Evidence Synthesis Number 162 Screening to Prevent Osteoporotic Fractures: An Evidence Review for the U.S. Preventive Services Task Force Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No. HHSA-290-2012-00015-I, Task Order No. 6 Prepared by: RTI International–University of North Carolina Evidence-based Practice Center Research Triangle Park, NC Investigators: Meera Viswanathan, PhD Shivani Reddy, MD, MSc Nancy Berkman, PhD Katie Cullen, BA Jennifer Cook Middleton, PhD Wanda K. Nicholson, MD, MPH, MBA Leila C. Kahwati, MD, MPH AHRQ Publication No. 15-05226-EF-1 October 2017 This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-290-2012-00015-I, Task Order No. 6). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients). The final report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report. Acknowledgments The authors acknowledge the following individuals for their contributions to this project: Tina Fan, MD, MPH, AHRQ Medical Officer; Tracy Wolff, MD, MPH, AHRQ Associate Scientific Director; current and former members of the U.S. Preventive Services Task Force who contributed to topic deliberations; Evelyn Whitlock, MD, MPH, former Director, Kaiser Permanente Research Affiliates EPC; Jennifer S. Lin, MD, Director, Kaiser Permanente; Rosanne Leipzig, MD, PhD, Diana Pettiti, MD, MPH, Margaret Gourlay, MD, MPH, Carolyn Crandall, MD, MS, Mary Roary, PhD, and Bruce Ettinger, MD, who contributed to peer review of the report; Research Affiliates EPC and RTI International–University of North Carolina EPC staff Kathleen N. Lohr, PhD; Lynn Whitener, DrPH; Andrew Kraska, BA; Janice Handler, BA; Stephanie Scope, BS; Carol Woodell, BSPH; Rachel Weber, PhD; Linda J. Lux, MPA; and Loraine Monroe. Screening to Prevent Osteoporotic Fractures ii RTI–UNC EPC Structured Abstract Purpose: To review evidence about screening to prevent osteoporotic fractures for the U.S. Preventive Services Task Force (USPSTF). Data Sources: MEDLINE, the Cochrane Library, Embase, and trial registries from November 1, 2009, through October 1, 2016 and surveillance of the literature through September 26, 2017; bibliographies from retrieved articles. Study Selection: Two investigators independently selected studies using a priori inclusion and exclusion criteria. We selected studies with a majority of adults age 40 years or older conducted in countries with a very high human development index. For screening studies, we required that studies include a majority of participants without prevalent low-trauma fractures. For treatment studies, we required that studies include a majority of participants with increased fracture risk. We selected studies of screening tests (fracture risk prediction instruments, bone measurement testing, or a combination of fracture risk prediction instruments and bone measurement testing) that were feasible for primary care settings and available in the United States. We selected studies of treatment approved by the U.S. Food and Drug Administration for synthesis of benefits and harms. We excluded studies of poor quality and of fracture risk prediction instruments without external validation. Data Extraction: One investigator extracted data and a second checked accuracy. Two reviewers independently rated quality for included studies using predefined criteria. Data Synthesis: We did not identify any fair or good quality studies that compared screening with no screening. We included 153 studies (in 161 articles) of fair or good quality; 96 (in 100 articles) assessed screening accuracy and 61 (in 65 articles) assessed benefits and harms of treatment. Using centrally measured dual-energy X-ray absorptiometry (DXA) as the reference standard for identifying osteoporosis, the pooled estimate of accuracy as measured by the area under the curve (AUC) for clinical risk assessment instruments for women ranges from 0.65 to 0.70 and for men from 0.75 to 0.80. AUCs for the accuracy of calcaneal quantitative ultrasound in identifying central DXA–measured osteoporosis for women is 0.77 (95% confidence interval [CI], 0.72 to 0.82, 7 studies) and for men is 0.80 (95% CI, 0.67 to 0.94, 3 studies). The AUCs of machine-based tests, including centrally measured DXA (areal bone mineral density and trabecular bone score) and calcaneal quantitative ultrasound, for predicting fractures ranged from 0.59 to 0.86 (21 studies). The AUCs for instruments predicting fractures, some of which incorporate machine-based tests, have similar accuracy (pooled AUC range for the Fracture Risk Assessment Tool: 0.62 to 0.79; 24studies). Available but limited evidence in studies including participants with a wide spectrum of baseline bone mineral density from normal to osteoporosis suggests no benefit from repeating a bone measurement test between 4 and 8 years after the initial screen. Evidence from placebo-controlled trials demonstrates the following benefits. For women, the risk of vertebral fractures can be reduced by bisphosphonates, parathyroid hormone, raloxifene, and denosumab by 36% to 68%. Relative risks (RRs) range from 0.32 [parathyroid hormone or denosumab] to 0.64 [raloxifene]). The risk of nonvertebral fractures can be reduced by 16% to 20% by bisphosphonates and denosumab (RR: 0.84 and 0.80, respectively). The risk Screening to Prevent Osteoporotic Fractures iii RTI–UNC EPC of hip fractures can be reduced by 40% by denosumab (RR: 0.60). Evidence from bisphosphonates does not demonstrate benefit for hip fractures. Evidence is very limited for men. The risk of morphometric vertebral fractures can be reduced by 67% by zoledronic acid [RR: 0.33]. No studies demonstrate reductions in risk of clinical vertebral fractures or hip fractures for men. Evidence on variations in effectiveness for subgroups is also limited; a single trial each for five drugs suggests no differences in effectiveness by age, baseline bone mineral density, prior fractures, or a combination of risk factors. Bisphosphonates are not consistently associated with discontinuations, serious adverse events, gastrointestinal events, or cardiovascular events. No included studies reported cases of osteonecrosis of the jaw or atypical femur fracture, although evidence from excluded studies (including active comparisons, case series, and secondary prevention populations) suggests an increased but rare risk of these outcomes. Raloxifene increases the risk of deep vein thrombosis (0.7% vs. 0.3%, RR, 2.14; 95% CI, 0.99 to 4.66; I2=0%, 3 studies, N=5,839) and hot flashes (11.2% vs. 7.6%, RR, 1.42; 95% CI, 1.22 to 1.66; I2=0%, 5 trials; N=6,249) when compared with placebo. Limitations: The evidence is limited by lack of information on the direct question of the benefits and harms of screening for elevated osteoporotic fracture risk. The indirect evidence pathway rests on studies evaluating (1) the accuracy of screening approaches in identifying osteoporosis and predicting fractures and (2) the benefits of treatment among those with osteoporosis or at high risk for fractures. Other limitations of the evidence base relate to underlying heterogeneity in baseline risk, prior fractures, prior treatment, and duration of followup. Conclusions: We did not find studies of either good or fair quality evaluating the direct benefits and harms of screening for osteoporotic fracture risk. The accuracy of clinical risk assessment tools for identifying osteoporosis or predicting fractures generally ranges from very poor (0.50) to good (0.90). Treatments reduce the risk of vertebral and nonvertebral fractures. Studies do not consistently demonstrate an increased risk of harms for drugs, although studies of raloxifene suggest a trend toward higher risk of deep vein thrombosis. Rare harms, such as osteonecrosis of the jaw and atypical femur fractures were not reported in this body of evidence but they may occur. The evidence is limited for subpopulations characterized by age, sex, baseline bone mineral density, and baseline fracture risk. Screening to Prevent Osteoporotic Fractures iv RTI–UNC EPC Table