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OMNISENSE 7000S/8000S
Screening for Osteoporosis in Postmenopausal Women: Recommendations and
Rationale
U.S. Preventive Services Task Force*
This statement summarizes the current U.S. Preventive
Services Task Force (USPSTF) recommendations on screening for osteoporosis and
the supporting scientific evidence and updates the 1996 USPSTF recommendations
on this topic. The complete USPSTF recommendation and rationale statement on
this topic, which includes a brief review of the supporting evidence, is
available through the USPSTF Web site (www.preventiveservices.ahrq.gov),
the National Guideline Clearinghouse (www.guideline.gov),
and in print through the Agency for Healthcare Research and Quality Publications
Clearinghouse (telephone, 800-358-9295; e-mail, ahrqpubs@ahrq.gov).
The complete information on which this statement is based, including evidence
tables and references, is available in the accompanying article in this issue
and in the summary of the evidence and the systematic evidence review on the Web
sites already mentioned.
Ann Intern Med. 2002;137:526-528. www.annals.org
See related article on pp 529-541. *For a list of the members of the U.S.
Preventive Services Task Force, see the Appendix.
SUMMARY OF RECOMMENDATIONS
The U.S. Preventive Services Task Force (USPSTF) recommends
that women 65 years of age and older be screened routinely for osteoporosis. The
USPSTF recommends that routine screening begin at 60 years of age for women at
increased risk for osteoporotic fractures (see Clinical Considerations for a
discussion of women at increased risk). This is a grade B recommendation. (See
Appendix Table 1 for a description of the USPSTF classification of
recommendations.)
The USPSTF found good evidence that the risk for osteoporosis
and fracture increases with age and other factors, that bone density
measurements accurately predict the risk for fractures in the short term, and
that treating asymptomatic women with osteoporosis reduces their risk for
fracture. (See Appendix Table 2 for a description of the USPSTF
classification of levels of evidence.) The USPSTF concludes that the benefits
of screening and treatment are of at least moderate magnitude for women at
increased risk by virtue of age or presence of other risk factors.
The USPSTF makes no recommendation for or against routine
osteoporosis screening in postmenopausal women who are younger than 60 years of
age or in women 60 to 64 years of age who are not at increased risk for
osteoporotic fractures. This is a grade C recommendation.
The USPSTF found fair evidence that screening women at lower
risk for osteoporosis or fracture can identify additional women who may be
eligible for treatment for osteoporosis, but it would prevent a small number of
fractures. The USPSTF concludes that the balance of benefits and harms of
screening and treatment is too close to make a general recommendation for this
age group.
CLINICAL CONSIDERATIONS
Modeling analysis suggests that the absolute benefits of screening for
osteoporosis among women 60 to 64 years of age who are at increased risk for
osteoporosis and fracture are comparable to those of routine screening in older
women. The exact risk factors that should trigger screening in this age group
are difficult to specify based on evidence. Lower body weight (weight < 70
kg) is the single best predictor of low bone mineral density (1, 2). Low weight
and no current use of estrogen therapy are incorporated with age into the
three-item Osteoporosis Risk Assessment Instrument (1). There is less evidence
to support the use of other individual risk factors (for example, smoking,
weight loss, family history, decreased physical activity, alcohol or caffeine
use, or low calcium and vitamin D intake) as a basis for identifying high-risk
women younger than 65 years of age. At any given age, African-American women on
average have higher bone mineral density than white women and are thus less
likely to benefit from screening.
Among different bone measurement tests performed at various
anatomic sites, bone density measured at the femoral neck by dual-energy x-ray
absorptiometry is the best predictor of hip fracture and is comparable to
forearm measurements for predicting fractures at other sites. Other technologies
for measuring peripheral sites include quantitative ultrasonography,
radiographic absorptiometry, single-energy x-ray absorptiometry, peripheral
dual-energy x-ray absorptiometry, and peripheral quantitative computed
tomography. Recent data suggest that peripheral bone density testing in the
primary care setting can also identify postmenopausal women who have a higher
risk for fracture over the short term (1 year). Further research is needed to
determine the accuracy of peripheral bone density testing in comparison with
dual-energy x-ray absorptiometry. The likelihood of being diagnosed with
osteoporosis varies greatly depending on the site and type of bone measurement
test, the number of sites tested, the brand of densitometer used, and the
relevance of the reference range.
Estimates of the benefits of detecting and treating
osteoporosis are based largely on studies of bisphosphonates. Some women,
however, may prefer other treatment options (for example, hormone replacement
therapy, selective estrogen receptor modulators, or calcitonin) based on
personal preferences or risk factors. Clinicians should review with patients the
relative benefits and harms of available treatment options, and uncertainties
about their efficacy and safety, to facilitate an informed choice. No studies
have evaluated the optimal intervals for repeated screening. Because of
limitations in the precision of testing, a minimum of 2 years may be needed to
reliably measure a change in bone mineral density; however, longer intervals may
be adequate for repeated screening to identify new cases of osteoporosis. Yield
of repeated screening will be higher in older women, those with lower bone
mineral density at baseline, and those with other risk factors for fracture.
There are no data to determine the appropriate age to stop
screening and few data on osteoporosis treatment in women older than 85 years of
age. Patients who receive a diagnosis of osteoporosis fall outside the context
of screening but may require additional testing for diagnostic purposes or to
monitor response to treatment.
The brief review of the evidence and other sections that are
normally included in USPSTF recommendations are available in the complete
recommendation and rationale statement on the USPSTF Web site (www.preventiveservices
.ahrq.gov).
RECOMMENDATIONS OF OTHERS
In 1998, the National Osteoporosis Foundation, in
collaboration with other professional organizations, issued screening guidelines
recommending bone density testing for all women 65 years of age or older, as
well as younger postmenopausal women who have had a fracture or who have one or
more risk factors for osteoporosis (3). Collaborating groups included the
American Academy of Orthopaedic Surgeons, the American College of Obstetricians
and Gynecologists, the American Geriatrics Society, the American College of
Radiology, the American College of Rheumatology, the American Academy of
Physical Medicine and Rehabilitation, the American Association of Clinical
Endocrinologists, the Endocrine Society, and the American Society for Bone and
Mineral Research. The American Association of Clinical Endocrinologists released
revised guidelines in 2001 (4). A 2000 Consensus Development Conference
sponsored by the U.S. National Institutes of Health concluded that the value of
universal osteoporosis screening was not yet established (5). The conference
panel recommended an individualized approach to screening, noting that bone
density measurement is appropriate when it will aid the patient’s decision to
institute treatment. The Canadian Task Force on Preventive Health Care is
currently revising its recommendations on screening for osteoporosis.
APPENDIX
Members of the U.S. Preventive Services Task Force are Alfred
O. Berg, MD, MPH, Chair (University of Washington, Seattle, Washington);
Janet D. Allan, PhD, RN, CS, Vice-Chair (School of Nursing, University of
Maryland, Baltimore, Baltimore, Maryland); Paul S. Frame, MD (Tri-County Family
Medicine, Cohocton, and University of Rochester, Rochester, New York); Charles
J. Homer, MD, MPH (National Initiative for Children’s Healthcare Quality,
Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and
Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey);
Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine,
Rochester, New York); Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health Care and
Harvard Medical School, Boston, Massachusetts); Cynthia D. Mulrow, MD, MSc
(University of Texas Health Science Center, Audie L. Murphy Memorial Veterans
Hospital, San Antonio, Texas); C. Tracy Orleans, PhD (The Robert Wood Johnson
Foundation, Princeton, New Jersey); Jeffrey F. Peipert, MD, MPH (Women and
Infants’ Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN
(University of Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH (Mount
Sinai School of Medicine, New York, New York); Steven M. Teutsch, MD, MPH (Merck
& Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia
University College of Physicians and Surgeons, New York, New York); and Steven
H. Woolf, MD, MPH (Virginia Commonwealth University, Fairfax, Virginia).
Appendix Table 1. U.S. Preventive Services Task Force
Grades and Recommendations*
| Grade |
Recommendation |
| A |
The USPSTF strongly recommends that clinicians routinely
provide [the service] to eligible patients. The USPSTF found good
evidence that [the service] improves important health outcomes
and concludes that benefits substantially outweigh harms. |
| B |
The USPSTF recommends that clinicians routinely provide
[the service] to eligible patients. The USPSTF found at least fair
evidence that [the service] improves important health outcomes
and concludes that benefits outweigh harms. |
| C |
The USPSTF makes no recommendation for or against routine
provision of [the service]. The USPSTF found at least fair evidence
that [the service] can improve health outcomes but concludes that
the balance of benefits and harms is too close to justify a general
recommendation. |
| D |
The USPSTF recommends against routinely providing [the
service] to asymptomatic patients. The USPSTF found at least fair
evidence that [the service] is ineffective or that harms outweigh
benefits. |
| I |
The USPSTF concludes that the evidence is insufficient to
recommend for or against routinely providing [the service]. Evidence
that the [service] is effective is lacking, of poor quality, or
conflicting, and the balance of benefits and harms cannot be determined. |
* The U.S. Preventive Services Task Force (USPSTF) grades its
recommendations according to one of five classifications (A, B, C, D, I)
reflecting the strength of evidence and magnitude of net benefit (benefits minus
harms).
Appendix Table 2. U.S. Preventive Services Task Force Grades for
Strength of Overall Evidence*
| Grade |
Definition |
| Good |
Evidence includes consistent results from well-designed,
wellconducted studies in representative populations that directly assess
effects on health outcomes |
| Fair |
Evidence is sufficient to determine effects on health
outcomes, but the strength of the evidence is limited by the number,
quality, or consistency of the individual studies; generalizability to
routine practice; or indirect nature of the evidence on health outcomes |
| Poor |
Evidence is insufficient to assess the effects on health
outcomes because of limited number or power of studies, important flaws
in their design or conduct, gaps in the chain of evidence, or lack of
information on important health outcomes |
* The U.S. Preventive Services Task Force (USPSTF) grades the quality of
the overall evidence for a service on a three-point scale (good, fair, poor).
From the U.S. Preventive Services Task Force, Agency for Healthcare
Research and Quality, Rockville, Maryland.
Requests for Single Reprints: Reprints are available from the USPSTF Web
site (www.preventiveservices.ahrq.gov)
and in print through the Agency for Healthcare Research and Quality Publications
Clearinghouse (800-358-9295).
References
1. Cadarette SM, Jaglal SB, Kreiger N, McIsaac
WJ, Darlington GA, Tu JV. Development and validation
of the Osteoporosis Risk Assessment Instrument to facilitate selection of women
for bone densitometry. CMAJ. 2000;162:1289-94. [PMID: 10813010]
2. Cadarette SM, Jaglal SB, Murray TM, McIsaac WJ, Joseph L, Brown JP, et al.
Evaluation of decision rules for referring women for bone densitometry by
dual-energy x-ray absorptiometry. JAMA. 2001;286:57-63. [PMID: 11434827]
3. Physician’s Guide to Prevention and Treatment of Osteoporosis. National
Osteoporosis Foundation. Washington, DC: National Osteoporosis Foundation; 1999.
Accessed at www.nof.org/physguide
on 29 July 2002.
4. American Association of Clinical Endocrinologists. 2001 Medical Guidelines
for Clinical Practice for the Prevention and Management of Postmenopausal
Osteoporosis. Accessed at www.aace.com/clin/guidelines/osteoporosis2001.pdf
on 27 February 2002.
5. Osteoporosis prevention, diagnosis, and therapy. NIH Consensus Statement.
2000;17:1-45. [PMID: 11525451] Accessed at http://odp.od.nih.gov/consensus/
cons/111/111_statement.htm on 27 February 2002.
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