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Original Investigation
Less Is More
July 27, 2020

Serial Bone Density Measurement and Incident Fracture Risk Discrimination in Postmenopausal Women

Author Affiliations
  • 1Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
  • 2Fred Hutchinson Cancer Research Center, Seattle, Washington
  • 3Department of Epidemiology, University of Alabama at Birmingham, Birmingham
  • 4Department of Physical Therapy, University of Illinois, Chicago
  • 5Department of Medicine, Stanford University School of Medicine, Stanford, California
  • 6Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville
  • 7Mercy Health Osteoporosis and Bone Health Services, Cincinnati, Ohio
  • 8Department of Epidemiology and Environmental Health, University at Buffalo, The State University of New York, Buffalo
  • 9Division of General Internal Medicine, Department of Medicine, The University of Tennessee Health Science Center College of Medicine, Memphis
  • 10Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
  • 11Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta
  • 12Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Ohio State University, Columbus
  • 13Division of Epidemiology & Community Health, Department of Medicine, University of Minnesota and Veterans Affairs Health Care System, Minneapolis
JAMA Intern Med. Published online July 27, 2020. doi:10.1001/jamainternmed.2020.2986
Key Points

Question  Is a second bone mineral density (BMD) measurement approximately 3 years after the initial baseline measurement associated with improved subsequent fracture risk discrimination in postmenopausal women?

Findings  This cohort study of 7419 postmenopausal women found that a second BMD assessment approximately 3 years after the initial measurement was not associated with improved risk discrimination, beyond the initial BMD assessment, between women who did and did not experience hip fracture or major osteoporotic fracture.

Meaning  The findings of this cohort study suggest that a second BMD measurement approximately 3 years after the initial measurement was not associated with improved accuracy of fracture risk assessment beyond a baseline bone mineral density measurement and should not routinely be performed in postmenopausal women.

Abstract

Importance  Repeated bone mineral density (BMD) testing to screen for osteoporosis requires resources. For patient counseling and optimal resource use, it is important for clinicians to know whether repeated BMD measurement (compared with baseline BMD measurement alone) improves the ability to discriminate between postmenopausal women who will and will not experience a fracture.

Objective  To assess whether a second BMD measurement approximately 3 years after the initial assessment is associated with improved ability to estimate fracture risk beyond the baseline BMD measurement alone.

Design, Setting, and Participants  The Women’s Health Initiative is a prospective observational study. Participants in the present cohort study included 7419 women with a mean (SD) follow-up of 12.1 (3.4) years between 1993 and 2010 at 3 US clinical centers. Data analysis was conducted between May 2019 and December 2019.

Main Outcomes and Measures  Incident major osteoporotic fracture (ie, hip, clinical spine, forearm, or shoulder fracture), hip fracture, baseline BMD, and absolute change in BMD were assessed. The area under the receiver operating characteristic curve (AU-ROC) for baseline BMD, absolute change in BMD, and the combination of baseline BMD and change in BMD were calculated to assess incident fracture risk discrimination during follow-up.

Results  Of 7419 participants, the mean (SD) age at baseline was 66.1 (7.2) years, the mean (SD) body mass index was 28.7 (6.0), and 1720 (23%) were nonwhite individuals. During the study follow-up (mean [SD] 9.0 [3.5] years after the second BMD measurement), 139 women (1.9%) experienced hip fractures, and 732 women (9.9%) experienced major osteoporotic fracture. In discriminating between women who experience hip fractures and those who do not, AU-ROC values were 0.71 (95% CI, 0.67-0.75) for baseline total hip BMD, 0.61 (95% CI, 0.56-0.65) for change in total hip BMD, and 0.73 (95% CI, 0.69-0.77) for the combination of baseline total hip BMD and change in total hip BMD. Femoral neck and lumbar spine BMD values had similar discrimination for hip fracture. For discrimination of major osteoporotic fracture, AU-ROC values were 0.61 (95% CI, 0.59-0.63) for baseline total hip BMD, 0.53 (95% CI, 0.51-0.55) for change in total hip BMD, and 0.61 (95% CI, 0.59-0.63) for the combination of baseline total hip BMD and change in total hip BMD. Femoral neck and lumbar spine BMD values had similar ability to discriminate between women who experienced major osteoporotic fracture and those who did not. Associations between change in bone density and fracture risk did not differ by subgroup, including diabetes, age, race/ethnicity, body mass index, or baseline BMD T score.

Conclusions and Relevance  The findings of this study suggest that a second BMD assessment approximately 3 years after the initial measurement was not associated with improved discrimination between women who did and did not experience subsequent hip fracture or major osteoporotic fracture beyond the baseline BMD value alone and should not routinely be performed.

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