title: Development and validation of a tool for identifying women with low bone mineral density and low-impact fractures: the São Paulo Osteoporosis Risk Index (SAPORI).
abstract: The performance of the São Paulo Osteoporosis Risk Index (SAPORI) was tested in 1,915 women from the original cohort, São Paulo Osteoporosis Study (SAPOS) (N = 4332). This new tool was able to identify women with low bone density (spine and hip) and low-impact fracture, with an area under the receiving operator curve (ROC) of 0.831, 0.724, and 0.689, respectively.
  
  
  BACKGROUND
  A number of studies have demonstrated the clinical relevance of risk factors for identifying individuals at risk of fracture (Fx) and osteoporosis (OP). The SAPOS is an epidemiological study for the assessment of risk factors for Fx and low bone density in women from the community of the metropolitan area of São Paulo, Brazil. The aim of the present study was to develop and validate a tool for identifying women at higher risk for OP and low-impact Fx.
  
  
  METHODS
  A total of 4,332 pre-, peri-, and postmenopausal women were analyzed through a questionnaire addressing risk factors for OP and Fx. All of them performed bone densitometry at the lumbar spine and proximal femur (DPX NT, GE-Lunar). Following the identification of the main risk factors for OP and Fx through multivariate and logistic regression, respectively, the SAPORI was designed and subsequently validated on a second cohort of 1,915 women from the metropolitan community of São Paulo. The performance of this tool was assessed through ROC analysis.
  
  
  RESULTS
  The main and significant risk factors associated with low bone density and low-impact Fx were low body weight, advanced age, Caucasian ethnicity, family history of hip Fx, current smoking, and chronic use of glucocorticosteroids. Hormonal replacement therapy and regular physical activity in the previous year played a protective role (p < 0.05). After the statistical adjustments, the SAPORI was able to identify women with low bone density (T-score ≤ -2 standard deviations) in the femur, with 91.4% sensitivity, 52% specificity, and an area under the ROC of 0.831 (p < 0.001). At the lumbar spine, the performance was similar (81.5% sensitivity, 50% specificity, and area under ROC of 0.724; p < 0.001). Regarding the identification of low-impact Fx, the sensitivity was 71%, the specificity was 52%, and the area under the ROC was 0.689 (p < 0.001).
  
  
  CONCLUSIONS
  The SAPORI is a simple, useful, fast, practice, and valid tool for identifying women at higher risk for low bone density and osteoporotic fractures.
authors.affiliation: Rheumatology Division, Universidade Federal de São Paulo/Escola Paulista de Medicina (Unifesp/EPM), São Paulo, Brazil. mpinheiro@uol.com.br
authors.forename: M M
authors.initials: MM
authors.lastname: Pinheiro
authors.forename: E T
authors.initials: ET
authors.lastname: Reis Neto
authors.forename: F S
authors.initials: FS
authors.lastname: Machado
authors.forename: F
authors.initials: F
authors.lastname: Omura
authors.forename: J
authors.initials: J
authors.lastname: Szejnfeld
authors.forename: V L
authors.initials: VL
authors.lastname: Szejnfeld
mesh_terms: D000328:Adult; D000368:Aged; D000886:Anthropometry / Q000379:methods; D015519:Bone Density / Q000502:physiology; D001938:Brazil / Q000453:epidemiology; D004812:Epidemiologic Methods; D005260:Female; D005272:Femur Neck / Q000503:physiopathology; D006801:Humans; D008159:Lumbar Vertebrae / Q000503:physiopathology; D017533:Marital Status; D008875:Middle Aged; D010024:Osteoporosis / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D015663:Osteoporosis, Postmenopausal / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D058866:Osteoporotic Fractures / Q000175:diagnosis* / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D018570:Risk Assessment / Q000379:methods; D012923:Social Class