Existing fracture risk assessment tools are not designed to forecast fracture-associated consequences. This, in turn, contributes to the current under-management of fragility fractures worldwide. In this study, a novel and robust statistical approach was used to develop a prediction model for individualization of progression to fracture and its consequences. This, in turn, facilitates informed decision making about risk beyond the fracture itself and thus aid in individualized treatment decisions (management for individuals with different risk profiles). 

The study aimed to develop a risk assessment tool for predicting and quantifying the probabilities of both an initial fragility fracture and its associated outcomes of subsequent fracture and mortality utilizing a multistate model. 

From the two similar prospective population-based cohort studies, DOES (Dubbo Osteoporosis Epidemiology Study) and the CaMos (Canadian Multicentre Osteoporosis Study), the study enrolled 8965 people aged ≥60 years. From X-ray reports and questionnaires, the incident fracture was identified. Mortality was ascertained by contact with a family member or obituary review.

The multistate model was used to quantify the effects of the predictors on the transition risks to an initial and subsequent incident fracture, and mortality, accounting for their confounding effects, complex inter-relationships, and death as a competing risk. 

During the median follow up of 13 years, there were 2364 initial fractures, 755 subsequent fractures, and 3300 deaths as depicted in the table:

The prediction model included age, bone mineral density, history of falls within 12 previous months, gender, prior fracture after the age of 50 years, cancer, cardiovascular disorders, hypertension, chronic pulmonary disorders, and diabetes mellitus.

The model precisely predicted fragility fractures up to 11 years of follow up, and post-fracture mortality up to 9 years, ranging from 7 years after hip fractures to 15 years after non-hip fractures.

In the elderly, the risk assessment tool can accurately predict fragility fractures and mortality.