A systematic evidence review published in JAMA suggests that osteoporosis screening programs for higher-risk women aged 65 and older lead to small but statistically significant reductions in hip and major fractures compared with usual care.

The review, conducted for the US Preventive Services Task Force (USPSTF), evaluated data from 3 randomized clinical trials involving 42,009 participants. Screening was associated with 5 to 6 fewer fractures per 1,000 participants screened. For hip fractures, the pooled relative risk (RR) was 0.83, and for major osteoporotic fractures, the RR was 0.94.

"Screening in higher-risk women 65 years or older was associated with a small absolute risk reduction in hip and major fractures compared with usual care," noted lead author Leila C. Kahwati, MD, MPH, of RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center.

Risk assessment instruments and bone mineral density (BMD) testing demonstrated poor to modest predictive accuracy, with most tools showing an area under the curve between 0.60 and 0.80 for predicting major osteoporotic or hip fractures. These findings highlight limitations in current tools for reliably identifying individuals at higher fracture risk.

Pharmacotherapy analysis showed promising results. Bisphosphonates reduced hip fracture risk with a pooled RR of 0.67, and denosumab showed an RR of 0.60. Importantly, researchers did not find statistically significant associations between these treatments and adverse events compared with placebo.

Key evidence gaps noted in by the authors included a lack of studies focused exclusively on BMD testing, the exclusion of men and younger women, modest adherence to screening and treatment protocols, and contamination in control groups, which may limit the generalizability of findings.

The review analyzed 145 studies published in 195 articles, including three pivotal trials (ROSE, SCOOP, and SOS) that used varied screening approaches such as two-stage strategies incorporating the Fracture Risk Assessment Tool (FRAX) followed by BMD testing when thresholds were met. The findings indicate a modest benefit of screening in reducing fractures, though further research may be needed to assess its effectiveness in broader populations and refine screening tools.

The authors declared having no competing interests.