ORIGINAL ARTICLE
Performance of four clinical screening tools to select peri- and
early postmenopausal women for dual X-ray absorptiometry
B. Rud Æ J. E. B. Jensen Æ L. Mosekilde Æ S. P. Nielsen
J. Hilden Æ B. Abrahamsen
Received: 1 June 2004 / Accepted: 25 August 2004 / Published online: 30 September 2004
Ó International Osteoporosis Foundation and National Osteoporosis Foundation 2004
Abstract Several methods to select postmenopausal
women for dual X-ray absorptiometry (DXA) have been
proposed. We decided to compare the performance of
three clinical decision rules (SCORE, ORAI, OST) with
the usual case-finding strategy based on the presence of a
major risk factor for future fracture (CFMRF). The
study subjects were 2009 healthy, white, peri- or early
postmenopausal women participating in the Danish
Osteoporosis Prevention Study (DOPS). DXA results
expressed as T-scores and scores on SCORE, ORAI,
OST and CFMRF were extracted from the DOPS
database. First, we evaluated the screening tools as
originally described by the developers. The resulting
sensitivities and specificities ranged from 18% to 92%
and from 66% to 85%, respectively. Only OST achieved
a high sensitivity (92%) with respect to femoral neck
T-score £ )2.5; however, the sensitivity with respect to
lumbar spine T-score £ )2.5 was only 51%. Next, the
performance of the screening tools was evaluated against
T-score £ )2.0 (and T-score £ )2.5) in at least one of
the regions: femoral neck, total hip or lumbar spine.
Using ROC curve analysis, we determined cut-offs
yielding sensitivities as close as possible to 90%. The
CFMRF and the ORAI tool were too coarse to yield
90% sensitivity. The performances of OST and SCORE
were equal from a clinical perspective in that the sensi-
tivities and the specificities varied from 89% to 94% and
from 23% to 28%, respectively. The performance of
CFMRF was no better than could be expected by
chance, yielding a sensitivity of 19% and a specificity of
85%. Applying SCORE or OST 75% of the women
would have to be referred for densitometry to identify
90% of the women with T-score £ )2.0 (or T-score
£ )2.5) in at least one region. In conclusion, our results
question the utility of all the evaluated tools for
screening peri- and early postmenopausal women for
low BMD. However, if a decision on referral has to be
made, it may be based on the simple OST rule, which
performed as well as or better than any of the other
tools.
Keywords Decision support techniques Æ
Densitometry X-ray Æ Mass screening Æ Osteoporosis,
postmenopausal Æ Practice guidelines Æ Sensitivity
and specificity
Introduction
Dual X-ray absorptiometry (DXA) is recommended by
several guidelines when postmenopausal women present
with a major clinical risk factor for future fracture
[1,2,3]. Although there is controversy regarding the
importance of some risk factors, consensus exists for risk
factors such as fragility fractures after the menopause, a
family history of osteoporosis or fractures, low body
mass index (BMI), treatment with systemic glucocor-
ticoids, early menopause and diseases associated with
low bone mineral density (BMD) [4]. However, only a
few small studies have validated the accuracy with which
this case-finding strategy identifies women with low
Osteoporos Int (2005) 16: 764–772
DOI 10.1007/s00198-004-1748-5
B. Rud (&) Æ J. E. B. Jensen
Osteoporosis Unit 545, Department of Endocrinology,
Hvidovre University Hospital, Kettegaard Alle
´
30,
2650 Hvidovre, Denmark
E-mail: bo.rud@hh.hosp.dk
Tel.: +45-23664065
Fax: +45-36323640
L. Mosekilde
Department of Medicine and Endocrinology,
Aarhus University Hospital, Aarhus, Denmark
S. P. Nielsen
Department of Diagnostic Imaging, Hilleroed Hospital,
Hilleroed, Denmark
J. Hilden
Department of Biostatistics, Faculty of Health Sciences,
Panum Institute, Copenhagen, Denmark
B. Abrahamsen
Department of Endocrinology, Odense University Hospital,
Odense, Denmark