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FRAX provides robust fracture prediction regardless of socioeconomic status

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Abstract

Summary

We investigated the fracture risk assessment tool (FRAX) Canada calibration and discrimination according to income quintile in 51,327 Canadian women, with and without a competing mortality framework. Our data show that, under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of socioeconomic status (SES).

Introduction

FRAX® predicts 10-year fracture risk. Social factors may independently affect fracture risk. We investigated FRAX calibration and discrimination according to SES.

Methods

Women aged ≥50 years with baseline femoral neck bone mineral density (BMD) were identified from the Manitoba Bone Density Program, Canada (n = 51,327), 1996–2011. Mean household income, extracted from 2006 census files, was categorized into quintiles. Ten-year fracture probabilities were calculated using FRAX Canada. Incident non-traumatic fractures were studied in relation to income quintile in adjusted Cox proportional hazards models. We compared observed versus predicted fractures with and without a competing mortality framework.

Results

During mean 6.2 ± 3.7 years of follow up, there were 6,392 deaths, 3,723 women with ≥1 major osteoporotic fracture (MOF), and 1,027 with hip fractures. Lower income was associated with higher risk for death, MOF, and hip fracture in adjusted models (all p < 0.005). More women in income quintile 1 (lowest) versus quintile 5 experienced death (19 vs. 8 %), MOF (10 vs. 6 %), or hip fracture (3.0 vs. 1.3 %) (all p ≤ 0.001). Adjustment for competing mortality mitigated the effect of SES on FRAX calibration, and good calibration was observed. FRAX provided good fracture discrimination for MOF and hip fracture within each income quintile (all p < 0.001). Area under the curve was slightly lower for income quintiles 1 versus 5 for FRAX with BMD to predict MOF (0.68, 95 % CI 0.66–0.70 vs. 0.71, 95 % CI 0.69–0.74) and hip fracture (0.79, 95 % CI 0.76–0.81 vs. 0.87, 95 % CI 0.84–0.89).

Conclusion

Increased fracture risk in individuals of lower income is offset by increased mortality. Under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of SES.

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Acknowledgments

The authors are indebted to Manitoba Health for the provision of data (HIPC file no. 2012/2013-15). The results and conclusions are those of the authors, and no official endorsement 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. SL Brennan is supported by a National Health and Medical Research Council (NHMRC) of Australia Early Career Fellowship (1012472), and a 2012 Dyason Fellowship from The University of Melbourne. LM Lix is supported by a Manitoba Health Research Chair.

Conflicts of interest

Sharon L Brennan and Anders Oden have no competing interests to declare.

William D Leslie has served on advisory boards for Novartis, Amgen, and Genzyme, received unrestricted research grants from Amgen, and received speaker fees from Amgen, Novartis, and Eli Lilly.

Helena Johansson is supported by ESCEO-AMGEN Osteoporosis Fellowship Award.

Eugene McCloskey received speaker fees and/or unrestricted research grants from Novartis, Amgen, AstraZeneca, Pfizer, Bayer, Warner-Chilcott/Procter & Gamble, Lilly, Roche, Servier, and Hologic.

John A Kanis, Industry, received grants from Amgen, USA, Switzerland and Belgium; D3A, France; Gador, Argentina; General Electric, USA; GSK, UK, USA; Hologic, Belgium and USA; Kissei, Japan; Lilly, USA, Canada, Japan, Australia, and UK; Merck Research Labs, USA; Merlin Ventures, UK; Novartis, Switzerland and USA; Novo Nordisk, Denmark; Nycomed, Norway; Ono, UK and Japan; Pfizer USA; Pharmexa, Denmark; ProStrakan, UK; Roche, Germany, Australia, Switzerland, and USA; Rotta Research, Italy; Sanofi-Aventis, USA; Servier, France and UK; Shire, UK; Solvay, France and Germany; Tethys, USA; Teijan, Japan; Teva, Israel; UBS, Belgium; Unigene, USA; Warburg-Pincus, UK. Governmental and non-government organizations: National Institute for Health and Clinical Excellence (NICE), UK; International Osteoporosis Foundation; National Osteoporosis Guideline Group (NOGG), UK; INSERM, France; Ministry of Public Health, China; Ministry of Health, Australia; National Osteoporosis Society, UK; and World Health Organization.

Lisa M Lix has received an unrestricted research grant from Amgen.

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Brennan, S.L., Leslie, W.D., Lix, L.M. et al. FRAX provides robust fracture prediction regardless of socioeconomic status. Osteoporos Int 25, 61–69 (2014). https://doi.org/10.1007/s00198-013-2525-0

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