1. Femoral neck bone mineral density (FNBMD) alone discriminated 5-year hip fracture risk at least as well as FRAX and Garvan tools incorporating FNBMD.

2. Fracture Risk Assessment Tool (FRAX) modestly underpredicted observed hip fracture probability in intermediate-risk individuals and Garvan greatly overpredicted observed hip fracture probability in high-risk individuals.

Evidence Rating Level: 2 (Good)

Adults 80 years and older make up 70% of hip fractures in the United States. Tools to estimate absolute risk of hip fracture include the Fracture Risk Assessment Tool (FRAX) and Garvan fracture risk calculator. However, it is unclear how well these tools perform in predicting hip fracture in late life when competing mortality risks may be prevalent. Using data from 3 prospective cohort studies, this study compared the performance of the FRAX, Garvan Fracture Risk Calculator, and femoral neck bone mineral density (FNBMD) alone in 5-year hip fracture prediction in adults 80 and over. Among 8890 participants (mean age = 82.6 + 2.7 years; women = 4906 (55.2%)), 321 women (6.5%) and 123 men (3.1%) experienced a hip fracture; 818 women (16.7%) and 921 men (23.1%) died before hip fracture during the 5-year follow-up. Among women, area under receiver operating characteristic curve (AUC) was 0.69 (95% CI, 0.67-0.72) for FRAX, 0.69 (95% CI, 0.66-0.72) for Garvan, and 0.72 (95% CI, 0.69-0.75) for FNBMD alone. FNBMD alone was superior to both FRAX (P = .01) and Garvan (P = .01) in hip fracture discrimination in women. Among men, AUC was 0.71 (95% CI, 0.66-0.75) for FRAX, 0.76 (95% CI, 0.72-0.81) for Garvan, and 0.77 (95% CI, 0.72-0.81) for FNBMD alone. Both Garvan and FNBMD alone were superior to FRAX (P < .001) in hip fracture discrimination in men. Among both sexes, Garvan greatly overestimated 5-year hip fracture probability among individuals in upper quintiles of predicted risk, while FRAX modestly underestimated risk among those in intermediate quintiles of predicted risk. Overall, until improved risk prediction tools are available, study results suggest clinicians should prioritize consideration of hip BMD, life expectancy, and patient preferences when deciding on drug treatment initiation for hip fracture prevention in adults 80 years and older.

Click to read the study in JAMA Network Open

Image: PD

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