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1 Close window Guideline Synthesis: Screening and Risk Assessment for Osteoporosis Guidelines Being Compared: 1. The North American Menopause Society (). Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause 2010 Jan-Feb;17(1):25-54; quiz [286 references] 2. University of Michigan Health System (). Osteoporosis: prevention and treatment. Ann Arbor (MI): University of Michigan Health System; 2011 Dec. 16 p. [13 references] 3. U.S. Preventive Services Task Force (). Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2011 Mar 1;154(5): [17 references] Areas of Agreement and Difference A direct comparison of the recommendations presented in the above guidelines for screening and risk assessment for osteoporosis is provided in the tables. Areas of Agreement Risk Assessment and recommend assessing patients for risk factors associated with osteoporosis and osteoporotic fracture. As the target populations of the guidelines differ, so too do the recommendations regarding who should be assessed: all postmenopausal women () or all adults (). As the focus of the guideline is screening, the Task Force does not provide any explicit recommendations on risk assessment. It does, however, address it in the context of determining eligibility for screening. All of the guidelines agree that the key components of a risk assessment are assessing the individual for both clinical risk factors (e.g., age, tobacco smoking, history of fragility fracture, low body weight) and secondary risk factors (e.g., glucocorticoid therapy, rheumatoid arthritis, other secondary causes of osteoporosis), determining an absolute fracture risk, and subsequent BMD testing (if indicated) based on risk profile. All three groups address the use of osteoporosis risk assessment tools and all cite the WHO's FRAX as an example of a well-validated and reliable risk assessment calculator. In addition to assessment of risk factors, also recommends a physical examination that includes an annual measurement of height and weight, along with an assessment for chronic back pain and kyphosis. Measurement of BMD: Modality and Frequency The guidelines agree that DXA is the preferred and most widely accepted technique for measurement of BMD. All of the groups acknowledge, however, that certain factors can interfere with the accuracy of DXA measurements. cites vertebral compression fractures, osteoarthritis, osteophytes, and vascular calcification as factors that may spuriously elevate BMD measurement by DXA. With regard to screening tools other than DXA, and also address calcaneal QUS. While the groups agree that benefits compared to DXA include being portable, not exposing patients to radiation, and being less expensive, neither recommends its routine use. A limitation cited by is that while calcaneal QUS predicts fractures of the femoral neck, hip, and spine as effectively as DXA, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on QUS or a combination of QUS and DXA have not been defined. and also address biochemical markers of bone formation and resorption. There is overall agreement that they do not predict BMD or reliably estimate fracture risk, and that their routine use in clinical practice is not recommended. The groups agree that these markers are most often used in research settings to monitor response to antiresorption therapy, owing to their potential to demonstrate changes in bone remodeling earlier (within several days to months) than BMD changes, which can require 1 to 3 years. In terms of when to repeat BMD testing, there is overall agreement that an interval of at least two years is appropriate for most people. provides repeat testing recommendations based on the T-score from the patient's first DXA and the level of clinical risk, with repeat testing intervals ranging from 6 to 12 months (in the case of glucocorticoid use and/or transplantation) to 3 to 5 years. Areas of Difference Screening in Women The groups agree that the decision to test BMD should be based on a woman's clinical risk factors/risk profile, as well as the potential impact of results on management. All three groups recommend BMD testing for all women aged 65 years or older, regardless of clinical risk factors. also recommends BMD testing for postmenopausal women younger than 65 with osteoporotic risk factors. and guidance differs from in that these two groups recommend screening women younger than 65 ( specifies 50 to 64), regardless of menopausal status, using a 10-year fracture risk threshold of 9.3% according to the FRAX tool. A 9.3% 10-year risk is the equivalent to that of a healthy 65 year-old woman ( specifies a 65-year-old white woman with no other risk factors). recommends that clinicians consider each patient's values and preferences and use clinical judgment when discussing screening with women in this age group. They note that menopausal status is one factor that may affect a decision about screening in this age group. Screening in Men considers men >70 years, as well as men <70 years with at least one osteoporotic risk factor, to be at high risk and therefore indicated for screening., in contrast to, concluded that the current evidence is insufficient to assess the balance of benefits and harms of 1 of 10 5/14/15 2:48 PM

2 screening for osteoporosis in men. They discuss factors that clinicians should consider when deciding whether to screen men for osteoporosis. Comparison of Recommendations Jump to - Risk Assessment - Indications for BMD Testing - Measurement of BMD: Modality and Frequency Risk Assessment Evaluation All postmenopausal women should be assessed for risk factors associated with osteoporosis and fracture. This assessment requires a history, physical examination, and any necessary diagnostic tests. The goals of this evaluation are to evaluate fracture risk, to rule out secondary causes of osteoporosis, to identify modifiable risk factors, and to determine appropriate candidates for pharmacologic therapy. History and Physical Examination The medical history and physical examination should solicit clinical risk factors for osteoporosis and fracture and also evaluate for secondary causes of osteoporosis and fragility fracture. This includes the WHO's FRAX risk factors (personal history of fracture after age 40, history of hip fracture in a parent, cigarette smoking, excess alcohol consumption, glucocorticoid use, RA, or other secondary causes of osteoporosis. See Table 1 in the original guideline document). Risk factors must be accurately collected, often with the aid of a simple questionnaire. Risk factors may help identify contributing causes of osteoporosis and are essential in the determination of FRAX. This tool, used with guidelines for treatment thresholds, is very helpful in identifying candidates for pharmacotherapy. Osteoporosis can be diagnosed by bone density testing in postmenopausal women over age 50. A fragility fracture can also indicate a clinical diagnosis of osteoporosis. Loss of height and kyphosis may be signs of vertebral fracture. After achieving maximal height, women can lose up to 1.0 to 1.5 inches ( cm) of height as part of the normal aging process, primarily as a result of degenerative arthritis and shrinkage of intervertebral disks. Height loss greater than 1.5 inches (3.8 cm) increases the likelihood that a vertebral fracture is present. Height should be measured annually with an accurate method, such as a wall-mounted ruler or a stadiometer. Loss of 1.5 inches (3.8 cm) or more calls for evaluation by a lateral thoracolumbar radiograph or vertebral fracture assessment (VFA) by DXA to identify vertebral fractures. Weight should also be recorded to identify those women with low BMI and to be aware of weight changes, which may interfere with the interpretation of changes in BMD over time. The evaluation should include eliciting symptoms of acute or chronic back pain, which may indicate the presence of vertebral fractures. Signs of percussion tenderness may indicate acute fracture or bony infiltrative disease. The midback vertebrae T11-T12 and L1 are the most common fracture sites, followed by T6 through T9. Vertebral compression fractures may result in kyphosis, the most obvious sign of osteoporosis. Because back pain, height loss, and kyphosis can occur without osteoporosis, and because two thirds of vertebral fractures are asymptomatic, vertebral fracture must be confirmed by lateral spine radiographs or VFA visualization of fracture at the time of BMD testing. Vertebral height loss of more than 20% more than 2 mm (measured) or 4 mm (historical) of the anterior, mid, or posterior dimension of a vertebra on imaging is indicative of vertebral fracture. Grading of vertebral fractures and percentage of height reduction (grade 1, mild, 20%-25%; grade 2, moderate, 25%-40%; grade 3, severe, over 40%) by a Genant semiquantitative methodology or equivalent is most important in the evaluation of the patient with severe osteoporosis. Both the number and the severity of existing vertebral fractures predict the risk of future fracture. Risk Assessment and Diagnosis Assess all adults, men and women, for clinical risk factors for osteoporotic fracture (see "Clinical Risk Categories for Osteoporosis and Osteoporotic Fractures" below and Table 3 [Medications with Risk for Bone Loss or Fracture] in the original guideline document) [IC]: Postmenopausal woman with one or more of the following: Age 65 years Current smoking Low body weight (BMI <20) Frailty (e.g., unable to rise from chair unassisted) Personal history of fracture without substantial trauma Hip, wrist, or spine fracture without substantial trauma in first-degree relative 50 Chronic glucocorticoid use (prednisone 5 mg daily, or equivalent, for 3 months) Organ transplant or pending transplant Other associated medical conditions (see below) and medications (Table 3 in the original guideline document) Risk for falling (Table 4 in the original guideline document) 2 of 10 5/14/15 2:48 PM

3 For women under 65, FRAX ( can be used to assess need for screening DXA. In this setting, FRAX can be used without entering BMD data. Risk Categories for Osteoporosis and Osteoporotic Fractures Extremely High Risk Prior osteoporotic fracture (fracture without significant trauma) Glucocorticosteroid use (prednisone 7.5 mg/d or equivalent for 6 months) Solid organ transplant (pre or post, especially in first 2-3 years) High Risk Glucocorticosteroid use (prednisone 5 mg/day or equivalent, for 3 months) Woman age >65 yrs or man age >70 yrs Postmenopausal woman or older man with one or more of: Personal history of low impact fracture Family history of fracture hip, wrist, or spine (first degree relative age 50 yrs) Currently smoking Rheumatoid arthritis BMI <20 Recent weight loss <10% Multiple risk factors for falling (see Table 4 in the original guideline document) Moderate Risk Hormonal conditions Hypogonadism Late menarche (age >15 yrs) Early menopause (age <45 yrs) Premenopausal amenorrhea, (e.g., anorexia nervosa, exercise, or hyperprolactinemia but not polycystic ovary syndrome or pregnancy) Cushing's syndrome Hyperparathyroidism (primary or secondary) Thyrotoxicosis Gastrointestinal and nutritional factors Gastrectomy Low gastric acid (e.g., atrophic gastritis, proton pump inhibitors, H2-blockers) Impaired absorption Celiac disease Bariatric surgery Inflammatory bowel disease (Crohn's disease more than ulcerative colitis) Pancreatic insufficiency Heavy alcohol use Medications (see Table 3 in the original guideline document) Family history of osteoporosis Other significant associations Severe liver disease Chronic kidney disease Type 1 diabetes mellitus Multiple myeloma Hemochromatosis Long-term immobilization Prior smoking Other possible associations 3 of 10 5/14/15 2:48 PM

4 Addison's disease Amyloidosis Thalassemia (major > minor) Multiple sclerosis nephrolithiasis Sarcoidosis Depression Assessment of Risk Multiple instruments to predict risk for low BMD and fractures have been developed and validated for use in postmenopausal women, but few have been validated for use in men. To predict fracture risk, the area under the receiver-operating characteristic curve ranges from 0.48 to Less complex instruments (that is, those with fewer variables) seem to perform as well as more complex ones. The found no studies that assessed the effect on patient outcomes of using risk prediction instruments alone or in combination with bone measurement tests. The used the FRAX (Fracture Risk Assessment) tool (World Health Organization Collaborating Centre for Metabolic Bone Diseases, Sheffield, United Kingdom), available at to estimate 10-year risks for fractures because this tool relies on easily obtainable clinical information, such as age, BMI, parental fracture history, and tobacco and alcohol use; its development was supported by a broad international collaboration and extensively validated in two large U.S. cohorts; and it is freely accessible to clinicians and the public. The FRAX tool includes questions about previous DXA results but does not require this information to estimate fracture risk. Based on the U.S. FRAX tool, a 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. White women between the ages of 50 and 64 years with equivalent or greater 10-year fracture risks based on specific risk factors include but are not limited to the following persons: 1) a 50-year-old current smoker with a BMI less than 21 kg/m 2, daily alcohol use, and parental fracture history; 2) a 55-year-old woman with a parental fracture history; 3) a 60-year-old woman with a BMI less than 21 kg/m 2 and daily alcohol use; and 4) a 60-year-old current smoker with daily alcohol use. The FRAX tool also predicts 10-year fracture risks for black, Asian, and Hispanic women in the United States. In general, estimated fracture risks in nonwhite women are lower than those for white women of the same age. Although the recommends using a 9.3% 10-year fracture risk threshold to screen women aged 50 to 64 years, clinicians also should consider each patient's values and preferences and use clinical judgment when discussing screening with women in this age group. Menopausal status is one factor that may affect a decision about screening in this age group. Indications for BMD Testing (Back to top) Indications for BMD Testing The decision to test BMD in a postmenopausal woman should be based on the woman's risk profile. Testing is not indicated unless the results will influence a management decision. Although perimenopausal women can be classified by WHO criteria and may be candidates for FRAX risk assessment, care must be taken to appropriately interpret DXA tests and to make correct recommendations for risk factor reduction and sometimes pharmacotherapy. Other factors, such as availability of BMD testing equipment and reimbursement by insurance, also affect the decision to measure BMD. recommends that BMD be measured in the following populations: All women age 65 and over, regardless of clinical risk factors Postmenopausal women with medical causes of bone loss (e.g., steroid use, hyperparathyroidism), regardless of age Postmenopausal women age 50 and over with additional risk factors (see below) Postmenopausal women with a fragility fracture (e.g., fracture from a fall from standing height) Testing should be considered for postmenopausal women age 50 and over when one or more of the following risk factors for fracture have been identified: Fracture (other than skull, facial bone, ankle, finger, and toe) after menopause Thinness (body weight <127 lb [57.7 kg] or BMI <21 kg/m 2 ) History of hip fracture in a parent Current smoker Rheumatoid arthritis Alcohol intake of more than two units per day (one unit is 12 oz of beer, 4 oz of wine, or 1 oz of liquor) Order DXA [IA] based on clinical risk factors and potential impact of results on management (see below and Table 5 in the original guideline document). For women under 65, FRAX ( can be used to assess need for screening DXA. DXA is indicated for women with 10-year total fracture risk of 9.3% (equivalent to that of a healthy 65 year-old woman). In this setting, FRAX can be used without entering BMD data. Evaluate appropriately and refer, when indicated, for secondary causes of osteoporosis (see Table 6 in the original guideline document) [IID]. 4 of 10 5/14/15 2:48 PM

5 Clinical Risk (includes factors in Tables 2 and 3 in the original guideline document not addressed by FRAX) (see previous section for definitions of the clinical risk categories below) Extremely High. Order first DXA? Yes High. Order first DXA? Yes Moderate. Order first DXA? Consider Summary of Recommendations and Evidence The recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. This is a B recommendation. The concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. This is an I statement. Clinical Considerations Patient Population Under Consideration This recommendation applies to older adults in the general U.S. population who do not have a history of an osteoporotic fracture, osteoporosis secondary to another condition, or other specific clinical indications for bone measurement testing. The did not define a specific upper age limit for screening in women because the risk for fractures continues to increase with age and treatment harms remain no greater than small. Clinicians should take into account the patient's remaining lifespan when deciding whether to screen patients with significant illness. In the Fracture Intervention Trial, the benefit of treatment emerged 18 to 24 months after initiation of treatment. The quantity and quality of data on osteoporotic fracture risk other than hip fracture are much less for Asian, American Indian or Alaska Native, Hispanic, and black women than for white women. The 's recommendation to screen women aged 65 years or older for osteoporosis applies to all racial and ethnic groups because the harms of the screening tests are no greater than small, the consequences of failing to identify and treat women who have low BMD are considerable, and the optimal alternative age at which to screen nonwhite women is uncertain. Considerations for Practice Regarding the I Statement When deciding whether to screen men for osteoporosis, clinicians should consider the following factors. Potential Preventable Burden Bone measurement tests may potentially detect osteoporosis in a large number of men and prevent a substantial part of the burden of fractures and fracture-related illness in this population. The aging of the U.S. population is likely to increase this potentially preventable burden in future years. Potential Harms Potential harms of screening men are likely to be small and consist primarily of opportunity costs. Current Practice Routine screening of men currently is not a widespread practice. Costs Many additional DXA scanners may be required to screen sizeable populations of men for osteoporosis; DXA machines range in cost from $25,000 to $85,000. Assuming that the relative benefits and harms of therapy in men are similar to those in women, the men most likely to benefit from screening would have 10-year risks for osteoporotic fracture equal to or greater than those of 65-year-old white women who have no additional risk factors. However, current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. Measurement of BMD: Modality and Frequency (Back to top) Recommendations When BMD testing is indicated, DXA is the preferred technique. The total hip, femoral neck, and posterioranterior lumbar spine should be measured, using the lowest of the three BMD scores. The routine use of biochemical markers of bone turnover in clinical practice is not generally recommended. For untreated postmenopausal women, repeat DXA testing is not useful until 2 to 5 years have passed. Bone-testing Options Fracture risk can be estimated by a variety of technologies at numerous skeletal sites. BMD measured by DXA is the only diagnostic technology by which measurements are made at hip, spine, and radius. These are also important sites of osteoporotic fracture. When BMD testing is indicated, recommends measuring the total hip, femoral neck, and posterioranterior lumbar spine, using the lowest of the three BMD scores for diagnosis. In some patients, degenerative or other artifacts at the spine site make measurements unreliable. In such cases, the one-third radius should be measured and used as a second site valid for diagnosis. The spine may be a useful site for BMD measurement in early postmenopausal women because decreases in BMD 5 of 10 5/14/15 2:48 PM

6 can be faster at the spine than at the hip. Although bone tests at peripheral sites (e.g., tibia, finger, calcaneus) can identify women at risk of fracture, they are not useful for the diagnosis of osteoporosis and have limited or no value in the follow-up of patients. Peripheral site measurements may be useful to raise awareness about bone health and have been utilized as a prescreen for DXA testing where DXA availability is limited. Follow-up BMD Testing In most cases, repeat DXA testing in untreated postmenopausal women is not useful until 2 to 5 years have passed, given the rate of bone loss of 1% to 1.5% per year. Postmenopausal women, after substantial BMD losses in early postmenopause, generally lose about 0.5 T-score units in BMD every 5 years. For women receiving osteoporosis therapy, BMD monitoring may not provide clinically useful information until after 1 to 2 years of treatment. Stable BMD (within the precision error of the instrument) indicates successful therapy; fracture risk reductions for patients on antiresorptive therapy are similar with stable bone density or with increases in BMD. Marked declines in BMD predict greater fracture risk and should trigger a reevaluation for secondary causes of osteoporosis or treatment nonadherence. Each DXA testing center should perform precision testing to determine the least significant change that can be detected in their patient population. Statistically insignificant decreases in BMD should be reported as stable bone density within the precision error of the instrument. Statistically significant changes in BMD (equal to or greater than the least significant change) should be reported as such. Bone Turnover Markers Biochemical markers of bone turnover can be measured in serum or urine. They can indicate either osteoclastic bone resorption (breakdown products of type I collagen in bone: N-telopeptides, C-telopeptides, deoxypyridinoline) or osteoblast functioning (bone matrix synthesis: bone-specific alkaline phosphatase, procollagen type I N-terminal propeptide, osteocalcin). Bone turnover markers cannot diagnose osteoporosis and have varying ability to predict fracture risk when studied in groups of patients in clinical trials. They also have varying value in predicting individual patient response to therapy. Nevertheless, these tests may show an individual patient's response to therapy earlier than BMD changes, sometimes within 2 to 3 months as opposed to the 1 to 3 years required with BMD. Most bone turnover markers vary greatly from day to day, are affected by food intake and time of day, and lack assay standardization, limiting their clinical utility. In some cases, persistently elevated bone turnover markers in the face of antiresorptive therapy may alert the clinician to nonadherence to therapy, poor absorption of medication, or other secondary causes of osteoporosis. The value of bone turnover markers in encouraging adherence to therapy has been debated. Several trials have found no difference in adherence when marker values are communicated to women. Diagnostic Testing DXA DXA is the test of choice for measuring BMD. Although various skeletal sites can be assessed by DXA, BMD of the nondominant hip is the best predictor of hip fracture and is an excellent predictor of vertebral or wrist fracture. Loss of vertebral bone is accelerated early in menopause and early in glucocorticoid use. Spine BMD measurements may be helpful in these settings. BMD measurement by DXA may be spuriously elevated by a number of factors. Vertebral compression fractures typically result in a "smaller" vertebral body with no change in the total amount of calcium, and thus produce an apparent increase in BMD. Vertebral osteophytes, degenerative joint disease, and aortic calcifications can also falsely raise BMD measurements. Hip measurements tend to have fewer artifacts. Recommendations for initial screening with DXA are presented in the previous section of this synthesis. When possible, use the L1-L4 value to diagnose osteoporosis at the spine. If anatomic abnormalities are present, use any combination of two or three vertebrae (e.g., L2-L4). Guidelines suggest not making a diagnosis of osteoporosis based on the T-score of one vertebral body. For diagnosing osteoporosis of the hip, the femoral neck or total hip are the preferred sites. Other diagnostic and monitoring modalities. Other testing modalities are available, but have limitations in routine testing. Quantitative calcaneal ultrasound devices are both portable and inexpensive, and are often used in informal osteoporosis screening programs, such as health fairs. However, meta-analysis suggests limited value for ultrasound screening. For example, a positive study in an otherwise healthy 65 year-old woman raises the likelihood of DXA confirmed osteoporosis from a population-based pre-test estimate of 22% only to 34%. Conversely, a negative study reduces the likelihood of osteoporosis from 22% to 10%. T-scores provided by ultrasound are not equivalent to DXA T-scores, and should therefore not be used for diagnostic purposes. Instead, patients with abnormally low ultrasound T-scores should be evaluated by DXA for more definitive diagnosis. Biochemical markers of bone resorption are used in research and may be used clinically to assess the effectiveness of antiresorptive therapy. In the latter setting, a decrease in these markers to premenopausal levels usually occurs after two to three months of therapy. Some data suggest that elevated levels of bone resorption markers in older women are an independent risk factor for fractures. However, bone markers are not a reliable predictor of BMD, and are not a substitute for DXA in women at risk. Generally, their use in the diagnosis of osteoporosis is not recommended. Follow-up 6 of 10 5/14/15 2:48 PM

7 Repeat DXA based on a patient's situation (refer to Tables 5 and 8 in the original guideline document) [IC-D]. Consider not repeating DXA on patients with moderate bone loss who are fracture-free on medical therapy [IIC]. For most persons, 2 years between DXAs provides the most meaningful information [B]. Early in glucocorticoid use and/or after transplantation consider repeating DXA in 6-12 months [IB]. Follow-up and When to Repeat DXA When deciding if and when to repeat a DXA scan, consider: The patient's clinical risk factors for progression of bone loss and for fracture The results from prior scans Whether a repeat DXA will change management Whether a repeat DXA result may improve compliance with therapy even if it will not change management Tables 5 and 8 in the original guideline document summarize these and additional factors that may play a role in ongoing management and follow up. Screening Tests The most commonly used bone measurement tests used to screen for osteoporosis are DXA of the hip and lumbar spine and quantitative ultrasonography of the calcaneus. Quantitative ultrasonography is less expensive and more portable than DXA and does not expose patients to ionizing radiation. Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as DXA. However, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on quantitative ultrasonography or a combination of quantitative ultrasonography and DXA have not been defined. Screening Intervals The potential value of rescreening women whose initial screening test did not detect osteoporosis is to improve fracture risk prediction. A lack of evidence exists about optimal intervals for repeated screening and whether repeated screening is necessary in a woman with normal BMD. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD; however, longer intervals may be necessary to improve fracture risk prediction. A prospective study of 4,124 women aged 65 years or older found that neither repeated BMD measurement nor the change in BMD after 8 years was more predictive of subsequent fracture risk than the original measurement. Strength of Evidence and Recommendation Grading Schemes Not applicable Levels of Evidence Levels of evidence reflect the best available literature in support of an intervention or test. A. Randomized controlled trials B. Controlled trials, no randomization C. Observational trials D. Opinion of expert panel Grade of Recommendation I. Generally should be performed II. May be reasonable to perform III. Generally should not be performed What the U.S. Preventive Services Task Force () Grades Mean and Suggestions for Practice Grade Grade Definitions Suggestions for Practice A B C The recommends the service. There is high certainty that the net benefit is substantial. The recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the Offer or provide this service. Offer or provide this service. Offer or provide this service only if other considerations support offering or providing the service in an individual patient. 7 of 10 5/14/15 2:48 PM

8 Grade Grade Definitions Suggestions for Practice net benefit is small. D I Statement The recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Discourage the use of this service. Read "Clinical Considerations" section of Recommendation Statement (see "Major Recommendations" field). If this service is offered, patients should understand the uncertainty about the balance of benefits and harms. Levels of Certainty Regarding Net Benefit Definition: The U.S. Preventive Services Task Force defines certainty as "likelihood that the assessment of the net benefit of a preventive service is correct." The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service. Level of Certainty High Moderate Description The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies. The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as: The number, size, or quality of individual studies Inconsistency of findings across individual studies Limited generalizability of findings to routine primary care practice Lack of coherence in the chain of evidence As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: The limited number or size of studies Important flaws in study design or methods Inconsistency of findings across individual studies Gaps in the chain of evidence Findings not generalizable to routine primary care practice A lack of information on important health outcomes More information may allow an estimation of effects on health outcomes. Methodology Click on the links below for details of guideline development methodology Methods used to collect/select the evidence were similar, in that all three groups performed searches of electronic databases and hand-searches of published literature (primary and secondary sources). The guideline differs in that a systematic evidence review was prepared by the Oregon Evidence-Based Practice Center (EPC) for the Agency for Healthcare Research and Quality to be used by the in the development of its guideline. All of the groups cite the databases searched and date ranges applied. and also provide the specific search terms used. To assess the quality and strength of the evidence, expert consensus was used by. and, in contrast, weighted the evidence according to a rating scheme and provide the scheme. To analyze the evidence, all three groups performed a systematic review (the systematic review was conducted by the Oregon EPC) and reviewed published meta-analyses. is the only group to have also conducted a meta-analysis. and provide a description of the evidence analysis process. With regard to formulation of recommendations, the guideline developers all employed expert consensus. also utilized balance sheets. and rate the strength of the recommendations according to a scheme. All three groups sought peer review as a method of guideline validation; also compared its guideline with those of other groups. Benefits and Harms 8 of 10 5/14/15 2:48 PM

9 Benefits Appropriate management of postmenopausal osteoporosis may help prevent fractures by slowing or stopping bone loss, maintaining bone strength, and minimizing or eliminating factors that may contribute to fractures. Improved identification of patients at high risk for osteoporosis and osteoporotic fractures Decreased incidence of osteoporotic fractures and associated morbidity and mortality Benefits of Detection and Early Intervention No controlled studies have evaluated the effect of screening for osteoporosis on fracture rates or fracture-related morbidity or mortality. In postmenopausal women who have no previous osteoporotic fractures, the found convincing evidence that drug therapies reduce the risk for fractures. In women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors, the judged that the benefit of treating screening-detected osteoporosis is at least moderate. Harms No harms related to screening/risk assessment are provided. No harms related to screening/risk assessment are provided. Harms of Detection and Early Intervention The found no new studies that described harms of screening for osteoporosis in men or women. Screening with DXA is associated with opportunity costs (time and effort required by patients and the health care system). Abbreviations BMD, bone mineral density BMI, body mass index DXA, dual-energy x-ray absorptiometry FRAX, WHO Fracture Risk Assessment Tool, The North American Menopause Society RA, rheumatoid arthritis QUS, quantitative ultrasound, University of Michigan Health System, U.S. Preventive Services Task Force VFA, vertebral fracture assessment WHO, World Health Organization Status This synthesis was prepared by ECRI Institute on February 5, The information was verified by on February 14, 2008 and by on March 18, This synthesis was updated in March 2010 to remove ACOG recommendations, update recommendations, and add ACPM recommendations. The information was verified by ACPM on April 16, 2010 and by on May 5, This synthesis was updated in December 2010 to update recommendations. This synthesis was updated in November 2011 to add recommendations. The updated information was verified by on December 30, This synthesis was updated in November 2012 to revise recommendations. This synthesis was updated in January 2015 to remove ACPM recommendations. Citation Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Screening and risk assessment for osteoporosis. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Apr (revised 2015 Feb). [cited YYYY Mon DD]. Available: AHRQ Home Questions? Contact AHRQ Site Map Accessibility Privacy Policy Freedom of Information Act Disclaimers 9 of 10 5/14/15 2:48 PM

10 U.S. Department of Health & Human Services The White House USA.gov: The U.S. Government's Official Web Portal Agency for Healthcare Research and Quality 540 Gaither Road Rockville, MD Telephone: (301) of 10 5/14/15 2:48 PM

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