Executive Summary
Too few women at high risk for osteoporosis are being tested for the condition, while too many women at low risk are being screened, results of a California-based study suggest.
- Researchers at University of California, Davis, examined electronic health records of some 51,000 women between ages 40-85 who received healthcare in the Sacramento region. The evaluation included osteoporosis risk factors and dual-energy X-ray absorptiometry, whether or not the women received a screening technique that measures bone mineral density.
- In A Seven-year Period, More Than 42% Of Eligible Women Between Ages 65-74 Were Not Screened, And Neither Were Nearly 57% Of Those Older Than 75. Researchers Also Found That 46% Of Low-risk Women Between Ages 50-59 Were Screened, As Were 59% Of Those Ages 60-64 Years Without Risk Factors.
Too few women at high risk for osteoporosis are being tested for the condition, while too many women at low risk are being screened, results of a California-based study suggest.1
As part of a University of California, Davis, research fellowship, Anna Lee Amarnath, MD, MPH, and a research team examined the electronic health records of some 51,000 women between the ages of 40-85 who received healthcare in the Sacramento region. The evaluation included osteoporosis risk factors and dual-energy X-ray absorptiometry (DXA), whether or not the women received a screening technique that measures bone mineral density. What prompted the team’s inquiry into this subject?
“I was curious about whether or not guidelines for osteoporosis were being followed in clinics,” says Amarnath. “The current recommendation is for screening to begin at age 65 for most women, or earlier for women with specific fracture risks.”
Osteoporosis is a medical condition that causes bone density to diminish and fracture risk to increase. Since gender and age are the factors most associated with the disease, the U.S. Preventive Services Task Force recommends screening for women who are age 65 and older. Younger women with certain risk factors, such as a small body frame, a history of fractures, or taking medication that thins the bones, also should be screened.2 (See box with recommendations from the American College of Obstetricians and Gynecologists on when to screen women below age 65.)
When to Screen Bone Mineral Density in Women under Age 65
- Medical history of a fragility fracture
- Body weight less than 127 pounds
- Medical causes of bone loss (medications or diseases)
- Parental medical history of hip fracture
- Current smoker
- Alcoholism
- Rheumatoid arthritis
Source: American College of Obstetricians and Gynecologists. Osteoporosis. Practice Bulletin. Obstet Gynecol 2012; 120(3):718-734.
According to the data, in a seven-year period, more than 42% of eligible women between ages 65-74 were not screened, and neither were nearly 57% of those older than 75, despite the favorable cost-effectiveness of screening in these age groups. Researchers also found that 46% of low-risk women between ages 50-59 were screened, as were 59% of those ages 60-64 years without risk factors.1
Findings from previous studies indicate that many providers might not be adhering to Task Force recommendations. In studies of Medicare beneficiaries ages 65 and older, screening has been reported to be as low as 30% to 48% over a seven-year period.3,4 Overuse of DXA screening in younger, lower-risk women has been a focus of the Choosing Wisely initiative, which was launched in 2012 to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.5
Both the American Academy of Family Physicians and the American College of Physicians have included use of DXA screening in their top five lists of frequently misused diagnostic tests or treatments, and they advise primary care physicians not to perform DXA screening in women younger than age 65 without osteoporosis risk factors.6
What might aid providers in doing a better job with screening? Technology-based solutions could help, according to study senior author Joshua Fenton, MD, MPH, associate professor of family and community medicine at the University of California, Davis School of Medicine. “Alert fields in electronic health records systems can match current preventive care guidelines with risks,” says Fenton. “Screening ‘flags’ or prompts can alert physicians when a specific test is recommended for a particular patient.”
As an addition to screening, FRAX, a fracture risk assessment tool developed by the World Health Organization, can help to further predict a person’s risk of bone fracture in the next 10 years. It can be used to determine if a patient is at high risk for fracture if her initial scan indicates low bone mass. The assessment tool is based on such risk factors as age, body mass index, history of fracture, daily alcohol intake, and whether or not a patient smokes, has rheumatoid arthritis, or any other secondary causes of osteoporosis. (To learn more about the tool, visit its web site, http://bit.ly/1CjBfzJ.)
- Amarnath AL, Franks P, Robbins JA, et al. Underuse and overuse of osteoporosis screening in a regional health system: A retrospective cohort study. J Gen Intern Med 2015; doi: 10.1007/s11606-015-3349-8.
- U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2011; 154(5):356-364.
- Curtis JR, Carbone L, Cheng H, et al. Longitudinal trends in use of bone mass measurement among older Americans, 1999–2005. J Bone Miner Res 2008; 23(7):1061-1067.
- King AB, Fiorentino DM. Medicare payment cuts for osteoporosis testing reduced use despite tests’ benefit in reducing fractures. Health Aff (Millwood) 2011; 30(12):2362-2370.
- Good Stewardship Working Group. The “top 5” lists in primary care: Meeting the responsibility of professionalism. Arch Intern Med 2011; 171(15):1385-1390.
- Cassel CK, Guest JA. Choosing wisely: Helping physicians and patients make smart decisions about their care. JAMA 2012; 307(17):1801-1802.
