The American Society for Bone and Mineral Research says more data is needed on bone density and osteoporosis or fracture risk in a racially and ethnically representative cohort of patients; additionally, more information is needed on how patients’ social determinants of health impact fracture risk.
Clinicians should consider discussing with Asian, Black, and Hispanic patients that this calculator may not identify their risk of fracture as well as it does in White patients; that their risk of fracture may be higher than what is identified in the calculator; and that more research is needed.
FOR IMMEDIATE RELEASE
April 8, 2024 —The U.S. Fracture Risk Assessment Tool (US-FRAX®), which doctors rely on to determine who is at risk for breaking a bone (fracture) and who would benefit from anti-osteoporosis treatment, should include much broader data, according to the American Society for Bone and Mineral Research (ASBMR) Task Force on Clinical Algorithms for Fracture Risk. The Task Force found that US-FRAX® relies on predictive tools populated primarily with data from older White women, which may obscure osteoporosis risk in patients from other racial or ethnic groups.
“In many areas of medicine, using race and ethnicity data in clinical algorithms can contribute to health inequities,” said Task Force Co-Chair Sherri-Ann Burnett-Bowie, MD, MPH, Physician, Massachusetts General Hospital and Associate Professor of Medicine, Harvard Medical School. “The Task Force found critical shortcomings in the performance of US-FRAX® and we need to ensure that all women at risk for fracture receive the proper care. It is tragic when preventable problems fall through the cracks.”
In its report, the Task Force noted that women from all racial and ethnic groups experience more incidents of fractures than incidents of invasive breast cancer, myocardial infarction, and stroke combined. Further, Black women are more likely to die or become disabled after hip fracture, yet women from racial and ethnic underrepresented groups are less likely to be screened with DXA or treated for osteoporosis. A standardized collection of data on race and ethnicity, and on social determinants of health, is needed to better understand fracture risk and bone density. Clinicians should consider providing Asian, Black, or Hispanic patients with a range regarding their risk for fracture, as opposed to the specific percentage generated by US-FRAX®.
“Algorithms are only as good as the data that feeds them, and the Task Force’s work has pointed a spotlight at where we need more data,” said Task Force Co-Chair Jane A. Cauley, DrPH, Distinguished Professor Department of Epidemiology, School of Public Health, University of Pittsburgh (Pennsylvania). “If US-FRAX® is working with shortcomings in race and ethnicity data, then all underrepresented groups, regardless of gender, will be shortchanged. We can fix this, though, with comprehensive data collection efforts.”
The Task Force urged that doctors follow the United States Preventive Services Task Force (USPSTF) recommendations for universal screening of all women ages 65 and older, and for women who are 50 to 64 and have certain risk factors.
Approximately 54 million people in the U.S. have low bone density or osteoporosis. Roughly half of all women and up to one in four men over the age of 50 will break a bone due to osteoporosis. Screening people (using dual-energy X-ray absorptiometry, or DXA scans) before they break bones helps avoid these incidents, which often bring added serious medical complications for older patients, including increased mortality.
Previous research found that Black women are six times less likely to be referred for DXA screening than White women and that, among women who experience fragility hip fracture, Black and Hispanic women are less likely to have received DXA screening before and after their hip fractures.
The University of Minnesota Evidence-based Practice Core assisted the Task Force in conducting a systematic review of US-FRAX®’s performance in predicting fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women’s Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were evaluated.
In its report, the Task Force noted that women from all racial and ethnic groups experience more incidents of fractures than incidents of invasive breast cancer, myocardial infarction, and stroke combined. Further, Black women are more likely to die or become disabled after hip fracture, yet women from racial and ethnic underrepresented groups are less likely to be screened with DXA or treated for osteoporosis.
According to the Task Force report, the recommendation to create non-race and non-ethnicity adjusted fracture risk calculations should not be equated as downplaying the significance of race and ethnicity. Instead, the report concludes that race and ethnicity reflect a “complex relationship comprised of socioeconomic, political, geographic, and environmental factors” that affect the health and wellbeing of people in many ways—including bone fractures.
“The bottom line is that fragility fractures are common and can be prevented. All individuals at risk — particularly women ages 65 and older— should get a bone density scan,” said ASBMR President Laura Calvi, MD. “Treatments are available to slow bone loss, and preventive measures can be taken to reduce risk, but all patients need to know their individual risks.”
# # #
The American Society for Bone and Mineral Research (ASBMR) is the leading professional, scientific and medical society established to bring together clinical and experimental scientists involved in the study of bone, mineral and musculoskeletal research. ASBMR encourages and promotes the study of this expanding field through annual scientific meetings, peer-reviewed journals (including the Journal of Bone and Mineral Research and JBMR® Plus), the Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, advocacy and interaction with government agencies and related societies. To learn more about upcoming meetings and publications, please visit www.asbmr.org.