Enormous variation in worldwide usage of FRAX revealed by IOF position paper
One of the most important advances in osteoporosis management of the past decade has been the advent of fracture risk assessment algorithms. Today, rather than relying on bone mineral density values alone, doctors use tools such as FRAX, a widely available calculator, to help identify patients in need of treatment.
A new position paper by the International Osteoporosis Foundation (IOF) Epidemiology and Quality of Life Working Group has assessed the uptake of FRAX worldwide. The study concludes that there were approximately 2.3 million FRAX calculations during a one-year period beginning in May 2012, with enormous variation in worldwide usage.
What is FRAX?
FRAX (WHO Fracture Risk Assessment Tool) calculates an individual's 10-year probability of a major osteoporotic fracture based on clinical risk factors. It integrates the weight of clinical risk factors for fracture and mortality risk, with or without information on bone mineral density (BMD) values. Each calculator is country specific, calibrated to the national epidemiology of fracture and mortality.
Now with specific models for 53 countries, FRAX is widely used by physicians around the world to help assess their patients' fracture risk in the course of a clinical assessment. The use of the tool improves risk assessment compared to the use of BMD alone, allowing physicians to make more informed treatment decisions.
Study reveals great variation in usage:
For the study, FRAX usage was computed as the number of calculations originating from each country (source Google Analytics) from 1 May 2012 to 30 April 2013 and expressed as calculations per million of the general population over the age of 50 years. As FRAX calculations are also available offline - in BMD equipment, on the iPhone and, in some countries, through handheld calculators - it was assumed (conservatively) that 25 % of calculations were undertaken independent of the web site, and the annual number of FRAX calculations was upwardly revised accordingly. An exception was Japan where a survey suggested that 71 % of doctors use the widely available handheld calculator.
The number of calculations per million of population over the age of 50 years (based on UN demographic data for 2015, where available) was classified as high use: (>1200 per million); Intermediate use (420-1200 per million); Low use (<320 >100 per million): and <100 very low use.
Key findings for the index year include:
- There were estimated to be 2,391,639 calculations sourced from 173 counties.
- The countries that used FRAX most frequently were the USA, UK, Canada, Spain, Japan, France, Belgium, Italy, Switzerland and Turkey. Collectively these 10 counties undertook more than 80 % of all calculations.
- Uptake of FRAX per capita of the population aged 50 years or more was highest in Slovenia, Switzerland, USA, Belgium, New Zealand, UK, Lebanon, Canada, Sweden and Ireland.
- Worldwide, there was a marked dearth of FRAX calculations in many of the countries of Africa and South East Asia.
- In Europe, there was a high usage in the majority of countries. However, low or very low use was noted in Albania, Belarus, Bulgaria, Bosnia and Herzegovina, Croatia, Germany, Latvia, Macedonia, Moldova, Serbia and Ukraine.
The authors also concluded that variations in uptake were not closely related to the availability of a country-specific model or to the availability of BMD scanners. Possible reasons for the heterogeneity could be the limited access to the internet in some countries, the low prioritization of bone health compared to other health care issues, the lack of assessment guidelines or the slow pace of incorporation of new technologies into existing guidelines.
"FRAX is a proven asset in osteoporosis management and a component of many national or international guidelines for the assessment of fracture risk. Nevertheless this study shows that FRAX is underutilized in many countries which could most benefit from this free and easily accessible assessment tool," said IOF President John A. Kanis, lead author of the study.
He added, "The thousand-fold range in usage of FRAX is far greater than the 10-fold range of age standardized hip fracture incidence worldwide, indicating a large gap in the provision of service in many countries. We hope that the comparative data revealed in study will encourage the development of new FRAX models and the uptake of FRAX into assessment guidelines worldwide."