Osteoporosis International

, Volume 16, Issue 11, pp 1353–1362

Osteoporosis case finding in the general practice: phalangeal radiographic absorptiometry with and without risk factors for osteoporosis to select postmenopausal women eligible for lumbar spine and hip densitometry

  • Katharina M. Gasser
  • Christian Mueller
  • Marcel Zwahlen
  • Manfred Kaufmann
  • Gaby Fuchs
  • Romain Perrelet
  • Gilbert Abetel
  • Ulrich Bürgi
  • Kurt Lippuner
Original Article


Mass screening for osteoporosis using DXA measurements at the spine and hip is presently not recommended by health authorities. Instead, risk factor questionnaires and peripheral bone measurements may facilitate the selection of women eligible for axial bone densitometry. The aim of this study was to validate a case finding strategy for postmenopausal women who would benefit most from subsequent DXA measurement by using phalangeal radiographic absorptiometry (RA) alone or in combination with risk factors in a general practice setting. The sensitivity and specificity of this strategy in detecting osteoporosis (T-score ≤2.5 SD at the spine and/or the hip) were compared with those of the current reimbursement criteria for DXA measurements in Switzerland. Four hundred and twenty-three postmenopausal women with one or more risk factors for osteoporosis were recruited by 90 primary care physicians who also performed the phalangeal RA measurements. All women underwent subsequent DXA measurement of the spine and the hip at the Osteoporosis Policlinic of the University Hospital of Berne. They were allocated to one of two groups depending on whether they matched with the Swiss reimbursement conditions for DXA measurement or not. Logistic regression models were used to predict the likelihood of osteoporosis versus “no osteoporosis” and to derive ROC curves for the various strategies. Differences in the areas under the ROC curves (AUC) were tested for significance. In women lacking reimbursement criteria, RA achieved a significantly larger AUC (0.81; 95% CI 0.72–0.89) than the risk factors associated with patients’ age, height and weight (0.71; 95% C.I. 0.62–0.80). Furthermore, in this study, RA provided a better sensitivity and specificity in identifying women with underlying osteoporosis than the currently accepted criteria for reimbursement of DXA measurement. In the Swiss environment, RA is a valid case finding tool for patients with risk factors for osteoporosis, especially for those who do not qualify for DXA reimbursement.


Case finding DXA General practice Postmenopausal osteoporosis Radiographic absorptiometry Risk factors 


  1. 1.
    Melton L, Atkinson E, O’Fallon W, Wahner H, Riggs B (1993) Long-term fracture prediction by bone mineral assessed at different skeletal sites. J Bone Miner Res 8:1227–1233PubMedGoogle Scholar
  2. 2.
    Cummings S, Black D, Nevitt M, et al (1993) Bone density at various sites for prediction of hip fractures: The study of osteoporotic fractures. Lancet 341:72–75CrossRefPubMedGoogle Scholar
  3. 3.
    WHO Study Group (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group, no. 843. WHO, GenevaGoogle Scholar
  4. 4.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312:1254–1259PubMedGoogle Scholar
  5. 5.
    Lydick E, Cook K, Turpin J, Melton M, Stine R, Byrnes C (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
  6. 6.
    Bauer DC, Browner WS, Cauley JA et al (1993) Factors associated with appendicular bone mass in older women. The Study of Osteoporotic Fractures Research Group. Ann Intern Med 118:657–665PubMedGoogle Scholar
  7. 7.
    Thompson PW (2000) A fracture risk profile using single-site bone density assessment and clinical risk factors. J Clin Densitom 3:73–77Google Scholar
  8. 8.
    Ungar WJ, Josse R, Lee S et al (2000) The Canadian SCORE questionnaire: optimizing the use of technology for low bone density assessment. Simple Calculated Osteoporosis Risk Estimate. J Clin Densitom 3:269–280CrossRefPubMedGoogle Scholar
  9. 9.
    O’Neill TW, Cooper C, Cannata JB et al (1994) Reproducibility of a questionnaire on risk factors for osteoporosis in a multicentre prevalence survey: the European Vertebral Osteoporosis Study. Int J Epidemiol 23:559–565Google Scholar
  10. 10.
    Ribot C, Pouilles JM, Bonneu M, Tremollieres F (1992) Assessment of the risk of post-menopausal osteoporosis using clinical factors. Clin Endocrinol (Oxf) 36:225–228Google Scholar
  11. 11.
    Compston JE (1992) Risk factors for osteoporosis. Clin Endocrinol (Oxf) 36:223–224Google Scholar
  12. 12.
    Johnell O (1996) Advances in osteoporosis: better identification of risk factors can reduce morbidity and mortality. J Intern Med 239:299–304CrossRefPubMedGoogle Scholar
  13. 13.
    Kroger H, Tuppurainen M, Honkanen R, Alhava E, Saarikoski S (1994) Bone mineral density and risk factors for osteoporosis—a population-based study of 1,600 perimenopausal women. Calcif Tissue Int 55:1–7Google Scholar
  14. 14.
    Cadarette SM, Jaglal SB, Kreiger N, McIsaac WJ, Darlington GA, Tu JV (2000) Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ 162:1289–1294PubMedGoogle Scholar
  15. 15.
    Geusens P, Hochberg MC, van der Voort DJ et al (2002) Performance of risk indices for identifying low bone density in postmenopausal women. Mayo Clin Proc 77:629–637PubMedGoogle Scholar
  16. 16.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936CrossRefPubMedGoogle Scholar
  17. 17.
    Meunier PJ, Delmas PD, Eastell R (1999) Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. Clin Ther 21:1025–1044CrossRefPubMedGoogle Scholar
  18. 18.
    Benitez CL, Schneider DL, Barrett-Connor E, Sartoris DJ (2000) Hand ultrasound for osteoporosis screening in postmenopausal women. Osteoporos Int 11:203–210CrossRefPubMedGoogle Scholar
  19. 19.
    Fiter J, Nolla JM, Gomez-Vaquero C, Martinez-Aguila D, Valverde J, Roig-Escofet D (2001) A comparative study of computed digital absorptiometry and conventional dual-energy X-ray absorptiometry in postmenopausal women. Osteoporos Int 12:565–569Google Scholar
  20. 20.
    Bouxsein ML, Michaeli DA, Plass DB, Schick DA, Melton ME (1997) Precision and accuracy of computed digital absorptiometry for assessment of bone density of the hand. Osteoporos Int 7:444–449CrossRefPubMedGoogle Scholar
  21. 21.
    Cosman F, Herrington B, Himmelstein S, Lindsay R (1991) Radiographic absorptiometry: a simple method for determination of bone mass. Osteoporos Int 2:34–38Google Scholar
  22. 22.
    Versluis RG, Petri H, Vismans FJ, van de Ven CM, Springer MP, Papapoulos SE (2000) The relationship between phalangeal bone density and vertebral deformities. Calcif Tissue Int 66:1–4Google Scholar
  23. 23.
    Huang C, Ross PD, Yates AJ et al (1998) Prediction of fracture risk by radiographic absorptiometry and quantitative ultrasound: a prospective study. Calcif Tissue Int 63:380–384CrossRefPubMedGoogle Scholar
  24. 24.
    Mussolino ME, Looker AC, Madans JH et al (1997) Phalangeal bone density and hip fracture risk. Arch Intern Med 157:433–438Google Scholar
  25. 25.
    Lippuner K, Fuchs G, Ruetsche AG, Perrelet R, Casez JP, Neto I (2000) How well do radiographic absorptiometry and quantitative ultrasound predict osteoporosis at spine or hip? A cost-effectiveness analysis. J Clin Densitom 3:241–249Google Scholar
  26. 26.
    Yang S, Hagiwara S, Engelke K, et al (1994) Radiographic absorptiometry for bone mineral measurement of the phalanges: precision and accuracy study. Radiology 192:857–859Google Scholar
  27. 27.
    Kleerekoper M, Nelson D, Flynn M, Pawluszka A, Jacobsen G, Peterson E (1994) Comparison of radiographic absorptiometry with dual-energy X-ray absorptiometry and quantitative computed tomography in normal older white and black women. J Bone Miner Res 9:1745–1749Google Scholar
  28. 28.
    Yates A, Ross P, Lydick E, Epstein R (1995) Radiographic absorptiometry in the diagnosis of osteoporosis. Am J Med 98 [Ssuppl 2]:2A–41S.Google Scholar
  29. 29.
    Tothill P (1998) Methods of bone mineral measurement. Phys Med Biol 31:546–550Google Scholar
  30. 30.
    Kalender W (1992) Effective dose values in bone mineral measurements by photon absorptiometry and computed tomography. Osteoporos Int 2:82–87Google Scholar
  31. 31.
    McClung MR, Geusens P, Miller PD et al (2001) Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med. 344:333–340Google Scholar
  32. 32.
    Consensus Development Conference (1993) Diagnosis, prophylaxis and treatment of osteopororosis. Am J Med 94:646–650CrossRefPubMedGoogle Scholar
  33. 33.
    Fogelman I, Ribot C, Smith R, Ethgen D et al (2000) Risedronate reverses bone loss in postmenopausal women with low bone mass: results from a multinational, double-blind, placebo-controlled trial. J Clin Endocrinol Metab 85:1895–900Google Scholar
  34. 34.
    Harris ST, Watts NB, Genant HK, McKeever CD et al (1999) Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. JAMA 282:1344–1352CrossRefPubMedGoogle Scholar
  35. 35.
    Liberman UA Weiss SR, Bröll J, Minne HW et al (1995) Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. N Engl J Med 333:1437–1443CrossRefPubMedGoogle Scholar
  36. 36.
    Black DM, Cummings SR, Karpf DB, Cauley JA et al (1996) Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 348:1535–1541CrossRefPubMedGoogle Scholar
  37. 37.
    Cummings SR, Black DM, Thompson DE, Applegate WB et al (1998) Effect of alendronate on risk of fracture in women with low bone density but without verlebral fractures: results from the Fracture Intervention Trial. JAMA 280:2077–2082CrossRefPubMedGoogle Scholar
  38. 38.
    Black DM, Thompson D, Bauer DC, Ensrud K et al (2000) Fracture risk reduction with alendronate in women with osteoporosis: the Fracture Intervention Trial. J Clin Endocrinol Metab 85:4118–4124CrossRefPubMedGoogle Scholar
  39. 39.
    Chesnut CH, Silverman S, Andriano K, Genant H et al (2000) A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. Am J Med 109:267–276CrossRefPubMedGoogle Scholar
  40. 40.
    Delmas PD, Ensrud KE, Adachi JD, Harper KD et al (2002) Efficacy of raloxifene on vertebral fracture risk reduction in postmenopausal women with osteoporosis: 4-year results from a randomized clinical trial. J Clin Endocrinol Metab 87:3609–3617CrossRefPubMedGoogle Scholar
  41. 41.
    Ettinger B, Black DM, Mitlak BH, Knickerbocker RK et al (1999) Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. JAMA 282:637–645CrossRefPubMedGoogle Scholar
  42. 42.
    Neer RM, Arnaud CD, Zanchetta JR, Prince R et al (2001) Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344:1434–1441CrossRefPubMedGoogle Scholar
  43. 43.
    Lindsay R, Nieves J, Formica C, Henneman E et al (1997) Randomised controlled study of effect of parathyroid hormone on vertebral-bone mass and fracture incidence among postmenopausal women on oestrogen with osteoporosis. Lancet 350:550–555CrossRefPubMedGoogle Scholar
  44. 44.
    Hodson J, Marsh J (2003) Quantitative ultrasound and risk factor enquiry as predictors of postmenopausal osteoporosis: comparative study in primary care. BMJ 326:1250–1251CrossRefPubMedGoogle Scholar
  45. 45.
    Diez-Perez A, Marin F, Vila J, Abizanda M et al (2003) Evaluation of calcaneal quantitative ultrasound in a primary care setting as a screening tool for osteoporosis in postmenopausal women. J Clin Densitom 6:237–245Google Scholar
  46. 46.
    Hernandez JL, Marin F, Gonzalez-Macias J, Diez-Perez A et al (2004) Discriminative capacity of calcaneal quantitative ultrasound and of osteoporosis and fracture risk factors in postmenopausal women with osteoporotic fractures. Calcif Tissue Int 74:357–365Google Scholar
  47. 47.
    Martin JC, Reid DM (1996) Appendicular measurements in screening women for low axial bone mineral density. Br J Radiol 69:234–240Google Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2005

Authors and Affiliations

  • Katharina M. Gasser
    • 1
  • Christian Mueller
    • 1
  • Marcel Zwahlen
    • 2
  • Manfred Kaufmann
    • 1
  • Gaby Fuchs
    • 1
  • Romain Perrelet
    • 1
  • Gilbert Abetel
    • 3
  • Ulrich Bürgi
    • 4
  • Kurt Lippuner
    • 1
  1. 1.Osteoporosis PoliclinicUniversity Hospital of BerneBerneSwitzerland
  2. 2.Department of Social and Preventive MedicineUniversity of BerneBerneSwitzerland
  3. 3.Swiss College of Family PractitionersClinical Research Group of the Swiss Foundation for General MedicineBerneSwitzerland
  4. 4.Department of Internal MedicineUniversity Hospital of BerneBerneSwitzerland

Personalised recommendations