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PLoS One. 2018 Sep 7;13(9):e0203533. doi: 10.1371/journal.pone.0203533. eCollection 2018.

Fracture risk in type 2 diabetic patients: A clinical prediction tool based on a large population-based cohort.

Author information

GREMPAL Research Group, IDIAP Jordi Gol Primary Care Research Institute, Autonomous University of Barcelona, Barcelona, Spain.
CIBER of Healthy Ageing and Frailty Research (CIBERFes), Instituto de Salud Carlos III, Majadahonda, Spain.
Ambit Barcelona, Primary Care Department, Institut Catala de la Salut, Barcelona, Spain.
Biostatistics Unit at Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
Department of Basic Medical Sciences, Universitat de Barcelona, Barcelona, Spain.
Department of Basic Medical Sciences, Universitat Rovira i Virgili, Reus, Tarragona, Spain.
Musculoskeletal Research Unit, IMIM-Hospital del Mar, Barcelona, Spain.
Oxford National Institute for Health Biomedical Research Centre, University of Oxford, Windmill Road, Oxford, United Kingdom.
Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom.
Centre for Statistics in Medicine (CSM), Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom.
Cancer Prevention and Control Program, Catalan Institute of Oncology-IDIBELL, L'Hospitalet de Llobregat, Spain.
CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.



An increased fracture risk has been described as a complication of Type 2 diabetes mellitus (T2DM). Clinical prediction models for general population have a limited predictive accuracy for fractures in T2DM patients. The aim was to develop and validate a clinical prediction tool for the estimation of 5-year hip and major fracture risk in T2DM patients.


A cohort of newly diagnosed T2DM patients (n = 51,143, aged 50-85, 57% men) was extracted from the Information System for the Development of Research in Primary Care (SIDIAP) database, containing computerized primary care records for >80% of the population of Catalonia, Spain (>6 million people). Patients were followed up from T2DM diagnosis until the earliest of death, transfer out, fracture, or end of study. Cox proportional hazards regression was used to model the 5-year risk of hip and major fracture. Calibration and discrimination were assessed. Hip and major fracture incidence rates were 1.84 [95%CI 1.64 to 2.05] and 7.12 [95%CI 6.72 to 7.53] per 1,000 person-years, respectively. Both hip and major fracture prediction models included age, sex, previous major fracture, statins use, and calcium/vitamin D supplements; previous ischemic heart disease was also included for hip fracture and stroke for major fracture. Discrimination (0.81 for hip and 0.72 for major fracture) and calibration plots support excellent internal validity.


The proposed prediction models have good discrimination and calibration for the estimation of both hip and major fracture risk in incident T2DM patients. These tools incorporate key T2DM macrovascular complications generally available in primary care electronic medical records, as well as more generic fracture risk predictors. Future work will focus on validation of these models in external cohorts.

[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

We have the following interests: DML has received support from FEIOMM (Bone Research Spanish Foundation) for the submitted work; DML has received personal fees from Eli Lilly, Amgen, and Novartis; CT has received lecture and personal fees from Boehringer Ingelheim; CC has received personal fees from Alliance for Better Bone Health, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Les Laboratoires Servier, Takeda and UCB; DPA has received grant support from Amgen, Les Laboratoires Servier, and UCB Pharma SRL related to other projects; DPA has previously consulted for UCB Pharma SRL; DPA has received lecture fees from Amgen; XN, MKJ, VM, ADP, and GSC have nothing to declare. There are no patents, products in development or marketed products to declare. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

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