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Research ArticleMethodology

Validation of a 4-Item Score Predicting Hip Fracture and Mortality Risk Among Elderly Women

Daniel M. Albertsson, Dan Mellström, Christer Petersson and Robert Eggertsen
The Annals of Family Medicine January 2007, 5 (1) 48-56; DOI: https://doi.org/10.1370/afm.602
Daniel M. Albertsson
MD
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Dan Mellström
MD, PhD
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Christer Petersson
MD, PhD
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Robert Eggertsen
MD, PhD
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Article Figures & Data

Figures

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  • Figure 1.
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    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.
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    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.
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    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

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    • View popup
    Table 1.

    Questions Used to Assess the 4 Risk Factors in Risk Model 1

    QuestionPoints
    * Specific question about vertebral radiographs posed only to women in the Vislanda population.
    1. What is your present age?
        ≥80 y1
        70–79 y0
    2. What is your current weight?
        <60 kg1
        ≥60 kg0
    3. Can you rise 5 times from a chair without using your arms? (Try if you want.)
        No, I must use my arms to rise1
        Yes0
    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 radiograph1
        No fracture, or fracture in some other location0
    • View popup
    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)

    CharacteristicResponse 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, y1,248 (100.0)78.8 ± 6.5–
    Weight, kg1,214 (97.2)67.3 ± 11.8–
    Height, cm1,213 (97.1)161 ± 6.1–
    Dairy calcium intake, mg/d1,208 (96.7)628 ± 292–
    Predefined risk factors
    Age, y
        70–741,248 (100.0)37730.2
        75–791,248 (100.0)38230.6
        80–841,248 (100.0)23618.9
        85–891,248 (100.0)15612.5
        90–1001,248 (100.0)977.8
    Weight <60 kg1,214 (97.2)30224.9
    Fragility fracture after age 40 y‡,§1,205 (96.6)39833.0
    Uses arms when rising 5 times from chair1,210 (97.0)36229.9
    Fell during last 12 mo1,192 (95.4)39733.3
    Other possible risk factors
    Any type of fracture after age 40 y§1,210 (97.0)48640.2
    Use of cortisone medication for >3 mo1,158 (92.7)14912.9
    Has never given birth1,238 (99.1)16413.2
    Lives in residential care (vs community)1,231 (98.6)12310.0
    Height >167 cm1,213 (97.1)18315.1
    Dairy calcium intake <500 mg/d1,208 (96.7)37731.2
    Impaired vision, self-reported (vs good vision)1,226 (98.2)35629.0
    History of maternal hip fracture1,108 (88.7)12311.1
    Subjective health poor (vs excellent or fair)1,224 (98.0)1209.8
    Current smoking1,231 (98.6)534.3
    Daily coffee intake ≥ 2 cups (vs 0-1 cup)1,233 (98.7)1,04084.3
    Menopausal age <45 y1,072 (85.8)12811.9
    No daily medication||1,229 (98.4)15212.4
    Any parent of non-Nordic origin (vs Nordic)||1,226 (98.2)231.9
    • View popup
    Table 3.

    Two-Year Hip Fracture Risk According to Clinical Risk Factors Among Women Aged 70-100 Years in 2001 (N = 1,248)

    CharacteristicHip 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 y19 (61)470 (39).01||2.7 (1.3–5.6)||2.2 (0.99–4.7)2.0 (0.9–4.7)
    Weight <60 kg15 (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 chair14 (47)348 (30).072.3 (1.1–4.7)||1.7 (0.8–3.6)1.5 (0.6–3.7)
    Fell during last 12 mo12 (41)385 (33).421.5 (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 mo7 (26)142 (13).072.4 (1.0–5.6)||—2.6 (1.1–6.3)||
    Has never given birth8 (26)156 (13).0542.4 (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 cm5 (17)178 (15).801.1 (0.4–2.9)—1.2 (0.4–3.5)
    Dairy calcium intake <500 mg/d9 (31)368 (31)1.001.0 (0.5–2.2)—1.0 (0.4–2.2)
    Impaired vision, self-reported (vs good vision)8 (26)348 (29).840.9 (0.4–2.0)—0.5 (0.2–1.3)
    History of maternal hip fracture4 (15)119 (11).52———
    Subjective health poor (vs excellent or fair)1 (3)119 (10).36———
    Current smoking0 (0)53 (4).64———
    Daily coffee intake ≥2 cups (vs 0–1 cup)28 (93)1,010 (84).21———
    Menopausal age <45 y4 (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———
    • View popup
    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 ModelTotal NEvents nNo Events nNPV/PPV (%)Specificity/Sensitivity (%)Odds Ratio (95% CI)P ExactVislanda (n = 435)P ExactTingsryd & 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 factor789678399.2/5.464/811.0<.001‡<.001‡.002§
        2–4 risk factors459254347.5 (3.0–18.4)‡
    Fragility fractures||,¶
        0–1 risk factor547953898.4/10.066/781.0<.001‡<.001‡.001§
        2–4 risk factors306312756.7 (3.2–14.3)‡
    Mortality
        0–1 risk factor7892576496.8/24.067/811.0<.001‡<.001‡<.001‡
        2–4 risk factors4591093509.5 (6.0–14.9)‡
    Risk model 2: Age, weight, previous fragility fracture,*† and fall
    Hip fractures
        0–1 risk factor775976698.8/4.763/711.0<.001‡.001§.052
        2–4 risk factors473224514.1 (1.9–9.1)‡
    Fragility fractures||,¶
        0–1 risk factor5371252597.8/8.965/701.0<.001‡<.001‡.04#
        2–4 risk factors316282884.2 (2.1–8.5)‡
    Mortality
        0–1 risk factor7753574095.5/21.066/74<.001‡<.001‡<.001‡
        2–4 risk factors473993745.6 (3.7–8.4)‡

Additional Files

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  • 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.
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The Annals of Family Medicine: 5 (1)
The Annals of Family Medicine: 5 (1)
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Validation of a 4-Item Score Predicting Hip Fracture and Mortality Risk Among Elderly Women
Daniel M. Albertsson, Dan Mellström, Christer Petersson, Robert Eggertsen
The Annals of Family Medicine Jan 2007, 5 (1) 48-56; DOI: 10.1370/afm.602

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Validation of a 4-Item Score Predicting Hip Fracture and Mortality Risk Among Elderly Women
Daniel M. Albertsson, Dan Mellström, Christer Petersson, Robert Eggertsen
The Annals of Family Medicine Jan 2007, 5 (1) 48-56; DOI: 10.1370/afm.602
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