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Comparative Study
. 2017 Jan 19:356:i6755.
doi: 10.1136/bmj.i6755.

External validation and comparison of three prediction tools for risk of osteoporotic fractures using data from population based electronic health records: retrospective cohort study

Noa Dagan  1   2 , Chandra Cohen-Stavi  3 , Maya Leventer-Roberts  3   4 , Ran D Balicer  3   5
Affiliations
Comparative Study

External validation and comparison of three prediction tools for risk of osteoporotic fractures using data from population based electronic health records: retrospective cohort study

Noa Dagan et al. BMJ. .

Abstract

Objective: To directly compare the performance and externally validate the three most studied prediction tools for osteoporotic fractures-QFracture, FRAX, and Garvan-using data from electronic health records.

Design: Retrospective cohort study.

Setting: Payer provider healthcare organisation in Israel.

Participants: 1 054 815 members aged 50 to 90 years for comparison between tools and cohorts of different age ranges, corresponding to those in each tools' development study, for tool specific external validation.

Main outcome measure: First diagnosis of a major osteoporotic fracture (for QFracture and FRAX tools) and hip fractures (for all three tools) recorded in electronic health records from 2010 to 2014. Observed fracture rates were compared to probabilities predicted retrospectively as of 2010.

Results: The observed five year hip fracture rate was 2.7% and the rate for major osteoporotic fractures was 7.7%. The areas under the receiver operating curve (AUC) for hip fracture prediction were 82.7% for QFracture, 81.5% for FRAX, and 77.8% for Garvan. For major osteoporotic fractures, AUCs were 71.2% for QFracture and 71.4% for FRAX. All the tools underestimated the fracture risk, but the average observed to predicted ratios and the calibration slopes of FRAX were closest to 1. Tool specific validation analyses yielded hip fracture prediction AUCs of 88.0% for QFracture (among those aged 30-100 years), 81.5% for FRAX (50-90 years), and 71.2% for Garvan (60-95 years).

Conclusions: Both QFracture and FRAX had high discriminatory power for hip fracture prediction, with QFracture performing slightly better. This performance gap was more pronounced in previous studies, likely because of broader age inclusion criteria for QFracture validations. The simpler FRAX performed almost as well as QFracture for hip fracture prediction, and may have advantages if some of the input data required for QFracture are not available. However, both tools require calibration before implementation.

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Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Population flowchart for comparative and tool specific external validation analyses (FRAX external validation population is same as population used for comparative analysis)
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Fig 2 Receiver operating curves of QFracture, FRAX, and Garvan predictive tools for hip and major osteoporotic fractures during five years of follow-up in comparative and tool specific external validation analyses
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Fig 3 Calibration plot of hip fracture predictions for QFracture, FRAX, and Garvan in the comparative analysis: five year observed risk and average predicted probabilities by probability 10ths (each mark represents approximately a 10th of the cohort belonging to the same probability 10th)
See this image and copyright information in PMC

References

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