Authors' objectives:

This report examines the evidence on the effectiveness of various strategies for diagnosing and monitoring postmenopausal women with osteoporosis. Specifically, it addresses: (1) the role of risk factors in identifying high-risk women and guiding their initial treatment, (2) the advantages and disadvantages of various techniques for bone measurement in predicting risk of hip or spine fracture, (3) the effectiveness of bone measurement tests for monitoring response to treatment and for guiding treatment change, (4) the role of markers of bone turnover in diagnosis and treatment management, (5) the evaluation of patients with osteoporosis for secondary causes, and (6) the costs and cost-effectiveness of various diagnostic strategies for osteoporosis.

Authors' results and conclusions: Epidemiologic studies report clinical risk factors for osteoporosis and fractures, but few studies evaluate how to use them to identify individual women at risk for fracture, and no studies provide evidence that treatment decisions based on clinical risk factors lead to better or worse fracture outcomes than those based on bone measurement tests. Because of differences between bone measurement techniques, and because individuals have different rates of bone loss at different sites, no one test can exclude osteoporosis at the most important fracture sites-hip, spine, and wrist. Dual-energy X-ray absorptiometry (DXA) of the femoral neck is the best validated test to predict hip fracture. Other techniques predict hip fracture less accurately or have not been evaluated in prospective studies. Recent results from clinical trials raise questions about the value of repeated, annual densitometry tests for patients on therapy to prevent osteoporosis or bone loss; moreover, there is no evidence from clinical trials that adjusting therapy based on serial densitometry at any interval improve outcomes. Markers of bone turnover correlate poorly with bone measurement tests and are not good predictors of fractures. Cost and cost-effectiveness studies, which are based solely on economic models, suggest targeting treatment to women with the lowest bone density and including a risk factor score or less expensive (and more widely available) technology to determine which women should receive hip DXA. The authors' supplementary analysis on cost-effectiveness favors a sequential strategy of quantitative ultrasound at the heel followed by densitometry of those identified by ultrasound as high risk over densitometry alone. In high-risk populations, ultrasound alone may also be cost-effective.

Authors' recommendations: Application of the results from epidemiologic studies to diagnosis and monitoring strategies for individual patients in the clinical setting is currently based on extrapolation from models or, for most questions addressed in this review, is simply lacking. To be more useful for clinicians and patients, future research should focus on the application of these data to the clinical setting.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/clinic/epcsums/osteosum.htm

Year Published: 2001

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)