© International Commission on Radiation Units and Measurements 2009
3. Quality and Performance Measures in Bone Densitometry
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3.1 Introduction
Bone densitometry plays a central role in the diagnosis of osteoporosis, in fracture prediction, and in monitoring treatment. However, there is still ongoing debate on the strengths and weaknesses of various techniques. In analogy to other devices that measure physically well-defined quantities, the performance of techniques used to determine bone mineral density (BMD) can be described by a few simple performance measures. For example, if in measuring the length of an object, two parameters, trueness1 and precision, suffice to analyze the performance of the measuring process. This is of course also true for quantities measured in bone densitometry.
However, the clinical application requires further considerations, since the evaluation of osteoporosis cannot be reduced to an assessment of the physical quantities measured by
3.2 Physical Performance Measures
3.2.1 Trueness and Bias
3.2.2 Precision
3.2.2.1 Short-term Imprecision
3.2.2.2 Long-term Imprecision
3.2.3 Clinical Limitations of Physical Performance Measures
3.3 Diagnostic Performance Measures
3.3.1 Conceptual Definition of Osteoporosis
3.3.2 Diagnostic Criteria for the Individual Patient
3.3.2.1 Fracture Status
3.3.2.2 Low Bone Mineral Density
Absolute Values
Percent Decrements
T-score and Z-score
3.3.2.3 Clinical Limitations of the WHO Definition of Osteoporosis
3.3.3 Diagnostic Performance of Techniques
3.3.3.1 Concepts of Diagnostic Performance
Diagnostic Response and Diagnostic Power
Standardized Bias
Sensitivity–Specificity Analysis
Analysis of the Area Under the Receiver Operator Curve
3.3.4 Reference Data
3.3.5 Clinical Limitations of Bone Mineral Density as Diagnostic Criterion
3.4 Performance Measures to Assess Fracture Risk
3.4.1 Relevance of Fracture Risk Assessment
3.4.2 Basic Definitions
3.4.3 Risk Factors and Fracture Risk
3.4.4 Statistical Methods for Characterizing Fracture Risk
3.4.4.1 Student's t-test Analysis
Performance Measures
3.4.4.2 Linear Discriminant Analysis
Performance Measures
3.4.4.3 Logistic Regression Analysis
Performance Measures
3.4.4.4 Poisson Regression Model
Performance Measures
3.4.4.5 Cox Proportional Hazard Model
Performance Measures
3.4.5 Comparison of Statistical Methods
3.4.5.1 Discriminant Analysis versus Logistic Regression
3.4.5.2 Comparison of Regression and Survival Models
3.4.6 Performance Measures for Risk Prediction
3.4.7 Combination of Risk Factors
3.4.8 The Individual Patient
3.4.8.1 Assessment of Fracture Risk
3.4.8.2 Treatment Decisions
3.5 Performance Measures to Assess Monitoring
3.5.1 Measures of Change
3.5.1.1 Longitudinal Response and Response Rates
3.5.1.2 Significant Changes and Monitoring Intervals
3.5.2 Monitoring Performance of Techniques
3.5.2.1 Longitudinal Sensitivity
3.5.2.1 Standardized Imprecision
3.5.3 Monitoring of Individual Patients
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