USPSTF Updates Screening Recommendations for Osteoporosis

The United States Preventive Services Task Force (USPSTF) updated its 2011 recommendation about osteoporosis screening, recommending that women over the age of 65 years continue to get screened and issuing new information about how clinicians should use screening tools to evaluate women younger than 65 years at high risk for developing the bone disease.

Risk factors should be determined by clinical tools to determine fracture risk assessment, which the USPSTF determined have benefit. The task force's recommendations were published Tuesday in JAMA.

Many people will not know they have osteoporosis, a skeletal disorder characterized by loss of bone mass, deterioration of bone tissue, and decline in bone quality, until they have a fracture. In some cases, fractures can lead to disability, chronic pain, loss of independence, lower quality of life, and even death. About 21% to 30% of patients who experience a hip fracture die within 1 year.¹

By 2020, approximately 12.3 million individuals in the United States older than 50 years are expected to have osteoporosis.

The USPSTF gave 2 recommendations a B grade, meaning that there is high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial.

One is the continued recommendation that women 65 years and older should have screening with bone measurement testing.

The other is that women under 65 years should be screened with bone measurement testing if they are at an increased risk of osteoporosis, as determined by formal clinical risk assessment tools.

"In this updated recommendation, we provide clinicians with more information about how to use evidence-based tools such as FRAX and SCORE to evaluate which younger, post-menopausal women are at higher risk for osteoporosis and should be considered for screening with bone measurement testing. The task force continues to recommend screening all women 65 and older for osteoporosis," said USPSTF member Chien-Wen Tseng, MD, MPH, MSEE, in an email to The American Journal of Managed Care^®. Tseng is the Hawaii Medical Service Association endowed chair in health services and quality research, an associate professor, and the associate research director in the Department of Family Medicine and Community Health at the University of Hawaii John A. Burns School of Medicine.

In this report, the USPSTF also found convincing evidence for the use of bone measurement tests in both women and men and found adequate evidence that clinical risk assessment tools are moderately accurate.

The most commonly used screening test is the central dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine. A DXA also gives a measurement of bone mineral density (BMD). A central DXA is commonly used to define osteoporosis according to some treatment guidelines and is used as the threshold for when to begin preventive drug therapies, according to the USPSTF recommendation statement.

Another test, quantitative ultrasound, has similar accuracy in predicting fracture risk as DXA while avoiding the risk of radiation exposure; however, it does not measure BMD.

"This recommendation updates and expands our evidence review on the accuracy of different tools to screen for osteoporosis, such as central DXA, and found them to be similar," said Tseng. "We also updated our evidence review on the effectiveness of various drug treatments in preventing fractures. Overall, there is good evidence that several drugs for treating osteoporosis successfully decrease fractures in post-menopausal women but there is insufficient evidence for men."

There are several tools available to assess risk; one of them, called the FRAX, gives a 10-year risk for a major fracture.

Risk factors for osteoporosis in both men and women include low body weight, excessive alcohol consumption, current smoking, long-term corticosteroid use, previous fractures, and history of falls within the past year.

The USPSTF continues to conclude that the evidence is insufficient to assess the risk and benefit of osteoporosis screening in men, the same as in the 2011 report. The USPSTF could not make a recommendation as to how often repeat screening should be conducted.

In an editorial published in JAMA Internal Medicine, an internist who also studies bone loss who was not on the USPSTF disagreed with 1 of the recommendations. The recommendation for women younger than 65 years should really have an I for insufficient evidence, wrote Margaret L. Gourlay, MD, MPH, of the Department of Family Medicine at the University of North Carolina School of Medicine.

“Given the myriad responsibilities of primary care practices caring for patients with high-acuity conditions, implementation of screening programs that are needlessly complex is burdensome and distracts from high-value medical care,” she wrote. Instead, the USPSTF should use decision modeling to determine which women younger than 65 should get bone density tests, she said.²

If the task force had given the screening recommendation for women younger than 65 an I, insurers may not have covered the screening tests. Under current law, preventive services receiving an A or B grade must be covered by most private insurance plans with no co-pay for patients. Other screening tests and services with different grades are up to the payer.

References

1. US Preventive Services Task Force. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(24):2521-2531. doi: 10.1001/jama.2018.7498.

2. Gourlay ML. Osteoporosis screening—2 steps may be too much for women younger than 65 years [published online June 26, 2018]. JAMA Intern Med. doi: 10.1001/jamainternmed.2018.2776.