Racial disparities, FRAX, and the care of patients with osteoporosis

Lewiecki, E. Michael; Wright, Nicole C.; Singer, Andrea

doi:10.1007/s00198-020-05655-y

Cited by 21 publications

(14 citation statements)

References 26 publications

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“…Among these populations, data indicates differences in fracture risk even at the same BMD. Although many limitations to this methodology have been described, it provides fracture risk stratification that can direct treatment to high-risk individuals most likely to benefit and avoid treatment of those at low risk [ 80 ]. Other countries, including some with considerable ethnic diversity, have used an alternative approach, with a single version of FRAX regardless of ethnicity.…”

Section: Diagnostic Considerationsmentioning

confidence: 99%

The clinician’s guide to prevention and treatment of osteoporosis

et al. 2022

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Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2-to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF)formerly the National Osteoporosis Foundationfirst published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores * M. S. LeBoff

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Section: Diagnostic Considerationsmentioning

confidence: 99%

The clinician’s guide to prevention and treatment of osteoporosis

et al. 2022

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“…( 6 ) In the United States, race/ethnicity‐specific probabilities are offered for white, Hispanic, black, and Asian adults, based on data demonstrating differing fracture rates between these groups despite similar BMD. ( 7 ) The FRAX algorithm returns lower fracture risk estimates for black, Hispanic, and Asian women, leading to concerns for the potential to delay osteoporosis therapy. ( 3 ) But given differences in the incidence atypical femur fractures, a rare complication of long‐term bisphosphonate use, between racial and ethnic groups, lower risk estimates might appropriately prevent overtreatment.…”

Section: Figurementioning

confidence: 99%

“…( 10 ) Providers will need guidance on how to account for country of origin and time in the United States in determining fracture risk. ( 7 )…”

Section: Figurementioning

confidence: 99%

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Considering Race and Ethnicity in the Management of Bone Health

2020

Journal of Bone and Mineral Research

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Considering Race and Ethnicity in the Management of Bone Health C ommunities of color have borne a disproportionate burden of infections, hospitalizations, and deaths throughout the global coronavirus disease 2019 (COVID-19) pandemic. (1) Along with a rising tide of anti-Asian xenophobia and social injustice protests, events of the past year and a half have triggered a reckoning on racism in the United States. The field of medicine is facing up to its own unfortunate history of racism, prompting hospitals and organizations to examine their own policies and practices for evidence of bias. (2) In this context the use of race and ethnicity in clinical decisionmaking is under scrutiny. (3) Health outcomes are influenced by myriad factors including genetics, health behaviors, socioeconomic status, and access to health care. Although the interactions of these factors are complex, it is clear that social determinants of health, the conditions in the environments in which individuals live, learn, and work, are important drivers of health outcomes. (4) The inclusion of race and ethnicity in clinical algorithms is beset by several challenges. Although a common implicit assumption is that race is a proxy for genetic or biological differences, race is a social construct and racial differences in health outcomes may instead reflect the effects of systemic racism. In addition, the use of broad racial and ethnic categories as standardized by the Office of Management and Budget aggregates heterogeneous subgroups and can mask substantial disparities within these communities.What is the role of race and ethnicity in the management of bone health? A commonly used clinical calculator, the Fracture Risk Assessment Tool (FRAX; https://www.sheffield.ac.uk/FRAX/) provides the 10-year probabilities of hip fracture or major osteoporotic fracture based on clinical risk factors and optional femoral neck bone mineral density (BMD). (5) Using algorithms developed from population-based cohorts in Europe, North America, Asia, and Australia, FRAX provides 73 country-specific models plus ethnicity-specific models in the United States, South Africa, and Singapore. (6) In the United States, race/ethnicity-specific probabilities are offered for white, Hispanic, black, and Asian adults, based on data demonstrating differing fracture rates between these groups despite similar BMD. (7) The FRAX algorithm returns lower fracture risk estimates for black, Hispanic, and Asian women, leading to concerns for the potential to delay osteoporosis therapy. (3) But given differences in the incidence atypical femur fractures, a rare complication of long-term bisphosphonate use, between racial and ethnic groups, lower risk estimates might appropriately prevent overtreatment. (8)

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“…[5][6][7] To account for this lower background risk, calibration factors (0.50 for Asian women, 0.64 for Asian men) 8 are applied to the US FRAX fracture risk calculator when calculating 10-year hip fracture probability for older US Asian adults. 9,10 Subsequent studies using national 11 and California [12][13][14] data similarly identify lower hip fracture incidence among Asian compared to NHW populations. Whether hip fracture rates vary among Asian/PI subgroups is less clear and understanding the variation in population fracture rates could be important for individualized fracture prevention care within this diverse population.…”

Section: Introductionmentioning

confidence: 99%

Sex‐ and ethnic‐specific patterns in the incidence of hip fracture among older US Asian and non‐Hispanic White adults

Chandra

Lee

et al. 2023

J American Geriatrics Society

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Background Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non‐Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. Methods Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000–2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age‐adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log‐Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. Results Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28–1.40) and 2.97 (2.94–3.01) per 1000 person‐years, respectively, with IRR 0.45 (0.43–0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58–0.67) and 1.81 (1.78–1.84) per 1000 person‐years, respectively, with IRR 0.34 (0.32–0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75–0.96]) had lower, and Japanese (IRR 1.36 [1.20–1.54]) and South Asian (IRR 1.36 [1.07–1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21–2.14]) compared to Chinese men. Conclusion Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup.

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Racial disparities, FRAX, and the care of patients with osteoporosis

Cited by 21 publications

References 26 publications

The clinician’s guide to prevention and treatment of osteoporosis

The clinician’s guide to prevention and treatment of osteoporosis

Considering Race and Ethnicity in the Management of Bone Health

Sex‐ and ethnic‐specific patterns in the incidence of hip fracture among older US Asian and non‐Hispanic White adults

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