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Fracture prediction from FRAX for Canadian ethnic groups: a registry-based cohort study

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Abstract

Summary

We identified large between-ethnicity calibration differences in the Canadian FRAX® tool which substantially overestimated the major osteoporotic fracture (MOF) risk in Asian women and Black women, and overestimated hip fracture risk in Asian women.

Purpose

FRAX® is calibrated using population-specific fracture and mortality data. The need for FRAX to accommodate ethnic diversity within a country is uncertain. We addressed this question using the population-based Manitoba Bone Mineral Density (BMD) Program registry and self-reported ethnicity.

Methods

The study population was women aged 40 years or older with baseline FRAX assessments (Canadian and other ethnic calculators), fracture outcomes, and self-reported ethnicity (White N = 68,907 [referent], Asian N = 1910, Black N = 356). Adjusted hazard ratios (HR) with 95% confidence intervals (CI) for time to MOF and hip fracture were estimated. We examined candidate variables from DXA that might contribute to ethnic differences including skeletal size, hip axis length (HAL), trabecular bone score (TBS), and estimated body composition.

Results

Adjusted for baseline risk using the Canadian FRAX tool with BMD, Asian women compared with White women were at much lower risk for MOF (HR 0.46, 95% CI 0.35–0.59) and hip fracture (0.16, 95% CI 0.08–0.34). Black women were also at lower MOF risk (HR 0.58, 95% CI 0.32–1.00); there were no hip fractures. The US ethnic-specific FRAX calculators accounted for most of the between-ethnicity differences in MOF risk (86% for Asian, 92% for Black) but only partially accounted for lower hip fracture risk in Asian women (40%). The candidate variables explained only a minority of the effect of ethnicity. Gradient of risk in analyses was similar (p-interactions ethnicity*FRAX non-significant).

Conclusions

We identified significant ethnic differences in performance of the Canadian FRAX tool with fracture probability overestimated among Asian and Black women. The US ethnic calculators helped to address this discrepancy for MOF risk assessment, but not for hip fracture risk among Asian women.

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Acknowledgments

The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository (HIPC 2016/2017-29). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Seniors and Active Living, or other data providers is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.

Funding

No funding support was received for this research. SNM is chercheur-boursier des Fonds de Recherche du Québec en Santé. LML is supported by a Tier I Canada Research Chair.

Author information

Authors and Affiliations

  1. University of Manitoba, Winnipeg, Canada

    W. D. Leslie & L.M. Lix

  2. McGill University, Montreal, Canada

    S.N. Morin

  3. Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK

    E.V. McCloskey, H. Johansson & J.A. Kanis

  4. Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Fitzroy, VIC, 3065, Australia

    H. Johansson & J.A. Kanis

  5. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

    N.C. Harvey

  6. NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK

    N.C. Harvey

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  1. W. D. Leslie
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  4. E.V. McCloskey
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Corresponding author

Correspondence to W. D. Leslie.

Ethics declarations

Conflicts of interest

Suzanne Morin: Nothing to declare for the context of this paper, but has received research grants, Amgen.

Eugene McCloskey: Nothing to declare for the context of this paper, but numerous ad hoc consultancies/speaking honoraria and/or research funding from Amgen, Bayer, General Electric, GSK, Hologic, Lilly, Merck Research Labs, Novartis, Novo Nordisk, Nycomed, Ono, Pfizer, ProStrakan, Roche, Sanofi-Aventis, Servier, Tethys, UBS, and Warner-Chilcott.

Nicholas Harvey: Nothing to declare for the context of this paper, but has received consultancy/lecture fees/honoraria/grant funding from Alliance for Better Bone Health, Amgen, UCB, MSD, Eli Lilly, Kyowa Kirin, Radius Health, Servier, Shire, Consilient Healthcare, and Internis Pharma.

John A. Kanis: Grants from Amgen, Lilly, Radius Health, and non-financial support from Medimaps outside the submitted work.

William Leslie, Lisa Lix, Helena Johansson: No conflicts of interest.

Ethical approval

The study was approved by the Health Research Ethics Board for the University of Manitoba.

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Leslie, W.D., Morin, S., Lix, L. et al. Fracture prediction from FRAX for Canadian ethnic groups: a registry-based cohort study. Osteoporos Int 32, 113–122 (2021). https://doi.org/10.1007/s00198-020-05594-8

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