Johnell O, Oden A et al (2001) Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int 12:989–95
Kanis JA, Johnell O, De Laet C et al (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–82
Kanis JA, Johansson H, Oden A et al (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19:893–9
Adachi JD, Olszynski WP, Hanley DA et al (2000) Management of corticosteroid-induced osteoporosis. Semin Arthritis Rheum 29:228–51
Leslie WD, Tsang JF, Lix LM (2009) Simplified system for absolute fracture risk assessment: clinical validation in Canadian women. J Bone Miner Res 24:353–60
Leslie WD, Lix LM (2010) Simplified 10-year absolute fracture risk assessment: a comparison of men and women. J Clin Densitom 13:141–6
Leslie WD, O’Donnell S, Jean S et al (2009) Trends in hip fracture rates in Canada. JAMA 302:883–9
Kanis JA, Oden A, Johansson H et al (2009) FRAX and its applications to clinical practice. Bone 44:734–43
Kanis JA, Oden A, Johnell O 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 18:1033–46
Leslie WD, Lix D, Langsetmo L, et al. (2010) Construction of a FRAX model for the assessment of fracture probability in Canada and implications for treatment. Osteoporis Int (in press)
Chen P, Krege JH, Adachi JD et al (2009) Vertebral fracture status and the World Health Organization risk factors for predicting osteoporotic fracture risk. J Bone Miner Res 24:495–502
Kreiger N, Tenenhouse A, Joseph L et al (1999) Research notes: the Canadian Multicentre Osteoporosis Study (CaMos) - background, rationale, methods. Can J Aging 18:376–87
Kanis JA, Johnell O, Oden A et al (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–97
Berger C, Langsetmo L, Joseph L et al (2009) Association between change in BMD and fragility fracture in women and men. J Bone Miner Res 24:361–70
Genant HK, Grampp S, Gluer CC et al (1994) Universal standardization for dual x-ray absorptiometry: Patient and phantom cross-calibration results. J Bone Miner Res 9:1503–14
Roos NP, Shapiro E (1999) Revisiting the manitoba centre for health policy and evaluation and its population-based health information system. Med Care 37:JS10–JS14
WHO Collaborating Centre for Drug Statistics Methodology (2005) Guidelines for ATC classification and DDD assignment. Norwegian Institute for Public Health, Oslo
Kozyrskyj AL, Mustard CA (1998) Validation of an electronic, population-based prescription database. Ann Pharmacother 32:1152–7
Leslie WD, Tsang JF, Caetano PA et al (2007) Effectiveness of bone density measurement for predicting osteoporotic fractures in clinical practice. J Clin Endocrinol Metab 92:77–81
Leslie WD, Metge C (2003) Establishing a regional bone density program: lessons from the Manitoba experience. J Clin Densitom 6:275–82
Leslie WD, MacWilliam L, Lix L et al (2005) A population-based study of osteoporosis testing and treatment following introduction of a new bone densitometry service. Osteoporos Int 16:773–82
Leslie WD, Caetano PA, MacWilliam LR et al (2005) Construction and validation of a population-based bone densitometry database. J Clin Densitom 8:25–30
Leslie WD (2006) The importance of spectrum bias on bone density monitoring in clinical practice. Bone 39:361–8
Janes H, Pepe MS, Gu W (2008) Assessing the value of risk predictions by using risk stratification tables. Ann Intern Med 149:751–60
Siminoski K, Leslie WD, Frame H et al (2005) Recommendations for bone mineral density reporting in Canada. Can Assoc Radiol J 56:178–88
Leslie WD, O’Donnell S, Lagace C et al (2009) Population-based Canadian hip fracture rates with international comparisons. Osteoporos Int 21:1317–1322
Kanis JA, Johnell O, De Laet C et al (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17:1237–44
Fraser L, Langsetmo L, Berger C et al (2010). Fracture prediction and calibration of a Canadian FRAX tool: a population-based report from CaMos. Osteoporis Int (in press)
Leslie WD, Lix LM, Johansson H et al (2010) Independent clinical validation of a Canadian FRAX((R)) tool: Fracture prediction and model calibration. J Bone Miner Res. doi:10.1002/jbmr.123
Acknowledgements
We would like to thank Ms. Helena Johansson and Dr. John Kanis for their generating the Canadian FRAX results for both the CaMos and Manitoba cohorts. We thank all those participants in CaMos whose careful responses and attendance made this analysis possible. The authors are indebted to Manitoba Health for the provision of data (HIPC File No. 2007/2008-49). The results and conclusions are those of the authors, and no official edndorsement by Manitoba Health is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee. The analyses and conclusions in this report reflect the opinions of individual experts and not thier affiliated organizations.
Conflicts of interest
William Leslie is part of a speaker bureau for Merck Frosst and Amgen. He has also received unrestricted educational and/or research grants from Amgen; Merck Frosst; sanofi-Aventis; Procter & Gamble; Genzyme and is a member of the following advisory boards: Genzyme; Novartis; and Amgen. Lisa Lix received an unrestricted research grant from Amgen. In the past 3 years, Eugene McCloskey has received speaker fees and/or unrestricted research grants from Novartis, Amgen, AstraZeneca, Pfizer, Bayer, Procter & Gamble, Lilly, Roche, Servier, and Hologic.
Source of funding
The Canadian Multicentre Osteoporosis Study was funded by the Canadian Institutes of Health Research (CIHR), Merck Frosst Canada Ltd., Eli Lilly Canada Inc., Novartis Pharmaceuticals Inc., The Alliance for Better Bone Health: Sanofi-Aventis, Procter & Gamble Pharmaceuticals Canada Inc., Amgen, The Dairy Farmers of Canada and The Arthritis Society.
CaMos Research Group
David Goltzman (co-principal investigator, McGill University, Montreal), Nancy Kreiger (co-principal investigator, University of Toronto, Toronto), Alan Tenenhouse (principal investigator emeritus, Toronto), CaMos Coordinating Centre, McGill University, Montreal, Quebec: Suzette Poliquin (national coordinator), Suzanne Godmaire (research assistant), Claudie Berger (study statistician). Memorial University, St. John’s Newfoundland: Carol Joyce (director), Christopher Kovacs (co-director), Emma Sheppard (coordinator). Dalhousie University, Halifax, Nova Scotia: Susan Kirkland, Stephanie Kaiser (co-directors), Barbara Stanfield (coordinator). Laval University, Quebec City, Quebec: Jacques P. Brown (director), Louis Bessette (co-director), Marc Gendreau (coordinator). Queen’s University, Kingston, Ontario: Tassos Anastassiades (director), Tanveer Towheed (co-director), Barbara Matthews (coordinator). University of Toronto, Toronto, Ontario: Bob Josse (director), Sophie Jamal (co-director), Tim Murray (past director), Barbara Gardner-Bray (coordinator) McMaster University, Hamilton, Ontario: Jonathan D. Adachi (director), Alexandra Papaioannou (co-director), Laura Pickard (coordinator). University of Saskatchewan, Saskatoon, Saskatchewan: Wojciech P. Olszynski (director), K. Shawn Davison (co-director), Jola Thingvold (coordinator). University of Calgary, Calgary, Alberta: David A. Hanley (director), Jane Allan (coordinator). University of British Columbia, Vancouver, British Columbia: Jerilynn C. Prior (director), Millan Patel (co-director), Brian Lentle (radiologist),Yvette Vigna (coordinator).
Author information
Authors and Affiliations
Consortia
Corresponding author
Rights and permissions
About this article
Cite this article
Leslie, W.D., Berger, C., Langsetmo, L. et al. Construction and validation of a simplified fracture risk assessment tool for Canadian women and men: results from the CaMos and Manitoba cohorts. Osteoporos Int 22, 1873–1883 (2011). https://doi.org/10.1007/s00198-010-1445-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00198-010-1445-5