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The utility of BMD Z-score diagnostic thresholds for secondary causes of osteoporosis

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Abstract

Summary

This very large dual X-ray absorptiometry (DXA) cohort confirmed a significant, inverse relationship between bone mineral density (BMD) Z-scores and the presence of secondary causes of osteoporosis but receiver operating characteristic (ROC) curves indicate that Z-score diagnostic thresholds (such as −2.0) discriminate poorly between the presence and absence of secondary causes of osteoporosis.

Introduction

BMD Z-score diagnostic thresholds have been proposed to detect secondary causes of osteoporosis. To determine the sensitivity and diagnostic utility of such thresholds, we analyzed comprehensive BMD and personal health information data from a large, multispecialty group practice.

Methods

Adult subjects were assigned their lowest axial BMD Z-score and ICD-9 diagnosis codes for secondary causes of osteoporosis when cited at least twice in their electronic medical record. Multiple logistic regression was used to model the prevalence of matching ICD-9 codes as a function of Z-score. ROC curves were used to investigate various Z-score cut points for sensitivity and specificity.

Results

Eighteen thousand six hundred seventy-four subjects were analyzed. Secondary causes of osteoporosis were identified in 31% of men and 16% of women. The frequency of secondary causes varied with age and between genders and varied inversely with Z-score. No inflection point was observed in this relationship to suggest a useful clinical decision threshold. The difference in mean Z-score of those with and without a secondary cause of osteoporosis was biologically slight (±0.3). Low Z-score diagnostic thresholds were insensitive to the presence of secondary causes of osteoporosis and provided relatively poor predictive value.

Conclusions

This DXA cohort confirmed a significant inverse relationship between Z-score and the presence of secondary causes of osteoporosis but diagnostic Z-score thresholds discriminate poorly between the presence and absence of secondary causes of osteoporosis. If only patients with very low Z-scores are evaluated for secondary causes of osteoporosis the diagnostic specificity may be high but most cases will be missed.

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Conflicts of interest

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Authors and Affiliations

  1. Center for Bone Disease, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI, USA

    F. E. McKiernan

  2. Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI, USA

    R. L. Berg & J. G. Linneman

Authors
  1. F. E. McKiernan
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  2. R. L. Berg
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  3. J. G. Linneman
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Corresponding author

Correspondence to F. E. McKiernan.

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Grant support

Marshfield Medical Research Foundation

Appendices

Appendix A

Table 5

Table 5 Comprehensive list of clinical conditions associated with secondary osteoporosis listed by diagnostic groups
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Appendix B

Table 6

Table 6 Short list of common clinical conditions associated with secondary osteoporosis listed by diagnostic groups
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McKiernan, F.E., Berg, R.L. & Linneman, J.G. The utility of BMD Z-score diagnostic thresholds for secondary causes of osteoporosis. Osteoporos Int 22, 1069–1077 (2011). https://doi.org/10.1007/s00198-010-1307-1

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  • DOI: https://doi.org/10.1007/s00198-010-1307-1

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