The Fracture Risk Assessment Tool (FRAX, threshold ≥ 9.3 %), Osteoporosis Risk Assessment Instrument (ORAI, ≥ 9), Osteoporosis Index of Risk (OSIRIS, < 1), Osteoporosis Self-Assessment Tool (OST, < 2), and Simple Calculated Osteoporosis Risk Estimation (SCORE, ≥ 6) have been endorsed by the US Preventive Services Task Force for evaluating the need for bone mineral density measurement by dual-energy X-ray absorptiometry in postmenopausal women.

To systematically compare the sensitivity and specificity of the five osteoporosis risk assessment tools for detecting bone mineral density-defined osteoporosis.

A systematic search was conducted across the Cochrane Library, Embase, PubMed and Web of Science databases up to January 29, 2024, to identify observational studies that evaluated comparative accuracy of these tools in postmenopausal women. The Quality Assessment of Diagnostic Accuracy Studies-2 and its comparative extension were utilized to evaluate the risk of bias and applicability. Pooled odds ratios (ORs) and 95 % confidence intervals (CIs) for relative sensitivity and specificity were calculated using a multivariate random-effects model, with tool rankings determined by Surface Under the Cumulative Ranking (SUCRA).

17 studies were included, involving 9669 postmenopausal women with bone mineral density-defined osteoporosis and 34,143 without the condition. The SCORE (OR = 12.11, 95 % CI [4.46–32.86]) exhibited significantly higher sensitivity than FRAX, followed by ORAI (OR = 7.01, 95 % CI [2.84–17.31]) and OST (OR = 6.90, 95 % CI [3.07–15.52]). Compared to OSIRIS, higher sensitivity was observed for SCORE (OR = 4.92, 95 % CI [2.41–10.05]), ORAI (OR = 2.85, 95 % CI [1.63–4.99]), and OST (OR = 2.80, 95 % CI [1.58–4.97]). However, specificity was lower for SCORE (OR = 0.16, 95 % CI [0.08–0.33]), ORAI (OR = 0.26, 95 % CI [0.13–0.51]), and OST (OR = 0.28, 95 % CI [0.15–0.53]) compared to FRAX. Similarly, SCORE (OR = 0.25, 95 % CI [0.15–0.41]), ORAI (OR = 0.40, 95 % CI [0.26–0.62]), and OST (OR = 0.44, 95 % CI [0.27–0.69]) showed significantly lower specificity than OSIRIS. Based on SUCRA values, SCORE (98.2 %) ranked as the most sensitive tool, followed by ORAI (64.2 %) and OST (62.6 %), whereas FRAX (96.7 %) was the most specific, followed by OSIRIS (78.3 %).

The risk assessment tools for identifying postmenopausal women with bone mineral density-defined osteoporosis, endorsed by the US Preventive Services Task Force, can be categorized into two groups. SCORE (≥ 6), ORAI (≥ 9), and OST (< 2) offer higher sensitivity, identifying more osteoporosis patients, whereas FRAX (≥ 9.3 %) and OSIRIS (< 1) provide higher specificity, identifying those without the condition more accurately.

Registration: PROSPERO (CRD42024507532).