Race-neutral FRAX outperforms FRAX without BMD in a multiethnic cohort with diabetes or hypertension
Authors' conclusion
In conclusion, we found that the current FRAX without BMD significantly underestimated major osteoporotic fractures in Black and Hispanic patients, while a hypothetical race-neutral FRAX improved performance overall.
Study context
- Population
- Patients followed for DM or hypertension (HTN) (controls) in the health system, averaging ≥1 visit per year; 17,400 Black (45.4% DM), 9,865 White (35.3% DM), 1,196 Hispanic (57.9% DM)
- Exposure
- Original FRAX without BMD vs hypothetical race-neutral FRAX
- Outcome
- Performance for incident major osteoporotic fractures: discrimination (AUC) and calibration (observed-to-predicted ratio, O/P)
Methodological detailsmultiethnic, major osteoporotic fractures (MOFs) and FRAX inputs collected using diagnosis codes or medication data
- Multiethnic
- MOFs and FRAX inputs collected using diagnosis codes or medication data
Main finding
As reported in the abstract
Discrimination similar for original FRAX (oFRAX) and race-neutral FRAX (rn-FRAX) (AUC)
0.72-0.73
O/P in DM patients, oFRAX
1.4
O/P in DM patients, rn-FRAX
1.0
Observational data: associations, not effects.
Further findings
Calibration (O/P) by race
- White patients, both calculators: good performance (O/P)
- 0.8-1.2
- Black patients, oFRAX underestimated risk (O/P)
- 1.3-2.3
- Black women, rn-FRAX overestimated risk (O/P)
- 0.7-0.8
- Black men, rn-FRAX performed well (O/P)
- 0.9-1.1
- Hispanic patients, oFRAX substantially underestimated fractures (O/P)
- 1.8-2.4
- Hispanic patients, rn-FRAX only partially alleviated (O/P)
- 1.2-1.6
Original publication
Race-neutral FRAX outperforms FRAX without BMD in a multiethnic cohort with diabetes or hypertension. J Bone Miner Res. Published 19 June 2026. doi:10.
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