Osteoporosis International

, Volume 15, Issue 5, pp 361–366

The validity of decision rules for selecting women with primary osteoporosis for bone mineral density testing

  • Suzanne M. Cadarette
  • Warren J. McIsaac
  • Gillian A. Hawker
  • Liisa Jaakkimainen
  • Alison Culbert
  • Gihane Zarifa
  • Ebele Ola
  • Susan B. Jaglal
Original Article

Abstract

The purpose of this study was to determine the validity of the Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST) chart and equation, and a criterion based on body weight for identifying women with asymptomatic primary osteoporosis. Prospective recruitment and chart abstractions from family practices of three University affiliated hospitals were completed for women aged 45 years or more with baseline bone mineral density (BMD) testing results by dual energy X-ray absorptiometry. Those taking bone active medication other than hormone therapy, with prior fragility fracture or with risk factors for secondary osteoporosis were excluded. Women were categorized as being normal, osteopenic or osteoporotic by lowest BMD T-score at either the femoral neck or lumbar spine (L1–L4). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve to identify those with osteoporosis were determined for each decision rule. The positive predictive value (PPV) for detecting osteoporosis after using a second cut point to convert each decision rule into a risk index (low, moderate or high risk) was also determined. The sensitivity of the decision rules to identify women with osteoporosis ranged from 92% to 95% and specificity from 35% to 46%. The area under the ROC curves were significantly better for the ORAI (0.80), OST chart (0.82) and OST equation (0.82) compared with the body weight criterion (0.73). PPV for detecting osteoporosis ranged from 30% to 58% among women deemed at high risk. These data confirm the validity of the ORAI, the OST chart and the OST equation as screening tools for BMD testing. Further evidence is required to confirm the validity of the body weight criterion.

Keywords

Decision aids Osteoporosis Screening Sensitivity Specificity Women 

References

  1. 1.
    Genant HK, Cooper C, Poor G et al. (1999) Interim report and recommendations of the World Health Organization task-force for osteoporosis. Osteoporos Int 10:259–264CrossRefPubMedGoogle Scholar
  2. 2.
    US Preventive Services Task Force (2002) Screening for osteoporosis in postmenopausal women: Recommendations and rationale. Ann Int Med 137:526–528PubMedGoogle Scholar
  3. 3.
    Brown JP, Josse RG, for the Scientific Advisory Council of the Osteoporosis Society of Canada (2002) 2002 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167:S1–S34PubMedGoogle Scholar
  4. 4.
    Sambrook PN, Seeman E, Phillips SR, Ebeling PR (2002) Preventing osteoporosis: outcomes of the Australian fracture prevention summit. Med J Aust 176:S1–S16PubMedGoogle Scholar
  5. 5.
    Nelson HD, Helfand M, Woolf SH, Allan JD (2002) Screening for postmenopausal osteoporosis: a review of the evidence for the US Preventive Services Task Force. Ann Int Med 137:529–541PubMedGoogle Scholar
  6. 6.
    Bates DW, Black DM, Cummings SR (2002) Clinical use of bone densitometry: clinical applications. JAMA 288:1898–1900CrossRefPubMedGoogle Scholar
  7. 7.
    Irwig L, Bossuyt P, Glasziou P, Gatsonis C, Lijmer J (2002) Designing studies to ensure that estimates of test accuracy are transferable. BMJ 321:669–671CrossRefGoogle Scholar
  8. 8.
    McGinn TG, Guyatt GH, Wyer PC et al. (2000) Users’ guides to the medical literature. XXII: How to use articles about clinical decision rules. JAMA 284:79–84CrossRefPubMedGoogle Scholar
  9. 9.
    Cadarette SM, Jaglal SB, Kreiger N et al. (2000) Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ 162:1289–1294PubMedGoogle Scholar
  10. 10.
    Michaëlsson K, Bergström R, Mallmin H et al. (1996) Screening for osteopenia and osteoporosis: selection by body composition. Osteoporos Int 6:120–126PubMedGoogle Scholar
  11. 11.
    Koh LKH, Ben Sedrine W, Torralba TP et al. (2001) A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int 12:699–705CrossRefPubMedGoogle Scholar
  12. 12.
    Sedrine WB, Chevallier T, Zegels B et al. (2002) Development and assessment of the Osteoporosis Index of Risk (OSIRIS) to facilitate selection of women for bone densitometry. Gynecol Endocrinol 16:245–250PubMedGoogle Scholar
  13. 13.
    Lydick E, Cook K, Turpin J et al. (1998) Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care 4:37–48PubMedGoogle Scholar
  14. 14.
    Weinstein L, Ullery B (2000) Identification of at-risk women for osteoporosis screening. Am J Obstet Gynecol 183:547–549Google Scholar
  15. 15.
    Geusens P, Hochberg MC, van der Voort DJM et al. (2002) Performance of risk indices for identifying low bone density in postmenopausal women. Mayo Clin Proc 77:629–637PubMedGoogle Scholar
  16. 16.
    Fujiwara S, Masunari N, Suzuki G, Ross PD (2001) Performance of osteoporosis risk indices in a Japanese population. Curr Ther Res 62:586–594CrossRefGoogle Scholar
  17. 17.
    Cadarette SM, Jaglal SB, Murray TM et al. (2001) Evaluation of decision rules for referring women for bone densitometry by dual-energy X-ray absorptiometry. JAMA 286:57–63CrossRefPubMedGoogle Scholar
  18. 18.
    National Osteoporosis Foundation (2003) Physician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington D.C.Google Scholar
  19. 19.
    World Health Organization (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO, GenevaGoogle Scholar
  20. 20.
    Canadian Task Force on the Periodic Health Examination (1994) The Canadian guide to clinical preventive health care. Minister of Supply & Services Canada, OttawaGoogle Scholar
  21. 21.
    NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy (2001) Osteoporosis prevention, diagnosis, and therapy. JAMA 285:785–795PubMedGoogle Scholar
  22. 22.
    American College of Obstetricians and Gynecologists Committee on Gynecologic Practice (2002) Bone density screening for osteoporosis. Obstet Gynecol 99:523–525CrossRefPubMedGoogle Scholar
  23. 23.
    Cummings SR, Bates D, Black DM (2002) Clinical use of bone densitometry: scientific review. JAMA 288:1889–1897CrossRefPubMedGoogle Scholar
  24. 24.
    Jaglal SB, Carrol J, Hawker G et al. (2003) How are family physicians managing osteoporosis? Qualitative study of their experiences and educational needs. Can Fam Phy 49:462–468Google Scholar
  25. 25.
    Davis DA, Thomson MA, Oxman AD, Haynes RB (1995) Changing physician performance: a systematic review of continuing medical education strategies. JAMA 274:700–705CrossRefPubMedGoogle Scholar
  26. 26.
    Williams MI, Petkov VI, Johnson SL et al. (2003) Applying the Osteoporosis Self-Assessment Tool (OST) in primary care practices uncovers osteoporosis in men: Preliminary report [abstract]. J Bone Miner Res 18:s154Google Scholar
  27. 27.
    Adler RA, Tran MT, Petkov VI (2003) Performance of the osteoporosis self-assessment screening tool for osteoporosis in American men. Mayo Clin Proc 78:723–727PubMedGoogle Scholar
  28. 28.
    Hochberg MC, Tracy JK, van der Klift M, Pols H (2002) Validation of a risk index to identify men with an increased likelihood of osteoporosis (abstract). J Bone Miner Res 17:s231Google Scholar
  29. 29.
    Kmetic A, Joseph L, Berger C, Tenenhouse A (2002) Multiple imputation to account for missing data in a survey: estimating the prevalence of osteoporosis. Epidemiology 13:437–444CrossRefPubMedGoogle Scholar
  30. 30.
    Ross PD (1997) Clinical consequences of vertebral fractures. Am J Med 103:30s–43sPubMedGoogle Scholar
  31. 31.
    Fletcher RH, Fletcher SW, Wagner EH (1996) Clinical epidemiology: the essentials, 3rd edn. Williams & Wilkins, BaltimoreGoogle Scholar
  32. 32.
    Laupacis A, Sekar N, Stiell IG (1997) Clinical prediction rules: a review and suggested modifications of methodological standards. JAMA 277:488–494CrossRefPubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Authors and Affiliations

  • Suzanne M. Cadarette
    • 1
    • 2
  • Warren J. McIsaac
    • 3
    • 4
  • Gillian A. Hawker
    • 1
    • 2
    • 5
  • Liisa Jaakkimainen
    • 3
    • 6
    • 7
  • Alison Culbert
    • 3
    • 7
  • Gihane Zarifa
    • 3
    • 4
  • Ebele Ola
    • 3
    • 4
  • Susan B. Jaglal
    • 1
    • 2
    • 8
  1. 1.Department of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
  2. 2.Osteoporosis Research Program, Women’s College Ambulatory Care CentreSunnybrook and Women’s College Health Sciences CentreTorontoCanada
  3. 3.Department of Family and Community MedicineUniversity of TorontoTorontoCanada
  4. 4.Mount Sinai Family Medicine CentreTorontoCanada
  5. 5.Division of Rheumatology, Women’s College Ambulatory Care CentreSunnybrook and Women’s College Health Sciences CentreTorontoCanada
  6. 6.Institute for Clinical Evaluative Sciences in OntarioTorontoCanada
  7. 7.Department of Family and Community MedicineSunnybrook and Women’s College Health Sciences CentreTorontoCanada
  8. 8.Graduate Department of Rehabilitation ScienceUniversity of TorontoTorontoCanada

Personalised recommendations