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Guidelines Unclear on Screening for Osteoporosis

Am Fam Physician. 2005 May 1;71(9):1808-1810.

Osteoporosis is increasing in prevalence as the population ages. However, it is unlikely that women at risk for osteoporosis are being screened according to recommendations. Furthermore, it may be that screening guidelines are not presenting a unified message to physicians and patients as to who should be screened. Morris and colleagues performed a structured review to determine whether the existing guidelines offer sufficient clarity regarding screening recommendations, and whether patient risk factors adequately define who should be screened. They also sought to determine whether effective strategies exist for improving screening rates.

Data were abstracted from clinical guidelines, articles on rates and predictors of bone mineral density (BMD) testing, and articles on interventions to increase testing rates. Of the 17 practice guidelines included in the review, almost one third did not provide information on how the guidelines were established, and more than one half gave no definition of “consensus.” Explanations of how evidence was graded and considerations of cost also were lacking in many of the guidelines. Ten of the guidelines were developed with pharmaceutical industry support. The guidelines were inconsistent about the age at which women should be screened and the risk factors that should be considered.

Articles on rates of BMD testing often focused on patients taking steroid medications or those with previously sustained fractures. In these, reports of testing rates varied widely. There were few consistent patient or physician characteristics that predicted BMD testing. Two studies showed that female patients and those under the care of a rheumatologist were more likely to undergo BMD testing. In terms of physician characteristics, being female and having a large postmenopausal patient population were associated with higher testing rates.

One trial of an intervention to improve testing rates found that counseling patients with a positive rather than negative focus was more likely to lead to BMD testing. Another study showed that longer narrative reports on BMD testing results led to higher physician testing rates than short technical reports.

In summary, the authors found that screening guidelines were lacking in uniform recommendations, that screening rates generally were low, and that few interventions to improve screening rates have been studied. Predictors of testing also have not been studied sufficiently, making it difficult to determine whether testing is being carried out on the appropriate patients. Furthermore, even if the criteria for testing were clearly defined, it is unclear what interventions could be used to improve screening rates.

Morris CA, et al. Patterns of bone mineral density testing. J Gen Intern Med. July 2004;19:783–90.


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