OST vs. alternative tests
Appendix 1: The search strategy
Electronic databases
PubMed:
#1 densitometry, X-ray [mh]
#2 densitometry [mh]
#3 bone density [mh]
#4 absorptiometry, photon [mh]
#5 dual x-ray [tw] OR dual energy x-ray [tw]
#6 bone density [tw] OR bone mineral density [tw] OR bmd [tw]
#7 osteoporosis, postmenopausal [mh]
#8 osteoporosis [mh]
#9 osteoporosis [tw]
#10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)
#11 self-assessment [tw] or tool[tw]
#12 ost [tw] OR osta [tw] OR fosta [tw] OR osteorisk[tw]
#13 (#11 OR #12)
#14 (#10 AND #13)
Embase (Webspirs)
#1 explode "dual energy x-ray absorptiometry" / all subheadings
#2 dual NEAR absorptiometry
#3 explode "bone mineral" / all subheadings
#4 bone NEAR density
#5 explode "bone characteristics and functions" / all subheadings
#6 explode "photon absorptiometry" / all subheadings
#7 explode "osteopenia" / all subheadings
#8 osteopenia in ti OR osteopenia in ab
#9 explode "bone demineralization" / all subheadings
#10 osteoporosis in ti OR osteoporosis in ab
#11 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10)
#12 ost in ti OR ost in ab
#13 osta in ti OR osta in ab
#14 fosta in ti OR fosta in ab
#15 osteorisk in ti OR osteorisk in ab
#16 self-assessment in ti OR self-assessment in ab
#17 tool in ti OR tool in ab
#18 (#12 OR #13 OR #14 OR #15 OR #16 OR #17)
#19 (#11 AND #18)
Synonyms for OST:
OST: The Osteoporosis Self-assessment Tool
OSTA: The Osteoporosis Self-assessment Tool for Asians
FOSTA: The Female Osteoporosis Self-assessment Tool for Asians
Osteorisk
Conference abstracts
We searched abstract CDs or abstract books from conferences hosted by the following societies since 2000:
- American Society of Bone mineral Metabolism
- International Osteoporosis Foundation
- National Osteoporosis Society
- European Calcified Tissue Society
- International Bone and Mineral Society
- International Society for Clinical Densitometry
as well as abstracts from the European Congresses on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis.
Appendix 2: Assessment of methodological quality - adaptation of the QUADAS checklist.
The adapted QUADAS checklist was used to assess aspects of study quality. All items were scored in the following categories: yes, no, unclear. Brief guidelines for scoring certain item are stated in parentheses. Items 3, 4, 7, 12 are shaded grey as these items were excluded:
Items 3 and 7 were dropped because DXA is a separate investigation and the reference standard technology for assessing BMD in clinical practice. Items 4 and 12 were considered inoperational for this review.
We added two items to the checklist. Item 15 to assess whether a primary studies was partially or completely paired, and item 16 to assess whether the sequence of application of triage tests could cause carry-over effects between tests. A carry-over effect occurs when the procedure involved with a test affects the procedure, evaluation or patient cooperation involved with subsequent tests to an extent that could bias estimates of accuracy.
1: / Was the spectrum of patients clinically representative?(Unselected patients recruited from the community or a primary care setting) / [ ] Yes [ ] No [ ] Unclear
2: / Were selection criteria clearly described?
(Patient selection considered reproducible) / [ ] Yes [ ] No
3: / Is DXA likely to correctly classify the target condition?
4: / Was the time period between DXA and the triage tests reasonable?
5: / Did the whole sample or a random selection here of have DXA? / [ ] Yes [ ] No [ ] Unclear
6: / Did patients receive DXA regardless of the result of the triage tests? / [ ] Yes [ ] No [ ] Unclear
7: / Did the result of the triage test form part of the DXA outcome?
8: / Was the triage tests described in sufficient detail to permit replication?
(Triage tests considered reproducible) / [ ] Yes [ ] No [ ] Unclear
9: / Was DXA described in sufficient detail to permit its replication?
(Manufacturer, model, reference values and region described) / [ ] Yes [ ] No
10: / Were the triage tests performed without knowledge of the DXA results?
(Triage tests before DXA or blinding explicitly stated) / [ ] Yes [ ] No [ ] Unclear
11: / Was DXA performed without knowledge of the result of the triage tests?
(DXA before triage tests or blinding explicitly stated) / [ ] Yes [ ] No [ ] Unclear
12: / Was the same data available when triage tests and DXA was performed as would be in clinical practice?
13: / Were uninterpretable and intermediate test results reported? / [ ] Yes [ ] No
14: / Were withdrawals from the study or missing data accounted for?
(A participant flow diagram can be established) / [ ] Yes [ ] No
15: / Was the study design completely paired?
(completely if ≥ 90% of participants received each of the triage tests under study) / [ ] Yes [ ] No [ ] Unclear
16: / Could the sequence of application of triage tests cause carry-over effects between the tests? / [ ] Yes [ ] No [ ] Unclear
Abreviations: DXA, dual energy x-ray absorptiometry; BMD, bone mineral density
According to our adaptation, the scoring of item 6, 8, 10 and 11 may turn out to differ between individual triage tests evaluated in a primary study. We see QUADAS as a tool for assessment of studies and not as a tool for assessing the quality of individual tests evaluations that may have been performed within a study. So, when the scoring of items 6, 8, 10 or 11 turned out to differ between the tests examined in a given primary study, we scored the study by its predominant characteristic: if the study complied for two out of its, say, three tests, we considered the study as complying with the item; a score of ‘unclear’ was used in case of a draw between test evaluations that did and did not comply.
7
OST vs. alternative tests
Appendix 3: structured summary of included studies
Study / Country,ethnicity,
sample size / Setting
and
recruitment procedure / Age
and
weight
[mean(SD)] / Triage tests compared
with OST according to
test type, device
and measurement site / BMD
targets / Prevalence
according to BMD target1
(%) / DXA-device(s)
(source of reference
material for T-score calculation) / Scoring of the QUADAS items
Cook 20052
[42] / England,
whites,
208 / Postmenopausal women
referred for DXA due to the presence of ≥ 1 risk factor for osteoporosis were recruited
from DXA scanning clinics / 59.7 y
65.6 kg / Clinical decision rules:
ORAI
OSIRIS
SCORE
SOFSURF
Quantitative ultrasonography:
Omnisense (Sunlight):
Distal radius, SOS T-score
Proximal phalanx, SOS T-score
Distal radius, SOS T-score
CUBA Clinical (McCue):
Calcaneus, BUA T-score
Calcaneus, SOS T-score / TTH,LS ≤ –2.5
TTH,LS ≤ –2.0 / 21.6
38.5 / Hologic QDR 4500c
(manufacturer) / Yes: 5,6,9,15
No: 1,2,13,14,16
Unclear: 8,10,11
Rud 2005
[41] / Denmark,
whites,
821 / Postmenopausal women attending for the 5-year visit in the Danish Osteoporosis Prevention Study. / Median(range):
55 (48-64) y
69 (40-127) kg / Quantitative ultrasonography:
Achilles (GE-Lunar):
Calcaneus, Stiffness index T-score / TFN ≤ –2.5
TTH ≤ –2.5
TLS ≤ –2.5
TFN,TH,LS ≤ –2.5
TFN ≤ –2.0
TTH ≤ –2.0
TLS ≤ –2.0
TFN,TH,LS ≤ –2.0 / 1.7
1.5
10.7
11.9
7.9
5.3
20.0
23.3 / Hologic QDR2000
(FN, TH: NHANES III
LS: manufacturer) / Yes: 1,5,6,9,14,15
No: 2, 13,16
Unclear: 8,10,11
Cadarette 20042
[43] / Canada,
whites,
644 / Women >44 y.:
1) attending two family practice clinics who had DXA according to the records
2) presenting consecutively for DXA at an ambulatory care center. / 62,4 (11.2) y
65.6 (54) kg / Clinical decision rule:
ORAI
Other:
Weight / TFN ≤ –2.5
TLS ≤ –2.5
TFN,LS ≤ –2.5
TFN ≤ –2.0
TLS ≤ –2.0
TFN,LS ≤ –2.0 / 10.5
11.2
16.5
22.5
19.7
30.7 / Hologic,
Lunar,
Norland
(NS) / Yes: 2,5,6,8,11,15
No: 1,9,13,14,16
Unclear: 10
Choi 2004
[46] / Korea,
Asians,
1001 / Women aged > 44 y. who had undergone testing with DXA at both the femoral neck and the lumbar spine / > 45 y
NS / Clinical decision rules:
ORAI
SCORE / TFN ≤ –2.5
TLS ≤ –2.5
TFN,LS ≤ –2.5 / 7.6
13.3
16.4 / NS
(NS) / Yes: 5,6,15
No: 2,8,9,13,14,16
Unclear: 1,10,11
Study / Country,
ethnicity,
sample size / Setting
and
recruitment procedure / Age
and
weight
[mean(SD)] / Triage tests
Compared with OST / T-score target / Prevalence
according to BMD target1
(%) / DXA-device(s)
(source of reference
material for T-score calculation) / Scoring of the QUADAS items
Gambacciani 20042
[38] / Italy,
whites,
276 / NS / 58 (7) y
NS / Quantitative ultrasonography:
Achilles Insight (GE-Lunar):
Calcaneus, Stiffness Index T-score / TTH ≤ –2.5
TLS ≤ –2.5
TTH,LS ≤ –2.5
TTH ≤ –2.0
TLS ≤ –2.0
TTH,LS ≤ –2.0 / 4.0
19.9
19.9
9.2
33.3
33.9 / Lunar DPX
(manufacturer) / Yes: 5,6,9,15
No: 2,13,14,16
Unclear: 1,8,10,11
Mossman 20042
[44] / USA,
whites,
8068 / Postmenopausal women referred to the Oregon Osteoporosis Center for DXA testing. / 62.9 (9.7) y
69.9 (15.5) kg / Other:
Weight / TFN ≤ –2.5
TLS ≤ –2.5
TFN,LS ≤ –2.5
TFN ≤ –2.0
TLS ≤ –2.0
TFN,LS ≤ –2.0 / 6.3
10.8
13.8
15.7
19.0
25.8 / Lunar Prodigy
(manufacturer) / Yes: 2,5,6,15
No: 1,8,9,13,14,16
Unclear: 10,11
Nguyen 20043
[Validation cohort]
[33] / Australia,
whites,
410 / All women > 60 y. living in Dubbo were invited to participate in the Dubbo Epidemiology Study. A subset
with complete data was in-cluded in the accuracy study. / 70.5 (7.5) y
65.0 (12.9) kg / Clinical decision rules:
DOEScore
ORAI
SOFSURF / TFN ≤ –2.5
TFN,LS ≤ –2.5 / 30.0
41.5 / Lunar DPX-L
(NS) / Yes: 5,6,9,11,15
No: 2,8,13,14,16
Unclear: 1,10
Pongchaiyakul 20043
[Validation cohort]
[36] / Thailand,
Asians,
192 / Women ≥ 45 y. in a specific geographic region were selected randomly for participation. / 60.5 (9.8) y
55.7 (9.8) kg / Clinical decision rule:
KKOS-score / TFN,LS ≤ –2.5 / (33.3)4 / Lunar DPX-IQ
(local) / Yes: 1,2,5,6,9,13,14,15
No:16
Unclear: 8,10,11
Poriau 20042
[40] / Belgium,
whites,
1087 / NS / 68 y
NS / Quantitative ultrasonography:
Achilles Solo (GE-Lunar):
Calcaneus, Stiffness Index T-score / TLS ≤ –2.5 / 30.5 / Lunar Prodigy,
Lunar DPX-NT
(manufacturer) / Yes: 5,6,9,15
No: 2,13,14,16
Unclear: 1,8,10,11
Richy 2004 (I)
[Clinic study]
[60] / Belgium,
whites,
4035 / Retrospective collection of medical data for women > 44 y. who had DXA at an out-patient osteoporosis Center. / 61.5: (8.8) y
65.1 (11.9) kg / Clinical decision rules:
ORAI
OSIRIS
SCORE / TFN ≤ –2.5
TTH ≤ –2.5
TLS ≤ –2.5
TFN,TH,LS ≤ –2.5
TFN ≤ –2.0
TTH ≤ –2.0
TLS ≤ –2.0
TFN,TH,LS ≤ –2.0 / 18.8
9.5
24.3
32.6
29.1
16.8
37.9
47.3 / Hologic QDR1000,
QDR2000, QDR4500
(Local) / Yes: 2,5,6,8,9,11,15
No: 1,13,14,16
Unclear: 10
Study / Country,
ethnicity,
sample size / Setting
and
recruitment procedure / Age
and
weight
[mean(SD)] / Triage tests
Compared with OST / T-score target / Prevalence
according to BMD target1
(%) / DXA-device(s)
(source of reference
material for T-score calculation) / Scoring of the QUADAS items
Richy 2004 (II)3
[ORACLE study - validation cohort]
[34] / Begium,
whites,
202 / Healthy postmenopausal women >44 y. attending a public screening for osteoporosis / 63.4 (6.6) y
68.8 (13) kg / Clinical decision rule:
ORACLE
Quantitative ultrasonography:
DBM Sonic 1200 (IGEA)
Proximal phalanx, Ad-SOS T-score
Proximal phalanx, UBPI / TFN ≤ –2.5 / (24%)4 / Hologic QDR 4500
(manufacturer) / Yes: 2,5,6,9,15
No: 8,13,14,16
Unclear: 1,10,11
Rud 2004
[45] / Denmark,
whites,
2009 / Healthy, peri- and recent postmenopausal women were recruited randomly from public registers for the Danish Osteoporosis Prevention Study / 50.5
(48.4-52.6)† y
65.9
(59.8-74.0)† kg / Clinical decision rules:
ORAI
SCORE
Other:
Case-finding based on risk factors
for fracture / TFN ≤ –2.5
TTH ≤ –2.5
TLS ≤ –2.5
TFN,TH,LS ≤ –2.5
TFN ≤ –2.0
TTH ≤ –2.0
TLS ≤ –2.0
TFN,TH,LS ≤ –2.0 / 0.7
0.3
4.2
4.6
4.6
2.3
10.9
13.0 / Hologic QDR1000
QDR2000
(FN, TH: NHANES III
LS: manufacturer) / Yes: 1,5,6,8,9,11,14,15
No: 2,13,16
Unclear: 10
Taguchi 2004
[49] / Japan,
Asians,
316 / Women visiting the an osteoporosis clinic for BMD measurement were recruited / 56.8 (7.7) y
51.5 (7.3) kg / Dental Panoramic Radiography
AZ 300 (Asahi)
Mandible, Cortical width
Mandible, Cortical shape / TLS ≤ –2.5 / 24.7 / Lunar DPX-alpha
(NS) / Yes: 2,5,6,8,15
No: 9,13,14,16
Unclear: 1,10,11
Wallace 20043
[37] / USA,
blacks,
174 / Subjects were recruited from African-American churches by a respected nurse. / 59.4 (12.5) y
79.8 (20.7) kg / Clinical decision rules:
ABONE
ORAI
SCORE
Other:
Weight / TFN ≤ –2.0 / NS / Hologic QDR 2000
(NHANES III) / Yes: 2,5,6,8,9,15
No: 13,14,16
Unclear: 1,10,11
Kung 2003
[48] / China,
Asians,
722 / Southern Chinese women recruited from the community when they passed public road shows, health fairs or health talks on osteoporosis. / 62 (8) y
55 (8) kg / Quantitative ultrasonography:
Sahara (Hologic):
Calcaneus, Quantitative Ultrasound
Index T-score / TFN ≤ –2.5
TLS ≤ –2.5
TFN,LS ≤ –2.5 / 21.5
30.6
37.7 / Hologic QDR2000+
(Local) / Yes: 2,5,6,8,9,15
No: 13,14,16
Unclear: 1,10,11
Cho 20023
[35] / Korea,
Asians,
837 / For women ≥ 40 y. information about risk factors and the
results of bone densitometry
was collected from 23 centers across Korea / > 40 y
NS / Other:
Case-finding for at least one risk
factor for fracture as recommended
by the National Osteoporosis
Foundation. / T ≤ –2.5
(Region NS) / (7.9%)4 / NS
(NS) / Yes: 2,5,6,11,15
No: 8,9,13,14,16
Unclear: 1,10
Study / Country,
ethnicity,
sample size / Setting
and
recruitment procedure / Age
and
weight
[mean(SD)] / Triage tests
Compared with OST / T-score target / Prevalence
according to BMD target1
(%) / DXA-device(s)
(source of reference
material for T-score calculation) / Scoring of the QUADAS items
Geusens 2002
[Fracture Inter-vention Trial]
[61] / USA,
whites,
23833 / Women screened with DXA
for participation in The
Fracture Intervention Trial. / 67 (6.5) y
NS / Clinical decision rules:
ORAI
SCORE
SOFSURF / TFN ≤ –2.5
TFN ≤ –2.0 / 21.1
42.8 / Hologic QDR2000
(NHANES III) / Yes:5,6,8,9,11,15
No: 2,13,14,16
Unclear: 1,10
Geusens 2002
[Rotterdam Study]
[61] / Holland,
whites,
3340 / All inhabitants in the district of Ommoord, Rotterdam aged
>54y were invited to partici-
pate in the Rotterdam Study. Subsamples with complete data were included in the accuracy study. / NS
NS / Clinical decision rules:
ORAI
SCORE
SOFSURF / TFN ≤ –2.5
TFN ≤ –2.0 / 19.1
38.4 / Lunar DPX-L
(NHANES III) / Yes: 5,6,8,9,11
No: 2,13,14,15,16
Unclear: 1,10
Mossman 20022
[39] / USA,
whites,
661 / Postmenopausal women referred to the Oregon Osteoporosis Center for DXA testing / 63.5 (10.8) y
68.0 (12.9) kg / Clinical decision rules:
ORAI
SCORE
Quantitative ultrasonography:
Achilles (GE-Lunar):
Calcaneus, Stiffness Index T-score / TFN ≤ –2.5
TLS ≤ –2.5
TFN ≤ –2.0 / 10.7
17.3
22.4 / Lunar Prodigy
Manufacturer / Yes: 5,6,9,13,15
No: 1,2,8,14,16
Unclear:10, 11
Fujiwara 2001
[47] / Japan,
Asians,
1127 / Women followed-up during 1994-5 in the Adult Health Study on the effects of radiation exposure. / 65 (47-91) y
NS / Clinical decision rules:
ORAI
SCORE
SOFSURF / TFN ≤ –2.5
TLS ≤ –2.5 / 16.3
26.0 / Hologic QDR 2000
(Local) / Yes: 5,6,8,9,11,15
No: 2,13,14,16
Unclear: 1,10
1: Calculated from the extracted 2×2 tables.