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Osteoporosis Self-assessment Tool (OST)

[& OSTA for Asians]

A simple clinical tool to identify women with osteoporosis

Professor J-Y Reginster

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Background

• Cost and availability limit access to bone mineral density (BMD) in some communities

• A simple risk assessment tool could:– target BMD to high-risk women– reduce the need for BMD measurements

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Osteoporosis Self-assessment Tool for

Asians (OSTA)

Adapted from:

L. Koh, et al. A simple tool to identify Asian women at increased

risk of osteoporosis.

Osteoporos Int 12:699-705, 2001.

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Objective

• Develop and assess a simple tool for predicting osteoporosis (femoral neck BMD T < -2.5) in postmenopausal Asian women, using risk factors obtained by questionnaire

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InvestigatorsThe Osteoporosis Self-assessment Tool for Asia (OSTA) Research

Group

China : Huang Qi Ren, Zhang Wei Bin, Huang Gong Yi, Lou Si Quan, Luo Xian Zheng, Liu Gui Lin

South Korea : In-Kwon Han, Ki-Hyun Park, Moo-Il Kang, Hyong-Moo Park, Hyoung-Woo Lee

Taiwan : Chun S Shih, Li H Chen, Keh-Sung Tsai, Yang Bor-Yau

Hong Kong : Annie Kung

Philippines : Tito P Torralba

Thailand : Rajata Rajatanavin

Malaysia : Siew-Pheng Chan

Singapore : Siok Bee Chionh, Tang Ching Lau, Paul Ho, Leonard Koh

Belgium (WHO) : Jean-Yves Reginster, Wafa Ben Sedrine

Japan (validation sample) : Saeko Fujiwara

USA (MSD) : Philip Ross, Larry Radican

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Method

• Community-dwelling postmenopausal women– 21 clinics in 8 Asian countries– Consecutive subjects– Routine check-up or follow-up of medical

conditions– 860 subjects completed questionnaires– Study was performed under the auspices of

the World Health Organization (WHO)

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Recruitment Criteria

• Inclusion– Postmenopausal– Any race except Caucasian– Hip anatomy suitable for BMD– Willingness and ability to participate

• Exclusion– History/evidence of metabolic bone disease– Presence of cancer with known metastasis to bone– Evidence of significant renal impairment– One or both ovaries removed– Both hips previously fractured or replaced– History of bisphosphonate, fluoride or calcitonin use

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Risk Factors Assessed in Questionnaire

• Ethnicity• Weight • Height (present/past)• Physical activity• Sunlight exposure• Smoking• Dairy / soybean intake• Reproductive history

• Physical disability

• Rheumatoid arthritis

• Fracture history

• Family history of fracture

• Calcium supplements

• Postmenopausal estrogen

• Thyroid medication

• Corticosteroids

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Results: Study Population

• DemographicsChinese: 59% Korean: 18% Thai: 11%Filipino: 9% Other: 4%

• Age (years) 62 (6)

• Weight (kg) 57 (9)

• Height (cm) 154 (6)

• Femoral neck BMD (g/cm2) 0.71 (0.14)– 14% of women had T-scores < -2.5

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Multivariate Analysis• Multivariable model - “best fit”

– 11 variables:• age• weight • estrogen• thyroid medication• any fracture since 45• prior spine fracture• Chinese• Thai• 3 countries (Malaysia, Hong Kong, Taiwan)

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Simple Model (2 variables)Performs Well

11 Variables Age & weight

AUC 0.85 0.79

Sensitivity 95% 91%

Specificity 47% 45%

Koh L, et al. Osteoporos Int 12:699-705, 2001.

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Calculation

Model with only 2 variables

(Weight - Age) x 0.2, drop decimal

example: Weight 59 kg, Age 72 yr

(59-72) x 0.2 = -2

Koh L, et al. Osteoporos Int 12:699-705, 2001.

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Risk Stratification

Risk level

Low

Medium

High

% of all women

40%

52%

8%

% with osteoporosis

3%

15%

61%

Koh L, et al. Osteoporos Int 12:699-705, 2001.

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Validation - JAPAN

• Adult Health Study, Hiroshima – Postmenopausal women in existing cohort– Ages 50 and older– N = 1123

• Sensitivity = 98%, specificity = 29%

Fujiwara S, et al. Curr Ther Res 62(8): 586-94, 2001.

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Validation (Japan)

Risk level

Low

Medium

High

% of all women

40%

52%

8%

% with osteo-porosis

3%

15%

61%

% with osteo-porosis

1%

10%

44%

% of all women

25%

50%

25%

Development(Asian)

Fujiwara S, et al. Curr Ther Res 62(8): 586-94, 2001.

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45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

40-44

95-99

45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-9440-44

Osteoporosis Self-assessment Tool for Asia (OSTA)Weight (kg)

Age(yr)

LOW RISK

HIGH RISKmeasure BMD & treat

AT RISKmeasure BMD

History of prior non-violent fracture: consider BMD measurement and treatment

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Validation - KOREA

• Postmenopausal women– Ages > 55 – N = 1101

• Sensitivity = 87%, specificity = 67%

Ben Sedrine W, et al. Arth Rheum 44(9 Suppl):S260, 2001.

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Validation (KOREA)

Risk level

Low

Medium

High

% of all women

40%

52%

8%

% with osteo-porosis

3%

15%

61%

% with osteo-porosis

2%

18%

64%

% of all women

61%

33%

5%

Development(Asian)

Fujiwara S, et al. Curr Ther Res 62(8): 586-94, 2001.

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Validation - SINGAPORE

• 125 Postmenopausal women– Mean 60 ± 7.5 yr (range 50 - 89 yr)– Sensitivity = 94%, specificity = 64%– AUC = 0.83

• 98 Men– Mean 61 ± 8.8 yr (range 50 - 88 yr)– Sensitivity = 50%, specificity = 78%– AUC = 0.71

Koh L, et al. J Bone Miner Res 16(Suppl 1):S394 & S396, 2001.

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WOMEN

Risk level

Low

Medium

High

% of all men

72%

24%

4%

% with osteo-porosis

13%

26%

75%

% with osteo-porosis

2%

24%

80%

% of all women

53%

43%

4%

MEN

Koh L, et al. J Bone Miner Res 16(Suppl 1):S394 & S396, 2001.

RESULTS - SINGAPORE

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Validation (SINGAPORE)

Risk level

Low

Medium

High

% with osteo-porosis

13%

26%

75%

% of all men

72%

24%

4%

Koh L, et al. J Bone Miner Res 16(Suppl 1):S394 & S396, 2001.

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Validation - CHINA

• 973 Postmenopausal women – Clinic in Shanghai

• 91 women (9%) had osteoporosis– 557 (57%) had osteopenia

• Sensitivity = 92%, specificity = 54%– AUC = 0.84

Ben Sedrine W, et al. Arth Rheum 44(9 Suppl):S258, 2001.

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Validation (China)

Risk level

Low

Medium

High

% of all women

40%

52%

8%

% with osteo-porosis

3%

15%

61%

% with osteo-porosis

1%

13%

42%

% of all women

50%

43%

7%

Development(Asian)

Ben Sedrine W, et al. Arth Rheum 44(9 Suppl):S258, 2001.

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Summary - OSTA• Age and weight alone performed well for

identifying osteoporosis– Consistent results among countries

• Including more variables did not substantially improve performance

• Using 3 categories may help to identify the highest and lowest risk groups– BMD measurements are probably unnecessary

in a substantial proportion of low risk women

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Osteoporosis Self-assessment Tool (OST)

Performance in Caucasians

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Validation - Caucasians

• Original “SCORE” population – Postmenopausal women in the US– Ages > 45 (mean = 61 yr)– N = 1102

• Sensitivity = 88%, specificity = 52%

• Adding other risk factors did not improve performance

Siris et al, J Bone Miner Res 16(Suppl 1):S341, 2001.

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Validation - Caucasians

• Screening for Fracture Intervention Trial – Postmenopausal women in the US– Mean age 68 yr (SD = 6)– N = 23,833

• Sensitivity = 95%, specificity = 34%

• Adding other risk factors did not improve performance

Hochberg et al, J Bone Miner Res 16(Suppl 1):S277, 2001.

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SCORE population

Risk level

Low (>1)

Medium

High (<-3)

% of all women

24%

67%

8%

% with osteo-porosis

4%

23%

57%

% with osteo-porosis

4%

18%

58%

% of all women

46%

48%

6%

FIT screenpopulation

Hochberg et al, J Bone Miner Res 16(Suppl 1):S277, 2001.Siris et al, J Bone Miner Res 16(Suppl 1):S341, 2001.

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45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90-94

40-44

95-99

55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 >9950-54

Osteoporosis Self-assessment Tool (OST)Weight (kg)

Age(yr)

LOW RISK

AT RISKmeasure BMD

HIGH RISKmeasure BMD & treat

History of prior non-violent fracture: consider BMD measurement and treatment

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OST - CaucasiansSimple Rules

Risk Level Age minus weight*

High > 20

Medium -9 to 19

Low < -9

*Age in yr minus weight in kg

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SUMMARY• Both OST and OSTA performed well

– Consistent results in different samples

• Using 3 categories may help to identify the highest and lowest risk groups– BMD measurements are probably unnecessary

in a substantial proportion of low risk women

• Category cut-points were slightly different in Caucasian versus Asian women