Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
Division of General Internal Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.
JAMA Netw Open. 2020 Jan 3;3(1):e1918954. doi: 10.1001/jamanetworkopen.2019.18954.
Fracture risk scores are used to identify individuals at high risk of major osteoporotic fracture or hip fracture for antiosteoporosis treatment. For those not meeting treatment thresholds at baseline, the optimal interval for reassessing fracture risk is uncertain.
To examine reassessment intervals for transition from low to high fracture risk under guidelines-defined treatment thresholds.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included persons aged 50 years or older with fracture risk below treatment thresholds at baseline who had fracture risk reassessed at least 1 year later. Data were obtained from a population-based bone mineral density registry (baseline assessment during 1996-2015; reassessment to 2016) in the Province of Manitoba, Canada. Primary analysis was performed from May to June 2019. Analysis for the revision was performed in October 2019.
The primary outcome was time to transition from low (below the treatment threshold) to high fracture risk (treatment-qualifying risk score using osteoporosis clinical practice guidelines strategies for Canada, the United States, and the United Kingdom).
The study population consisted of 10 564 individuals (94.1% women; mean [SD] age at baseline, 63.2 [8.2] years). At the time of reassessment (a mean [SD] interval of 5.2 [2.9] years between initial and subsequent fracture risk assessment), 690 (6.6%) had reached the fixed major osteoporotic fracture treatment threshold of 20%, 1546 (16.2%) had reached the fixed hip treatment threshold of 3%, and 932 (9.4%) had reached the age-dependent major osteoporotic fracture treatment threshold. Among those below 25% of the treatment threshold at baseline for each guideline, few (0%-3.0%) reached guidelines-defined high fracture risk at follow-up. In contrast, among those at the upper end of the scale for each guideline (75%-99% of the treatment threshold at baseline), 30.6% to 74.4% reached guidelines-defined high fracture risk. An increased number of clinical risk factors was associated with increased likelihood of reaching guidelines-defined high fracture risk (range for 3 guidelines, 17.1%-28.2%) compared with unchanged or decreased clinical risk factors (range for 3 guidelines, 3.3%-12.8%) (P < .001). Estimated time for 10% of the population to reach treatment-qualifying high fracture risk ranged from fewer than 3 years to more than 15 years.
The findings suggest that baseline fracture risk (as a fraction of the treatment threshold) and change in clinical risk factors can identify individuals with low and high probability of guidelines-defined high fracture risk during follow-up, thereby potentially helping to inform the reassessment interval.
骨折风险评分用于识别有发生重大骨质疏松性骨折或髋部骨折风险的高危人群，以便进行抗骨质疏松治疗。对于基线时未达到治疗阈值的患者，重新评估骨折风险的最佳间隔时间尚不确定。
根据指南定义的治疗阈值，研究从低风险到高风险的过渡时的重新评估间隔。
设计、地点和参与者：本回顾性队列研究纳入了基线时骨折风险低于治疗阈值且至少 1 年后再次进行骨折风险评估的 50 岁及以上人群。数据来自加拿大马尼托巴省的一个基于人群的骨密度登记处（1996 年至 2015 年基线评估；至 2016 年重新评估）。主要分析于 2019 年 5 月至 6 月进行。2019 年 10 月对修订进行了分析。
主要结局为从低风险（低于治疗阈值）到高风险（使用加拿大、美国和英国骨质疏松症临床实践指南策略的治疗合格风险评分）的时间。
研究人群由 10564 人组成（94.1%为女性；基线时平均[标准差]年龄为 63.2[8.2]岁）。在重新评估时（首次和后续骨折风险评估之间的平均[标准差]间隔为 5.2[2.9]年），690 人（6.6%）达到了 20%的固定重大骨质疏松性骨折治疗阈值，1546 人（16.2%）达到了 3%的固定髋部治疗阈值，932 人（9.4%）达到了年龄依赖性重大骨质疏松性骨折治疗阈值。在每个指南中，基线时骨折风险低于治疗阈值的 25%的患者中，很少（0%-3.0%）在随访中达到指南定义的高骨折风险。相比之下，在每个指南中处于量表上限的患者（基线时治疗阈值的 75%-99%）中，30.6%至 74.4%达到了指南定义的高骨折风险。与临床风险因素不变或减少相比（3 项指南的范围为 3.3%-12.8%），临床风险因素增加与达到指南定义的高骨折风险的可能性增加相关（3 项指南的范围为 17.1%-28.2%）（P < 0.001）。预计有 10%的人群达到治疗合格的高骨折风险所需的时间从不到 3 年到超过 15 年不等。
研究结果表明，基线骨折风险（作为治疗阈值的分数）和临床风险因素的变化可以确定在随访期间具有低概率和高概率达到指南定义的高骨折风险的个体，从而有助于确定重新评估间隔。
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