title: A clinical decision rule to enhance targeted bone mineral density testing in healthy mid-life women.
abstract: CONCLUSIONS
  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.
  
  
  BACKGROUND
  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.
authors.affiliation: Osteoporosis Research Program, Women's College Research Institute, Women's College Hospital, 76 Grenville Street, 8th floor, Room 815, Toronto, ON, M5S 1B2, Canada. gillian.hawker@wchospital.ca
authors.forename: G
authors.initials: G
authors.lastname: Hawker
authors.forename: A
authors.initials: A
authors.lastname: Mendel
authors.forename: M A
authors.initials: MA
authors.lastname: Lam
authors.forename: P S
authors.initials: PS
authors.lastname: Akhavan
authors.forename: J
authors.initials: J
authors.lastname: Cancino-Romero
authors.forename: E
authors.initials: E
authors.lastname: Waugh
authors.forename: S
authors.initials: S
authors.lastname: Jamal
authors.forename: S
authors.initials: S
authors.lastname: Mian
authors.forename: S
authors.initials: S
authors.lastname: Jaglal
mesh_terms: D015502:Absorptiometry, Photon / Q000379:methods; D000328:Adult; D015519:Bone Density / Q000502:physiology*; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008875:Middle Aged; D010024:Osteoporosis / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D015663:Osteoporosis, Postmenopausal / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology; D017698:Postmenopause / Q000502:physiology; D011237:Predictive Value of Tests; D017697:Premenopause / Q000502:physiology; D012307:Risk Factors; D019564:Unnecessary Procedures