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    Original Investigation
    Diabetes and Endocrinology
    January 10, 2020

    Reassessment Intervals for Transition From Low to High Fracture Risk Among Adults Older Than 50 Years

    Author Affiliations
    • 1Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
    • 2Division of General Internal Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
    • 3Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
    • 4Section of Nuclear Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
    • 5Harvard Medical School, Boston, Massachusetts
    • 6Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
    • 7Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
    • 8MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
    • 9NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
    JAMA Netw Open. 2020;3(1):e1918954. doi:10.1001/jamanetworkopen.2019.18954
    Key Points español 中文 (chinese)

    Question  What is the optimal reassessment interval to detect high fracture risk for those who do not meet the treatment threshold at baseline?

    Findings  In this cohort study of 10 564 individuals, after a mean interval of 5.2 years between initial and subsequent fracture risk assessment, a range of 6.6% to 16.2% of the population reached high fracture risk according to 3 guidelines-defined treatment thresholds. Simple criteria, such as baseline fracture risk as a fraction of the treatment threshold and change in number of clinical risk factors, were associated with transition to high fracture risk.

    Meaning  The findings suggest that baseline fracture risk and change in clinical risk factors can identify individuals with low and high probability of achieving a guidelines-defined treatment threshold and potentially help optimize the reassessment interval in routine clinical practice.


    Importance  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.

    Objective  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.

    Main Outcomes and Measures  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).

    Results  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.

    Conclusions and Relevance  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.