General comorbidity indicators contribute to fracture risk independent of FRAX: registry-based cohort study

Abstract

CONTEXT: FRAX® estimates 10-year fracture probability from osteoporosis-specific risk factors. Medical comorbidity indicators are associated with fracture risk but whether these are independent from those in FRAX is uncertain.

OBJECTIVE: We hypothesized Johns Hopkins Aggregated Diagnosis Groups (ADG®) scores or recent hospitalization number may be independently associated with increased risk for fractures.

DESIGN: Retrospective cohort study.

SETTING: Manitoba BMD Registry (1996-2016).

PARTICIPANTS: Women and men age 40 with at least 3 years prior health care data.

EXPOSURES: Using linked administrative databases, ADG® scores were constructed along with number of hospitalizations for each individual.

MAIN MEASURES: Incident Major Osteoporotic Fracture and Hip Fracture was ascertained during average follow up of 9 years; Cox regression analysis determined the association between increasing ADG® score or number of hospitalizations and fractures.

RESULTS: Separately, hospitalizations and ADG® score independently increased the hazard ratio for fracture at all levels of comorbidity (hazard range 1.2-1.8, all p < 0.05), irrespective of adjustment for FRAX, BMD and competing mortality. Taken together, there was still a higher than predicted rate of fracture at all levels of increased comorbidity, independent of FRAX and BMD but attenuated by competing mortality. Using an intervention threshold of major fracture risk > 20%, application of the comorbidity hazard ratio multiplier to the patient population FRAX scores would increase the number of treatment candidates from 8.6% to 14.4%.

CONCLUSIONS: Both complex and simple measures of medical comorbidity may be used to modify FRAX-based risk estimates to capture the increased fracture risk associated with multiple comorbid conditions in older patients.

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