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Development and validation of the Fracture Risk Scale (FRS) that predicts fracture over a 1-year time period in institutionalised frail older people living in Canada: an electronic record-linked longitudinal cohort study
  1. George Ioannidis1,2,
  2. Micaela Jantzi3,
  3. Jenn Bucek3,
  4. Jonathan D Adachi1,2,
  5. Lora Giangregorio4,
  6. John Hirdes3,
  7. Laura Pickard1,2,
  8. Alexandra Papaioannou1,2
  1. 1 Department of Medicine, McMaster University, Hamilton, Ontario, Canada
  2. 2 Geriatric Education and Research in Ageing Sciences Centre, Hamilton, Ontario, Canada
  3. 3 Department of Health Studies and Gerontology, University of Waterloo, Waterloo, Ontario, Canada
  4. 4 Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
  1. Correspondence to Dr George Ioannidis; g.ioannidis{at}


Objectives To develop and validate our Fracture Risk Scale (FRS) over a 1-year time period, using the long-term care (LTC) Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS 2.0).

Design A retrospective cohort study.

Setting LTC homes in Ontario, Canada.

Participants Older adults who were admitted to LTC and received a RAI-MDS 2.0 admission assessment between 2006 and 2010.

Results A total of 29 848 LTC residents were enrolled in the study. Of these 22 386 were included in the derivation dataset and 7462 individual were included in the validation dataset. Approximately 2/3 of the entire sample were women and 45% were 85 years of age or older. A total of 1553 (5.2%) fractures were reported over the 1-year time period. Of these, 959 (61.8%) were hip fractures. Following a hip fracture, 6.3% of individuals died in the emergency department or as an inpatient admission and did not return to their LTC home. Using decision tree analysis, our final outcome scale had eight risk levels of differentiation. The percentage of individuals with a hip fracture ranged from 0.6% (lowest risk level) to 12.6% (highest risk level). The area under the curve of the outcome scale was similar for the derivation (0.67) and validation (0.69) samples, and the scale exhibited a good level of consistency.

Conclusions Our FRS predicts hip fracture over a 1-year time period and should be used as an aid to support clinical decisions in the care planning of LTC residents. Future research should focus on the transformation of our scale to a Clinical Assessment Protocol and to assess the FRS in other healthcare settings.

  • Fracture
  • Prediction Model
  • Resident Assessment Instrument Minimum Data Set Version 2.0
  • Frail Older Adults

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  • Contributors Contributions: GI was responsible for study design, data analysis interpretation and drafting of manuscript, MJ was responsible for study design, data analysis and interpretation and drafting of manuscript. JB, JDA, LG, JH, LP and AP were responsible for study design, data interpretation and critical review of the manuscript. All authors read and approved the final manuscript.

  • Funding The Ministry of Health and Long-Term care through the Ontario Osteoporosis Strategy for Long-Term Care.

  • Disclaimer The funding sources had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review or approval of the manuscript.

  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work (GI, MJ, JB, JH). LG reports personal fees from ICON. AP and LP report grants from Ontario Ministry of Health and Long-Term Care Ontario Osteoporosis Strategy. JDA reports grants and personal fees from Amgen, grants and personal fees from Eli Lilly, personal fees from AgNovos, during the conduct of the study; non-financial support from Osteoporosis Canada, non-financial support from International Osteoporosis Foundation, outside the submitted work.

  • Ethics approval Obtained from the University of Waterloo Office of Research Ethics (ORE no 17045).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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