OBJECTIVES : The prevalent vertebral fracture (VF) is a risk factor for future VF, which can be decreased with drug therapy. However, most VFs are not recognized clinically. Vertebral fracture assessment (VFA) by dual-energy x-ray absorptiometry (DXA) and spine x-ray can be performed to detect these prevalent VFs. This study aimed to estimate the costs, effectiveness, and radiation exposure of VF diagnostic strategies. METHODS: Markov model over a 10-year period was used to calculate the medical costs for diagnostic tests and VF treatment, the reduction of incident VFs of patients who have experienced a VF, and the radiation doses in target population aged over 50. We compared three strategies: ‘VFA followed by confirmatory radiography (VFA screening)’, ‘only VFA’ and ‘only x-ray’ every 2 years, to ‘no screening before recognition’. We assumed that all patients tested positive for VF received drug therapy. A discount rate of 5% was applied in cost. RESULTS: The results showed the incremental costs for women over age 50 who had VFA screening, only VFA, and only x-ray were $1,112, $1,546, and $1,270 per person, respectively. Future VF incidence was reduced by 29% in both VFA screening and only VFA and 35% in only x-ray as compared with no screening for 10 years. Radiation exposure was highest in the only x-ray strategy. Also, the effectiveness and medical costs were more increased in female and old age people than in male and over age 50. The sensitivity analyses showed that these results are robust to variety assumptions including cycle length, medical costs, and diagnostic accuracy. CONCLUSIONS: This study suggests that VFA screening strategy can be relevant option for new VF prevention as considering lower cost and less radiation. This study is expected to provide useful information as establishing the VF diagnostic strategy in clinical practice.