Failure to calibrate for ethnicity in fracture epidemiology would do more harm than good

September 09, 2020

The Fracture Risk Assessment Tool (FRAX®) is a widely used calculation tool that integrates clinical information in a quantitative manner to predict a 10-year probability of major osteoporotic fracture for both women and men in different countries.1

A recent article from the New England Journal of Medicine (NEJM) questioned the use of race or ethnicity in risk assessment algorithms, including FRAX.2 In response to this article, the new editorial 'FRAX and Ethnicity' in the journal Osteoporosis International, authored by experts from the International Osteoporosis Foundation (IOF), sets out key messages and considerations related to the inclusion of race/ethnicity in FRAX algorithms.3

Professor John Kanis, lead author, IOF Honorary President, and Director of the Centre for Metabolic Bone Diseases at Sheffield and Professor at the Catholic University of Australia, stated:

"It is important to understand the reality of fracture epidemiology and risk assessment. Fracture probability varies markedly in different regions of the world due to differences in fracture risk and mortality. In the case of hip fracture there is a ten-fold range in probability which far exceeds the differences in incidence between the sexes within a country. Ethnicity-specific risk often exceeds the differences between the sexes as well. Therefore failure to include ethnicity-specific models where applicable and where data is available, would negate the integrity of fracture risk assessment, resulting in large and avoidable errors in the stratification of risk."

The editorial highlights the following key considerations:

-Fracture ethnicity is not a direct input variable in the FRAX model. FRAX models are calibrated for specific national fracture and mortality rates. In addition to 73 country-specific models, ethnicity-specific models have been calibrated specifically for the most common ethnicities in the USA, South Africa and Singapore. As variations in ethnicity-specific risk often exceed the differences in risk between sexes, failure to calibrate for ethnicity would have adverse consequences greater than failure to calibrate for sex.Professor Cyrus Cooper, IOF President and Professor at the MRC Lifecourse Epidemiology Unit, Universities of Southampton and Oxford, UK, stated:

"The use of ethnicity in FRAX is not the major problem and indeed, FRAX helps to resolve inequalities rather than increase them. The key problem is that, as a disease, osteoporosis suffers from undertreatment worldwide. Fewer than 20% of individuals who fracture receive therapies to reduce the risk of future fracture within the year following a fracture. This crisis of undertreatment in osteoporosis clearly contrasts with the situation following myocardial infarction, in which 75% of patients receive beta blockers to prevent recurrent myocardial infarction."

"Disparities in the osteoporosis treatment gap can be addressed through good clinical judgement. Fracture risk estimates derived from FRAX should not be used uncritically in the management of patients. Used well, FRAX helps direct treatment to those most at need and avoids unnecessary intervention in those at low risk, amongst all segments of society."

1. Fracture Risk Assessment Tool (FRAX)

2. N Engl J Med 2020; 383:874-882. DOI: 10.1056/NEJMms2004740

3. J. A. Kanis, C. Cooper, B. Dawson-Hughes, N. C. Harvey, H. Johansson, M. Lorentzon, E. V. McCloskey, J.-Y. Reginster, R. Rizzoli & on behalf of the International Osteoporosis Foundation. FRAX and ethnicity. Osteoporos Int (2020).

About FRAX

FRAX® is a simple calculation tool that integrates clinical information in a quantitative manner to predict a 10-year probability of major osteoporotic fracture for both women and men in different countries. The tool was developed at the Centre for Metabolic Bone Diseases, University of Sheffield, UK in collaboration with international researchers. It assists primary health-care providers to better target people in need of interventions to reduce fracture risk, thus improving the allocation of health-care resources towards patients most likely to benefit from treatment. The FRAX calculator, freely available for use online, is available for 66 countries and in 34 languages. It is the most widely used risk assessment tool, incorporated into national and regional guidelines worldwide.

About IOF

The International Osteoporosis Foundation (IOF) is the world's largest nongovernmental organization dedicated to the prevention, diagnosis and treatment of osteoporosis and related musculoskeletal diseases. IOF members, including committees of scientific researchers as well as 260 patient, medical and research societies, work together to make fracture prevention and healthy mobility a worldwide heath care priority. @iofbonehealth

International Osteoporosis Foundation

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