1 School of Medical and Health Sciences, Nutrition & Health Innovation Research Institute, Edith Cowan University, Perth, WA, 6027, Australia. marc.sim@ecu.edu.au.
2 Medical School, The University of Western Australia, Perth, Australia. marc.sim@ecu.edu.au.
3 School of Medical and Health Sciences, Nutrition & Health Innovation Research Institute, Edith Cowan University, Perth, WA, 6027, Australia.
4 Department of Computer Science, Concordia University, Montreal, Canada.
5 Department of Statistics, University of Manitoba, Winnipeg, Canada.
6 Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
7 George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada.
8 Centre for AI&ML, School of Science, Edith Cowan University, Perth, Australia.
9 Department of Computer Science and Software Engineering, The University of Western Australia, Perth, Australia.
10 Medical School,

Abdominal aortic calcification (AAC), a subclinical measure of cardiovascular disease (CVD) that can be assessed on vertebral fracture assessment (VFA) images during osteoporosis screening, is reported to be a falls risk factor. A limitation to incorporating AAC clinically is that its scoring requires trained experts and is time-consuming. We examined if our machine learning (ML) algorithm for AAC (ML-AAC24) is associated with a higher fall-associated hospitalisation risk in the Manitoba Bone Mineral Density (BMD) Registry. A total of 8565 individuals (94.0% female, age 75.7 ± 6.8 years) who had a BMD and VFA image from DXA between February 2010 and December 2017 were included. ML-AAC24 was categorised based on established categories (ML-AAC24 = low < 2; moderate 2 to < 6; high = 6). Cox proportional hazards models assessed the relationship between ML-AAC24 categories and incident fall-associated hospitalisations obtained from linked health records (mean ± SD follow-up, 3.9 ± 2.2 years). Individuals with moderate (9.6%) and high ML-AAC24 (11.7%) had a greater proportion of fall-associated hospitalisations, compared to those with low ML-AAC24 (6.0%). In age and sex-adjusted models, compared to low ML-AAC24, moderate (HR 1.49, 95% CI 1.24-1.79) and high ML-AAC24 (HR 1.89, 95% CI 1.56-2.28) were associated with greater hazards for a fall-associated hospitalisation. Results were comparable (HR 1.37, 95% CI 1.13-1.65 and HR 1.60, 95% CI 1.31-1.95, respectively) after multivariable adjustment, including prior falls and CVD, as well as medication use. Integrating ML-AAC24 into bone density machine software to identify high risk individuals would opportunistically provide important information on fall and cardiovascular disease risk to clinicians for evaluation and intervention.