Article Figures & Data
Figures
- Figure 1.
Two-year cumulative incidence of hip fracture, fragility fracture, and total mortality, divided into tertiles of women with 0, 1, or 2 to 4 risk factors.
Note: Risk assessment with 0, 1, or 2 to 4 risk factors among age =80 years, weight <60 kg, previous fragility fracture, and using arms to rise. The proportions of women with 0, 1, and 2 to 4 risk factors were 30%, 34%, and 37%, respectively.
- Figure 2.
Two-year cumulative incidence of hip fracture and total mortality according to number of risk factors.
Note: Hip fracture and total mortality for women with 0, 1, 2, 3, or 4 risk factors among age =80 years, weight <60 kg, previous fragility fracture, and using arms to rise. The proportions of women in these groups were 30%, 34%, 22%, 12%, and 3%, respectively.
- Figure 3.
FRAMO Index 2-year cumulative hazard for hip fracture.
FRAMO = Fracture and Mortality.
Note: In these Kaplan-Meier curves, women were excluded after death or first hip fracture.
Tables
Question Points * Specific question about vertebral radiographs posed only to women in the Vislanda population. 1. What is your present age? ≥80 y 1 70–79 y 0 2. What is your current weight? <60 kg 1 ≥60 kg 0 3. Can you rise 5 times from a chair without using your arms? (Try if you want.) No, I must use my arms to rise 1 Yes 0 4. Have you broken any bones after the age of 40 y? If so, which bone? Have your vertebrae been x-rayed?* Fracture of wrist/lower arm, upper arm, hip, or vertebrae, or vertebral compression seen on radiograph 1 No fracture, or fracture in some other location 0 - Table 2.
Response Rates and Distributions for 19 Possible Risk Factors in the Questionnaire Completed by Women Aged =70 Years in 2001 (N = 1,248)
Characteristic Response Rate No. (%) Study Population No. or Mean Value* %† * Mean value is given as arithmetic mean ± SD. † Estimated percentage for participants with valid data for that measure. ‡ Previous fragility fracture in hip, lower arm, upper arm, or vertebrae after age 40 years. § Only the Vislanda population was asked the additional question about vertebral radiographs. || This subgroup expected to have lower fracture risk. Continuous risk factors Age, y 1,248 (100.0) 78.8 ± 6.5 – Weight, kg 1,214 (97.2) 67.3 ± 11.8 – Height, cm 1,213 (97.1) 161 ± 6.1 – Dairy calcium intake, mg/d 1,208 (96.7) 628 ± 292 – Predefined risk factors Age, y 70–74 1,248 (100.0) 377 30.2 75–79 1,248 (100.0) 382 30.6 80–84 1,248 (100.0) 236 18.9 85–89 1,248 (100.0) 156 12.5 90–100 1,248 (100.0) 97 7.8 Weight <60 kg 1,214 (97.2) 302 24.9 Fragility fracture after age 40 y‡,§ 1,205 (96.6) 398 33.0 Uses arms when rising 5 times from chair 1,210 (97.0) 362 29.9 Fell during last 12 mo 1,192 (95.4) 397 33.3 Other possible risk factors Any type of fracture after age 40 y§ 1,210 (97.0) 486 40.2 Use of cortisone medication for >3 mo 1,158 (92.7) 149 12.9 Has never given birth 1,238 (99.1) 164 13.2 Lives in residential care (vs community) 1,231 (98.6) 123 10.0 Height >167 cm 1,213 (97.1) 183 15.1 Dairy calcium intake <500 mg/d 1,208 (96.7) 377 31.2 Impaired vision, self-reported (vs good vision) 1,226 (98.2) 356 29.0 History of maternal hip fracture 1,108 (88.7) 123 11.1 Subjective health poor (vs excellent or fair) 1,224 (98.0) 120 9.8 Current smoking 1,231 (98.6) 53 4.3 Daily coffee intake ≥ 2 cups (vs 0-1 cup) 1,233 (98.7) 1,040 84.3 Menopausal age <45 y 1,072 (85.8) 128 11.9 No daily medication|| 1,229 (98.4) 152 12.4 Any parent of non-Nordic origin (vs Nordic)|| 1,226 (98.2) 23 1.9 - Table 3.
Two-Year Hip Fracture Risk According to Clinical Risk Factors Among Women Aged 70-100 Years in 2001 (N = 1,248)
Characteristic Hip Fracture (n = 31)No. (%)* No Hip Fracture (n = 1,217)No. (%)* P Exact† Univariate‡ HR (95% CI) Multivariate‡ 4 Risk Factors HR (95% CI) Multivariate‡,§ 11 Risk Factors HR (95% CI) HR = hazard ratio; CI = confidence interval. * Estimated percentage of participants with valid data for that measure. † Exact P value according to the Fisher exact test, 2-sided. ‡ Cox regression analysis (for time alive before hip fracture) for participants with valid data and only for variables with cell values greater than 4. § The variable “any type of fracture” was excluded from multivariate analysis because it competed with and was highly correlated with “previous fragility fracture.” || P <.05 ¶ Previous fragility fracture in the hip, lower arm, upper arm, or vertebrae after age 40 years. # Reported vertebral fractures included from responses to the question about radiographs posed only to the Vislanda population. ** This subgroup had a lower fracture risk in previous studies. Predefined risk factors Age 80–100 y 19 (61) 470 (39) .01|| 2.7 (1.3–5.6)|| 2.2 (0.99–4.7) 2.0 (0.9–4.7) Weight <60 kg 15 (48) 287 (24) .005|| 3.1 (1.5–6.2)|| 2.4 (1.2–5.0)|| 2.6 (1.2–5.8)|| Fragility fracture after age 40 y¶,# 17 (55) 381 (32) .01|| 2.5 (1.3–5.2)|| 2.3 (1.1–4.7)|| 2.6 (1.2–5.6)|| Uses arms when rising 5 times from chair 14 (47) 348 (30) .07 2.3 (1.1–4.7)|| 1.7 (0.8–3.6) 1.5 (0.6–3.7) Fell during last 12 mo 12 (41) 385 (33) .42 1.5 (0.7–3.1) — 1.0 (0.4–2.3) Other possible risk factors Any type of fracture after age 40 y# 19 (61) 468 (40) .02|| 2.4 (1.7–5.0)|| — — Use of cortisone medication for >3 mo 7 (26) 142 (13) .07 2.4 (1.0–5.6)|| — 2.6 (1.1–6.3)|| Has never given birth 8 (26) 156 (13) .054 2.4 (1.1–5.4)|| — 2.4 (1.0–5.6) Lives in residential care (vs community) 7 (23) 116 (10) .03|| 3.3 (1.4–7.8)|| — 1.8 (0.6–5.0) Height >167 cm 5 (17) 178 (15) .80 1.1 (0.4–2.9) — 1.2 (0.4–3.5) Dairy calcium intake <500 mg/d 9 (31) 368 (31) 1.00 1.0 (0.5–2.2) — 1.0 (0.4–2.2) Impaired vision, self-reported (vs good vision) 8 (26) 348 (29) .84 0.9 (0.4–2.0) — 0.5 (0.2–1.3) History of maternal hip fracture 4 (15) 119 (11) .52 — — — Subjective health poor (vs excellent or fair) 1 (3) 119 (10) .36 — — — Current smoking 0 (0) 53 (4) .64 — — — Daily coffee intake ≥2 cups (vs 0–1 cup) 28 (93) 1,010 (84) .21 — — — Menopausal age <45 y 4 (18) 124 (12) .32 — — — No daily medication** 2 (6) 150 (12) .42 — — — Any parent of non-Nordic origin (vs Nordic)** 2 (7) 21 (2) .10 — — — - Table 4.
Hip Fracture, Fragility Fracture, or Death Within 2 Years, Predicted by 2 to 4 vs 0 to 1 Risk Factors, According to Risk Model
Total Population (N = 1,248) Risk Model Total N Events n No Events n NPV/PPV (%) Specificity/Sensitivity (%) Odds Ratio (95% CI) P Exact Vislanda (n = 435)P Exact Tingsryd & Emmaboda (n = 418& 395)P Exact NPV = negative predictive value; PPV = positive predictive value; CI = confidence interval; FRAMO = Fracture and Mortality. Note: Hypothesis tested by the Fisher exact test. Risk model 1 (FRAMO Index): age =80 years, weight <60 kg, previous fragility fracture, and using arms when rising at least 5 times from sitting position.*† Risk model 2: age =80 years, weight <60 kg, previous fragility fracture, and falls during the past 12 months. Women with missing data were recoded as having a low fracture risk; therefore, data for all 1,248 women were included in the Fisher exact 2-sided test and the binary logistic regression analysis. * Previous fragility fractures: fractures in the hip, lower arm, upper arm, or vertebrae after age 40 years. † Included reported vertebral fractures from responses to the radiograph question in the Vislanda population. ‡ P <.001. § P <.01. || Fragility fractures: fractures of the hip, distal radius, proximal humerus, pubic bone, ischial bone, or vertebrae during 2002–2003. ¶ Data for all types of fragility fractures were obtained only for the Vislanda and Tingsryd populations (n = 853). # P <.05. Risk model 1 (FRAMO Index): Age, weight, previous fragility fracture,*† and using arms to rise Hip fractures 0–1 risk factor 789 6 783 99.2/5.4 64/81 1.0 <.001‡ <.001‡ .002§ 2–4 risk factors 459 25 434 7.5 (3.0–18.4)‡ Fragility fractures||,¶ 0–1 risk factor 547 9 538 98.4/10.0 66/78 1.0 <.001‡ <.001‡ .001§ 2–4 risk factors 306 31 275 6.7 (3.2–14.3)‡ Mortality 0–1 risk factor 789 25 764 96.8/24.0 67/81 1.0 <.001‡ <.001‡ <.001‡ 2–4 risk factors 459 109 350 9.5 (6.0–14.9)‡ Risk model 2: Age, weight, previous fragility fracture,*† and fall Hip fractures 0–1 risk factor 775 9 766 98.8/4.7 63/71 1.0 <.001‡ .001§ .052 2–4 risk factors 473 22 451 4.1 (1.9–9.1)‡ Fragility fractures||,¶ 0–1 risk factor 537 12 525 97.8/8.9 65/70 1.0 <.001‡ <.001‡ .04# 2–4 risk factors 316 28 288 4.2 (2.1–8.5)‡ Mortality 0–1 risk factor 775 35 740 95.5/21.0 66/74 <.001‡ <.001‡ <.001‡ 2–4 risk factors 473 99 374 5.6 (3.7–8.4)‡
The Article in Brief
Validation of a 4-Item Score Predicting Hip Fracture and Mortality Risk Among Elderly Women
Daniel M. Albertsson , and colleagues
Background The aim of this study was to develop and test a practical tool to assess the risk of hip fracture and death in elderly women.
What This Study Found The Fracture and Mortality Index uses simple yes/no questions about 4 risk factors for hip fracture: old age, low weight, previously broken bones, and using arms to rise from a sitting position. This tool predicts hip fractures as well as more complex scoring systems. Among 1,248 women participating in the survey, most (63%) had 0 or 1 risk factor, which suggests a very low risk of hip fracture and death within 2 years. The risk of hip fracture was more than 7 times higher for the 37% of women with at least 2 risk factors.
Implications
- The Fracture and Mortality Index is a simple, practical tool for routine use in primary care.
