title: Diagnostic accuracy of FRAX in predicting the 10-year risk of osteoporotic fractures using the USA treatment thresholds: A systematic review and meta-analysis.
abstract: The aim of this study was to conduct a systematic review and meta-analysis on the performance of the WHO's Fracture Risk Assessment (FRAX) instrument in predicting 10-year risk of Major Osteoporotic Fractures (MOF) and Hip Fractures (HF), using the USA treatment thresholds, in populations other than their derivation cohorts.
  
  
  
  EMBASE and MEDLINE database were searched with search engine PubMed and OVID as well as Google Scholar for the English-language literature from July 2008 to July 2016. Limiting our search to articles that analyzed only MOF and/or HF as an outcome, 7 longitudinal cohorts from 5 countries (USA, Poland, France, Canada, New Zealand) were identified and included in the meta-analysis. SAS NLMIXED procedure (SAS v 9.3) was applied to fit the Hierarchical Summary Receiver Operating Characteristics (HSROC) model for meta-analysis. Forest plot and HSROC plot was generated by Review Manager (RevMan v 5.3).
  
  
  
  Seven studies (n=57,027) were analyzed to assess diagnostic accuracy of FRAX in predicting MOF, using 20% as the 10-year fracture risk threshold for intervention, the mean sensitivity, specificity, and diagnostic odds ratio (DOR) along with their 95% confidence intervals (CI) were 10.25% (3.76%-25.06%), 97.02% (91.17%-99.03%) and 3.71 (2.73-5.05), respectively. For HF prediction, using 3% as the 10-year fracture risk threshold, six studies (n=50,944) were analyzed. The mean sensitivity, specificity, and DOR along with their 95% confidence intervals (CI) were 45.70% (24.88%-68.13%), 84.70% (76.41%-90.44%) and 4.66 (2.39-9.08), respectively.
  
  
  
  Overall, using the 10year intervention thresholds of 20% for MOF and 3% for HF, FRAX performed better in identifying patients who will not have a MOF or HF within 10years, than those who will. A substantial number of patients who developed fractures, especially MOF within 10years of follow up, were missed by the baseline FRAX assessment.
authors.affiliation: Department of ObGyn, The Reading Hospital, Reading, PA, United States; Department of ObGyn, Sidney Kimmel Medical College of Thomas Jefferson University, United States. Electronic address: Daniel.jiang@readinghealth.org.
authors.forename: Xuezhi
authors.initials: X
authors.lastname: Jiang
authors.affiliation: Department of ObGyn, The Reading Hospital, Reading, PA, United States.
authors.forename: Morgan
authors.initials: M
authors.lastname: Gruner
authors.affiliation: Centre de Ménopause, Hôpital Paule de Viguier, Toulouse, France.
authors.forename: Florence
authors.initials: F
authors.lastname: Trémollieres
authors.affiliation: Department and Clinic of Internal Diseases, Diabetology and Nephrology-Metabolic Bone Diseases Unit, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland.
authors.forename: Wojciech
authors.initials: W
authors.lastname: Pluskiewicz
authors.affiliation: INSERM Research UMR 1033, Université de Lyon, Lyon, France.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Sornay-Rendu
authors.affiliation: Department and Clinic of Pediatrics, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Poland.
authors.forename: Piotr
authors.initials: P
authors.lastname: Adamczyk
authors.affiliation: Department of ObGyn, The Reading Hospital, Reading, PA, United States; Internal Medicine, The Reading Hospital, Reading, PA, United States; Department of ObGyn, Sidney Kimmel Medical College of Thomas Jefferson University, United States; Department of Internal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Schnatz
mesh_terms: D015519:Bone Density / Q000502:physiology; D005260:Female; D006801:Humans; D008297:Male; D058866:Osteoporotic Fractures / Q000175:diagnosis* / Q000378:metabolism / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States
keywords: FRAX; Fractures prediction; Meta-analysis