Common Fracture Predictors Often Fall Short

Two commonly used screening tools to detect risk of fracture often fail at that purpose for younger postmenopausal women of every race and ethnicity, according to a new study published this week in JAMA Internal Medicine.

One of the screenings, the US Fracture Risk Assessment Tool (FRAX), proved relatively ineffective at identifying women who developed osteoporosis. The other screening, the Osteoporosis Self-Assessment Tool (OST), excelled at identifying osteoporosis for women in every racial and ethnic group, but also failed at identifying who was most likely to experience a fracture. Osteoporosis experts say that primary care physicians should test for the condition in anyone with any risk factor for it, even if a screening tool suggests doing so is unnecessary.

The United States Preventive Services Task Force (USPSTF) recommends routine testing of bone mineral density in women age 65 years and older to detect risk of developing osteoporosis, which in turn leads to an increased risk for fractures of the hip, spine, shoulder, or forearm. For women aged 50-64, whether bone mineral density accurately reflects who will develop osteoporosis is less clear. In this age range, the USPSTF recommends using either FRAX or OST rather than routine bone mineral density tests.

Dr Carolyn Crandall

“I have the utmost respect for the United States Preventive Services Task Force, which lists both of these as valid screening tools for younger postmenopausal women. What I hope this study does is to inform the next iteration of the screening guidelines,” by maintaining the recommendation to use the OST while not keeping FRAX, said Carolyn J. Crandall, MD, MS, an internal medicine physician and health services researcher at UCLA’s David Geffen School of Medicine, who helped conduct the research.

The US version of FRAX requires identifying someone’s race, height, and weight, then answering whether they have different risk factors for a fracture such as a previous fracture, rheumatoid arthritis, or smoking. The result was thought to indicate a cumulative risk for major fracture over the next 10 years. Patients at significant risk should then undergo a bone density test.

The tool can also incorporate information about bone mineral density, if available, but the FRAX analyses in Crandall’s study did not include that data because the study aimed to test the measure’s predictive ability in the absence of a bone scan.

The OST includes only two variables — weight and age — to calculate risk for osteoporosis, and generally takes seconds to complete. It does not include race. As with FRAX, anyone deemed at significant risk for developing osteoporosis should undergo a bone density test.

“OST is really simple, that makes it very appealing,” Crandall said. “OST could probably be automatically calculated in the electronic medical record.” 

Using data from the Women’s Health Initiative, Crandall and colleagues tracked more than 67,000 women ages 50-64 for 10 years following enrollment in the study to see who experienced a fracture or developed osteoporosis over that decade. The investigators found that neither FRAX nor OST was particularly good at predicting who went on to experience a fracture. 

The accuracy of FRAX at fracture prediction peaked at 65% for Asian women (area under the receiver operating curve [AUC], 0.65; 95% CI, 0.58 – 0.71), and was lowest for Black women (AUC 0.55; 95% CI, 0.52 – 0.59). OST also was most accurate for Asian women, but only up to 62% (AUC 0.62; 95% CI, 0.56 – 0.69), and was again lowest for Black women (AUC 0.53; 95% CI, 0.50 – 0.57)

“It is just very hard to predict fractures in this age group,” Crandall said, noting that more evidence exists about risk for fracture in people older than 65.

The story diverges with predicting risk of osteoporosis in the neck. The OST did this roughly 80% of the time, for all racial groups. That figure proved better than FRAX, without including race.

Treatment Gap

“This evidence supports using OST instead of FRAX” for selecting younger postmenopausal women who should undergo a bone mineral density exam, said E. Michael Lewiecki, MD, director of the New Mexico Clinical Research & Osteoporosis Center in Albuquerque. 

Lewiecki, who was not involved in the new study, noted that the US version of FRAX specifies race due to some clinical evidence that different races have different rates of fracture. But he and Crandall said the validity of race-based algorithms to guide clinical care is a controversial and evolving topic in medicine. Lewiecki said the Canadian version of FRAX, which is similarly applied to a diverse population as in the United States, omits race and works as well as the US version. Future iterations of the instrument in the United States may not include race, Lewiecki said.

“The study is perfectly valid as far as it goes. But the big gorilla in the room is that most patients who need a bone density test are not getting it,” Lewiecki added. Sometimes a patient might break a bone in their wrist, for example, and tell their primary care provider that anyone would have broken that bone because the fall was so hard. Even if that’s true, Lewiecki said, any woman older than 45 who has broken a bone should undergo a bone density test to determine if they have osteoporosis, even if it seems like there are other possible reasons for why the break occurred.

“Most of the clinical practice guidelines that are used by physicians recommend getting a bone density test in postmenopausal women under the age of 65 who have a risk factor for fracture,” Lewiecki said, with a primary risk factor being a prior fracture. Lewiecki said he would rather that anyone who could benefit from a bone density test receive it, rather than someone foregoing a scan based on a screening tool that may be flawed.

“Most patients — men and women — who have osteoporosis are currently not being identified. Even when they are being identified, they are commonly not being treated. And when they are started on treatment, many patients discontinue treatment before they’ve taken it long enough to benefit,” Lewiecki said.

Crandall and Lewiecki report no relevant financial relationships.

JAMA Intern Med. Published online May 22, 2023. Abstract

Marcus A. Banks, MA, is a journalist based in New York City who covers health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.

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