Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA.
HealthPartners Institute, Park Nicollet Clinic and University of Minnesota, Minneapolis, MN, USA.
J Bone Miner Res. 2019 Aug;34(8):1419-1427. doi: 10.1002/jbmr.3717. Epub 2019 May 17.
We examined among women aged ≥40 years the performance of the Fracture Risk Assessment Tool (FRAX) and FRAX-based osteoporosis treatment thresholds under the US National Osteoporosis Foundation (NOF) and UK National Osteoporosis Guideline Group (NOGG) guidelines. We used registry data for all women aged ≥40 years in Manitoba, Canada, with baseline bone mineral density (BMD) testing (n = 54,459). Incident major osteoporotic fracture (MOF), hip fracture, and clinical fracture were assessed from population-based health services data (mean follow-up 10.5 years). Age-stratified hazard ratios (HR) were estimated from Cox regression models. We assessed the sensitivity, specificity, positive predictive value (PPV), number needed to screen (NNS), and number needed to treat (NNT) to prevent a fracture (assuming 20% relative risk reduction on treatment) for osteoporosis treatment thresholds under the NOF and NOGG guidelines. Femoral neck T-score and FRAX (with and without BMD) predicted all fracture outcomes at all ages. There was good calibration in FRAX-predicted versus observed 10-year MOF and hip fracture probability. Overall sensitivity (PPV) for incident MOF was 25.7% (24.0%) for femoral neck T-score ≤ -2.5; 20.3% (26.3%) for FRAX (with BMD)-predicted 10-year MOF risk ≥20% (NOF threshold); 27.3% (22.0%) for FRAX-predicted 10-year MOF risk ≥ age-dependent cut-off (NOGG threshold), 59.4% (19.0%) for the NOF treatment algorithm; and 28.5% (18.4%) for the NOGG treatment algorithm. Sensitivity for identifying incident MOF varied by age, ranging from 0.0% to 26.3% in women 40 to 49 years old and from 49.0% to 93.3% in women aged 80+ years. The gradient of risk for fracture prediction from femoral neck T-score and FRAX (with and without BMD) as continuous measures was strong across the age spectrum. The sensitivity and PPV of the strategies based on dichotomous cut-offs are low, especially among women aged 40 to 49 years (who have lowest incidence rates). Threshold-based approaches should be reassessed, particularly in younger women. © 2019 American Society for Bone and Mineral Research.
我们考察了年龄≥40 岁的女性中，美国国家骨质疏松基金会（NOF）和英国国家骨质疏松症指南组（NOGG）指南下使用骨折风险评估工具（FRAX）和 FRAX 为基础的骨质疏松治疗阈值的表现。我们使用了加拿大马尼托巴省所有年龄≥40 岁的基线骨密度（BMD）检测的登记数据（n=54459）。从基于人群的健康服务数据（平均随访 10.5 年）评估了主要骨质疏松性骨折（MOF）、髋部骨折和临床骨折。年龄分层的风险比（HR）是从 Cox 回归模型中估计的。我们评估了基于 NOF 和 NOGG 指南的骨质疏松治疗阈值的灵敏度、特异性、阳性预测值（PPV）、筛查所需人数（NNS）和治疗所需人数（NNT），以预防骨折（假设治疗后相对风险降低 20%）。股骨颈 T 评分和 FRAX（有和没有 BMD）可以预测所有年龄段的所有骨折结局。FRAX 预测的 10 年 MOF 和髋部骨折概率与实际观察结果有很好的校准。股骨颈 T 评分≤-2.5 时，新发 MOF 的总体灵敏度（PPV）为 25.7%（24.0%）；FRAX（有 BMD）预测的 10 年 MOF 风险≥20%（NOF 阈值）为 20.3%（26.3%）；FRAX 预测的 10 年 MOF 风险≥年龄依赖性截断值（NOGG 阈值）为 27.3%（22.0%），NOF 治疗算法为 59.4%（19.0%）；NOGG 治疗算法为 28.5%（18.4%）。识别新发 MOF 的灵敏度因年龄而异，40 至 49 岁女性为 0.0%至 26.3%，80 岁以上女性为 49.0%至 93.3%。股骨颈 T 评分和 FRAX（有和没有 BMD）作为连续测量值的骨折预测风险梯度在整个年龄范围内都很强。基于二分截断值的策略的灵敏度和 PPV 较低，尤其是在 40 至 49 岁的女性中（她们的发病率最低）。基于阈值的方法应该重新评估，特别是在年轻女性中。 © 2019 美国骨矿研究协会。
