Calcified Tissue International

, Volume 79, Issue 4, pp 199–206 | Cite as

Application of a Triage Approach to Peripheral Bone Densitometry Reduces the Requirement for Central DXA but is not Cost Effective

  • Elizabeth J. Harrison
  • Judith E. Adams
Clinical Investigations


A method proffered for the interpretation of measurements from peripheral dual energy X-ray absorptiometry (pDXA) is a triage approach to stratify patients into one of three risk categories; (i) high-treat, (ii) medium-refer for central DXA and (iii) low-reassure. The aim of this study was to apply the triage approach to measures from peripheral scanners and risk indices and stratify patients into one of three risk categories (i), (ii) or (iii). 207 post-menopausal women had central DXA from which they were categorised as non-osteoporotic or osteoporotic. Additional peripheral scans of the left calcaneus were performed on three scanners (GE Lunar Achilles and PIXI, McCue CubaClinical). From demographic details four risk indices were calculated and algorithms combining measures from peripheral scanners and one risk index were obtained. All peripheral measures, risk indices and combination algorithms were good at identifying women at risk of osteoporosis (ROC areas: 0.67–0.82). Each tool stratified varying numbers of osteoporotic and non-osteoporotic women into each risk category using the triage approach. One combination algorithm (PIXI & osteoporosis indices of risk (OSIRIS)) performed best by minimising misclassification (10% non-osteoporotic, 10% osteoporotic) and reducing requirement for central DXA to 36%. However the cost of implementing the triage approach for PIXI & OSIRIS was greater (263%) than central DXA (100%) scanning all women. Although the triage approach was an effective tool at identifying women at risk of osteoporosis the unnecessary treatment of non-osteoporotic women in the high risk category make it impractical. Therefore an alternative more cost-effective method has been suggested.


Peripheral dual energy X-ray absorptiometry (pDXA) Quantitative ultrasound (QUS) Risk indices Triage application 


  1. 1.
    Compston JE, Cooper C, Kanis JA (1995) Fortnightly Review: Bone densitometry in clinical practice. BMJ 310:1507–1510PubMedGoogle Scholar
  2. 2.
    National Osteoporosis Society. Position statement on the use of peripheral X-ray absorptiometry in the management of osteoporosis (2004) Bath, EnglandGoogle Scholar
  3. 3.
    Koh LKH, Ben Sedrine W, Torralba TP, Kung A, Fujiwara S, Chan SP, Huang QR, Rajatanavin R, Tsai KS, Park HM, Reginster JY (2001) A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int 12:699–705PubMedCrossRefGoogle Scholar
  4. 4.
    Cadarette SM, Jaglal SB, Kreiger N, McIssac 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
  5. 5.
    Cadarette SM, McIsaac WJ, Hawker GA, Jaakkimainen L, Culbert A, Zarifa G, Ola E, Jaglal SB (2004) The validity of decision rules for selecting women with primary osteoporosis for bone mineral density testing. Osteoporos Int 15:361–366PubMedCrossRefGoogle Scholar
  6. 6.
    Richy F, Gourlay M, Ross PD, Sen SS, Radican L, De Ceulaer F, Ben Sedrine W, Ethgen O, Bruyere O, Reginster JY (2004) Validation and comparative evaluation of the osteoporosis self-assessment tool (OST) in a Caucasian population from Belgium. QJM 97:39–46PubMedCrossRefGoogle Scholar
  7. 7.
    Sedrine WB, Chevallier T, Zegels B, Kvasz A, Micheletti MC, Gelas B, Reginster JY (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
  8. 8.
    Lydick E, Zimmerman SI, Yawn B, Love B, Kleerekoper M, Ross P, Martin A, Holmes R (1997) Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL). J Bone Miner Res 12:456–463PubMedCrossRefGoogle Scholar
  9. 9.
    Pearson J, Dequeker J, Henley M, Bright J, Reeve J, Kalender W, Lavaljeantet AM, Ruegsegger P, Felsenberg D, Adams J, Birkenhager JC, Braillon P, Curiel MD, Fischer M, Galan F, Geusens P, Hyldstrup L, Jaeger P, Jonson R, Kalefezras J, Kotzki P, Kroger H, Vanlingen A, Nilsson S, Osteaux M, Cano RP, Reid DM, Reiners C, Ribot C, Schneider P, Slosman DO, Wittenberg G (1995) European Semi-Anthropomorphic Spine Phantom for the Calibration of Bone Densitometers - Assessment of Precision, Stability and Accuracy - the European Quantitation of Osteoporosis Study- Group. Osteoporos Int 5:174–184PubMedCrossRefGoogle Scholar
  10. 10.
    Looker A, Wahner H, Dunn W, Calvo M, Harris T, Heyse S, Johnston C, Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8:468–489PubMedCrossRefGoogle Scholar
  11. 11.
    WHO Study group (1984). Assessment of fracture risk and its implication to screening for postmenopausal osteoporosis. WHO Technical Report. Volume 843. GenevaGoogle Scholar
  12. 12.
    Harrell F (1996) Regression coefficients and scoring rules. J Clin Epidemiol 49:819PubMedCrossRefGoogle Scholar
  13. 13.
    Moons K, Harrell F, Steyerberg E (2002) Should scoring rules be based on odds ratios or regression coefficients? J Clin Epidemiol 55:1054–1055PubMedCrossRefGoogle Scholar
  14. 14.
    Mellström D, Sörenson O, Goemaere S, Roux C, Johnson T, Chines A (2004) Seven yeasr of treatment with risedronate in women with post-menopausal osteoporosis. Calcif Tissue Int 75:462–468PubMedCrossRefGoogle Scholar
  15. 15.
    Bone H, Hosking D, Devogelaer J-P, Tucci J, Emkey R, Tonino R, Rodriguez-Portales J, Downs R, Gupta J, Santora A, Liberman U (2004) Ten years’ experience with alendronate for osteoporosis in post-menopuausal women. N Engl J Med 350:1189–1199PubMedCrossRefGoogle Scholar
  16. 16.
    All Party Parlimentary Group (APPOG) December 2004. Falling short: Delivery integrated falls and osteoporosis services in EnglandGoogle Scholar
  17. 17.
    Miller CG, Herd RJM, Ramalingam T, Fogelman I, Blake GM (1993) Ultrasonic Velocity-Measurements through the Calcaneus - Which Velocity Should Be Measured. Osteoporos Int 3:31–35PubMedCrossRefGoogle Scholar
  18. 18.
    Blake GM, Chinn DJ, Steel SA, Patel R, Panayiotou E, Thorpe J, Fordham JN (2005) A list of device-specific thresholds for the clinical interpretation of peripheral x-ray absorptiometry examinations. Osteoporos Int 16:2149–2156PubMedCrossRefGoogle Scholar
  19. 19.
    Cook R, Collins D, Tucker J, Zioupos P (2005) Comparison of questionnaire and quantitative ultrasound techniques as screening tools for DXA. Osteoporos Int 16:1565–1575PubMedCrossRefGoogle Scholar
  20. 20.
    Garton M, Cooper C, Reid DM (1997) Perimenopausal bone density screening- will it help prevent osteoporosis? Maturitas 26:35–43PubMedCrossRefGoogle Scholar
  21. 21.
    Marin F, Lopez-Bastida J, Diez-Perez A, Sacristan JA, Investigators. EDSG (2004) Bone mineral density referral for dual energy X-ray absorptiometry using quantitative ultrasound as a prescreening tool in postmenopausal women from the general population: A cost effectiveness analysis. Calcif Tissue Int 74:277–283PubMedCrossRefGoogle Scholar
  22. 22.
    Richy F, Ethgen O, Bruyere O, Mawet A, Reginster JY (2004) Primary prevention of osteoporosis: mass screening scenario or pre-screening with questionnaires? An economic perspective. J Bone Miner Res 19:1955–1960PubMedCrossRefGoogle Scholar
  23. 23.
    van der Voort DJM, Brandon S, Dinant GJ, van Wersch JWJ, (2000) Screening for osteoporosis using easily obtainable biometrical data: diagnostic accuracy of measured, self-reported and recalled BMI, and related costs of bone mineral density measurements. Osteoporos Int 11:233–239PubMedCrossRefGoogle Scholar
  24. 24.
    Sedrine BW, Broers P, Devogelaer JP, Depresseux G, Kaufman JM, Goemaere S, Reginster JY (2002) Interest of a prescreening questionnaire to reduce the cost of bone densitometry. Osteoporos Int 13:434–442PubMedCrossRefGoogle Scholar
  25. 25.
    Anonymous (1998) Osteoporosis: review of the evidence for prevention, diagnosis and treatment and cost-effectiveness analysis. Osteoporos Int 8 Suppl 4:S7–S80Google Scholar
  26. 26.
    Sim M, Stone M, Phillips C, Cheung W, Johansen A, Vasishta S, Pettit R, Evans WD (2005) Cost effectiveness analysis of using quantitative ultrasound as a selective pre-screen for bone densitometry. Technol Health Care 13:75–85PubMedGoogle Scholar
  27. 27.
    Abbott T, Mucha L, Manfredonia D, Schwartz E, Berger M (1999) Efficient patient identification strategies for women with osteoporosis. J Clin Densitom 2:223–230PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  1. 1.Clinical Radiology, Imaging Science and Biomedical EngineeringThe University of ManchesterManchesterUK

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