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Bone-Mineral Density Assessment: Who Needs It?

As our ability to prevent and treat osteoporosis improves, critical assessment of guidelines for ordering bone-mineral density (BMD) studies is important. These Canadian investigators compared the diagnostic properties of 5 approaches to selecting menopausal women for dual-energy X-ray absorptiometry (DEXA).

Subjects (n=2365) were drawn from a region-stratified random sample of the Canadian population that included menopausal women (age, 45) with a DEXA measurement of the femoral neck. Exclusion criteria included a diagnosis of osteoporosis, hormone therapy for 5 years or longer, current use of bisphosphonates or calcitonin, and risk factors for secondary osteoporosis (not defined by the authors).

The 5 assessed criteria included the National Osteoporosis Foundation guidelines, which are based on age, weight, personal or family history of fracture, and smoking history; a risk score based on race, history of rheumatoid arthritis or fracture, age, estrogen therapy, and weight; 2 distinct assessments based on age, weight, and estrogen use (including the Osteoporosis Risk Assessment Instrument [ORAI]); and a criterion based strictly on body weight.

Compared with the other selection criteria, the ORAI performed the best and was simple to apply. The ORAI is based on age (15 points if aged 75, 9 if 65-74, and 5 if 55-64); weight (9 points if < 60.0 kg, 3 if 60.0-69.9 kg); and estrogen use (2 points for nonuse). The selection cut point is 9 points or greater. The ORAI selected 94 percent of women below the treatment threshold (defined as a T score < -2.0) and 98 percent of those with osteoporosis for BMD assessment, while selecting substantially fewer women with normal BMD (56 percent) than did the other 4 criteria.

Comment: Although DEXA is noninvasive, cost considerations justify validation of screening guidelines. Routine BMD assessment is warranted in peri- and post-menopausal women who have certain clinical characteristics and risk factors, including cigarette smoking, corticosteroid use, medical conditions associated with malabsorption, and monitored treatment of known osteoporosis or osteopenia.

— AM Kaunitz

Published in Journal Watch Women's Health September 6, 2001

Citation(s):

Cadarette SM et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001 Jul 4 286 57-63.

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