What is the current evidence for cost-effective screening for osteoporosis?

Current Evidence for Cost-Effective Osteoporosis Screening

Screen all women aged 65 years and older with DXA of the hip and lumbar spine, and screen younger postmenopausal women (ages 50-64) whose 10-year fracture risk equals or exceeds 9.3% using the FRAX tool. 1, 2

Screening Recommendations by Population

Women

• All women ≥65 years: Universal screening with DXA is recommended regardless of risk factors 1, 2
• Women ages 50-64 years: Screen if their 10-year fracture risk equals or exceeds that of a 65-year-old white woman without additional risk factors (9.3% threshold) 1
• Use the FRAX tool (available at www.shef.ac.uk/FRAX/) to calculate 10-year fracture risk based on age, BMI, parental fracture history, tobacco use, and alcohol consumption—no DXA required for initial risk assessment 1

Men

• Evidence is insufficient to recommend routine screening in men, though potential benefit exists 1
• Consider screening men ≥70 years or younger men (ages 50-69) with specific high-risk factors: age >70, BMI <20-25 kg/m², weight loss >10%, physical inactivity, oral corticosteroid use, previous fragility fracture, or androgen deprivation therapy 1, 3
• Screening men with fall history is cost-effective: For men ≥65 years who fell at least once in the past year, DXA screening followed by treatment has an incremental cost-effectiveness ratio of $33,169/QALY gained, with screening becoming cost-saving at age 77 and older 4

Cost-Effectiveness Evidence

Screening Strategies

• DXA screening is cost-effective in appropriate populations, with cost per QALY ranging from $30,000 to $248,000 depending on age and risk factors 1
• Pre-screening with FRAX followed by DXA is more cost-effective than universal DXA alone in populations aged 70 and older 5
• All screening strategies (universal DXA, FRAX pre-screening, or quantitative ultrasound pre-screening) are consistently more cost-effective than no screening for people aged ≥65 years 5
• Opportunistic screening using existing abdominal CT scans with biomechanical computed tomography analysis is cost-effective and prevents 3.1 hip fractures per 1000 women and 1.9 per 1000 men over 5 years compared to usual care 6

Treatment Cost-Effectiveness

• Generic zoledronic acid is the most cost-effective injectable option at $58-$92.79 per year, with maximum benefit in high-risk patients 7
• Treatment with bisphosphonates reduces fracture risk in postmenopausal women with low BMD and no previous fractures, with benefits emerging 18-24 months after initiation 1

Screening Intervals and Monitoring

• Minimum 2-year intervals between DXA scans are required to reliably measure BMD changes 1
• Women with normal BMD at age 65 may not need repeat screening for up to 17 years, as they typically do not transition to osteoporosis during this period 2
• Patients with osteopenia may need screening every 4-8 years unless baseline T-score is below -2.0 2
• Do not perform bone density monitoring during the initial 5-year treatment period for patients on pharmacologic therapy 8

Key Risk Factors That Trigger Screening

The most important risk factors that should prompt earlier screening include: 1

• Age >70 years
• Low body weight (BMI <20-25 kg/m²)
• Weight loss >10% from usual adult weight
• Physical inactivity
• Oral corticosteroid use (especially ≥30 mg/day prednisone equivalent) 8
• Previous fragility fracture
• Androgen deprivation therapy in men
• Parental history of hip fracture

Common Pitfalls to Avoid

• Do not screen more frequently than every 2 years in patients with normal BMD—this provides no clinical benefit and exposes patients to unnecessary radiation 2
• Do not rely solely on BMD T-scores for treatment decisions; use FRAX to calculate absolute 10-year fracture risk 8
• Do not arbitrarily stop screening at a specific age without considering individual life expectancy, treatment candidacy, and functional status 2
• Do not overlook that fracture risk increases with age, making screening potentially more valuable in older adults who remain treatment candidates 2
• Recognize that DXA machines cost $25,000-$85,000, which may limit widespread screening availability 1

Treatment Thresholds

Initiate pharmacologic treatment when: 8

• T-score ≤-2.5 at femoral neck, total hip, or lumbar spine, OR
• Low bone mass (T-score -1.0 to -2.5) AND 10-year probability of major osteoporotic fracture ≥20% OR hip fracture ≥3% based on FRAX, OR
• History of hip or vertebral fracture