The UK National Screening Committee is re-evaluating whether to recommend a national osteoporosis screening programme for women, after previous reviews reached contradictory conclusions about whether screening actually prevents fractures. Osteoporosis causes bones to become weak and brittle, often leading to hip and other fractures that can cause long-term disability or death. In 2019, an estimated 41.5 million people worldwide had the condition, with projections of 263.2 million new cases between 2030 and 2034. Previous reviews commissioned by the UK NSC found mixed results: some showed small but meaningful reductions in fractures from screening women over 65, while others found little to no benefit, even when analysing largely the same clinical trials. This project will produce two outputs: an evidence map cataloguing all available research on screening effectiveness and cost-effectiveness for women over 65 and younger women with risk factors, and an umbrella review that systematically examines why existing reviews disagree. The researchers will compare review objectives, inclusion criteria, statistical methods, and author interpretations to identify the methodological factors driving conflicting conclusions. If successful, the findings will directly inform UK NSC policy recommendations on whether to introduce a national screening programme. This could determine whether millions of women are offered routine bone density scans to detect osteoporosis early and prevent fractures through treatment.
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Background: Osteoporosis is a systemic metabolic bone disorder characterized by reduced bone mass and deterioration of bone microarchitecture. In 2019, the global incidence of osteoporosis was estimated at 41.5 million cases, with projections suggesting 263.2 million cases between 2030 and 2034. Fragility fractures, particularly hip fractures, represent a major public health concern due to their association with significant disability and mortality. Fragility fractures can be largely prevented through the early detection, diagnosis, and treatment of osteoporosis. Implementing an effective early screening programme might help prevent fractures while reducing the clinical, humanistic, and economic burden of the disease. However, previous reviews commissioned by the UK National Screening Committee (UK NSC) in 2019 and 2024 identified data uncertainties and evidence gaps, leading to a recommendation against introducing a national osteoporosis screening programme for postmenopausal women. The 2024 evidence map showed mixed findings from systematic reviews of screening women over 65. Some reviews reported small but meaningful reductions in fractures, while others found little to no benefit even though they were based on similar criteria and largely the same primary trials. The UK NSC has commissioned an updated evidence map and an umbrella review to identify new evidence for all age groups and examine the included studies and reviews for methodological and other factors contributing to differences in conclusions to clarify these discrepancies and inform policy recommendations. Objective: The evidence map was designed to answer the following questions: Question 1a. What is the volume and type of evidence exploring the clinical benefit of whole population screening of women over 65, in reducing osteoporotic fractures compared to standard care? Question 1b. What is the volume and type of evidence exploring the clinical benefit of targeted screening of women aged under 65 with risk factors for osteoporosis, in reducing osteoporotic fractures compared to standard care? Question 2. What is the volume of evidence exploring the cost-effectiveness of screening (whole population and targeted) for osteoporosis? The “umbrella review” was designed to answer the following question: What methodological factors could explain the mixed conclusions across existing reviews on the effectiveness of screening for osteoporosis in women, considering: • women aged over 65 (whole population) • women with identifiable risk factors (targeted screening)? Methods: The evidence map will follow the UK NSC assessment framework. Systematic literature searches will be conducted in EMBASE, Medline, the Cochrane Database of Systematic Reviews, Epistemonikos, CEA Registry, CINAHL Ultimate, Google Scholar, Science Citation Index (SCI), Social Sciences Citation Index (SSCI) using osteoporosis-related terms to capture evidence relevant to all questions. Records retrieved will be imported into EndNote, deduplicated, and screened in Covidence by a single reviewer at title and abstract level. Full texts will not be assessed. For Question 1a and 1b, eligible studies must assess outcomes (such as fractures or mortality or harms such as overdiagnosis, adverse events from treatment) in women > 65 (whole population) and <65 years (with risk factors for osteoporosis) respectively who have received screening interventions that involved any combination of risk assessment and dual energy x-ray scan (DXA) versus standard care or no screening. For Question 2, eligible studies will compare the screening intervention versus any comparator, reporting cost effectiveness outcomes (such as the incremental cost-effectiveness ratio (ICER), quality-adjusted life years (QALYs), cost per life-year gained etc). The umbrella review will follow a structured approach. Reviews identified in both the 2024 evidence map and updated evidence map, along with the individual studies included within them, will undergo double-blind data extraction into Excel. Risk of bias will be assessed for each review and its included studies. The reviews will be evaluated using a structured approach covering four main areas: review objectives and key questions, primary studies included, meta-analyses or numerical data, and author conclusions or interpretations. The evaluation will include the following: 1) The stated aims of each review will be compared to assess alignment or divergence in scope. 2) The search strategies, inclusion criteria, and primary studies will be examined to determine how methodological differences contributed to variations in the included trials, study populations, and reported outcomes. 3) For meta-analyses, the statistical approaches will be compared, data inputs will be verified against original trial publications, and the consistency and direction of treatment effects across reviews will be assessed. 4) Author interpretations and conclusions will be validated, including those based on trial-level estimates where no meta-analysis was conducted. Using this framework, the analysis will identify underlying reasons for discrepancies in conclusions across reviews, which may relate to factors such as the timing of the review, inclusion criteria, statistical methodology, trial data used, interpretation of numerical results, or the review’s authorship and purpose. Conclusion: This work will provide a comprehensive overview of the current evidence base on osteoporosis screening of women over 65 or younger with risk factors, highlighting areas of consistency and uncertainty across existing reviews. By systematically mapping and comparing the clinical evidence, this review will clarify the factors contributing to differing conclusions on screening effectiveness. The findings will inform future UK NSC policy recommendations and identify priority areas for further research to address remaining evidence gaps.
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