Effect of competing mortality risks on predictive performance of the QFracture-2012 risk prediction tool for major osteoporotic fracture and hip fracture: external validation cohort study in a UK primary care population
Authors: Livingstone Shona J , Morales Daniel R , McMinn Megan , Eke Chima , Donnan Peter , Guthrie Bruce 
Published: October 2022

ObjectiveTo externally evaluate the QFracture-2012 risk prediction tool for predicting the risk of major osteoporotic fracture and hip fracture.DesignExternal validation cohort study.SettingUK primary care population. Linked general practice (Clinical Practice Research Datalink (CPRD) Gold), mortality registration (Office of National Statistics), and hospital inpatient (Hospital Episode Statistics) data, from 1 January 2004 to 31 March 2016.Participants2 747 409 women and 2 684 730 men, aged 30-99 years, with up-to-standard linked data that had passed CPRD checks for at least one year.Main outcome measuresTwo outcomes were modelled based on those predicted by QFracture: major osteoporotic fracture and hip fracture. Major osteoporotic fracture was defined as any hip, distal forearm, proximal humerus, or vertebral crush fracture, from general practice, hospital discharge, and mortality data. The QFracture-2012 10 year predicted risk of major osteoporotic fracture and hip fracture was calculated, and performance evaluated versus observed 10 year risk of fracture in the whole population, and in subgroups based on age and comorbidity. QFracture-2012 calibration was examined accounting for, and not accounting for, competing risk of mortality from causes other than the major osteoporotic fracture.Results2 747 409 women with 95 598 major osteoporotic fractures and 36 400 hip fractures, and 2 684 730 men with 34 321 major osteoporotic fractures and 13 379 hip fractures were included in the analysis. The incidence of all fractures was higher than in the QFracture-2012 internal derivation. Competing risk of mortality was more common than fracture from middle age onwards. QFracture-2012 discrimination in the whole population was excellent or good for major osteoporotic fracture and hip fracture (Harrell’s C statistic in women 0.813 and 0.918, and 0.738 and 0.888 in men, respectively), but was poor to moderate in age subgroups (eg, Harrell’s C statistic in women and men aged 85-99 years was 0.576 and 0.624 for major osteoporotic fractures, and 0.601 and 0.637 for hip fractures, respectively). Without accounting for competing risks, QFracture-2012 systematically under-predicted the risk of fracture in all models, and more so for major osteoporotic fracture than for hip fracture, and more so in older people. Accounting for competing risks, QFracture-2012 still under-predicted the risk of fracture in the whole population, but over-prediction was considerable in older age groups and in people with high comorbidities at high risk of fracture.ConclusionsThe QFracture-2012 risk prediction tool systematically under-predicted the risk of fracture (because of incomplete determination of fracture rates) and over-predicted the risk in older people and in those with more comorbidities (because of competing mortality). The current version of QFracture-2016 that is used by the UK's health service needs to be externally validated, particularly in people at high risk of death from other causes.