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Testing a theoretical model of imminent fracture risk in elderly women: an observational cohort analysis of the Canadian Multicentre Osteoporosis Study



We examined the underlying relationship between fracture risk factors and their imminent risk. Results suggested that having past year fracture, worse past year general health, worse past year physical functioning, and lower past year BMD T-score directly predicted higher imminent fracture risk. Past year falls indirectly predicted imminent risk through physical functioning and general health.


This study aimed to examine direct and indirect effects of several factors on imminent (1 year) fracture risk.


Data from women age 65 and older from population-based Canadian Multicentre Osteoporosis Study were used. Predictors were identified from study years 5 and 10, and imminent fracture data (1-year fracture) came from years 6 and 11 (year 5 predicts year 6, year 10 predicts year 11). A structural equation model (SEM) was used to test the theoretical construct. General health and physical functioning were measured as latent variables using items from the 36-Item Short Form Health Survey (SF-36) and bone mineral density (BMD) T-score was a latent variable based on observed site-specific BMD data (spine L1-L4, femoral neck, total hip). Observed variables were fractures and falls. Model fit was evaluated using root mean square error of approximation (RMSEA), Tucker Lewis index (TLI), and comparative fit index (CFI).


The analysis included 3298 women. Model fit tests showed that the SEM fit the data well; χ2(172) = 1122.10 < .001, RMSEA = .03, TLI = .99, CFI = .99. Results suggested that having past year fracture, worse past year general health, worse past year physical functioning, and lower past year BMD T-score directly predicted higher risk of fracture in the subsequent year (p < .001). Past year falls had a statistically significant but indirect effect on imminent fracture risk through physical functioning and general health (p < .001).


We found several direct and indirect pathways that predicted imminent fracture risk in elderly women. Future studies should extend this work by developing risk scoring methods and defining imminent risk thresholds.

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    Note, the terms “direct effect” and “indirect effect” are standard terms used in SEM to describe the relationship between variables. If a relationship is observed “directly” between two variables it is a “direct effect”. If a relationship is mediated by one or more variables, it is an “indirect effect.” The term “effect” is not intended to suggest a causal relationship.


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This study was funded by Amgen Inc. and UCB Pharma. Sponsors of CaMos have included Actavis, Amgen Inc., the Arthritis Society, the Canadian Institutes of Health Research (CIHR), Dairy Farmers of Canada, Merck, Eli Lilly, Novartis, P&G, Sanofi-Aventis, and Servier.

Author information

Study design: AP, JDA, YJ, RB, and DG. Data collection: AP, JDA, CB, TPA, KSD, DAH, GI, SMK, CSK, WDL, SNM, JCP, TT, and DG. Data analysis: JSM and RJW. Data interpretation: all authors. Drafting manuscript outline: AP and JDA. Writing support: YJ, JSM, and RJW. Revising manuscript: all authors. Approving final version of manuscript: all authors.

Correspondence to Y. Jiang.

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Conflicts of interest

AP receives grants and speaking honoraria from Amgen Inc. JDA receives grants, consulting fees, and speaking honoraria from Amgen Inc. YJ was an employee of Amgen Inc. when the submitted work was conducted and is presently an associate professor with Sun Yat-sen University School of Public Health (Shenzhen). RB is an employee of Amgen Inc. and holds stocks of Amgen Inc. JSM is an employee of Vector Psychometrics Group, LLC. RJW is an employee of Vector Psychometrics Group, LLC. DAH receives speaking honoraria from Amgen Inc. and has been a local principal investigator for a multinational clinical trial sponsored by Amgen Inc. SMK receives consulting fees from Amgen Inc., Merck, Eli Lilly, speaking honoraria from Amgen Inc., Merck, Sanofi, and has been a clinical trial investigator of studies sponsored by Amgen Inc., Eli Lilly, and Merck. SNM receives grants from Amgen Inc. and Merck & Co., Inc. TT receives consulting fees from Amgen Inc. DG receives grants from Amgen Inc. and Eli Lilly & Co. and consulting fees from Amgen Inc. CB, TPA, KSD, GI, CSK, WDL, and JCP claim no conflicts of interests.

Ethical approval

For this type of study, formal consent is not required. The submitted work is a post hoc analysis of CaMos data. For the primary CaMos study, ethics approval was granted through McGill University and the appropriate research ethics board for each of the 9 participating centers. Signed informed consent was obtained from every study participant in accordance with the Helsinki Declaration.

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Papaioannou, A., Adachi, J.D., Berger, C. et al. Testing a theoretical model of imminent fracture risk in elderly women: an observational cohort analysis of the Canadian Multicentre Osteoporosis Study. Osteoporos Int (2020). https://doi.org/10.1007/s00198-020-05330-2

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  • CaMos
  • epidemiology
  • fracture risk
  • imminent
  • older women
  • osteoporosis