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Preventive Services Task Force urges routine osteoporosis screening for women 65 and older

The U.S. Preventive Services Task Force has issued its recommendation that women 65 and older be routinely screened for osteoporosis to reduce the risk of fracture and spinal abnormalities often associated with the disease. The Task Force also recommends that routine screening begin at 60 for those women identified as high risk because of their weight or estrogen use.

The Task Force is an independent panel of experts sponsored by the Agency for Healthcare Research and Quality. These recommendations, which appear in the September 17, 2002, issue of the Annals of Internal Medicine, mark the first time the Task Force has called for routine osteoporosis screening.

Osteoporosis, a condition that occurs when bone tissue thins or develops small holes, can cause pain, broken bones, and loss of body height. For women who live to be 85, approximately 50 percent will have an osteoporosis-related fracture during their lives, 25 percent of these women will develop an abnormality of the spine, and 15 percent will fracture their hip.

Age is the greatest risk factor for osteoporosis. The Task Force found that 12 percent to 28 percent of women 65 and older have osteoporosis and that the proportion increases with age. The Task Force concluded that screening and treating women in this age group would prevent the greatest number of fractures. Although the risk of osteoporosis and fracture is lower in women 60 to 64, the Task Force concluded that it was sufficiently high in a subgroup of these women (those under 154 pounds and not using estrogen) to justify selective screening in this age group. Although screening women without risk factors and those under 60 may detect additional cases of osteoporosis, the Task Force concluded that the number of fractures that might be prevented was too small to make a general recommendation for screening those women. The Task Force instead advised clinicians to use their judgment in deciding which women to screen.

The Task Force found that dual-energy x-ray absorptiometry (DEXA), a noninvasive test, is the most accurate method for measuring bone density. DEXA of the hip (which can cost between $125 and $200 depending on whether it is performed in a physician's office or hospital) is the best predictor of hip fracture, but bone density of the hand, wrist, forearm, and heel (which can cost between $38 and $75) also can be measured to detect risk. Medicare Part B covers DEXA screening for women 65 and older once every 2 years if their physicians determine that they are at risk for bone loss.

The U.S. Food and Drug Administration has approved various medications for the treatment of osteoporosis, including calcitonin, bisphosphonates such as alendronate and risedronate, and selective estrogen-receptor modulators such as raloxifene. According to the Task Force, each of these treatments has potential benefits and harms.

The Task Force, the leading independent panel of private-sector experts in prevention and primary care, conducts rigorous, impartial assessments of all the scientific evidence for a broad range of preventive services. Its recommendations are considered the gold standard for clinical preventive services. The Task Force based its conclusion on a report from a team led by Heidi Nelson, M.D., M.P.H., and Mark Helfand, M.D., M.P.H., from AHRQ's Evidence-based Practice Center at Oregon Health & Science University in Portland.

The Task Force grades the strength of the evidence as "A" (strongly recommends), "B" (recommends), "C" (no recommendation for or against), "D" (recommends against) or "I" (insufficient evidence to recommend for or against screening).

In 1996, the Task Force found insufficient evidence to recommend for or against osteoporosis screening (an "I" recommendation). Now, after reviewing new clinical trial data that showed various medications can reduce the risk of fracture, the Task Force recommends that clinicians routinely provide screening for women 65 and older and those 60 to 64 who have risk factors for osteoporosis (a "B" recommendation). The Task Force made no recommendation for or against osteoporosis screening for women without risk factors and those under 60 (a "C" recommendation).

Select for osteoporosis recommendations and materials for clinicians.

Previous Task Force recommendations, summaries of the evidence, easy-to-read fact sheets explaining the recommendations, and related materials are also available from the AHRQ Publications Clearinghouse.

Clinical information also is available from the National Guideline Clearinghouse™.

Editor's Note: For more information, see "Screening for postmenopausal osteoporosis: A review of the Evidence for the U.S. Preventive Services Task Force," by Heidi D. Nelson, M.D., M.P.H., Mark Helfand, M.D., M.P.H., Steven H. Woolf, M.D., M.P.H., and Janet D. Allan, Ph.D., R.N., in the September 17, 2002, Annals of Internal Medicine 137(6), pp. 529-541.

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