Evaluating the Impact of a Race-Neutral US FRAX Model on Osteoporosis Treatment Eligibility

A reanalysis of the US Fracture Risk Assessment Tool (FRAX) using NHANES data shows a race-neutral model modestly shifts treatment eligibility—under 5% net change—raising eligibility for Black, Hispanic, and Asian patients and slightly lowering it for White patients.

Investigators re-ran the FRAX algorithm without a race coefficient using NHANES data in a race-neutral FRAX analysis and compared treatment-eligibility outcomes from the race-specific and race-neutral calculators using NHANES 2013–2014 (n=3,035) and pooled NHANES 2005–2010 (n≈8,458). Participants were aged >40 with femur and spine DXA; FRAX was calculated with and without BMD. Primary endpoints were changes in the proportion eligible for treatment and absolute percentage-point differences by race/ethnicity. Overall net changes in eligibility were under 5 percentage points.

Subgroup results were consistent but modest. In NHANES 2013–2014, White women eligible by FRAX fell from 18.4% to 14.9% (≈−3.5 percentage points), while Black women rose from 1.9% to 5.2% (+≈3.3 pp), Hispanic women from 3.9% to 7.0% (+≈3.1 pp), and Asian women from 9.3% to 12.6% (+≈3.3 pp). Changes in men were smaller. Age-stratified analyses showed larger shifts among adults >65 (roughly 3–5 pp fewer White and 5–9 pp more Black, Hispanic, and Asian participants eligible). Many reclassifications were attenuated when clinical criteria such as BMD or prior hip/vertebral fracture were included.

Removing the race coefficient changes predicted fracture probability by recalibrating baseline population rates and redistributing the influence of other FRAX inputs. These subgroup shifts therefore alter which patients cross current guideline treatment thresholds rather than defining new biologic risk categories.

The ASBMR-taskforce-aligned move to a race-neutral calculator is an equity-motivated adjustment that would likely produce a modest uptick in candidates from underrepresented groups and a small reduction among White patients, with downstream effects on screening workload, BMD testing demand, and shared-decision encounters.

Key Takeaways:

• Switching US FRAX to a race-neutral calculator produces modest (<5%) net changes in treatment eligibility—raising eligibility for Black, Hispanic, and Asian groups and slightly reducing it for White groups.
• Most reclassification occurs in older adults and is smaller when BMD or prior hip/vertebral fracture are used as clinical criteria, limiting population-level impact.