title: Systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for osteoporosis or low bone density.
abstract: We performed a systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for DXA-determined osteoporosis or low bone density. Commonly evaluated risk instruments showed high sensitivity approaching or exceeding 90% at particular thresholds within various populations but low specificity at thresholds required for high sensitivity. Simpler instruments, such as OST, generally performed as well as or better than more complex instruments.
  
  
  BACKGROUND
  The purpose of the study is to systematically review the performance of clinical risk assessment instruments for screening for dual-energy X-ray absorptiometry (DXA)-determined osteoporosis or low bone density.
  
  
  METHODS
  Systematic review and meta-analysis were performed. Multiple literature sources were searched, and data extracted and analyzed from included references.
  
  
  RESULTS
  One hundred eight references met inclusion criteria. Studies assessed many instruments in 34 countries, most commonly the Osteoporosis Self-Assessment Tool (OST), the Simple Calculated Osteoporosis Risk Estimation (SCORE) instrument, the Osteoporosis Self-Assessment Tool for Asians (OSTA), the Osteoporosis Risk Assessment Instrument (ORAI), and body weight criteria. Meta-analyses of studies evaluating OST using a cutoff threshold of <1 to identify US postmenopausal women with osteoporosis at the femoral neck provided summary sensitivity and specificity estimates of 89% (95%CI 82-96%) and 41% (95%CI 23-59%), respectively. Meta-analyses of studies evaluating OST using a cutoff threshold of 3 to identify US men with osteoporosis at the femoral neck, total hip, or lumbar spine provided summary sensitivity and specificity estimates of 88% (95%CI 79-97%) and 55% (95%CI 42-68%), respectively. Frequently evaluated instruments each had thresholds and populations for which sensitivity for osteoporosis or low bone mass detection approached or exceeded 90% but always with a trade-off of relatively low specificity.
  
  
  CONCLUSIONS
  Commonly evaluated clinical risk assessment instruments each showed high sensitivity approaching or exceeding 90% for identifying individuals with DXA-determined osteoporosis or low BMD at certain thresholds in different populations but low specificity at thresholds required for high sensitivity. Simpler instruments, such as OST, generally performed as well as or better than more complex instruments.
authors: Swedish Center for Research and Innovation, Swedish Health Services, Swedish Medical Center, 747 Broadway, Seattle, WA, 98122-4307, USA, smita.nayak@swedish.org.
authors: S
authors: S
authors: Nayak
authors: D L
authors: DL
authors: Edwards
authors: A A
authors: AA
authors: Saleh
authors: S L
authors: SL
authors: Greenspan
mesh_terms: D015519:Bone Density; D006801:Humans; D008403:Mass Screening / Q000379:methods*; D010024:Osteoporosis / Q000175:diagnosis* / Q000503:physiopathology; D018570:Risk Assessment / Q000379:methods; D012680:Sensitivity and Specificity
references: J Clin Densitom. 2013 Oct-Dec;16(4):570-8
references: 23452870
references: J Rheumatol. 2012 Feb;39(2):247-53
references: 22174197
references: J Bone Miner Res. 2007 Mar;22(3):465-75
references: 17144789
references: Scand J Rheumatol. 2001;30(1):35-9
references: 11252690
references: Osteoporos Int. 2009 Apr;20(4):599-607
references: 18716823
references: J Bone Miner Metab. 2008;26(1):47-52
references: 18095063
references: J Am Geriatr Soc. 2014 Mar;62(3):442-6
references: 24617899
references: J Clin Densitom. 2009 Oct-Dec;12(4):434-40
references: 19775920
references: Osteoporos Int. 2008 Jul;19(7):1087-92
references: 18239959
references: Curr Osteoporos Rep. 2011 Sep;9(3):129-40
references: 21655931
references: JAMA. 2001 Jul 11;286(2):180-7
references: 11448281
references: J Bone Miner Metab. 2013 Jul;31(4):423-32
references: 23420298
references: Osteoporos Int. 2005 Dec;16(12):1565-75
references: 15883661
references: Rheumatol Int. 2008 Jul;28(9):825-30
references: 18301897
references: AJR Am J Roentgenol. 2004 Dec;183(6):1755-60
references: 15547223
references: J Am Board Fam Med. 2010 Mar-Apr;23(2):186-94
references: 20207929
references: Osteoporos Int. 2012 Jul;23(7):1931-8
references: 22159633
references: J Med Assoc Thai. 2012 Apr;95(4):487-92
references: 22612000
references: Ann Intern Med. 2011 Dec 6;155(11):751-61
references: 22147714
references: J Med Assoc Thai. 2007 Aug;90(8):1518-23
references: 17926979
references: J Korean Acad Nurs. 2011 Dec;41(6):758-67
references: 22310860
references: Clin Orthop Relat Res. 2004 Aug;(425):126-34
references: 15292797
references: Osteoporos Int. 2006;17(8):1182-8
references: 16699739
references: J Orthop Surg (Hong Kong). 2012 Aug;20(2):205-8
references: 22933680
references: Osteoporos Int. 2005 Dec;16(12):1789-93
references: 16027957
references: Acta Reumatol Port. 2008 Jul-Sep;33(3):314-28
references: 18846011
references: J Am Board Fam Med. 2013 Jul-Aug;26(4):436-44
references: 23833159
references: J Rheumatol. 2007 Jun;34(6):1307-12
references: 17552058
references: J Natl Med Assoc. 2004 Mar;96(3):290-6
references: 15040510
references: J Gen Intern Med. 2006 Jun;21(6):630-5
references: 16808748
references: J Osteoporos. 2013;2013:150154
references: 23533947
references: J Clin Densitom. 2007 Oct-Dec;10(4):404-7
references: 17662631
references: Reumatol Clin. 2007 Mar;3(2):63-6
references: 21794400
references: Mayo Clin Proc. 2002 Jul;77(7):629-37
references: 12108600
references: J Am Geriatr Soc. 2009 Feb;57(2):218-24
references: 19207137
references: J Clin Nurs. 2014 Sep;23(17-18):2628-35
references: 24372848
references: Ann Intern Med. 2010 Jul 20;153(2):99-111
references: 20621892
references: Aging Male. 2014 Sep;17(3):166-73
references: 25027466
references: Osteoporos Int. 2005 Aug;16(8):921-7
references: 16028108
references: J Bone Miner Metab. 2015 Mar;33(2):230-8
references: 24748148
references: Calcif Tissue Int. 2013 Jul;93(1):62-8
references: 23608922
references: Zhonghua Yi Xue Za Zhi. 2011 Aug 16;91(30):2112-5
references: 22093986
references: J Med Assoc Thai. 2005 Oct;88 Suppl 5:S80-3
references: 16871660
references: Ann Rheum Dis. 2002 Dec;61(12):1085-9
references: 12429540
references: Osteoporos Int. 2005 Nov;16(11):1444-50
references: 16170443
references: Arch Intern Med. 2004 Jul 26;164(14):1525-30
references: 15277283
references: Gynecol Endocrinol. 2004 Jan;18(1):3-8
references: 15106358
references: J Clin Densitom. 2007 Jul-Sep;10(3):289-97
references: 17459748
references: Mayo Clin Proc. 2003 Jun;78(6):723-7
references: 12934782
references: Med J Aust. 2004 Mar 1;180(5 Suppl):S18-22
references: 14984358
references: J Med Assoc Thai. 2007 Mar;90(3):420-5
references: 17427514
references: J Bone Miner Res. 2014 Jul;29(7):1661-6
references: 24431262
references: Bone. 2001 Oct;29(4):374-80
references: 11595621
references: J Med Assoc Thai. 2010 Dec;93 Suppl 7:S76-82
references: 21294400
references: Arch Intern Med. 2005 Mar 14;165(5):530-6
references: 15767529
references: Osteoporos Int. 2009 Jul;20(7):1157-66
references: 19011728
references: Climacteric. 2013 Feb;16(1):127-32
references: 22741522
references: QJM. 2004 Jan;97(1):39-46
references: 14702510
references: J Orthop Surg Res. 2006 Nov 21;1:14
references: 17150121
references: J Clin Densitom. 2014 Jan-Mar;17(1):32-7
references: 23489972
references: Osteoporos Int. 1999;10(1):85-90
references: 10501785
references: Reumatol Clin. 2011 May-Jun;7(3):161-6
references: 21794807
references: J Med Assoc Thai. 2004 Nov;87(11):1286-92
references: 15825701
references: Osteoporos Int. 2010 Jun;21(6):977-83
references: 19727909
references: J Clin Densitom. 2007 Apr-Jun;10(2):138-46
references: 17449308
references: J Med Assoc Thai. 2012 Nov;95(11):1365-71
references: 23252200
references: Osteoporos Int. 2003 Sep;14(9):716-21
references: 12897978
references: BMC Musculoskelet Disord. 2008;9:13
references: 18230132
references: Dis Manag. 2003 Fall;6(3):159-68
references: 14570384
references: J Bone Miner Res. 2013 Aug;28(8):1701-17
references: 23592255
references: Osteoporos Int. 2014 Jan;25(1):23-49
references: 24105431
references: Osteoporos Int. 2005 Jul;16(7):764-72
references: 15986263
references: BMC Musculoskelet Disord. 2003 Oct 31;4:24
references: 14588078
references: Osteoporos Int. 2009 Mar;20(3):363-70
references: 18633665
references: Sex Reprod Healthc. 2011 Apr;2(2):77-82
references: 21439525
references: J Med Assoc Thai. 2007 Oct;90(10):2016-23
references: 18041418
references: JAMA. 2001 Jul 4;286(1):57-63
references: 11434827
references: Osteoporos Int. 2001;12(8):699-705
references: 11580084
references: J Bone Miner Res. 2008 Jun;23(6):812-8
references: 18302506
references: Osteoporos Int. 2005 Feb;16(2):134-41
references: 15197546
references: J Clin Densitom. 2003 Fall;6(3):231-6
references: 14514992
references: J Dent. 2002 May;30(4):171-5
references: 12450724
references: Osteoporos Int. 2008 Aug;19(8):1175-83
references: 18219434
references: BMC Musculoskelet Disord. 2013;14:271
references: 24053509
references: J Clin Densitom. 2003 Fall;6(3):247-50
references: 14514994
references: JAMA. 2002 Oct 16;288(15):1889-97
references: 12377088
references: Clin Rheumatol. 2007 Dec;26(12):2037-41
references: 17404784
references: Osteoporos Int. 2004 May;15(5):361-6
references: 14730421
references: Osteoporos Int. 2006;17(5):684-92
references: 16523248
references: Aging Clin Exp Res. 2004 Oct;16(5):413-9
references: 15636469