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.

Introduction: 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.

Fig. 1

Flow diagram of literature search and study selection

Fig. 2

Scatter plot of sensitivity (true positive rate) versus 1–specificity (false positive rate) for studies evaluating clinical risk assessment instrument performance for identifying postmenopausal women with DXA-determined osteoporosis (T-score≤−2.5) at the femoral neck, total hip, or lumbar spine. Each point is labeled with the corresponding risk instrument, risk instrument cutoff threshold (cutoff value used to separate positive from negative results), and associated reference. Points are proportional to the number of study participants; however, sizes are not to scale