Report of a National Bone Health Alliance Working Group: Expanded Criteria for the Clinical Diagnosis of Osteoporosis

The National Bone Health Alliance working group expanded criteria for the clinical diagnosis of osteoporosis to include T-score < 2.5 at the spine or hip; low-trauma hip fracture; low-trauma vertebral, proximal humerus, pelvis or some distal forearm fractures in the setting of osteopenia; or FRAX score in a patient with osteopenia meeting or exceeding the National Osteoporosis Foundation (NOF) Guidelines.

Ethel Siris, MD, from Columbia University College of Physicians and Surgeons, discussed the results of an NBHA working group’s effort to expand the criteria by which a diagnosis of osteoporosis could be made in postmenopausal women and men older than 50 years of age at the 2014 American Society of Bone and Mineral Research Conference in Houston, Texas.

Dr Siris started with a working definition of osteoporosis. It is defined as “a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture, where bone strength is the sum of bone quantity and bone quality.”

At this point in time, greatly improved treatments are available for osteoporosis. However, patients are not seeing the results of this progress. Physicians do not understand how to appropriately use diagnostic tools and do not appropriately diagnose patients. Patients are also reluctant to agree to treatment because they are nervous about side-effects from current drugs.

Currently, the operational criterion for making a diagnosis of osteoporosis in the US focuses on bone mineral density (BMD), particularly T-score threshold at the lumbar spine or hip. Unfortunately, most fractures in postmenopausal women occur in those who carry a diagnosis of osteopenia, leading to disconnect between who is at risk and who gets treated.

As a result of basing diagnosis on BMD, patients may not understand their fracture risk when they are diagnosed with osteopenia, clinicians don’t appropriately treat older post-fracture patients, and third party payers bill differently for payment.

The NBHA addressed these problems by expanding the criteria for osteoporosis:

The diagnosis of osteoporosis should be made in postmenopausal women and men age 50 or older if any one of the following is present:

- T-score < 2.5 at the spine or hip

- Low trauma hip fracture, with or without BMD

- Low trauma vertebral, proximal humerus, pelvis or some distal forearm fractures in the setting of osteopenia

- FRAX score in a patient with osteopenia meeting or exceeding the NOF Guide treatment cut points.

These recommendations are from a US-based committee and depend on how osteoporosis is diagnosed in the United States.

Future directions include gaining endorsements from physician and advocacy groups to change the diagnostic criteria, and having these criteria included in the ICD-9 and ICD-10 diagnostic codes for osteoporosis.

When asked how much these expanded criteria will increase the pool of patients diagnosed with osteoporosis, Dr Siris responded, “Not much.” She noted that the goal of this paper is not necessarily to greatly expand the number of patients receiving treatment; rather, healthcare providers should thoughtfully base their diagnosis of osteoporosis on clinical symptoms (particularly fractures), in addition to the numerical threshold provided by diagnostic tests.