Dear Editor,

We read with great interest the article by Korthoewer and Chandran [1], in which the authors presented physicians’ attitudes regarding osteoporosis management in general and more specifically with respect to utilization of the WHO Fracture Risk Assessment Tool (FRAX®) in the Asia-Pacific region. In Table 2, they showed the proportion of physicians in each country who had an awareness of FRAX, as well as the percentage who used the tool in practice. Some readers must be curious as to the reason for the low usage despite the fact that all of the respondents from Korea and Brunei were aware of the FRAX tool. We suggest that there are other considerations.

The number of participants from Brunei and Korea was only two and one, respectively, which is too small to permit generalization of the results to the broader population. As such, the reasons for the lack of utilization of the tool in practice should be reevaluated before widespread adoption throughout Asia-Pacific.

Ha et al. recently surveyed members of the Korean Society for Bone and Mineral Research (KSBMR) regarding contemporary issues, including use of the FRAX tool [2]. Their survey showed that most respondents in Korea (88 %) were aware of the tool, and that approximately 20 % of these participants also used the tool in their practice. The most common reasons for lack of use were “too busy and hence lack of time to perform a FRAX calculation” 76 %, followed by the “feeling that the FRAX tool was not applicable to their practice” 13 %.

A second factor to consider is the reimbursement system established by the Korean government. Reimbursement guidelines for osteoporosis treatment not yet include fracture risk assessment techniques such as FRAX, and currently require assessment of bone mineral density (BMD) using dual X-ray absorptiometry (DXA). According to the recent International Osteoporosis Foundation (IOF) audit, Korea has the highest number of DXA machines among all Asian countries 24.5 machines per one million population (http://www.iofbonehealth.org/sites/default/files/media/PDFs/Regional%20Audits/2013-Asia_Pacific_Audit-Rep_Korea_0_0.pdf) These are two possible reasons for the low FRAX utilization rates in Korea.

Although we do not know the exact situation in Brunei, there may be other similar or unique considerations.

We suggest, therefore, that the status of osteoporosis management should be evaluated individually within each country, given that situations and circumstances may vary across the Asia-Pacific region.