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Screening for osteoporosis to prevent fractures: an evidence review for the U.S. preventive services task force
- Author(s):
- Kahwati, Leila C
- Kistler, Christine E
- Booth, Graham
- Sathe, Nila
- Gordon, Rachel
- Cox, Alexia
- Okah, Ebiere
- Wines, Roberta C
- Viswanathan, Meera
- Title(s):
- Screening for osteoporosis to prevent fractures: an evidence review for the U.S. preventive services task force / Leila C. Kahwati, Christine E. Kistler, Graham Booth, Nila Sathe, Rachel Gordon, Alexia Cox, Ebiere Okah, Roberta C. Wines, Meera Viswanathan.
- Series:
- Evidence synthesis
- Country of Publication:
- United States
- Publisher:
- Rockville (MD) : Agency for Healthcare Research and Quality (US), 2025.
- Description:
- 1 online resource (1 PDF file (x pages))
-
Language:
- English
- Electronic Links:
- https://www.ncbi.nlm.nih.gov/books/NBK611438/
- Summary:
- PURPOSE: To review the evidence on screening for osteoporosis to prevent fractures in community-dwelling adults in primary care settings. DATA SOURCES: MEDLINE, Embase, the Cochrane Library, and trial registries through January 9, 2024; bibliographies from retrieved articles, outside experts, and surveillance of the literature through July 31, 2024. STUDY SELECTION: Two reviewers independently selected English-language studies. We included trials or systematic reviews (SRs) that evaluated the benefits or harms of screening for osteoporosis or fracture risk in adults without known osteoporosis or medical conditions associated with bone metabolism compared with no screening or usual care and that reported fracture, mortality, or harm outcomes. We included studies or recent SRs that reported on the accuracy of risk assessment instruments or bone mineral density (BMD) for predicting fracture or the diagnostic accuracy of risk assessment instruments for identifying osteoporosis. We included randomized, controlled trials (RCTs) that reported on U.S. Food and Drug Administration (FDA)-approved bisphosphonates or denosumab for the treatment of osteoporosis among participants without secondary osteoporosis or prior fragility fracture. Except for studies of predictive accuracy, we excluded studies with poor methodological quality. DATA EXTRACTION: One reviewer extracted data and a second checked accuracy. Two reviewers independently rated methodological quality for all included studies using predefined criteria. When more than one similar study was available, we conducted meta-analyses. DATA SYNTHESIS: We included 145 studies (in 195 publications). Three RCTs and three SRs reported on the direct benefits of screening in European women (median ages, 71 to 76 years); one of the trials and one of the SRs also reported on the direct harms of screening. Two-staged screening interventions were used by two trials, which included a Fracture Risk Assessment Tool [FRAX(r)] risk estimate followed by BMD testing if the estimated risk was above a specified threshold; the third trial, which required participants to have at least one clinical risk factor, performed BMD testing, vertebral fracture assessment, falls risk assessment, and laboratory measures related to bone metabolism. Across trials, screening was associated with a reduced risk of hip fractures (pooled relative risk [RR], 0.83 [95% confidence interval {CI}, 0.73 to 0.93]; 3 RCTs; 42,009 participants) and major osteoporotic fractures (MOFs) (pooled RR, 0.94 [95% CI, 0.88 to 0.99]; 3 RCTs; 42,009 participants) compared with usual care. The absolute risk differences corresponding to these estimates are 5 (hip) to 6 (MOF) fewer fractures per 1,000 participants screened. One RCT reported no difference in anxiety between screened and unscreened participants. One SR estimated the risk for overdiagnosis as between 11.8 and 24.1 percent. For predicting fracture, six SRs and 30 unique cohorts reported on the accuracy of 11 risk assessment instruments, and 22 unique cohorts reported on the accuracy of BMD alone. Calibration outcomes were limited. For risk assessment instruments, discrimination as measured by area under the curve (AUC) ranged from 0.52 to 0.93 and varied by instrument, inclusion of BMD as an input, and fracture type. The AUC of BMD alone for predicting MOF or hip fracture ranged from 0.60 to 0.86. Forty-three unique cohorts reported on the diagnostic accuracy of risk assessment instruments for identifying osteoporosis. In women, AUCs ranged from 0.32 to 0.87 across 11 instruments. In men, AUCs ranged from 0.62 to 0.94 across 12 instruments. Five studies reported information relevant to screening intervals that suggested no additional predictive accuracy for repeat BMD testing at an interval of 4 to 8 years. Twenty-seven RCTs reported on the benefits of treatment, and 40 RCTs and three cohort studies reported on the harms of treatment. Compared with placebo, bisphosphonates (pooled RR, 0.67 [95% CI, 0.45 to 1.00]; 6 RCTs; 12,055 participants) and denosumab (RR, 0.60 [95% CI, 0.37 to 0.97] from the largest RCT of 7,808 participants) were associated with a reduction in hip fractures; these drugs were also associated with reductions in vertebral fractures and nonvertebral fractures. The absolute risk difference across fracture types and medications ranged from 3 fewer to 44 fewer per 1,000 participants treated compared with placebo. For mortality, the pooled RR for bisphosphonates was 0.71 (95% CI, 0.49 to 1.05; 6 RCTs; 3,714 participants) and the pooled RR for denosumab was 0.79 (95% CI, 0.58 to 1.07; 5 RCTs; 8,828 participants). Compared with placebo, no statistically significant associations were observed for discontinuation due to adverse events, serious adverse events, or gastrointestinal adverse events (pooled RRs ranging from 0.97 to 2.18). LIMITATIONS: Direct evidence for BMD screening alone was not available. Direct evidence was available for screening in older European women that included country-specific fracture risk estimations, but this evidence was limited by modest adherence in intervention groups and contamination in control groups. Limited direct evidence for harms was identified. Predictive and diagnostic accuracy were limited by heterogeneity in populations evaluated, analytic methods used, and insufficient reporting of calibration. For treatment, populations exclusively comprising persons with prior fragility fracture or secondary osteoporosis or in long-term care were not included. Only FDA-approved bisphosphonates for prevention or treatment of osteoporosis and denosumab were included, and comparative effectiveness and harms were not addressed. Few studies of treatment in men were eligible. Treatment studies enrolled persons with osteoporosis based on BMD rather than fracture risk, and sample sizes and treatment durations may not have been adequate for the detection of rare harms such as osteonecrosis of the jaw and atypical femur fractures. CONCLUSIONS: Screening in older, higher-risk women was associated with a small absolute risk reduction in hip and MOF fractures compared with usual care. Screening strategies varied and no direct evidence evaluated screening using dual-energy X-ray absorptiometry alone or screening in women younger than age 65 years or in men. Risk assessment instruments, BMD at the hip or spine has poor to modest discrimination in men and older women for predicting fracture and studies of calibration were limited. For identifying osteoporosis, risk assessment instruments had modest to good accuracy in men and modest accuracy in older women. In women younger than age 65 years, risk assessment instruments had poor predictive (fracture) and diagnostic (osteoporosis) discrimination. Treatment of osteoporosis with FDA-approved bisphosphonates or denosumab was associated with reductions in vertebral, nonvertebral, and hip fractures with no increase in discontinuations due to adverse events or serious adverse events compared with placebo in studies conducted over one to several years' duration; however, data about rare and longer-term harms were limited from the evidence included in this update.
- Notes:
- Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857; https://www.ahrq.gov Contract No. HHSA-75Q80120D00007, Task Order No. 75Q80122F32003 Prepared by: RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, NC.
- NLM ID:
- 9918986595406676 [Electronic Resource]