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As part of our series to highlight bias in clinical formulas, we are featuring a commonly used assessment tool employed in predicting what patients may be at risk for developing osteoporosis with a risk of future bone fractures. From the research done by our clinical team, it appears the Fracture Risk Assessment Tool (FRAX) and other related osteoporosis screening tools can further inequities and perpetuate bias.

Each year, there are more than two million osteoporosis-related fractures in the United States, leading to more than 19 billion dollars in healthcare costs. To help providers identify what patients may be at an increased risk for fracture the FRAX calculator can be used to help to determine an individual’s risk for osteoporosis and the probability of future fractures. Bone density, age, gender, lifestyle, and prior injuries are a few factors considered when calculating a FRAX score. In the U.S., race, and ethnicity are also used to calculate a FRAX score.

Studies show that the FRAX calculator returns a lower fracture risk for Asian, Black, or Hispanic women compared with White women with the same risk factors. Different geographical and ethnic minority populations are presumed to have varied relative risks for fracture based on epidemiological data. Studies show these populations are less likely to be screened for osteoporosis than other populations, and when shown to be at risk, they are also less likely to receive additional screening and medications aimed at slowing loss of bone density and preventing fractures. Studies have also found that doctors may be more likely to order and prescribe pain medication for White individuals compared to Black individuals, even when the symptoms are identical, attributed to implicit bias. These differences in care can lead to worse outcomes for minority patients and delay intervention with osteoporosis therapy.

There are several other potential sources of racial bias in fracture risk assessment tools. First, these tools are based on data from predominantly White populations using older data samples. Also, these tools do not consider other important risk factors and their causes that are more commonly observed in minorities. Downstream effects of systemic inequities such as differences in obesity rates, and vitamin D deficiency also contribute to differences in bone density.

While there is no easy solution to addressing racial bias, educating clinicians and all healthcare workers is important so they can consider all factors (e.g., nutrition and genetics) during osteoporosis screenings and treatment. This can also help clinicians treat all patients appropriately, regardless of race. Additionally, the Truity health equity platform enables care teams to provide multi-level interventions for diverse populations by exposing these clinical biases in real time at the point of care.

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