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Calculated Risk: fracture assessment · 'Bone Up'

0:00
Hello and welcome to Bone Up, the podcast all about bones.
0:06
How we make them, why we break them and if we fully understand them.
0:10
I'm David Armstrong.
0:11
Hi, and I'm Richie Abel and over this series we're going to be exploring osteoporosis,
0:17
bones, what we know and what we yet to discover and we hope you will join us on the journey.
0:24
So for anyone keen to learn more about our infrastructure of calcified collagen, this
0:29
is Bone Up.
0:57
So hello again, it's great to be back for the difficult second podcast.
1:02
I'm delighted to hear we have some listeners out there.
1:06
Richie, we haven't been talking to ourselves entirely so far.
1:10
The numbers are looking good, David.
1:12
So far we've got about 370 downloads in the first 30 days and we've had listeners in six
1:20
continents which is amazing.
1:23
South America, South America, Europe, Asia, Australasia and Africa.
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That's really great.
1:30
It's good to be able to take people on the journey with us through osteoporosis.
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Hopefully we're going to get a lot.
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Yeah, and one of the things is, you know, that we've really good feedback, people asking
1:42
questions, people asking us to cover different topics and people responding even to things
1:46
that we talked about in the first episode.
1:50
So we had a rough idea of what we wanted to cover in some of our next few episodes.
1:57
We have moved that about a bit to try to be more responsive, I think, to the feedback
2:02
we've had so far.
2:04
And I think we can reassure people that if you have something you really want to hear
2:08
about, do keep listening and we will get round to it eventually.
2:13
Slowly we'll work our way through it.
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And I think we have a really, really good start today.
2:18
We're starting off with perhaps an unusual topic today and that is talking about risk.
2:24
Risk is something we hear about a lot, the risk of catching coronavirus, the risk of
2:28
getting side effects from the vaccine for coronavirus.
2:33
Risk is a big subject in terms of business, in terms of government and in terms of science.
2:38
And risk is a big part of osteoporosis and risk is a big part of deciding on treatment
2:46
on osteoporosis.
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And in the first episode you heard us talk about a thing called a fracture risk assessment
2:53
or a FRAX.
2:55
I suspect that many people listening to this episode of the podcast will have had a fracture
3:01
risk assessment and perhaps already been offered a treatment on the back of that risk assessment.
3:09
When do people have a fracture risk assessment?
3:12
Well, that's a good question and really they can have fracture risk assessment at any time.
3:22
We talked, I think, in the first episode about us going on a journey through osteoporosis.
3:28
And for many patients it will feel for them as well that they are going on a journey.
3:33
And the fracture risk assessment really can happen at any time on that journey, but it's
3:37
probably true to say that the earlier it happens, the better.
3:43
Most people, the diagnosis of osteoporosis will come as a shock to them.
3:49
The diagnosis, of course, properly should come from a DEXA scan, according to the World
3:54
Health Organization.
3:57
Whereas the management of the condition, and that is the choice of drugs or whether to
4:03
treat people with drugs or not, is based more on their fracture risk assessment.
4:08
Now that can be carried out in primary care.
4:11
And I know many of the GPs who refer patients into me now use the online tool from the University
4:17
of Sheffield to do a fracture risk assessment for the patient.
4:21
There's no reason why a patient themselves cannot access that tool on the internet as
4:25
well.
4:27
Everyone who comes into secondary care, and certainly everyone who attends the fracture
4:32
liaison service that I run at the hospital here, will have a FRAX score calculated, usually
4:39
actually by the fracture liaison nurse when they come to the clinic.
4:44
But what I find is patients are sometimes still a little in shock that they have fractured.
4:49
They're in shock that they have osteoporosis.
4:51
And I have to explain to them at that stage that I'm using the FRAX to guide them towards
4:58
the best management.
5:00
It's not something that I use as a figure by itself, but it's something I try to share
5:07
with the patient and say to them that this is giving us an idea of how we should best
5:12
treat you.
5:16
I guess a question that people might have now is, what does the fracture risk assessment
5:20
include?
5:21
Yeah, well, the fracture risk assessment is a calculation based on what are called independent
5:29
risk factors.
5:30
I know I mentioned this in the first episode, but if you had 10 people in a room, you could
5:37
ask them to divide themselves in two.
5:42
You could say those whose parent has fractured a hip, you go and stand on the right side
5:46
of the room.
5:48
Those whose parents didn't fracture a hip, you go and stand on the left.
5:51
And then all those who stood on the right side of the room would have a higher risk
5:55
of having a fracture themselves than those on the left.
5:59
If you then got everyone together again in the middle and said, I now want those who
6:03
are current smokers to go and stand on the right, and those who don't smoke or have never
6:08
smoked go and stand on the left.
6:10
And again, you could point to those on the right and say, you will be at an increased
6:14
risk of fracture in your lifetime.
6:18
Now if you're thinking you don't want to come to one of my parties, Richie, if this is the
6:21
sort of games that we play, you'd maybe be justified in thinking that.
6:25
I'll come to your party, David.
6:27
But at the end of an exciting evening, what I like to do then is say to my guests, those
6:32
of you who spent most of the evening on the right side of the room, I can tell without
6:37
even doing a DEXA scan, I can tell that you are at a much higher risk of fracture than
6:42
those of my friends who spent most of their evening on the left side of the room.
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And at a very simple level, the FRAC score is a complicated calculation to really put
6:54
a figure onto that process.
6:59
And what you get is a figure for your risk of having a major osteoporotic fracture or
7:07
having a hip fracture specifically over the next 10 years.
7:12
So David, what are the main questions you ask when you deliver a FRAC for a patient?
7:20
Assessing if you've had a previous fracture yourself, if your parent fractured a hip,
7:24
if you're a smoker, if you take glucocorticoids or certainly if you take a reasonable dose
7:30
for any length of time, if you have rheumatoid arthritis, if you have a range of secondary
7:37
causes of osteoporosis or secondary contributors to osteoporosis, such as an early menopause,
7:43
celiac disease, other malabsorption syndromes.
7:48
If you take excessive amounts of alcohol.
7:51
And in fact, it also includes height and weight because we know people who are very underweight
7:56
have an increased risk of low bone density and fracture as well.
8:00
David, how are the results of the FRAC assessment expressed and how do you explain them to the
8:07
patient?
8:08
There's an algorithm that can be put together and produce a score at the end of all that.
8:15
But the score has to be put in context for patients.
8:18
So simply to say to someone you have a 20% risk of let's say fracturing your hip in the
8:25
next 10 years, that has to be explained in the context of whether that's high or low
8:32
for someone of their age and indeed what we can do to reduce that with medication.
8:40
And your answer there, I think neatly brings us on to our interview guest today.
8:46
We have Professor Eugene Mikoski from Sheffield University.
8:50
And this interview is a real coup.
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Eugene is huge in the bone world.
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He was a key member of the team that created the FRAC tool, which we've been talking about
9:00
today.
9:01
Over to you, David.
9:06
We're delighted to welcome our first guest for the episode, indeed our first guest for
9:10
the series, Professor Eugene Mikoski.
9:14
Welcome to the podcast, Eugene.
9:17
Thank you very much, David.
9:18
It's a real pleasure to be here.
9:19
Welcome to the Calcified Collagen Club.
9:22
Your virtual membership card will be in the post.
9:25
Good, good.
9:28
Would you like just initially to sort of set out for us, you're a medical doctor, you see
9:32
patients, but you also are heavily involved in research.
9:37
You have your hand on the rudder of the good ship FRAC.
9:41
I've just thought of that metaphor.
9:42
So if you want to discard it, then feel free to do so.
9:46
But could you initially just set out for us sort of what your role is, what your job is,
9:50
what you do day to day?
9:52
Yeah.
9:53
So I'm a specialist in metabolic bone diseases.
9:58
So that means that I'm a failed GP, a failed rheumatologist and a failed endocrinologist.
10:05
So I started out wanting medicine to be a GP, fell in love with bones and calcium very
10:13
early in my career, did some rheumatology and endocrinology and then specialize in metabolic
10:18
bone diseases.
10:19
And so I started really working in the field of metastatic bone disease and the spread
10:24
of cancer to bone.
10:27
And then it became quite clear that the real burden of disease was in this disease of osteoporosis.
10:32
And so in my day to day clinical practice, I see patients with osteoporosis, but with
10:37
a whole range of other metabolic bone diseases.
10:41
And that the nice thing was that I was able to combine that clinical career with a research
10:46
career, having sort of landed almost accidentally in Sheffield, where there was a huge interest
10:51
in bone research.
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And my career arose from there.
10:56
So it's really just a combination of trying to see and manage patients as best we can,
11:02
but also to try and feed into how we might do things better in the future.
11:08
It's very interesting how you said you did a little rheumatology and a little endocrinology
11:12
and then ended up as a bone specialist.
11:15
I think that's probably fuel for another episode in the future, whether or not it's possible
11:20
to specialize as a bone expert in the UK.
11:24
But what we really would like to hear from you today is more about fracts.
11:30
We talked about this a little in our first episode, how that we use the dexascanner to
11:36
diagnose osteoporosis.
11:39
But if our dexascanner is broken for the day, then there's all these other risk factors
11:43
we can use to assess someone's actual risk of fracture and the concept of being able
11:48
to put those together to produce some sort of a fracture risk.
11:53
So could you give us some idea just of how fracts was developed and maybe what the idea
12:00
was behind it?
12:02
OK, the background to fracts really is, gosh, it's almost 25 years old now.
12:11
And this was back in the late 1990s when the World Health Organization was looking at what
12:19
was happening in the field of communicable diseases and looking towards the future.
12:24
And they realized that many of the communicable diseases were coming under control.
12:28
And I would have to say that in the middle of the biggest pandemic for the last 100 years.
12:34
But they felt that communicable diseases were coming under control and that the future burden
12:39
of disease globally would be in non-communicable diseases.
12:43
And they had a look at diseases that they could have an interest in.
12:47
And they identified osteoporosis as one of those areas because the burden of fractures
12:51
was high, particularly in developing countries or developed countries, but was going to become
12:57
increasingly high in developing countries in the future.
13:00
So what they wanted to do was to have a mechanism by which doctors and nurses working in various
13:07
health care settings around the world could undertake a fairly simple assessment of someone's
13:12
fracture risk that could be conducted if we had the luxury of access to a bone density
13:17
scanner or it could be conducted in the absence of that access.
13:21
And it would enable risk assessment through fairly simple, easily captured clinical risk
13:26
factors.
13:27
So it was that desire to have that such a tool that led to many years of work around
13:34
various meta-analyses of different risk factors and things that brought together the FRACS
13:39
tool as it is today.
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And of course, it's a living tool.
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So we continue to tweak at it and we will continue to work on it to change it in the
13:49
future as well.
13:51
Could you tell us how many times FRACS has been used?
13:57
Well that's a good question.
13:59
And the answer is I don't know.
14:02
Because the FRACS questionnaire is available in paper formats, it's available in iPhone
14:08
formats and it's available, the most common use that I'm familiar with of course is on
14:12
the website, the FRACS website.
14:15
And we launched it in 2008 and it only occurred to us in 2011 that it would be quite interesting
14:22
to put a counter on the website.
14:24
So we started counting in 2011 and there's just under 35 million calculations since 2011
14:34
on the website.
14:35
We can look at it through other things such as Google Analytics and in Google Analytics
14:39
we don't count calculations, we count visits.
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And there we get about 2.8, 2.9 million visits per year.
14:48
So it's getting reasonably well used.
14:50
Yeah, it's a fantastic tool and it's used I think around the world.
14:56
One of the things that occurs to people I suppose when they're using it day to day is
15:01
just how the different risk factors are weighted in the algorithm.
15:08
Could you give us a little background into how that was developed or how you and your
15:14
colleagues went about weighting the different risk factors?
15:18
Yeah, so it would be interesting to see how we'd develop such a tool today compared to
15:26
how we did it 20 years ago.
15:27
But it was really based on the first thing was what were the candidate risk factors and
15:32
that was really driven by the clinical and scientific community as to what we thought
15:36
the risk factors were.
15:38
And then it was really a matter of getting access to cohorts where we could explore these
15:44
risk factors because we wanted it to be globally applicable.
15:49
So we wanted to know that a risk factor could perform equally well in Japan, as in Australia,
15:56
as in North America, as in Europe and so on.
15:59
We wanted to explore how those risk factors interacted with each other.
16:04
We wanted to have access to data sets that would allow us to adjust one risk factor for
16:08
all the other risk factors that might be present in that individual.
16:11
So it took quite a lot of time.
16:14
Also with the goal of trying to keep it simple because these things should be easily asked
16:18
in a GP surgery anywhere in the world or a primary care facility anywhere in the world.
16:24
So that was really the construct that we brought together, all these risk factors.
16:29
We built a database that allowed us to adjust each risk factor for all the other risk factors
16:34
and that really drove the coefficients that came about.
16:37
And of course, you would recognize that there are some strong risk factors and there are
16:41
some weak risk factors.
16:44
And a weak risk factor, for example, would be smoking or alcohol intake.
16:50
And a strong risk factor would be having broken a bone already or being on glucocorticoid
16:55
medications or one of the strong risk factors is really the parental history of hip fracture.
17:01
That really affects about nine or 10% of the population, but there's a pretty strong risk
17:06
factor.
17:07
I suppose a question that springs to mind is, why does the FRAX tool use 10 years as
17:12
the timeframe for risk?
17:14
Yeah, that's a good question and an increasingly asked question.
17:19
And I think whenever we first put it together, we partly looked at what was happening in
17:24
other disease areas.
17:27
So the cardiovascular world were a little bit ahead of us in terms of risk calculators
17:32
and they were using 10 year risk predictions.
17:36
And that seemed intuitive to us because we would be looking at maybe giving a treatment
17:42
over a four or five, six year term at least to modify fracture risk.
17:47
So knowing your fracture risk in the longer term, if you call 10 years long term, seemed
17:52
an attractive thing to do.
17:55
It's also about the numbers.
17:57
So the risk over a longer time is higher than the risk over a shorter time.
18:02
Just that's a natural fact of the mathematics.
18:06
So expressing risk over a short period of time just generates a lower number.
18:12
And then it comes down to how patients understand risk.
18:17
But generally, if you give them a low number for an event that means they either have to
18:21
change their lifestyle or take a treatment to modify that risk, the lower the number
18:25
is, the less likely they are to react to that advice.
18:31
So that was really why it was over 10 years at that time.
18:36
How well do patients understand the fracture risk prediction calculated over 10 years?
18:45
That's again a good question that we haven't really done specific research into.
18:50
There has been research done in other areas with other risk assessments and expressed
18:54
to patients over short periods, one year, five years, 10 years.
19:01
And the feedback from those sort of studies is that generally the patients prefer the
19:04
longer time interval because the number is bigger.
19:07
It's something that they can get their head around much more easily than the smaller number
19:13
over a shorter time frame.
19:15
So we haven't looked at it specifically with FRACS.
19:19
But it really comes down to whether you think 10 years is long term or in the concept of
19:24
life remaining lifetime risk, whether it's actually a short term after all.
19:31
That reminds me of something my granny once said.
19:34
I remember when I was about 16, I asked her why it was that every year seems to go quicker
19:39
than the last year.
19:41
She replied, when you get to my age, every decade goes quicker than the last decade.
19:45
Yes, yes.
19:47
Now that's, and that's said to us a lot in our clinics and with increasing age, we all
19:54
appreciate that even more.
19:57
So I think it's remaining lifetime is an important concept.
20:03
And the older we get, remaining lifetime becomes more important.
20:07
It's something we're hoping to talk to Zoe Paskins about later on in this episode, but
20:11
she has done some specific work on communicating risk to patients.
20:16
So it's a very interesting area.
20:21
Once a patient has had the initial risk assessment with FRACS, is it possible to use the FRACS
20:27
tool for monitoring bone health or treatment outcomes?
20:32
The short answer to that is no.
20:35
And the tool was never really designed to be a monitoring tool because when you think
20:40
about it, there's a relatively small number of risk factors in there.
20:45
And then what can you change with the treatment?
20:48
So we can't make you younger.
20:51
We could stop your glucocorticoids if that was part of the management strategy.
20:55
And for example, the epidemiological data would say that risk reverses to some extent.
21:01
But really the things that we're doing with the treatments that we're giving are to change
21:04
your BMD.
21:07
And monitoring BMD actually seems a much more direct measure of response to treatment.
21:13
And in some cases, some of us would say actually responsive biochemical markers as an even
21:19
better acute measure of response to bisphosphonate treatments or response to anabolic treatments
21:25
than even BMD is.
21:27
So we don't encourage its use as a marker of response to treatment because, as I say,
21:34
your risk will tend to go up anyway as you get older and you tend to collect other risk
21:39
factors which are independent of the treatment that we're giving.
21:48
It's great to be able to sort of see behind the curtain a bit into the development of
21:52
FRACS and the thinking of how FRACS works.
21:56
I mean, I suppose there's a couple of questions that regular users of FRACS always ask and
22:03
it would be remiss of me not to ask them.
22:06
Of you today, Eugene, I mean, one of them I suppose is the, what you might call the
22:12
weaker areas of it or the patients for whom we calculate a FRACS and then we come away
22:18
and maybe don't even present it to the patient because we know it's not as good for that
22:24
patient.
22:25
So what I'm talking about, for example, is the patient who says, I have two sisters and
22:29
they've both fractured a hip and my brother's got osteoporosis.
22:34
And I know I would like to include that as a strong family history for that patient,
22:39
but I can't because it's not a parental hip fracture.
22:44
Or for example, the patient who has fractured a wrist once 10 years ago compared with the
22:49
patient who has had six vertebral fractures in the last few months.
22:54
And yet those are sort of equally weighted in FRACS.
23:00
And those are areas which obviously come up as weaker.
23:05
Those obviously occur to you when it was developed.
23:09
Oh, for sure.
23:11
You know, this is the limitation of every single tool in medicine.
23:15
I think you can only build a tool on the information that's available to you.
23:19
And then it comes down to us as clinicians and nurses and other healthcare professionals
23:24
to apply the art of medicine to the science.
23:28
And so, for example, you know, we would love to have had information on siblings and hip
23:33
fracture risk and other risks, but we just don't have access to that sort of information.
23:38
What I tend to do in my practice is that I illustrate the potential impact of including
23:44
that risk factor.
23:45
So I will say, you know, okay, your two sisters have broken their hip, but I can't put that
23:52
into the model, but I can show you what it would look like if your mum had broken her
23:55
hip.
23:56
And it gives you an illustration of the uplift in the risk that might come because of that
24:01
family history that's there.
24:03
So I think I use it in a sort of illustrative way rather than an artistic way, if you like,
24:10
rather than a scientific way.
24:12
You know, that's, I was going to say that's such a reassuring thing to hear you say, because
24:20
I think many of us in the osteoporosis community will do that sort of thing, but wouldn't have
24:25
admitted it on air before.
24:27
But now as the man, I go for the shit metaphor again, the man with his hand on the rudder
24:32
of the good shit frax has admitted that he sometimes does that.
24:36
I think we will all feel maybe happier at using exactly that sort of thing, saying this
24:41
is what it is.
24:42
But you know, if we were able to include that, then it would change differently.
24:46
So yeah, that's...
24:47
Yeah, no, I think that's, as I say, you can apply that to any tool that's out there for
24:52
cardiovascular disease or for diabetes and so on, because there's always limitations
24:56
in the data.
24:57
And what we want to do is I think we always want that sort of combination of what we think
25:02
is right for the individual patient in front of us.
25:05
But the nice thing about these tools is that they sometimes make us step back a little
25:09
bit and think, well, maybe that risk isn't as high as I thought it was going to be.
25:13
It doesn't fit my preconceptions, or maybe it's much higher than I thought it was going
25:17
to be.
25:18
And maybe I'm taking an action that I wouldn't have planned otherwise.
25:21
So I think the interaction between us as users and the tool is really an important one.
25:27
Of course, there are some patients for which you don't need frax.
25:30
So when someone says to me about the patient with six vertical fractures, I never look
25:35
at frax in that setting because that patient needs treatment and it's just really a choice
25:40
for me.
25:41
How can I treat them best?
25:43
What's the sequence of therapy that I'm going to use?
25:46
How can I monitor a response in that individual rather than what their frax assessment will
25:51
be?
25:52
So I think we just need to remember that tools such as frax are never the complete gatekeeper
25:59
into management pathways for individual patients sitting in front of us.
26:04
Which brings me right nicely, I suppose, to the last main question, and that is about
26:08
future developments of frax.
26:12
If they are happening and if they were to happen, which areas would you be looking to
26:19
develop?
26:20
Yeah, so they are happening.
26:23
I guess all along we've been sort of adding to the tool by adding in new countries and
26:30
new epidemiology from different countries and we'll continue to do that.
26:35
But we're frequently reminded, as you mentioned earlier, in the limitations, we're frequently
26:38
reminded about the lack of falls input to the tool and other limitations as well that
26:46
we openly acknowledge.
26:48
So there's a desire on our part to include easily captured further clinical risk factors
26:54
and to update the coefficients that we have for the existing risk factors because they
26:59
might change over time with further information as well.
27:03
So really that just comes down to collecting lots more cohorts and the nice thing is that
27:09
the number of cohorts that have become available over the last 20 years or so, well certainly
27:14
13 years since we launched frax, is that there's a lot more information out there.
27:19
There's a lot more information on men and risk factors for osteoporosis than there were
27:24
back in the early 2000s.
27:27
So we're in the process of just pulling that all together and we have a substantial, I
27:33
mean the lovely thing is that we have a lovely collaboration with all these various cohorts
27:36
from all around the world who provide the individual level data that will allow us in
27:42
meta-analysis to adjust for all these different risk factors.
27:47
The key ones I think are falls.
27:50
I think we have to address falls in one way or another.
27:53
We tried to address it in the original frax but the question around falls was only present
27:58
in a small number of the cohorts available to us and it was asked in different ways over
28:02
different timeframes.
28:03
Have you fallen in the last week?
28:05
Have you fallen in the last year?
28:06
Have you fallen?
28:07
And that impacts on the prevalence wildly.
28:11
So we hope to be able to look at falls.
28:14
We know that falls are already captured to some extent by frax because most fractures
28:20
involve a fall.
28:21
So if you had a fracture that's already put some sort of fall input to it.
28:25
If you're 10 years older, we know your falls risk has gone up, that age captures some of
28:30
that falls risk but we want to really refine that and make it an individual data entry
28:36
point if possible.
28:38
Other things like diabetes, particularly type 2 diabetes, lots of information coming through
28:43
on that and the secondary causes basket in frax was something that we took a really conservative
28:51
approach to.
28:52
So rheumatoid arthritis was a standalone disease for entry as a variable because there was
28:58
pretty good evidence back in the 2000s that rheumatoid arthritis had a risk of fracture
29:03
that was independent of glucocorticoid use and was independent of BMD.
29:08
For all the other secondary causes, we made the assumption that most of their risk is
29:12
mediated by their impact on BMD.
29:15
So once I know your BMD, the disease itself didn't carry any additional weight and that
29:20
was a really conservative position to take.
29:24
And again, we hope to be able to look at other diseases, including type 2 diabetes and see
29:28
how we can include those, maybe not in the secondary causes box, but make them standalone
29:33
entry variables in the tool.
29:37
Your achievement in delivering frax and improving so many people's lives is absolutely incredible.
29:46
How does it feel to have been able to do that?
29:53
Very fortunate.
29:55
I mean, you have to be in the right place at the right time.
30:00
So I was fortunate enough to work with some brilliant people who had visions that inspired
30:07
me and got me involved in research.
30:10
And as I say, the bone research team in Sheffield was fantastic through people like John Canis,
30:17
Graham Russell and Richard Eastl and others.
30:20
So it was really a great environment to work within.
30:25
The fact that we've had a clinically applicable tool is really just a wonderful thing.
30:31
And it really still amazes me that we are in a position now where as experts, we used
30:36
to tot up in our heads, oh, that risk factor increases the risk and the addition of that
30:41
risk factor I know will increase the risk, but I couldn't put a number on it.
30:45
I couldn't have a magnitude for it.
30:48
And for us to be able to do that now and for GPs to be able to do that and for other health
30:52
care professionals to be able to do that, to allow them to make decisions and routine
30:56
daily clinical practice is just I think it's just been very fortunate to be part of that
31:01
team.
31:03
And we hope to continue to improve it.
31:07
That's wonderful.
31:08
It's been really interesting talking to you today, Eugene.
31:10
We really appreciate you coming on.
31:13
And you have given us some genuine insights and not even one or two clinical pointers
31:17
as well to how we should use FRACS.
31:20
Perhaps you would come on in the future at some point and talk to us about other interesting
31:25
things that you do.
31:27
No, that'd be absolutely a pleasure.
31:30
And it's really it's really good to be able to talk about these things in sort of this
31:35
sort of setting.
31:36
So thanks very much for the invitation.
31:39
Thank you very much for joining us, Eugene.
31:41
You set a very high bar for the rest of our podcast series.
31:46
You can edit that bit out.
31:50
OK, thank you very much.
31:54
Thank you very much indeed.
31:56
So Richie, I'm interested here because I'm someone who uses FRACS every day.
32:02
As I said earlier, it's like my stethoscope as an osteoporosis specialist using FRACS.
32:08
You're someone who comes from more of a distance to it as a bone research scientist and as
32:14
a specialist in the science of bone.
32:17
What did you learn about FRACS or predicting the chances of patients fracturing?
32:25
I learned a lot from today's chat with Eugene.
32:28
I suppose to give some background on this.
32:31
The reason why I wanted to start doing this podcast with you is so that I could learn
32:37
more about the diagnostics and fracture risk assessments in clinical practice, because
32:42
I hope that maybe one day my research is going to feed in and improve those measurements
32:49
and help to prevent fractures.
32:51
And I've always found DEXA and FRACS a bit confusing.
32:55
It's really hard to understand how they work.
32:59
And really, Eugene was the most important interview that I wanted to do.
33:05
And the thing that I really took away today generally is that FRACS is a very personalized
33:11
way of doing medicine that allows the clinician perhaps to communicate with the patient on
33:17
a very personal level and to tell them what's wrong with their bones and maybe how effective
33:24
treatments might be in preventing new fractures.
33:28
And the other thing I learned today is just how well used FRACS is.
33:36
I think that Eugene says they've got what, 2.5 million FRACS calculated a year, and that
33:42
is the lower estimate, and maybe 35 million hits a year on the website.
33:47
I didn't realize that FRACS was such a global tool.
33:52
And I suppose the thing that I was most pleased to hear about today is that FRACS is a really
34:00
wonderful tool for helping people to take positive action in their lives.
34:05
That the tool can be used to guide patients, guide people towards treatments or lifestyle
34:14
changes or supplements or vitamins, whatever the intervention might be, to improve their
34:19
bone health.
34:21
And I know we're going to talk about some of those things in future episodes.
34:27
You're the doctor who uses this every day.
34:29
At the beginning of this episode, we got your view on FRACS, and clearly you're very knowledgeable
34:34
about it.
34:36
Today was your chance to talk to the creator of FRACS as well.
34:40
I wondered, what did you learn today?
34:45
I think anyone who uses FRACS anywhere in the world will be excited to hear that there
34:51
are developments planned.
34:54
I think anyone who has an inquisitive mind and gets any new tool or machine, once you
35:00
get over the initial excitement of using it, you wonder how it works, and then you start
35:05
to wonder if you could improve it.
35:07
And it was very exciting to hear Eugene saying today that there are improvements planned.
35:15
On a day to day basis, one of the weaknesses of FRACS, I suppose, if you could call it
35:21
that, was this inability to incorporate family history other than hip fracture into it.
35:30
And I was really interested to hear how Eugene dealt with that, because what we have are
35:39
many patients for whom family history is really important in their fracture risk.
35:47
In some patients that manifests as their parent fracturing a hip.
35:53
And if that's the case, then we can tick the family history box or the parental hip fracture
35:57
box and that moves that patient's personal FRACS score up quite a bit.
36:05
If it hasn't manifested by their parent fracturing a hip, if maybe they have three siblings who
36:10
fracture a hip, then it doesn't get included in FRACS.
36:14
And we, as day to day users, can come away a little disappointed feeling we haven't been
36:19
able to really represent to the patient the risk we feel that they're at.
36:24
And it was really good to hear Eugene explaining how he can reconcile those two things by saying
36:32
to the patient, you appear to have a family history.
36:38
We don't have the data to give you an exact figure because your family history has been
36:45
manifested, for example, in your siblings.
36:47
But if that family history had been manifested, for example, by your mother breaking her hip,
36:53
here's the score that you would have got.
36:55
I can't tell you that's exactly your score, but it gives you some idea of the level of
36:59
concern I have for you because of your family history.
37:04
And I thought that's a very clever way, a very nice way of being true to the data and
37:09
saying to the patient, we don't have the data for siblings or for cousins or for uncles
37:14
or aunts or grandparents, but we do have the data for parents.
37:19
And it's just a nice way of including family history in the calculation while being true
37:24
to the data.
37:25
So that's, again, one thing that I will take away that will probably influence my day to
37:29
day practice and indeed I can see myself in the clinic within the next week using exactly
37:35
that tool for patients.
37:38
That's such an amazing outcome from today's interview.
37:42
And I suppose it's time to draw this episode to a close.
37:46
My mam listened to the first episode and she said to me, Richie, keep it short and bite
37:51
size.
37:55
So I'm going to take her advice.
37:57
I've really enjoyed doing this episode with you and I look forward to seeing you again,
38:02
David.
38:03
Yeah, looking forward to the next episode.
38:04
Bye bye, everyone.
38:05
Bye, bye, everyone.
38:28
you