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BMJ Open. 2019 Apr 3;9(4):e024951. doi: 10.1136/bmjopen-2018-024951.

Predicting fracture risk in patients with chronic obstructive pulmonary disease: a UK-based population-based cohort study.

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Nottingham Respiratory Research Unit, NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, Nottingham, UK.
Institute for Lung Health, University Hospitals of Leicester Glenfield Site, Leicester, UK.



To assess the incidence of hip fracture and all major osteoporotic fractures (MOF) in patients with chronic obstructive pulmonary disease (COPD) compared with non-COPD patients and to evaluate the use and performance of fracture risk prediction tools in patients with COPD. To assess the prevalence and incidence of osteoporosis.


Population-based cohort study.


UK General Practice health records from The Health Improvement Network database.


Patients with an incident COPD diagnosis from 2004 to 2015 and non-COPD patients matched by age, sex and general practice were studied.


Incidence of fracture (hip alone and all MOF); accuracy of fracture risk prediction tools in COPD; and prevalence and incidence of coded osteoporosis.


Cox proportional hazards models were used to assess the incidence rates of osteoporosis, hip fracture and MOF (hip, proximal humerus, forearm and clinical vertebral fractures). The discriminatory accuracies (area under the receiver operating characteristic [ROC] curve) of fracture risk prediction tools (FRAX and QFracture) in COPD were assessed.


Patients with COPD (n=80 874) were at an increased risk of fracture (both hip alone and all MOF) compared with non-COPD patients (n=308 999), but this was largely mediated through oral corticosteroid use, body mass index and smoking. Retrospectively calculated ROC values for MOF in COPD were as follows: FRAX: 71.4% (95% CI 70.6% to 72.2%), QFracture: 61.4% (95% CI 60.5% to 62.3%) and for hip fracture alone, both 76.1% (95% CI 74.9% to 77.2%). Prevalence of coded osteoporosis was greater for patients (5.7%) compared with non-COPD patients (3.9%), p<0.001. The incidence of osteoporosis was increased in patients with COPD (n=73 084) compared with non-COPD patients (n=264 544) (adjusted hazard ratio, 1.13, 95% CI 1.05 to 1.22).


Patients with COPD are at an increased risk of fractures and osteoporosis. Despite this, there is no systematic assessment of fracture risk in clinical practice. Fracture risk tools identify those at high risk of fracture in patients with COPD.


COPD; fracture; fracture risk prediction tool; osteoporosis

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Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare the following: CEB, TMM and JES received an investigator-sponsored study grant from Pfizer for the submitted work; CEB reports grants from MRC/Association of British Pharmaceutical Industry, TSB,GSK and other support from Chiesi and Boehringer, outside the submitted work;JES reports personal fees from Astra Zeneca, Boehringer-Ingelheim, Nutricia,Chiesi, Sandoz, Novartis, Pfizer, MIMS, RCGP, Cogora and other support from PCRS-UK, Education for Health, Teva and NICE, outside the submitted work; and no financial relationship with any organisation that might have an interest in the submitted work in the previous three years, no other relationship or activity that could appear to have influenced the submitted work.

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