Changes in treatment eligibility with race-neutral US FRAX would be modest: estimates using the National Health and Nutrition Examination Survey (NHANES)

To understand the effects of removing race from fracture calculators, we analyzed the changes in osteoporosis treatment eligibility between race-specific and race-neutral FRAX in NHANES. Overall, we found small changes in treatment eligibility (< 5%) with slight increases among Black, Hispanic, and Asian participants and a slight decrease among White participants. PURPOSE: The Fracture Risk Assessment Tool (FRAX) calculates the 10-year risk of major osteoporotic fracture (MOF) and hip fracture. In the USA, the calculator adjusts the probability down by 0.43-0.64 in Black, Hispanic, and Asian people based on historical data. Recently, an ASBMR Taskforce recommended the creation of a population-based, race-neutral calculator. The effects of this recommendation on treatment eligibility are not clear, so this study sought to quantify changes in treatment eligibility in the National Health and Nutrition Examination Survey (NHANES). METHODS: We analyzed participants in NHANES 2013-2014 and 2005-2010 and calculated the current FRAX based on questionnaires and bone mineral density (BMD). We then calculated a separate race-neutral FRAX using census data and compared treatment eligibility between the two calculators based on thresholds of 20% for MOF or 3% for hip fracture. We also examined treatment eligibility based on either clinical criteria (BMD T-score ≤ -2.5 or prior hip or vertebral fracture) or FRAX eligibility. RESULTS: Among 3035 and 8458 participants in NHANES 2013-2014 and 2005-2010, we found small absolute changes to treatment eligibility. In NHANES 2013-2014, the percent eligible using race-neutral FRAX decreased from 18.4 to 14.9% for White women and increased from 1.9 to 5.2% for Black women, from 3.9 to 7.0% for Hispanic women, and from 9.3 to 12.6% for Asian women. Changes in men were even smaller. CONCLUSION: We found that changing US FRAX to a race-neutral calculator would only modestly increase treatment eligibility in US Black, Hispanic, and Asian people, while slightly decreasing eligibility in White people.