The break in FRAX: Equity concerns in estimating fracture risk in racial and ethnic minorities.
The break in FRAX: Equity concerns in estimating fracture risk in racial and ethnic minorities.
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DOI：
10.1111/jgs.17316
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发表时间：
2021-09
影响因子：
6.3
通讯作者：
Lee, Richard H.
中科院分区：
文献类型：
--
作者：
Reid, Hadley W.;Selvan, Bharathi;Batch, Bryan C.;Lee, Richard H.
虽然对少数种族和民族的公平照顾一直是医学界长期关注的问题，但Vyas等人最近的《新英格兰医学杂志》文章强调了临床算法的一个子集，这些算法对种族的使用可能会使临床护理中的不平等永久化。1，2这包括美国骨折风险评估工具（FRAX），该工具在西方国家中独一无二，区分了4个种族/民族：高加索人，黑人，西班牙裔和亚洲人。3，4尽管FRAX已成为临床决策的有用工具，当FRAX系统性地低估了非白人人群的风险时，我们看到继续使用FRAX来估计骨折风险和确定骨质疏松症治疗的严重问题。FRAX是由谢菲尔德大学的世界卫生组织代谢性骨病合作中心在通过Meta分析确定了骨折的重要危险因素后开发的，大型观察性队列分析。3该小组确定了不同国家和美国境内不同种族/民族之间骨折风险的差异，导致了单独计算器的开发。在美国，黑人、西班牙裔和亚裔计算器包括与白人计算器相同的变量，但也包含校正因子，导致这些组中计算的骨折风险较低（见表1）。4这些校正因子源自20世纪80年代和90年代过时的队列研究，该研究显示了不同种族和民族的骨折风险差异。[4]种族和民族差异与骨矿物质密度（BMD）的差异有关，因此暗示了可以由种族和民族代表的生物学或遗传学。然而，在医学和社会学中，越来越多的人认为种族/民族是一种社会结构。5因此，种族/族裔并不代表生物差异，而是一种复杂的关系，也包括社会经济、政治、地理和环境因素。我们的结论是，在美国，而不是其他西方国家，FRAX强加的简化论，在临床环境中传播结构性种族主义。
Though equitable care for racial and ethnic minorities has been a longstanding concern in medicine, the Vyas et al.’s recent New England Journal of Medicine article highlighted a subset of clinical algorithms whose use of race may perpetuate inequities in clinical care. 1, 2 This includes the US Fracture Risk Assessment Tool (FRAX) which, uniquely among Western countries, differentiates among 4 racial/ethnic groups: Caucasian, Black, Hispanic, and Asian. 3, 4 Though FRAX has become useful for clinical decision making, we see serious concerns in continuing to use FRAX to estimate fracture risk and determine osteoporosis treatment when it systematically underestimates the risk in non-White populations.FRAX was developed by the World Health Organization Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield after identifying significant risk factors for fracture through meta-analyses of large observational cohorts. 3 The group identified differences in fracture risk across countries and, within the US, across racial/ethnic groups that led to the development of separate calculators. In the United States, the Black, Hispanic and Asian calculators include the same variables as the Caucasian calculator but also incorporate a correction factor which results in lower calculated fracture risk among these groups (See Table 1). 4 These correction factors were derived from outdated cohort studies from the 1980s and 1990s, which showed a differential fracture risk by race and ethnicity. 4 Racial and ethnic differences have been associated with differences in bone mineral density (BMD) and thus by implication with biology or genetics that can be proxied by race and ethnicity. However, there is an increasing consensus in both medicine and sociology that race/ethnicity is a social construct. 5 As such, race/ethnicity does not represent biological difference, but a complex relationship also comprised of socioeconomic, political, geographic, and environmental factors. We conclude that the reductionism imposed by FRAX in the US, and no other Western nation, propagates structural racism in the clinical setting.
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