Independent External Validation of <scp>FRAX</scp> and Garvan Fracture Risk Calculators: A Sub‐Study of the <scp>FRISBEE</scp> Cohort

Baleanu, Felicia; Iconaru, Laura; Charles, Adrian; Kinnard, V.; Fils, Jean‐François; Moreau, Michel; Karmali, Rafik; Surquin, Murielle; Benoit, Florence; Mugisha, Aude; Paesmans, Marianne; Laurent, Michaël; Bergmann, Pierre; Body, Jean-Jacques

doi:10.1002/jbm4.10532

Cited by 13 publications

(6 citation statements)

References 27 publications

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“…Berry et al compared the results of traditional survival analysis (Kaplan-Meier or Cox proportional hazards regression) with a competing risk approach to estimate the risk of a second hip fracture and concluded indeed that in older populations (median age at first fracture was 81 years and ranged from 45 to 99 years) survival analysis overestimated the 5-year risk of second hip fracture by 37% and the 10-year risk by 75% when compared with competing risk estimates ( 31 ). Our previous studies of existing prediction models applied to patients included in the FRISBEE cohort ( 14 , 32 ) showed important calibration problems in part linked, for MOFs, to the discordance between MOFs/hip incident ratios and those used for the Belgium FRAX construction ( 32 ).…”

Section: Discussionmentioning

confidence: 99%

“…FRAX and Garvan have been internationally validated, but their external calibration was not always found to be optimal, notably because the distribution of risk factors and of fracture types vary across different populations ( 12-15 ). In terms of predictive accuracy, these tools have been reported to have area under the receiver operating curve (AUROC) values ranging between 0.6 and 0.8, which is considered to be acceptable to good ( 14 , 15 ). This suboptimal performance is inherent to the stochastic aspect of external factors causing fractures (eg, low trauma, physical strain) but could also result in part from the fact that some important risk factors were not included in the risk estimation, such as falls in the FRAX tool.…”

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confidence: 99%

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Fragility Fractures in Postmenopausal Women: Development of 5-Year Prediction Models Using the FRISBEE Study

Baleanu

Moreau

Charles

et al. 2022

The Journal of Clinical Endocrinology &Amp; Metabolism

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Context Individualized fracture risk may help to select patients requiring a pharmacological treatment for osteoporosis. FRAX and the Garvan fracture risk calculators are the most used tools, though their external validation has shown significant differences in their risk prediction ability. Objective and Methods Using data from the FRISBEE study, a cohort of 3560 post-menopausal women aged 60-85 years, we aimed to construct original 5-year fracture risk prediction models using validated clinical risk factors (CRFs). Three models of competing risk analysis were developed to predict major osteoporotic fractures (MOFs), all fractures and central fractures (femoral neck, shoulder, clinical spine, pelvis, ribs, scapula, clavicle, sternum). Results Age, a history of fracture and hip or spine BMD were predictors common to the three models. Excessive alcohol intake, and the presence of comorbidities were specific additional CRFs for MOFs, a history of fall for all fractures and rheumatoid arthritis for central fractures. Our models predicted the fracture probability at 5-years with an acceptable accuracy (Brier scores ≤ 0.1) and had a good discrimination power (area under the receiver operating curve of 0.73 for MOFs and 0.72 for central fractures) when internally validated by bootstrap. Three simple nomograms, integrating significant CRFs and the mortality risk were constructed for different fracture sites. In conclusion, we derived three models predicting fractures with an acceptable accuracy, particularly for MOFs and central fractures. The models are based on a limited number of CRFs and we constructed nomograms for use in clinical practice.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Fragility Fractures in Postmenopausal Women: Development of 5-Year Prediction Models Using the FRISBEE Study

Baleanu

Moreau

Charles

et al. 2022

The Journal of Clinical Endocrinology &Amp; Metabolism

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“…Still, clinical judgement should assume even higher risk for very high glucocorticoid doses, even when given for < 3 months duration ( 109 ). Of note, national FRAX ® models may require recalibration, as recently shown by a large Belgian population-based study ( 110 , 111 ).…”

Section: Resultsmentioning

confidence: 99%

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

et al. 2022

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Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.

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“…The three models have a moderate discriminative value, with AUCs between 0.6 to 0.8, similar to those reported for FRAX and Garvan, used to evaluate the fracture risk at 5 or 10 years. ( 28,38,39 ) The model for central imminent fracture had a greater predictive power than the models for MOFs or all fractures.…”

Section: Discussionmentioning

confidence: 96%

“…The estimated 2‐year risks of our imminent fracture models for MOFs and all fractures were compared by concordance analysis with the 10‐ and 5‐years risks derived from FRAX (Belgium) and Garvan models (https://www.garvan.org.au/bone-fracture-risk/), respectively, using baseline data with BMD. Concerning falls, to overcome some limitations when dealing with missing falls history data in the computation of the Garvan score, we used the following falls classification: instead of 0, 1, and 2 falls per year, we used 0, 1.5, and 4.2 for those with no falls, 1 to 3 falls, and 4 or more falls per year, respectively (similar to counting in Baleanu and colleagues ( 28 ) ). However, for our imminent all fractures model, we used falls as a dichotomous variable (yes/no) and we did not take into account their number.…”

Section: Methodsmentioning

confidence: 99%

Prediction of an Imminent Fracture After an Index Fracture – Models Derived From the Frisbee Cohort

Iconaru

Charles

Baleanu

et al. 2020

Journal of Bone and Mineral Research

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Patients who sustain a fracture are at greatest risk of recurrent fracture during the next 2 years. We propose three models to identify subjects most at risk of an imminent fracture, according to fracture site (any fracture, major osteoporotic fracture [MOF] or central). They were constructed using data of the prospective Frisbee cohort, which includes 3560 postmenopausal women aged 60 to 85 years who were followed for at least 5 years. A total of 881 subjects had a first incident validated fragility fracture before December 2018. Among these, we validated 130 imminent fractures occurring within the next 2 years; 79 were MOFs, and 88 were central fractures. Clinical risk factors were re-evaluated at the time of the index fracture. Fine and Gray proportional hazard models were derived separately for each group of fractures. The following risk factors were significantly associated with the risk of any imminent fracture: total hip bone mineral density (BMD) (p < 0.001), a fall history (p < 0.001), and comorbidities (p = 0.03). Age (p = 0.05 and p = 0.03, respectively) and a central fracture as the index fracture (p = 0.04 and p = 0.005, respectively) were additional predictors of MOFs and central fractures. The three prediction models are presented as nomograms. The calibration curves and the Brier scores based on bootstrap resampling showed calibration scores of 0.089 for MOF, 0.094 for central fractures, and 0.132 for any fractures. The predictive accuracy of the models expressed as area under the receiver operating characteristic (AUROC) curve (AUC) were 0.74 for central fractures, 0.72 for MOFs, and 0.66 for all fractures, respectively. These AUCs compare well with those of FRAX and Garvan to predict the 5-or 10-year fracture probability. In summary, five predictors (BMD, age, comorbidities, falls, and central fracture as the incident fracture) allow the calculation with a reasonable accuracy of the imminent risk of fracture at different sites (MOF, central fracture, and any fracture) after a recent sentinel fracture.

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Independent External Validation of FRAX and Garvan Fracture Risk Calculators: A Sub‐Study of the FRISBEE Cohort

Abstract: This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as

Cited by 13 publications

References 27 publications

Fragility Fractures in Postmenopausal Women: Development of 5-Year Prediction Models Using the FRISBEE Study

Fragility Fractures in Postmenopausal Women: Development of 5-Year Prediction Models Using the FRISBEE Study

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

Prediction of an Imminent Fracture After an Index Fracture – Models Derived From the Frisbee Cohort

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