Skip to main content
Log in

BMD, clinical risk factors and their combination for hip fracture prevention

  • Original Article
  • Published:
Osteoporosis International Aims and scope Submit manuscript

Abstract

Summary

This study examined the effects of the use of clinical risk factors (CRFs) alone, BMD alone or the combination using the FRAX® tool for the detection of women at risk of hip fracture. BMD tests alone selected women at higher risk and a greater number of hip fracture cases were identified compared to the use of CRFs alone. The combined use of CRFs and BMD identified fewer women above a threshold risk than the use of BMD alone, but with a higher hip fracture risk and thus had the more favourable positive predictive value (PPV) and number needed to treat (NNT).

Introduction

Algorithms have recently become available for the calculation of hip fracture probability from CRFs with and without information on femoral neck BMD. The aim of this study was to examine the effects of the use of CRFs alone, BMD alone or their combination using the FRAX® tool for the detection of women at risk of hip fracture.

Methods

Data from 10 prospective population based cohorts, in which BMD and CRFs were documented, were used to compute the 10-year probabilities of hip fracture calibrated to the fracture and death hazards of the UK. The effects of the use of BMD tests were examined in simulations where BMD tests were used alone, CRFs alone or their combined use. The base case examined the effects in women at the age of 65 years. The principal outcome measures were the number of women identified above an intervention threshold, the number of hip fracture cases that would be identified, the positive predicted value and the NNT to prevent a hip fracture during a hypothetical treatment with an effectiveness of 35% targeted to those above the threshold fracture risk. We also examined BMD values in women selected for treatment. Sensitivity analysis examined the effect of age and limited use of BMD resources.

Results

BMD tests alone selected women at higher risk of hip fracture than the use of CRFs alone (6.1% versus 5.3%). BMD tests alone also identified a greater number of hip fracture cases (219/1,000) compared to the use of CRFs alone (140/1,000). The combined use of CRFs and BMD identified fewer women above a threshold risk than the use of BMD alone (168/1,000 versus 219/1,000, respectively), but with a higher hip fracture risk (PPV, 8.6% versus 6.1%), and consequently a lower number needed to treat (NNT) (33 versus 47). In sensitivity analyses, the PPV and NNT were always better for the combination than either BMD or CRFs alone across all ages studied (50–70 years).

Conclusions

The use of FRAX® in combination with BMD increases the performance characteristics of fracture risk assessment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

References

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

    CAS  Google Scholar 

  2. Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA et al (2005) Predictive value of bone mineral density for hip and other fractures. J Bone Miner Res 20:1185–1194

    Article  PubMed  Google Scholar 

  3. Kanis JA, Johnell O, Oden A, Jönsson B, De Laet C, Dawson A (2000) Risk of hip fracture according to World Health Organization criteria for osteopenia and osteoporosis. Bone 27:585–590

    Article  PubMed  CAS  Google Scholar 

  4. Hui SL, Slemenda CW, Johnston CC (1988) Age and bone mass as predictors of fracture in a prospective study. J Clin Invest 81:1804–1809

    Article  PubMed  CAS  Google Scholar 

  5. De Laet CEDH, van Hout BA, Burger H, Hofman A, Pols HAP (1997) Bone density and risk of hip fracture in men and women: cross sectional analysis. Br Med J 315:221–225

    Google Scholar 

  6. World Health Organization (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report Series 843. WHO, Geneva

  7. De Laet C, Oden A, Johansson H, Johnell O, Jonsson B, Kanis JA (2005) The impact of the use of multiple risk indicators for fracture on case-finding strategies: a mathematical approach. Osteoporos Int 16:313–318

    Article  PubMed  Google Scholar 

  8. Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA et al (2001) Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA 286:2815–2822

    Article  PubMed  CAS  Google Scholar 

  9. Kanis JA, Johnell O, Oden A, Jönsson B, Dawson A, Dere W (2000) Risk of hip fracture derived from relative risks: an analysis applied to the population of Sweden. Osteoporos Int 11:120–127

    Article  PubMed  CAS  Google Scholar 

  10. Kanis JA, Johnell O, Oden A, De Laet C, Jonsson B, Dawson A (2002) Ten-year risk of osteoporotic fracture and the effect of risk factors on screening strategies. Bone 30:251–285

    Article  PubMed  CAS  Google Scholar 

  11. Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Eisman JA et al (2004) A family history of fracture and fracture risk: a meta-analysis. Bone 35:1029–1037

    Article  PubMed  CAS  Google Scholar 

  12. Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Melton LJ III et al (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19:893–899

    Article  PubMed  Google Scholar 

  13. Kanis JA, Johnell O, De Laet C et al (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  Google Scholar 

  15. Kanis JA, Johansson H, Oden A et al (2005) A meta-analysis of milk intake and fracture risk: low utility for case finding. Osteoporos Int 16:799–804

    Article  PubMed  Google Scholar 

  16. Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA et al (2005) Smoking and fracture risk: a meta-analysis. Osteoporos Int 16:155–162

    Article  PubMed  CAS  Google Scholar 

  17. De Laet C, Kanis JA, Oden A, Johansson H, Johnell O, Delmas P et al (2005) Body mass index as a prediction of fracture risk. A meta-analysis. Osteoporos Int 16:1330–1338

    Article  PubMed  Google Scholar 

  18. 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 18:1033–1046

    Article  PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  20. Kanis JA on behalf of the World Health Organization Scientific Group (2008) Assessment of osteoporosis at the primary health-care level. Technical Report. WHO Collaborating Centre, University of Sheffield, UK, 2008

  21. Kanis JA, Johnell O (2005) Requirements for DXA for the management of osteoporosis in Europe. Osteoporos Int 16:229–238

    Article  PubMed  CAS  Google Scholar 

  22. Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D, European Foundation for Osteoporosis and Bone Disease (1997) Guidelines for diagnosis and management of osteoporosis. Osteoporos Int 7:390–406

    Article  PubMed  CAS  Google Scholar 

  23. Royal College of Physicians (1999) Osteoporosis: clinical guidelines for prevention and treatment. The Royal College of Physicians of London

  24. Royal College of Physicians (2001) Osteoporosis: clinical guidelines for prevention and treatment. Update on pharmacological interventions and an algorithm for management. RCP, London

  25. Hofman A, Grobbee DE, de Jong PT, van den Ouweland FA (1991) Determinants of disease and disability in the elderly: the Rotterdam Elderly Study. Eur J Epidemiol 7:403–422

    Article  PubMed  CAS  Google Scholar 

  26. De Laet CEDH, Van Hout BA, Burger H, Hofman A, Weel AEAM, Pols HAP (1998) Hip fracture prediction in elderly men and women: validation of the Rotterdam study. J Bone Miner Res 13:1587–1593

    Article  PubMed  Google Scholar 

  27. O’Neill TW, Felsenberg D, Barlow J, Cooper C, Kanis JA, Silman AJ (1996) The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 11:1010–1017

    Article  PubMed  Google Scholar 

  28. Kreiger N, Tenenhouse A, Joseph L et al (1999) The Canadian Multicentre Osteoporosis Study CaMos: background, rationale, methods. Can J Aging 18:376–387

    Google Scholar 

  29. Melton LJ III, Crowson CS, O’Fallon WM, Wahner HW, Riggs BL (2003) Relative contributions of bone density, bone turnover and clinical risk factors to long-term fracture prediction. J Bone Miner Res 18:312–318

    Article  PubMed  Google Scholar 

  30. Melton LJ III, Atkinson EJ, O’Connor MK, O’Fallon WM, Riggs BL (1998) Bone density and fracture risk in men. J Bone Miner Res 13:1915–1923

    Article  PubMed  Google Scholar 

  31. McCloskey EV, Beneton M, Charlesworth D, Kayan K, deTakats D, Dey A et al (2007) Clodronate reduces the incidence of fractures in community-dwelling elderly women unselected for osteoporosis: results of a double-blind, placebo-controlled randomized study. J Bone Miner Res 22:135–141

    Article  PubMed  CAS  Google Scholar 

  32. Jones G, Nguyen TV, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA (1994) Symptomatic fracture incidence in elderly men and women. The Dubbo Osteoporosis Epidemiology Study DOES. Osteoporos Int 4:277–282

    Article  PubMed  CAS  Google Scholar 

  33. Svanborg A (1977) 70 year old people in Gothenburg. A population study in an industrialised Swedish city. II. Journal presentation of social and medical conditions. Acta Med Scand 611(suppl):5

    CAS  Google Scholar 

  34. Johansson C, Black D, Johnell O, Oden A, Mellstrom D (1998) Bone mineral density is a predictor of survival. Calcif Tissue Int 63:190–196

    Article  PubMed  CAS  Google Scholar 

  35. Fujiwara S, Kasagi F, Yamada M, Kodama K (1997) Risk factors for hip fracture in Japanese cohort. J Bone Miner Res 12:998–1004

    Article  PubMed  CAS  Google Scholar 

  36. Fujiwara S, Fumiyoshi K, Masunari W, Narito K, Suzuki G, Fukunagi M (2003) Fracture prediction from bone mineral density in Japanese men and women. J Bone Miner Res 18:1547–1553

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  38. National Osteoporosis Foundation (NOF) (2003) Physician’s Guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington, DC (http://www.nof.org/physguide/Physicians_Guide.pdf)

  39. Kanis JA, Borgstrom F, Zethraeus N, Johnell O, Oden A, Jonsson B (2005) Intervention thresholds for osteoporosis in the UK. Bone 36:22–32

    Article  PubMed  Google Scholar 

  40. Johansson H, Oden A, Johnell O, Jonsson B, De Laet C, Oglesby A et al (2004) Optimisation of BMD measurements to identify high risk groups for treatment—a test analysis. J Bone Miner Res 19:906–913

    Article  PubMed  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  42. Deeks JJ, Altman DG (2004) Diagnostic tests 4: likelihood ratios. Br Med J 329:168–169

    Article  Google Scholar 

  43. Brown J, Josse RG, The Scientific Advisory Council of the Osteoporosis Society of Canada (2002) Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. Canad Med Assoc J 167(suppl 10):S1–S34

    Google Scholar 

  44. Community European (1998) Report on osteoporosis in the European Community. EC, Strasbourg

    Google Scholar 

  45. Kanis JA, Burlet N, Cooper C, On behalf of the European Society for Clinical, Economic Aspects of Osteoporosis, Osteoarthritis (ESCEO) et al (2008) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 19:399–428

    Article  PubMed  CAS  Google Scholar 

  46. Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936

    Article  PubMed  Google Scholar 

  47. De Laet C, Oden A, Johnell O, Jonsson B, Kanis JA (2005) The impact of the use of multiple risk factors on case finding strategies: a mathematical framework. Osteoporos Int 16:313–318

    Article  PubMed  Google Scholar 

  48. McCloskey E, Johansson H, Oden A, Jalava T, Kanis J (2008) Efficacy of clodronate on fracture risk in women selected by 10-year fracture probability. J Bone Miner Res 22(1):S17

    Google Scholar 

  49. Kanis JA, Johansson H, Oden A, McCloskey EV (2008) Bazedoxifene reduces vertebral and clinical fractures in postmenopausal women at high risk assessed with FRAX®. Bone, in press

  50. Kanis JA, Oden A, Johnell O, Jonsson B, De Laet C, Dawson A (2001) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–427

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to J. A. Kanis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Johansson, H., Kanis, J.A., Oden, A. et al. BMD, clinical risk factors and their combination for hip fracture prevention. Osteoporos Int 20, 1675–1682 (2009). https://doi.org/10.1007/s00198-009-0845-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00198-009-0845-x

Keywords

Navigation