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Screening for Osteoporosis

Systematic Review to Update the 2002 U.S. Preventive Services Task Force Recommendation

Evidence Syntheses, No. 77

Investigators: , MD, MPH, , MD, , MD, , MLS, , PhD, and , BS.

Oregon Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 10-05145-EF-1

Structured Abstract

Background:

Osteoporosis and related fractures are common in older individuals and lead to premature mortality, loss of function and independence, reduced quality of life, and high costs. Despite its importance, osteoporosis is under detected in the United States. This review updates evidence since the 2002 U.S. Preventive Services Task Force recommendation on osteoporosis screening.

Purpose:

To determine the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures; the performance of risk-assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and efficacy and harms of medications to reduce primary fractures.

Data Sources:

Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the 4th Quarter of 2009), MEDLINE (January 2001 to December 2009), reference lists, and Web of Science searches.

Study Selection:

Randomized, controlled trials of screening or medications with fracture outcomes published in English; performance studies of validated risk-assessment instruments; and systematic reviews and population-based studies of bone measurement tests or medication harms.

Data Extraction:

Data on patient populations, study design, analysis, follow-up, and results were abstracted; study quality was rated by using criteria developed by the USPSTF.

Data Synthesis:

Risk-assessment instruments are modest predictors of low bone density (area under the curve, 0.13 to 0.87; 14 instruments) and fractures (area under the curve, 0.48 to 0.89; 11 instruments); simple and complex instruments perform similarly. Dual-energy x-ray absorptiometry predicts fractures similarly for men and women; calcaneal quantitative ultrasonography also predicts fractures, but correlation with dual-energy x-ray absorptiometry is low. Repeating a bone density measurement up to 8 years after an initial measurement does not significantly improve predictive performance for fracture outcomes. For postmenopausal women, bisphosphonates, parathyroid hormone, raloxifene, and estrogen reduce primary vertebral fractures; bisphosphonates reduce primary nonvertebral fractures in sensitivity analysis. Medications are effective for bone density T-scores of −2.5 or less for women without previous known fractures. Primary prevention trials are lacking for men. Bisphosphonates are not consistently associated with serious adverse events; raloxifene and estrogen increase thromboembolic events; estrogen increases stroke; and estrogen with progestin increases coronary heart disease and breast cancer.

Limitations:

Trials of screening with fracture outcomes, screening intervals, and medications to reduce primary fractures, particularly enrolling men, are lacking.

Conclusions:

Although methods to identify risk for osteoporotic fractures are available and mediations to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals.

Contents

The authors acknowledge the contributions of Rochelle Fu, PhD, for conducting statistical sensitivity analyses, and Andrew Hamilton, MLS, MS, for creating literature searches. Kenneth Lin, MD, served as the AHRQ Project Officer and Rosanne Leipzig, MD, PhD, Diana Petitti, MD, MPH, and George Sawaya, MD, were the U.S. Preventive Services Task Force leads for this project.

This report is based on research conducted by the Oregon Evidence-based Practice Center (EPC)1 under contract to the Agency for Healthcare Research and Quality (AHRQ),2 Rockville, MD (Contract No. 290-2007-10057-I-EPC3, Task Order Number 3).

Suggested citation:

Nelson HD, Haney EM, Chou R, Dana T, Fu R, Bougatsos C. Screening for Osteoporosis: Systematic Review to Update the 2002 U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 77. AHRQ Publication No. 10-05145-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, July 2010.

The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

1

Oregon Health & Science University, Mail Code BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098. www​.ohsu.edu/epc

2

540 Gaither Road, Rockville, MD 20850. www​.ahrq.gov

Bookshelf ID: NBK45201PMID: 20722176

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