Who are the older Australians referred for a bone density scan? Data from the Barwon region

Referral pattern for DXA scanning in a tertiary care centre from southern India

Referral patterns for bone mineral density testing by dual energy X-ray absorptiometry (DXA) scanning are seldom studied. In our study, the overall proportion of referrals from specialties remained low. This highlights the need for adequate utilisation of DXA by specialties treating subjects at risk for osteoporosis.

PURPOSE/OBJECTIVES

The knowledge of referral patterns for DXA scanning (dual energy X-ray absorptiometry) for bone mineral density (BMD) measurement is relevant in a developing country like India. We studied the referral source and clinical and densitometric profile of patients referred for DXA scanning at a south Indian tertiary care centre.

METHODS

We conducted a cross-sectional study over 3 months and included subjects referred during this period for BMD assessment (lumbar spine and femoral neck) by DXA scan. Details regarding referring departments and reasons for referral were collected. The number of patients seen in individual departments was obtained during the study period and respective proportions of patients referred were calculated.

RESULTS

Of the 1932 subjects included in the study, we observed a definite female preponderance (90.2%), with a mean (SD) age of 51.6 (13.3) years. The greatest number of referrals came from the departments of rheumatology (37%; n = 724) and endocrinology (20%; n = 382). Overall, 36% were referred for inflammatory arthritis or systemic inflammatory disorders (n = 696) and 34% for postmenopausal state screening (n = 657). In relation to the individual outpatient strength, the departments who referred the highest proportion of their patients were rheumatology (6.8%), endocrinology (1.76%) and geriatrics (1.05%). A diagnosis of osteoporosis at any one site was made in 41% (448 of 1107) and the BMD was below the expected range for age in 37% (304 of 825) of the referrals.

CONCLUSION

Most referrals for DXA scanning were from rheumatology. Among the referred patients, about two fifth had osteoporosis and over one third had BMD below expected range for age. Although referrals by rheumatology were relatively higher, overall referrals from all departments remained low. This underscores the need for adequate utilisation of DXA by specialties treating subjects at risk for osteoporosis.

Do reductions in out-of-pocket expenses for dual energy X-ray absorptiometry scans translate to reduced fracture incidence amongst older Australians? A population-based study

This study aimed to compare fracture incidence in the elderly pre- and post-revision of bone density scan reimbursement guidelines, which changed in 2007. Fracture incidence by age group was calculated using population-specific data. Guideline changes did not appear to reduce fracture incidence in the study region located in south-eastern Australia.

PURPOSE

In 2007, Medicare Australia revised reimbursement guidelines whereby individuals aged 70 years and over received reduced out-of-pocket expenses for dual energy X-ray absorptiometry (DXA) scans. The current study aims to determine whether fracture incidence in the elderly has changed since the revision of reimbursement guidelines.

METHOD

Keyword searches of the two major radiological centres servicing the Barwon Statistical Division (BSD) were used to identify incident fractures for residents aged 75 years and over for 2006 and 2012. Pathological fractures were excluded. Fracture incidence by age strata (75-79 years, 80-84 years and 85+ years) were calculated using population-specific data from the Australian Bureau of Statistics (2006 and 2012). Standardised fracture ratios were calculated for men and women.

RESULTS

In total, 996 fracture events were identified for BSD residents during 2006 and 1260 identified in 2012. The standardised fracture ratios between 2006 and 2012 were 1.12 (95%CI 1.11, 1.25) for men and 1.08 (95%CI 1.11, 1.16) for women.

CONCLUSION

The change in reimbursement guidelines appears to have had little impact on reducing fracture incidence during this time frame for elderly men and women, in fact, fracture rates increased. Future research should investigate osteoporosis management following DXA over a longer time frame.

Male Osteoporosis Awareness in the Elderly: an Analysis of Dual-Energy X-Ray Absorptiometry Use in Australia Between 1995 and 2015

Osteoporosis is commonly perceived to be a disease confined to aging females, despite ongoing educational interventions. There are few data on the temporal change of dual-energy X-ray absorptiometry (DXA) use in aging males compared to females. Australian Medicare DXA claims between 1995 and 2015 were analyzed to investigate gender differences and temporal change of DXA use in males and females aged 45-85 yr. In females aged 45-54 and 55-64 yr, there was a progressive increase in DXA claims per capita between 1995 until 2002, with little subsequent change from 2002 to 2015 in the younger group, but a slow subsequent increase in females aged 55-64 yr. In males aged 45-54 and 55-64 yr, there was a progressive increase in DXA claims per capita between 1995 and 2002 with an ongoing slow increase from 2002 to 2015. In older females and males aged 65-74, 75-84, or ≥85 yr, there was a progressive increase in DXA claims per capita between 1995 and 2002, with a slow increase thereafter until 2007. After 2007, following the introduction of Medicare eligibility for age over 70, claims per capita increased sharply in all 3 age groups, with a subsequent ongoing increase. The male : female claim ratio in all groups demonstrates low relative male DXA use, with the ratio consistently below 1.0. Following the 2007 Medicare change, the male : female ratio improved in the 65-74, 75-84, and ≥85 age groups. The rate of increase in the male : female ratio in subjects ≥85 yr was significantly greater than that in the 65-74 (p < 0.001) and 75-84 (p < 0.001) age groups. DXA use in males is consistently lower than that in females. Government funding intervention appears to have been most effective in relation to very elderly males over 85 yr but less so in relation to the age group 65-84. There is a need for improved education of health professionals about the risk of osteoporosis in males aged 65-84 yr.

Utility of DXA for monitoring, technical aspects of DXA BMD measurement and precision testing

Monitoring a patient's bone mineral density (BMD) is one of the main reasons for dual-energy X-ray absorptiometry (DXA) referral. It is widely recommended by clinical guidelines, and the accepted standard in practice for managing patients with osteoporosis and other disorders. Clinicians and DXA providers must be familiar with the scientific rationale and procedures involved in measurement science to obtain accurate and reproducible results. Their importance is critical to maximise the value of scan acquisition and interpretation. Scanning individual patients, with different needs and disorders, requires excellence in training, experience, and is more complex than just simply 'measuring BMD'. Over the past 3 decades many studies have validated the importance of monitoring BMD for fracture risk assessment, and for patients on osteoporosis treatment. New DXA features enhance the value of DXA monitoring today. Quality BMD measurement remains an essential component of patient care in osteoporosis and other disorders, playing a critical role in informed decision making for clinicians assessing and managing their patients. In this article we describe some of the technical aspects of measurement and discuss the utility of DXA for monitoring patients in clinical practice.