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Fracture prediction and calibration of a Canadian FRAX® tool: a population-based report from CaMos

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Abstract

Summary

A new Canadian WHO fracture risk assessment (FRAX®) tool to predict 10-year fracture probability was compared with observed 10-year fracture outcomes in a large Canadian population-based study (CaMos). The Canadian FRAX tool showed good calibration and discrimination for both hip and major osteoporotic fractures.

Introduction

The purpose of this study was to validate a new Canadian WHO fracture risk assessment (FRAX®) tool in a prospective, population-based cohort, the Canadian Multicentre Osteoporosis Study (CaMos).

Methods

A FRAX tool calibrated to the Canadian population was developed by the WHO Collaborating Centre for Metabolic Bone Diseases using national hip fracture and mortality data. Ten-year FRAX probabilities with and without bone mineral density (BMD) were derived for CaMos women (N = 4,778) and men (N = 1,919) and compared with observed fracture outcomes to 10 years (Kaplan–Meier method). Cox proportional hazard models were used to investigate the contribution of individual FRAX variables.

Results

Mean overall 10-year FRAX probability with BMD for major osteoporotic fractures was not significantly different from the observed value in men [predicted 5.4% vs. observed 6.4% (95%CI 5.2–7.5%)] and only slightly lower in women [predicted 10.8% vs. observed 12.0% (95%CI 11.0–12.9%)]. FRAX was well calibrated for hip fracture assessment in women [predicted 2.7% vs. observed 2.7% (95%CI 2.2–3.2%)] but underestimated risk in men [predicted 1.3% vs. observed 2.4% (95%CI 1.7–3.1%)]. FRAX with BMD showed better fracture discrimination than FRAX without BMD or BMD alone. Age, body mass index, prior fragility fracture and femoral neck BMD were significant independent predictors of major osteoporotic fractures; sex, age, prior fragility fracture and femoral neck BMD were significant independent predictors of hip fractures.

Conclusion

The Canadian FRAX tool provides predictions consistent with observed fracture rates in Canadian women and men, thereby providing a valuable tool for Canadian clinicians assessing patients at risk of fracture.

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References

  1. Berger C, Goltzman D, Langsetmo L, Joseph L, Kreiger N, Tenenhouse A, Davison KS, Josse R, Prior J, Hanley D, CaMos Research Group (2010) Peak bone mass from longitudinal data: implications for the prevalence, pathophysiology, and diagnosis of osteoporosis. J Bone Miner Res 25:1948–1957

    Article  PubMed  Google Scholar 

  2. Hanley DA, Josse RG (1996) Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 1. Introduction. CMAJ 155(7):921–923

    CAS  PubMed  Google Scholar 

  3. Jaglal SB, Sherry PG, Schatzker J (1996) The impact and consequences of hip fracture in Ontario. Can J Surg 39(2):105–111

    CAS  PubMed  Google Scholar 

  4. Melton LJ III (2003) Epidemiology worldwide. Endocrinol Metab Clin North Am 32(1):1–13, v

    Article  PubMed  Google Scholar 

  5. Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17(12):1726–1733

    Article  CAS  PubMed  Google Scholar 

  6. Ioannidis G, Papaioannou A, Hopman WM, khtar-Danesh N, Anastassiades T, Pickard L, Kennedy CC, Prior JC, Olszynski WP, Davison KS, Goltzman D, Thabane L, Gafni A, Papadimitropoulos EA, Brown JP, Josse RG, Hanley DA, Adachi JD (2009) Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ 181(5):265–271

    PubMed  Google Scholar 

  7. Adachi JD, Ioannidis G, Berger C, Joseph L, Papaioannou A, Pickard L, Papadimitropoulos EA, Hopman W, Poliquin S, Prior JC, Hanley DA, Olszynski WP, Anastassiades T, Brown JP, Murray T, Jackson SA, Tenenhouse A (2001) The influence of osteoporotic fractures on health-related quality of life in community-dwelling men and women across Canada. Osteoporos Int 12(11):903–908

    Article  CAS  PubMed  Google Scholar 

  8. Hallberg I, Rosenqvist AM, Kartous L, Lofman O, Wahlstrom O, Toss G (2004) Health-related quality of life after osteoporotic fractures. Osteoporos Int 15(10):834–841

    Article  CAS  PubMed  Google Scholar 

  9. Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T, Keller M, Chesnut CH III, Brown J, Eriksen EF, Hoseyni MS, Axelrod DW, Miller PD (1999) Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA 282(14):1344–1352

    Article  CAS  PubMed  Google Scholar 

  10. Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C (2002) Meta-analyses of therapies for postmenopausal osteoporosis. IX: summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev 23(4):570–578

    Article  CAS  PubMed  Google Scholar 

  11. Goeree R, Blackhouse G, Adachi J (2006) Cost-effectiveness of alternative treatments for women with osteoporosis in Canada. Curr Med Res Opin 22(7):1425–1436

    Article  PubMed  Google Scholar 

  12. Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312(7041):1254–1259

    CAS  PubMed  Google Scholar 

  13. Cranney A, Jamal SA, Tsang JF, Josse RG, Leslie WD (2007) Low bone mineral density and fracture burden in postmenopausal women. CMAJ 177(6):575–580

    PubMed  Google Scholar 

  14. Langsetmo L, Goltzman D, Kovacs CS, Adachi JD, Hanley DA, Kreiger N, Josse R, Papaioannou A, Olszynski WP, Jamal SA (2009) Repeat low-trauma fractures occur frequently among men and women who have osteopenic bone mineral density. J Bone Miner Res 24(9):1515–1522

    Article  PubMed  Google Scholar 

  15. Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E (2008) FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19(4):385–397

    Article  CAS  PubMed  Google Scholar 

  16. Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, Burckhardt P, Cooper C, Christiansen C, Cummings S, Eisman JA, Fujiwara S, Gluer C, Goltzman D, Hans D, Krieg MA, La CA, McCloskey E, Mellstrom D, Melton LJ III, Pols H, Reeve J, Sanders K, Schott AM, Silman A, Torgerson D, van ST W, NB YN (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(8):1033–1046

    Article  CAS  PubMed  Google Scholar 

  17. Leslie WD, O'Donnell S, Lagace C, Walsh P, Bancej C, Jean S, Siminoski K, Kaiser S, Kendler DL, Jaglal S (2009) Population-based Canadian hip fracture rates with international comparisons. Osteoporos Int 21:1317–1322

    Article  PubMed  Google Scholar 

  18. Ettinger B, Black DM, wson-Hughes B, Pressman AR, Melton LJ III (2010) Updated fracture incidence rates for the US version of FRAX. Osteoporos Int 21(1):25–33

    Article  CAS  PubMed  Google Scholar 

  19. Kreiger N, Tenenhouse A, Joseph L, MacKenzie T, Poliquin S, Brown JP, Prior JC, Rittmaster (1999) Research notes: the Canadian Multicentre Osteoporosis Study (CaMos)—background, rationale, methods. Can J Aging 18:376–387

    Article  Google Scholar 

  20. Lu Y, Fuerst T, Hui S, Genant HK (2001) Standardization of bone mineral density at femoral neck, trochanter and Ward’s triangle. Osteoporos Int 12(6):438–444

    Article  CAS  PubMed  Google Scholar 

  21. Genant HK (1995) Universal standardization for dual X-ray absorptiometry: patient and phantom cross-calibration results. J Bone Miner Res 10(6):997–998

    Article  CAS  PubMed  Google Scholar 

  22. Berger C, Langsetmo L, Joseph L, Hanley D, Davison KS, Josse RG, Kreiger N, Tenenhouse A, Goltzman D (2008) Change in bone mineral density as a function of age in women and men and association with the use of antiresorptive agents. Can Med Assoc J 178(13):1660–1668

    Article  Google Scholar 

  23. Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA (2010) Independent clinical validation of a Canadian FRAX® tool: fracture prediction and model calibration. J Bone Miner Res. doi:10.1002/jbmr.123

  24. Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17(7):1237–1244

    Article  PubMed  Google Scholar 

  25. Kanis JA, Oden A, Johansson H, Borgstrom F, Strom O, McCloskey E (2009) FRAX and its applications to clinical practice. Bone 44(5):734–743

    Article  PubMed  Google Scholar 

  26. Fujiwara S, Nakamura T, Orimo H, Hosoi T, Gorai I, Oden A, Johansson H, Kanis JA (2008) Development and application of a Japanese model of the WHO fracture risk assessment tool (FRAX). Osteoporos Int 19(4):429–435

    Article  CAS  PubMed  Google Scholar 

  27. Dawson-Hughes B, Tosteson AN, Melton LJ III, Baim S, Favus MJ, Khosla S, Lindsay RL (2008) Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int 19(4):449–458

    Article  CAS  PubMed  Google Scholar 

  28. Lippuner K, Johansson H, Kanis JA, Rizzoli R (2010) FRAX assessment of osteoporotic fracture probability in Switzerland. Osteoporos Int 21(3):381–389

    Article  PubMed  Google Scholar 

  29. Siminoski K, Leslie WD, Frame H, Hodsman A, Josse RG, Khan A, Lentle BC, Levesque J, Lyons DJ, Tarulli G, Brown JP (2005) Recommendations for bone mineral density reporting in Canada. Can Assoc Radiol J 56(3):178–188

    PubMed  Google Scholar 

  30. Richards JB, Leslie WD, Joseph L, Siminoski K, Hanley DA, Adachi JD, Brown JP, Morin S, Papaioannou A, Josse RG, Prior JC, Davison KS, Tenenhouse A, Goltzman D (2007) Changes to osteoporosis prevalence according to method of risk assessment. J Bone Miner Res 22(2):228–234

    Article  PubMed  Google Scholar 

  31. Leslie WD, Tsang JF, Lix LM (2009) Simplified system for absolute fracture risk assessment: clinical validation in Canadian women. J Bone Miner Res 24(2):353–360

    Article  PubMed  Google Scholar 

  32. Chen P, Krege JH, Adachi JD, Prior JC, Tenenhouse A, Brown JP, Papadimitropoulos E, Kreiger N, Olszynski WP, Josse RG, Goltzman D (2009) Vertebral fracture status and the World Health Organization risk factors for predicting osteoporotic fracture risk. J Bone Miner Res 24(3):495–502

    Article  PubMed  Google Scholar 

  33. Johansson H, Kanis JA, Oden A, Johnell O, McCloskey E (2009) BMD, clinical risk factors and their combination for hip fracture prevention. Osteoporos Int 20(10):1675–1682

    Article  CAS  PubMed  Google Scholar 

  34. Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA, Fujiwara S, Kroger H, Mellstrom D, Meunier PJ, Melton LJ III, O’Neill T, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20(7):1185–1194

    Article  PubMed  Google Scholar 

  35. Leslie WD, Metge C, Ward L (2003) Contribution of clinical risk factors to bone density-based absolute fracture risk assessment in postmenopausal women. Osteoporos Int 14(4):334–338

    Article  CAS  PubMed  Google Scholar 

  36. Schuit SC, van der Klift M, Weel AE, de Laet CE, Burger H, Seeman E, Hofman A, Uitterlinden AG, van Leeuwen JP, Pols HA (2004) Fracture incidence and association with bone mineral density in elderly men and women: the Rotterdam Study. Bone 34(1):195–202

    Article  CAS  PubMed  Google Scholar 

  37. Siris ES, Chen YT, Abbott TA, Barrett-Connor E, Miller PD, Wehren LE, Berger ML (2004) Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 164(10):1108–1112

    Article  PubMed  Google Scholar 

  38. Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, Nevitt MC, Cummings SR (2003) BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res 18(11):1947–1954

    Article  PubMed  Google Scholar 

  39. De Laet C, Kanis JA, Oden A, Johanson H, Johnell O, Delmas P, Eisman JA, Kroger H, Fujiwara S, Garnero P, McCloskey EV, Mellstrom D, Melton LJ III, Meunier PJ, Pols HA, Reeve J, Silman A, Tenenhouse A (2005) Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int 16(11):1330–1338

    Article  PubMed  Google Scholar 

  40. Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Eisman JA, McCloskey EV, Mellstrom D, Melton LJ III, Pols HA, Reeve J, Silman AJ, Tenenhouse A (2004) A family history of fracture and fracture risk: a meta-analysis. Bone 35(5):1029–1037

    Article  CAS  PubMed  Google Scholar 

  41. Kanis JA, Johnell O, De Laet C, Johansson H, Oden A, Delmas P, Eisman J, Fujiwara S, Garnero P, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35(2):375–382

    Article  CAS  PubMed  Google Scholar 

  42. Kanis JA, Johansson H, Oden A, Johnell O, de LC M, LJ III, Tenenhouse A, Reeve J, Silman AJ, Pols HA, Eisman JA, McCloskey EV, Mellstrom D (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19(6):893–899

    Article  PubMed  Google Scholar 

  43. Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A (2005) Alcohol intake as a risk factor for fracture. Osteoporos Int 16(7):737–742

    Article  PubMed  Google Scholar 

  44. Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H, McCloskey EV, Mellstrom D, Melton LJ, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Smoking and fracture risk: a meta-analysis. Osteoporos Int 16(2):155–162

    Article  CAS  PubMed  Google Scholar 

  45. Borgstrom F, Johnell O, Kanis JA, Jonsson B, Rehnberg C (2006) At what hip fracture risk is it cost-effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int 17(10):1459–1471

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We thank all those participants in CaMos whose careful responses and attendance made this analysis possible. Dr. Fraser is supported by the University of Western Ontario Resident Research Career Development Program. 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: sanofi-aventis & Procter and Gamble Pharmaceuticals Canada Inc.; Servier Canada Inc.; Amgen Canada Inc.; The Dairy Farmers of Canada; and The Arthritis Society.

CaMos Research Group

David Goltzman (co-principal investigator, McGill University), Nancy Kreiger (co-principal investigator, 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 A 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 British Columbia, Vancouver, British Columbia: Jerilynn C. Prior (director), Milan Patel (co-director),Yvette Vigna (coordinator); Brian C. Lentle (radiologist)

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada

    L.-A. Fraser, G. Ioannidis, J. D. Adachi & A. Papaioannou

  2. CaMos National Coordinating Center, McGill University, Montreal, Quebec, Canada

    L. Langsetmo, C. Berger & D. Goltzman

  3. Department of Medicine, University of Toronto, Toronto, Ontario, Canada

    R. Josse & S. Jamal

  4. Faculty of Medicine, Memorial University of Newfoundland, St. John’s Newfoundland, Canada

    C. S. Kovacs

  5. Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

    W. P. Olszynski

  6. Department of Medicine, Queen’s University, Kingston, Ontario, Canada

    T. Towheed

  7. Department of Medicine, University of Calgary, Calgary, Alberta, Canada

    D. A. Hanley

  8. Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada

    S. M. Kaiser

  9. Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada

    J. Prior

  10. Department of Medicine, Laval University, Quebec City, Quebec, Canada

    J. P. Brown

  11. Department of Epidemiology, University of Toronto Cancer Care Ontario, Toronto, Ontario, Canada

    N. Kreiger

  12. Gothenburg, Sweden

    H. Johansson & A. Oden

  13. Osteoporosis Centre, Northern General Hospital, Sheffield, UK

    E. McCloskey

  14. WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

    J. A. Kanis

  15. Department of Medicine (C5121), University of Manitoba St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba, Canada, R2H 2A6

    W. D. Leslie

Authors
  1. L.-A. Fraser
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  2. L. Langsetmo
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  3. C. Berger
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  4. G. Ioannidis
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  5. D. Goltzman
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  6. J. D. Adachi
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  7. A. Papaioannou
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  8. R. Josse
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  9. C. S. Kovacs
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  10. W. P. Olszynski
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  11. T. Towheed
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  12. D. A. Hanley
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  13. S. M. Kaiser
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  14. J. Prior
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  15. S. Jamal
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  16. N. Kreiger
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  17. J. P. Brown
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  18. H. Johansson
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  19. A. Oden
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  20. E. McCloskey
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  21. J. A. Kanis
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  22. W. D. Leslie
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CaMos Research Group

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Correspondence to W. D. Leslie.

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Fraser, LA., Langsetmo, L., Berger, C. et al. Fracture prediction and calibration of a Canadian FRAX® tool: a population-based report from CaMos. Osteoporos Int 22, 829–837 (2011). https://doi.org/10.1007/s00198-010-1465-1

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  • DOI: https://doi.org/10.1007/s00198-010-1465-1

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