Health technology reviews

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Screening and monitoring tests for osteopenia / osteoporosis

Status: Decision completed

View findings and decision

Policy context

In 2011, the U.S. Preventive Services Task Force (USPSTF) issued updated recommendations on screening for osteoporosis, taking into account two systematic evidence reviews prepared by or for, the AHRQ in 2002 and 2010.

The following are current USPSTF recommendations:

  • Screening for osteoporosis should be conducted in women aged ≥ 65 years without previous known fractures or secondary causes of osteoporosis. (Grade B recommendation)
  • Screening for osteoporosis should be conducted in women aged < 65 years whose 10-year fracture risk is equal to or greater than that of a 65-year-old white woman without additional risk factors. (Grade B recommendation)
  • No recommendation may be made for men who have no previous known fractures or secondary causes of osteoporosis. (Grade I for insufficient evidence).

Regarding the optimal interval for screening, the USPSTF has no formal recommendation but advises that a minimum of two years may be needed to reliably measure a change in BMD because of the imprecision of testing and that longer intervals may be necessary to improve fracture risk prediction.

In 2013 the Oregon Health Evidence Review Commission (OR HERC) issued guidance that mirrors the USPSTF recommendations for initial screening in men and women. The guidance statement also recommends that screening should not be repeated more often than every 15 years for women with normal BMD, every 4 years for women with moderate osteopenia, and every 2 years for women with advanced osteopenia or osteoporosis. The recommendations for repeat screening are based on a recently published population-based study designed to address this issue. The OR HERC guidance document did not cite any new evidence pertaining to screening in men.

An analysis of the evidence supporting these public health and policy statements and the most recently published evidence can help promote the most efficient use of osteoporosis screening for beneficiaries of Washington Health Care Authority (HCA) plans. Additionally, an analysis of the evidence regarding the benefits of treatment monitoring with BMD testing will permit a more comprehensive policy.

Primary criteria ranking

  • Safety = Medium
  • Efficacy = Medium
  • Cost = Medium

 

Assessment timeline

  • Draft key questions published: May 19, 2014
  • Public comment period: May 19 - June 2, 2014
  • Final key questions published: June 13, 2014
  • Draft report published: September 5, 2014
  • Public comment period: September 5 – October 6, 2014
  • Final report published: October 20, 2014
  • HTCC public meeting: November 21, 2014

Background

Osteoporosis is a systemic skeletal condition characterized by both low bone mass and deteriorating bone quality, resulting in an increased risk of fracture.  Primary osteoporosis occurs without a known cause. One estimate suggests a lifetime risk of osteoporotic fracture of 50% for Americans over the age of 50, with women being at higher risk than men. Fractures in this population are associated with higher mortality and diminished function and quality of life (QOL). Various classes of medications have been found to be effective in correcting or preventing osteoporosis.

Osteoporosis is diagnosed when a fragility (nontraumatic) fracture occurs or bone mineral density (BMD) measured by dual-energy x-ray absorptiometry (DXA) is found to be outside the normal distribution in young health individuals. DXA is generally used to obtain central measures of BMD in the femoral neck (hip) and lumbar spine. An alternative method of bone measurement is quantitative ultrasonography (QUS), which measures bone quality, and typically is used for peripheral measurements such as in the calcaneus (heel). DXA and QUS have been shown to perform comparably well in predicting hip or vertebral fracture. However, standard diagnostic criteria for osteoporosis as well as patient selection in studies of osteoporosis medications are based on DXA scores, not on QUS scores, which do not correlate strongly with DXA scores. Practice guidelines recommend screening with DXA.

Numerous methods have been validated for predicting low BMD and for predicting fracture. A 2010 evidence review conducted for the Agency for Healthcare Research and Quality (AHRQ) found that simple and complex methods perform similarly.