{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,2]],"date-time":"2025-11-02T01:55:30Z","timestamp":1762048530033,"version":"build-2065373602"},"reference-count":44,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2022,4,25]],"date-time":"2022-04-25T00:00:00Z","timestamp":1650844800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>In Spain, the Fracture Risk Assessment Tool (FRAX) was adapted using studies with a small number of patients, and there are only a few external validation studies that present limitations. In this prospective cohort study, we compared the performance of FRAX and a simple age and sex model. We used data from the ESOSVAL cohort, a cohort composed of a Mediterranean population of 11,035 women and men aged 50 years and over, followed for up to 8 years, to compare the discrimination, calibration, and reclassification of FRAX calibrated for Spain and a logistic model including only age and sex as variables. We found virtually identical AUC, 83.55% for FRAX (CI 95%: 80.46, 86.63) and 84.10% for the age and sex model (CI 95%: 80.91, 87.29), and there were similar observed-to-predicted ratios. In the reclassification analyses, patients with a hip fracture that were reclassified correctly as high risk by FRAX, compared to the age and sex model, were \u22122.86%, using either the 3% threshold or the observed incidence, 1.54% (95%CI: \u22128.44, 2.72 for the 3% threshold; 95%CI: \u22127.68, 1.97 for the incidence threshold). Remarkably simple and inexpensive tools that are easily transferable into electronic medical record environments may offer a comparable predictive ability to that of FRAX.<\/jats:p>","DOI":"10.3390\/jcm11092409","type":"journal-article","created":{"date-parts":[[2022,4,25]],"date-time":"2022-04-25T21:16:28Z","timestamp":1650921388000},"page":"2409","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Predictive Performance of the FRAX Tool Calibrated for Spain vs. an Age and Sex Model: Prospective Cohort Study with 9082 Women and Men Followed for up to 8 Years"],"prefix":"10.3390","volume":"11","author":[{"given":"An\u00edbal","family":"Garc\u00eda-Sempere","sequence":"first","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"},{"name":"Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isabel","family":"Hurtado","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"},{"name":"Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3902-569X","authenticated-orcid":false,"given":"Salvador","family":"Peir\u00f3","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"},{"name":"Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3011-9884","authenticated-orcid":false,"given":"Francisco","family":"S\u00e1nchez-S\u00e1ez","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yared","family":"Santaana","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2617-8635","authenticated-orcid":false,"given":"Clara","family":"Rodr\u00edguez-Bernal","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"},{"name":"Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gabriel","family":"Sanf\u00e9lix-Gimeno","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"},{"name":"Spanish Network for Research in Primary Care and Chronicity (RICAPPS), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jos\u00e9","family":"Sanf\u00e9lix-Genov\u00e9s","sequence":"additional","affiliation":[{"name":"Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), 46020 Valencia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,4,25]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"171","DOI":"10.5312\/wjo.v7.i3.171","article-title":"Major osteoporotic fragility fractures: Risk factor updates and societal impact","volume":"7","author":"Pisani","year":"2016","journal-title":"World J. Orthop."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2863","DOI":"10.1007\/s00198-012-1935-8","article-title":"Burden of non-hip, non-vertebral fractures on quality of life in postmenopausal women: The Global Longitudinal study of Osteoporosis in Women (GLOW)","volume":"23","author":"Roux","year":"2012","journal-title":"Osteoporos. Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2239","DOI":"10.1007\/s00198-012-1964-3","article-title":"A systematic review of hip fracture incidence and probability of fracture worldwide","volume":"23","author":"Kanis","year":"2012","journal-title":"Osteoporos. Int."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1243","DOI":"10.1007\/s00198-019-04939-2","article-title":"Spanish National Hip Fracture Registry (RNFC): Analysis of its first annual report and international comparison with other established registries","volume":"30","author":"Currie","year":"2019","journal-title":"Osteoporos. Int."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1267","DOI":"10.1007\/s00198-013-2586-0","article-title":"Changing trends in the epidemiology of hip fracture in Spain","volume":"25","author":"Azagra","year":"2014","journal-title":"Osteoporos. Int."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1007\/s00198-010-1477-x","article-title":"Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: A 4-year prospective controlled study","volume":"22","author":"Lih","year":"2011","journal-title":"Osteoporos. Int."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1035","DOI":"10.2147\/CIA.S76695","article-title":"Fracture prevention service to bridge the osteoporosis care gap","volume":"10","author":"Baroni","year":"2015","journal-title":"Clin. Interv. Aging"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1007\/BF01623782","article-title":"Guidelines for diagnosis and management of osteoporosis","volume":"7","author":"Kanis","year":"1997","journal-title":"Osteoporos. Int."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1302\/0301-620X.88B5.16893","article-title":"Peri-prosthetic bone mineral density after total knee arthroplasty","volume":"88-B","author":"Watson","year":"2006","journal-title":"J. Bone Jt. Surg. Br."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1007\/s11926-004-0087-z","article-title":"Is it ethical to use placebos in osteoporosis clinical trials?","volume":"6","author":"Watts","year":"2004","journal-title":"Curr. Rheumatol. Rep."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1958","DOI":"10.1136\/annrheumdis-2015-207907","article-title":"The accuracy of osteoporotic fracture risk prediction tools: A systematic review and meta-analysis","volume":"74","author":"Marques","year":"2015","journal-title":"Ann. Rheum. Dis."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1007\/s11657-018-0510-0","article-title":"A brief history of FRAX","volume":"13","author":"Kanis","year":"2018","journal-title":"Arch. Osteoporos."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1359\/jbmr.2002.17.7.1237","article-title":"International Variations in Hip Fracture Probabilities: Implications for Risk Assessment","volume":"17","author":"Kanis","year":"2002","journal-title":"J. Bone Miner. Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1016\/j.afos.2019.12.002","article-title":"The diversity of Fracture Risk Assessment Tool (FRAX)-based intervention thresholds in Asia","volume":"5","author":"Lekamwasam","year":"2019","journal-title":"Osteoporos. Sarcopenia"},{"key":"ref_15","unstructured":"Grupo de Variaciones en la Pr\u00e1ctica M\u00e9dica de la Red tem\u00e1tica de Investigaci\u00f3n en Resultados y Servicios de Salud (Grupo VPM-IRYS) (2005). Variaciones en cirug\u00eda ortop\u00e9dica y traumatolog\u00eda en el Sistema Nacional de Salud. Atlas Var Pract. Med. SNS, 1, 17\u201336."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1016\/j.jocd.2012.05.007","article-title":"Validation of the FRAX Predictive Model for Major Osteoporotic Fracture in a Historical Cohort of Spanish Women","volume":"16","author":"Casas","year":"2013","journal-title":"J. Clin. Densitom."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Azagra, R., Roca, G., Encabo, G., Aguy\u00e9, A., Zwart, M., G\u00fcell, S., Puchol, N., Gene, E., Casado, E., and Sancho, P. (2012). FRAX\u00ae tool, the WHO algorithm to predict osteoporotic fractures: The first analysis of its discriminative and predictive ability in the Spanish FRIDEX cohort. BMC Musculoskelet. Disord., 13.","DOI":"10.1186\/1471-2474-13-204"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/j.bone.2011.11.006","article-title":"Probability of fractures predicted by FRAX\u00ae and observed incidence in the Spanish ECOSAP Study cohort","volume":"50","author":"Marin","year":"2012","journal-title":"Bone"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2087","DOI":"10.1001\/archinternmed.2009.404","article-title":"Study of Osteoporotic Fractures Research Group. A Comparison of Prediction Models for Fractures in Older Women: Is more better?","volume":"169","author":"Ensrud","year":"2009","journal-title":"Arch. Intern. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1793","DOI":"10.1359\/jbmr.090511","article-title":"FRAX and Risk of Vertebral Fractures: The Fracture Intervention Trial","volume":"24","author":"Donaldson","year":"2009","journal-title":"J. Bone Miner. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1093\/ije\/dyz266","article-title":"Data Resource Profile: The Valencia Health System Integrated Database (VID)","volume":"49","author":"Sanchez","year":"2020","journal-title":"Int. J. Epidemiol."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Sanfelix-Genov\u00e9s, J., Peir\u00f3, S., Sanf\u00e9lix-Gimeno, G., Giner, V., Gil, V., Pascual, M., Fluix\u00e1, C., Fuertes, A., Hurtado, I., and Ferreros, I. (2010). Development and validation of a population-based prediction scale for osteoporotic fracture in the region of Valencia, Spain: The ESOSVAL-R study. BMC Public Health, 10.","DOI":"10.1186\/1471-2458-10-153"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Sanfelix-Genov\u00e9s, J., Peir\u00f3, S., Sanf\u00e9lix-Gimeno, G., Hurtado, I., De La Torre, M.P., Trillo-Mata, J.L., and Giner-Ruiz, V. (2010). Impact of a multifaceted intervention to improve the clinical management of osteoporosis. The ESOSVAL-F study. BMC Health Serv. Res., 10.","DOI":"10.1186\/1472-6963-10-292"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Sanf\u00e9lix-Gimeno, G., Sanfelix-Genov\u00e9s, J., Peir\u00f3, S., Hurtado, I., Trillo, J.L., Us\u00f3, R., Ruiz, V.G., De La Torre, M.P., and Ferreros, I. (2011). Adherence to and appropriateness of anti-osteoporotic treatments in patients aged 50 and over in the Valencia Region (Spain). The ESOSVAL-AD Study. BMC Musculoskelet. Disord., 12.","DOI":"10.1186\/1471-2474-12-178"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1045","DOI":"10.1007\/s00198-012-2018-6","article-title":"Prevalence of osteoporotic fracture risk factors and antiosteoporotic treatments in the Valencia region, Spain. The baseline characteristics of the ESOSVAL cohort","volume":"24","author":"Hurtado","year":"2013","journal-title":"Osteoporos. Int."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2286","DOI":"10.1002\/jbmr.1977","article-title":"Prevalence, determinants, and inappropriateness of calcium supplementation among men and women in a Spanish Mediterranean area: Cross-sectional data from the ESOSVAL cohort","volume":"28","author":"Hurtado","year":"2013","journal-title":"J. Bone Miner. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1210\/jc.2013-3448","article-title":"Impact on the Population of Different Bone Mineral Density Testing Criteria and Appropriateness of Densitometries in the ESOSVAL Cohort, Spain","volume":"99","author":"Hurtado","year":"2014","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"768","DOI":"10.3389\/fphar.2019.00768","article-title":"Impact of Drug Safety Warnings and Cost-Sharing Policies on Osteoporosis Drug Utilization in Spain: A Major Reduction But With the Persistence of Over and Underuse. Data From the ESOSVAL Cohort From 2009 to 2015","volume":"10","year":"2019","journal-title":"Front. Pharmacol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1487","DOI":"10.1136\/bmj.b606","article-title":"Prognosis and prognostic research: Application and impact of prognostic models in clinical practice","volume":"338","author":"Moons","year":"2009","journal-title":"BMJ"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1432","DOI":"10.1136\/bmj.b605","article-title":"Prognosis and prognostic research: Validating a prognostic model","volume":"338","author":"Altman","year":"2009","journal-title":"BMJ"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1373","DOI":"10.1136\/bmj.b604","article-title":"Prognosis and prognostic research: Developing a prognostic model","volume":"338","author":"Royston","year":"2009","journal-title":"BMJ"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1317","DOI":"10.1136\/bmj.b375","article-title":"Prognosis and prognostic research: What, why, and how?","volume":"338","author":"Moons","year":"2009","journal-title":"BMJ"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1016\/S0895-4356(01)00341-9","article-title":"Internal validation of predictive models: Efficiency of some procedures for logistic regression analysis","volume":"54","author":"Steyerberg","year":"2001","journal-title":"J. Clin. Epidemiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1864","DOI":"10.1503\/cmaj.100771","article-title":"2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary","volume":"182","author":"Papaioannou","year":"2010","journal-title":"Can. Med Assoc. J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"788","DOI":"10.1016\/j.recesp.2011.04.017","article-title":"Performance Measures for Prediction Models and Markers: Evaluation of Predictions and Classifications","volume":"64","author":"Steyerberg","year":"2011","journal-title":"Rev. Esp. Cardiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1103","DOI":"10.1001\/jamainternmed.2019.0688","article-title":"Considering the Risks and Benefits of Osteoporosis Treatment in Older Adults","volume":"179","author":"Berry","year":"2019","journal-title":"JAMA Intern. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"423","DOI":"10.1007\/s00198-011-1846-0","article-title":"Pitfalls in the external validation of FRAX","volume":"23","author":"Kanis","year":"2011","journal-title":"Osteoporos. Int."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1491","DOI":"10.1007\/s00198-014-3015-8","article-title":"Regional variability in changes in the incidence of hip fracture in the Spanish population (2000\u20132012)","volume":"26","author":"Arrospide","year":"2015","journal-title":"Osteoporos. Int."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"829","DOI":"10.1007\/s00198-010-1465-1","article-title":"Fracture prediction and calibration of a Canadian FRAX\u00ae tool: A population-based report from CaMos","volume":"22","author":"Fraser","year":"2011","journal-title":"Osteoporos. Int."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2350","DOI":"10.1002\/jbmr.123","article-title":"Manitoba Bone Density Program. Independent clinical validation of a Canadian FRAX tool: Fracture prediction and model calibration","volume":"25","author":"Leslie","year":"2010","journal-title":"J. Bone Miner. Res."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1016\/j.jocd.2011.06.006","article-title":"Methods for Assessing Fracture Risk Prediction Models: Experience With FRAX in a Large Integrated Health Care Delivery System","volume":"14","author":"Pressman","year":"2011","journal-title":"J. Clin. Densitom."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"i6755","DOI":"10.1136\/bmj.i6755","article-title":"External validation and comparison of three prediction tools for risk of osteoporotic fractures using data from population based electronic health records: Retrospective cohort study","volume":"356","author":"Dagan","year":"2017","journal-title":"BMJ"},{"key":"ref_43","first-page":"15","article-title":"Variability in the recommendations for the clinical management of osteoporosis","volume":"142","author":"Hurtado","year":"2014","journal-title":"Med. Clin."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"11784","DOI":"10.1038\/s41598-017-10899-6","article-title":"Primary and secondary non-adherence to osteoporotic medications after hip fracture in Spain. The PREV2FO population-based retrospective cohort study","volume":"7","author":"Hurtado","year":"2017","journal-title":"Sci. Rep."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/9\/2409\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T23:00:53Z","timestamp":1760137253000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/9\/2409"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,4,25]]},"references-count":44,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2022,5]]}},"alternative-id":["jcm11092409"],"URL":"https:\/\/doi.org\/10.3390\/jcm11092409","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2022,4,25]]}}}