Article Text

other Versions

Download PDFPDF
Extended report
The accuracy of osteoporotic fracture risk prediction tools: a systematic review and meta-analysis
  1. Andréa Marques1,2,
  2. Ricardo J O Ferreira1,2,
  3. Eduardo Santos1,2,
  4. Estíbaliz Loza3,
  5. Loreto Carmona3,
  6. José António Pereira da Silva1,4
  1. 1Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
  2. 2Health Sciences Research Unit: Nursing (UICiSA:E), Coimbra, Portugal
  3. 3Instituto de Salud Musculoesquelética—InMusc, Madrid, Spain
  4. 4Faculty of Medicine, Clínica Universitária de Reumatologia, University of Coimbra, Coimbra, Portugal
  1. Correspondence Professor José António Pereira da Silva, Serviço de Reumatologia, Piso 7, Centro Hospitalar Universitário de Coimbra, EPE, Avenida Dr. Bissaya Barreto, Coimbra 3000-075, Portugal; jdasilva{at}


Objectives To identify and synthesise the best available evidence on the accuracy of the currently available tools for predicting fracture risk.

Methods We systematically searched PubMed MEDLINE, Embase and Cochrane databases to 2014. Two reviewers independently selected articles, collected data from studies, and carried out a hand search of the references of the included studies. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) checklist was used, and the primary outcome was the area under the curve (AUC) and 95% CIs, obtained from receiver operating characteristic (ROC) analyses. We excluded tools if they had not been externally validated or were designed for specific disease populations. Random effects meta-analyses were performed with the selected tools.

Results Forty-five studies met inclusion criteria, corresponding to 13 different tools. Only three tools had been tested more than once in a population-based setting: FRAX (26 studies in 9 countries), GARVAN (6 studies in 3 countries) and QFracture (3 studies in the UK, 1 also including Irish participants). Twenty studies with these three tools were included in a total of 17 meta-analyses (for hip or major osteoporotic fractures; men or women; with or without bone mineral density).

Conclusions Most of the 13 tools are feasible in clinical practice. FRAX has the largest number of externally validated and independent studies. The overall accuracy of the different tools is satisfactory (>0.70), with QFracture reaching 0.89 (95% CI 0.88 to 0.89). Significant methodological limitations were observed in many studies, suggesting caution when comparing tools based solely on the AUC.

  • Osteoporosis
  • Bone Mineral Density
  • Epidemiology

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles