A clinical decision rule to enhance targeted bone mineral density testing in healthy mid-life women

• Published in: Osteoporosis international 2012-07, Vol.23 (7), p.1931-1938
• Main Authors: Hawker, G., Mendel, A., Lam, M. A., Akhavan, P. S., Cancino-Romero, J., Waugh, E., Jamal, S., Mian, S., Jaglal, S.
• Format: Article
• Language: English
• Subjects: Absorptiometry, Photon - methods; Adult; Age; Bone density; Bone Density - physiology; Bone loss; Bone mass; Bone mineral density; Decision Support Techniques; Dual energy X-ray absorptiometry; Endocrinology; Female; Fractures; Humans; Inventories; Medical tests; Medicine; Medicine & Public Health; Middle age; Middle Aged; Original Article; Orthopedics; Osteoporosis; Osteoporosis - diagnosis; Osteoporosis - etiology; Osteoporosis - physiopathology; Osteoporosis, Postmenopausal - diagnosis; Osteoporosis, Postmenopausal - etiology; Osteoporosis, Postmenopausal - physiopathology; Post-menopause; Postmenopause - physiology; Predictive Value of Tests; Premenopause - physiology; Regression analysis; Rheumatology; Risk assessment; Risk Factors; Self-assessment; Unnecessary Procedures; Women
• ISSN: 0937-941X; 1433-2965
• DOI: 10.1007/s00198-011-1862-0

Summary The rates of bone mineral density testing for osteoporosis among healthy mid-life women are high, although their osteoporosis or fracture risk is low. To reduce unnecessary testing, we created and evaluated a tool to guide bone density testing based on the woman’s age, weight, fracture history, and menopausal status. Introduction This study aims to improve case finding of mid-life women with low bone mass on bone mineral density (BMD) assessment. Methods Among healthy women aged 40–60 years having their first BMD test, osteoporosis risk factors were assessed by questionnaire and BMD by dual-energy X-ray absorptiometry. The combination of risk factors that best discriminated women with/without low bone mass (T-score ≤ −2.0) was determined from the logistic regression model area under the curve (AUC) and internally validated using bootstrapping. Using the model odds ratios, a clinical prediction rule was created and its discriminative properties assessed and compared with that of the osteoporosis self-assessment tool (OST). Sensitivity analyses examined results for pre-/peri- and post-menopausal women, separately. Results Of 1,664 women referred for baseline BMD testing, 433 with conditions known to be associated with bone loss were excluded. Of 1,231 eligible women, 944 (77%) participated and 87 (9.2%) had low bone mass (35 pre-/peri- and 52 post-menopausal). Four risk factors for low bone mass were identified and incorporated into a clinical prediction rule. Selecting women for BMD testing with weight of ≤70 kg or any two of age >51, years’ post-menopause of ≥1, and history of fragility fracture after age 40 was associated with 93% sensitivity to identify women with low bone mass, compared with 47% sensitivity for an OST score of ≤1 (AUC 0.75 versus OST AUC 0.69, p  = 0.04). Results restricted to post-menopausal women were similar. Conclusions Among healthy mid-life women receiving a baseline BMD test, few had low bone mass, supporting the need for guidance about testing. A prediction rule with four risk factors had improved sensitivity over the OST. Further validation is warranted.