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A systematic review of intervention thresholds based on FRAX

A systematic review of intervention thresholds based on FRAX
A systematic review of intervention thresholds based on FRAX
In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation. We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n=58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n=22). Two guidelines have adopted both age-dependent and fixed thresholds. Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilized a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the US. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (US, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the ‘fracture threshold’) should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (? 70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity. The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds need to be country-specific.
1862-3522
1-98
Kanis, J.A.
8da04a36-08a7-4310-b4b4-a6d432439587
Harvey, N.C.
ce487fb4-d360-4aac-9d17-9466d6cba145
Cooper, C.
e05f5612-b493-4273-9b71-9e0ce32bdad6
Johansson, H.
05aa5476-bcb9-4b97-905e-00f1dfd9d691
Oden, A.
c018cdda-62cd-44a0-be3a-227484a568bb
McCloskey, E.V.
38518227-db8f-4a53-88a6-462f469151de
Kanis, J.A.
8da04a36-08a7-4310-b4b4-a6d432439587
Harvey, N.C.
ce487fb4-d360-4aac-9d17-9466d6cba145
Cooper, C.
e05f5612-b493-4273-9b71-9e0ce32bdad6
Johansson, H.
05aa5476-bcb9-4b97-905e-00f1dfd9d691
Oden, A.
c018cdda-62cd-44a0-be3a-227484a568bb
McCloskey, E.V.
38518227-db8f-4a53-88a6-462f469151de

Kanis, J.A., Harvey, N.C., Cooper, C., Johansson, H., Oden, A. and McCloskey, E.V. (2016) A systematic review of intervention thresholds based on FRAX. Archives of Osteoporosis, 1-98. (In Press)

Record type: Article

Abstract

In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation. We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n=58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n=22). Two guidelines have adopted both age-dependent and fixed thresholds. Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilized a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the US. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (US, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the ‘fracture threshold’) should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (? 70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity. The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds need to be country-specific.

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Accepted/In Press date: 20 June 2016
Organisations: Faculty of Medicine

Identifiers

Local EPrints ID: 397860
URI: http://eprints.soton.ac.uk/id/eprint/397860
ISSN: 1862-3522
PURE UUID: fc3615a3-a0d0-4fb6-bdef-471fac7d2a6d
ORCID for N.C. Harvey: ORCID iD orcid.org/0000-0002-8194-2512
ORCID for C. Cooper: ORCID iD orcid.org/0000-0003-3510-0709

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Date deposited: 08 Jul 2016 09:26
Last modified: 18 Feb 2021 17:02

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Contributors

Author: J.A. Kanis
Author: N.C. Harvey ORCID iD
Author: C. Cooper ORCID iD
Author: H. Johansson
Author: A. Oden
Author: E.V. McCloskey

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