An additional limitation is that the incidence rates of hip fracture were derived from the year 2004/2005 and were therefore not completely up to date. Unfortunately, Dutch national hip fracture data are no longer reliable after 2005. Due to a change in law, Dutch hospitals are no longer required to record their hospitalization rates by ICD9 code and send them to the national registry [9]. In order to overcome this limitation,

a future study has been designed, in which hip fracture rates will be updated by linkage of various Dutch epidemiological registries. A third limitation of FRAX in general is that it makes no use of several other important clinical risk factors for fracture (such as previous vertebral fractures, a history of falls, vitamin D deficiency, and use of psychotropic drugs) [10, Ralimetinib see more 11, 18, 46, 47]. Although the model does take prior fractures into account, the number and recency of these fractures have not been included as predictors in the model, because of the lack of data available in the construct cohorts [19], but they probably are important. For instance, a Dutch retrospective cohort study showed that the incidence of new clinical fractures was higher among patients who had sustained multiple baseline fractures, when compared to those who

had sustained only a single fracture at baseline [48]. In addition, in the FRAX ® model, current use of oral glucocorticoids was not specified by cumulative or daily dose, which may be more accurate to use in order Tau-protein kinase to predict osteoporotic fractures [49, 50]. To overcome this limitation, a recent

study has shown a methodology to adjust conventional FRAX estimates of hip and osteoporotic fracture probabilities based on knowledge of the daily glucocorticoid dose in an individual patient [51]. The FRAX model assumes that the weight of each clinical risk factor on the risk of death and fracture is the same as that derived from the cohorts used in the construction of FRAX rather than on empirical data from the Dutch population. In the absence of national data, the assumption is reasonable, particularly since the weight of the clinical risk factors has been validated in an international perspective [6]. Finally, in contrast to the UK, cost-effectiveness has not been evaluated in the Netherlands, using FRAX® as a decision tool for BMD MCC950 in vitro assessment or to start drug treatment [36]. Therefore, it is currently unclear at which fracture risk threshold interventions (such as BMD measurement or treatment with calcium and bisphosphonate) should be recommended in the Netherlands. Furthermore, fracture risk estimation by FRAX is limited to treatment-naive patients only. In conclusion, this paper describes the development of the Dutch FRAX model. This tool allows the estimation of 10-year absolute risks of hip and osteoporotic fracture in Dutch residents.