MORES Bests FRAX as Screening Tool for Osteoporosis in Men

Pam Harrison

July 15, 2016

The easily calculated Male Osteoporosis Risk Estimation Score (MORES), based on clinical risk factors alone, is a more effective screening tool for osteoporosis in men than the web-based, more complex Fracture Risk Assessment tool (FRAX), a new comparative study has found.

"You'll never get 100% rule-out, but…if a man screens negative on MORES — in other words, he has no risk factors — you can be pretty confident that that he has less than a 1% to 2% chance of actually having osteoporosis," lead author Alvah Cass, MD, of the University of Texas Medical Branch, Galveston, told Medscape Medical News.

"So for clinicians and patients who are concerned about osteoporosis, the MORES provides a simple clinical approach to identifying men at greatest risk for osteoporosis and for whom a DXA scan is reasonable," he added.

The study was published in the July/August issue of the Annals of Family Medicine.

Study Details

Dr Cass and colleagues compared the performance of the MORES with that of FRAX in 1498 men 50 years of age and older involved in the National Health and Nutrition Examination Survey III (NHANES III). The mean age of men included in the sample was 64.2 years and almost all were non-Hispanic white.

MORES uses only age and weight and whether or not a patient has a history of chronic obstructive pulmonary disease (COPD) to stratify men 50 years of age and older for osteoporosis risk.

In contrast, FRAX requires that physicians use a computer program and provide clinical information such as the patient's T-score, which is less readily available.

"The MORES and FRAX have different operating characteristics for identifying men with osteoporosis," Dr Cass explains.

For example, in this comparative study, 41.6% of men would be referred for DXA based on calculation of the MORES and 10.2% of this group would have osteoporosis.

By way of comparison, 12.3% of men in the study would be referred for DXA based on the FRAX and out of this group,14.1% would have osteoporosis.

"Given the low prevalence of osteoporosis, neither instrument served as a rule-in test; however, both tools were reasonably effective as a rule-out test," Dr Cass observes.

Comparison of Operating Characteristics of FRAX and MORES for Predicting Osteoporosis in Men Based on T-Scores From the Hip

Parameter FRAX MORES
Sensitivity 0.39 0.96
Specificity 0.89 0.61
Predictive positive value 0.14 0.10
Predictive negative value 0.79 1.00
Area under the curve 0.79 0.87
Depends on the Goal

Asked if it is better to have more accurate sensitivity than specificity, Dr Cass noted that it depends on what the goal is.

"However, generally with a screening test, you want a higher sensitivity, even if that comes at the expenses of specificity," he said.

"So in this case, at least in this population, the MORES achieved a pretty high sensitivity."

As for the area under the curve (AUC), here again the higher the AUC, the greater the probability that a positive test is a true positive and a negative test a true negative.

For example, an AUC of 90% or more is very good, while an AUC of 80% to 90% is good. An AUC of between 70 to 80% is fair, while an AUC of 50% or less fails as a test.

Dr Cass and colleagues still suggest that an "integrated approach" relying initially on the MORES to identify men who are at higher risk for osteoporosis — and who should therefore be referred for a DXA scan— be combined with FRAX to help guide treatment decisions.

"IF DXA results come back and the man tests positive for osteoporosis, you probably don't need to use FRAX because the National Osteoporosis Foundation says if you have osteoporosis, defined by a T-score of less than -2.5, you should be treated," he noted.

However, it's less obvious about what to do with men who have low bone-mineral density (BMD) in the form of osteopenia, he added.

"By using the actual BMD at the femoral neck, FRAX will give you their 10-year risk of fracture," Dr Cass explained.

Cost-effectiveness studies suggest that if a patient's risk of hip fracture in 10 years is in excess of 3% or if their risk of a major osteoporotic fracture is greater than 20% for any of the major osteoporotic fracture sites, "then that [person] would be a good candidate for treatment because the benefits of treatment ought to be there," he added.

Indeed, by integrating both the MORES and FRAX, Dr Cass and colleagues were able to identify 82% of study subjects who were candidates for treatment vs only 50% of the men using FRAX alone.

Men With Osteoporosis Benefit as Much From Treatment as Women

In 2011, the US Preventive Services Task Force (USPSTF) made no recommendation for or against screening men for osteoporosis as the evidence supporting screening for men was simply not there at the time.

Since then, however, more and more data are emerging that men with osteoporosis probably benefit from treatment as much as women do.

Indeed, it's predicted that by the year 2030, osteoporotic fractures will increase at a greater rate in men than in women.

"We believe the MORES is a better screening tool for osteoporosis in men than the FRAX, whereas the FRAX is a valuable tool to guide treatment decisions," Dr Cass affirmed.

The authors reported no relevant financial relationships.

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Ann Fam Med. 2016;14:365-369. Article

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