Trends in dual-energy X-ray absorptiometry in the United States, 2000-2009

Dual-energy X-ray Absorptiometry Trends Among US Medicare Beneficiaries: 2005-2019

INTRODUCTION

Bone density measured using dual-energy X-ray absorptiometry (DXA) volume, performance site and interpreters have changed in the US since 2005. The purpose of this report is to provide updated trends in DXA counts, rates, place of service and interpreter specialty for the Medicare fee-for-service population.

METHODS

The 100 % Medicare Physician/Supplier Procedure Summary Limited Data Set between 2005-2019 was used. DXA counts and annual rates per 10,000 Medicare beneficiaries were calculated. Annual distributions of scan performance location, provider type and interpreter specialty were described. Place of service trends (significance assigned at p < 0.05) of the mean annual share of DXA utilization were identified using linear regression.

RESULTS

Annual DXA use per 10,000 beneficiaries peaked in 2008 at 832, declined to 656 in 2015 then increased (p < 0.001) by 38 per year to 807 in 2019. From 2005 to 2019 DXA performance in office settings declined from 70.7 % to 47.2 %. Concurrently, outpatient hospital (OH) DXA increased from 28.6 % to 51.7 %. In 2005, 43.5 % of DXAs were interpreted by radiologists. This increased (p < 0.001) in the office and OH, averaging 0.3 and 2.0 percentage points per year respectively, reaching 73.5 % in 2019. Interpretation by most non-radiologist specialties declined (p < 0.001).

CONCLUSIONS

From 2005-2019, total DXA use among Medicare beneficiaries declined reaching a nadir in 2015 then returned to 2005 levels by 2019. Office DXA declined since 2005 with 51.7 % of all scans now occurring in an OH setting. The proportion of DXAs interpreted by radiologists increased over time, reaching 73.5 % in 2019.

Bone mineral density estimation from a plain X-ray image by learning decomposition into projections of bone-segmented computed tomography

Osteoporosis is a prevalent bone disease that causes fractures in fragile bones, leading to a decline in daily living activities. Dual-energy X-ray absorptiometry (DXA) and quantitative computed tomography (QCT) are highly accurate for diagnosing osteoporosis; however, these modalities require special equipment and scan protocols. To frequently monitor bone health, low-cost, low-dose, and ubiquitously available diagnostic methods are highly anticipated. In this study, we aim to perform bone mineral density (BMD) estimation from a plain X-ray image for opportunistic screening, which is potentially useful for early diagnosis. Existing methods have used multi-stage approaches consisting of extraction of the region of interest and simple regression to estimate BMD, which require a large amount of training data. Therefore, we propose an efficient method that learns decomposition into projections of bone-segmented QCT for BMD estimation under limited datasets. The proposed method achieved high accuracy in BMD estimation, where Pearson correlation coefficients of 0.880 and 0.920 were observed for DXA-measured BMD and QCT-measured BMD estimation tasks, respectively, and the root mean square of the coefficient of variation values were 3.27 to 3.79% for four measurements with different poses. Furthermore, we conducted extensive validation experiments, including multi-pose, uncalibrated-CT, and compression experiments toward actual application in routine clinical practice.

DXA2: An Automated Program for Extraction of Dual-Energy X-Ray Absorptiometry Data

INTRODUCTION/BACKGROUND

Since the 1970s imaging devices have been rapidly advancing to provide researchers, clinicians, radiologists, and practitioners greater capabilities to image bone. Today, dual-energy X-ray absorptiometry (DXA) has emerged as the gold standard for the assessment of bone and body composition. Despite recent improvements in DXA image quality and reduced radiation dosages and scan times, the data extraction process has yet to be streamlined. The objective of this study was to design an application to allow DXA users to quickly and accurately transfer DXA report data directly into a user-friendly format.

METHODOLOGY

Initial development of the DXA Data Xtraction Assistant (DXA²) included processing 485 DXA reports from a previous study. Using Python script, numeric data from these DXA reports were converted to .csv files and then merged into one file, effectively compiling and organizing all table data from each report, by participant and visit number. A graphical user interface was then developed and beta tested using multiple DXA manufacturers, models, and software versions. To compare the effectiveness of the DXA² to the current standard of manual extraction, all 485 reports were manually transcribed into Microsoft Excel. The time required per report and the error rates were compared.

RESULTS

Manual transcription, by an experienced researcher, took over 10 h with an error rate of 0.6% and average error magnitude of 51%. Data extraction from DXA² took less than 25 min to retrospectively reformat all DXA reports for the DXA² and transcribe all 485 reports with 100% accuracy.

CONCLUSION

The DXA² application automates DXA report data extraction and aggregation for clinical, research, and applied settings and drastically reduces manual data entry time and eliminates transcription errors.

Opportunistic CT screening predicts individuals at risk of major osteoporotic fracture

Millions of CT scans are performed annually and could be also used to opportunistically assess musculoskeletal health; however, it is unknown how well this secondary assessment relates to osteoporotic fracture. This study demonstrates that opportunistic CT screening is a promising tool to predict individuals with previous osteoporotic fracture.

INTRODUCTION

Opportunistic computed tomography (oCT) screening for osteoporosis and fracture risk determination complements current dual X-ray absorptiometry (DXA) diagnosis. This study determined major osteoporotic fracture prediction by oCT at the spine and hip from abdominal CT scans.

METHODS

Initial 1158 clinical abdominal CT scans were identified from administrative databases and were the basis to generate a cohort of 490 men and women with suitable abdominal CT scans. Participant CT scans met the following criteria: over 50 years of age, the scan had no image artifacts, and the field-of-view included the L4 vertebra and proximal femur. A total of 123 participants were identified as having previously suffered a fracture within 5 years of CT scan date. Fracture cause was identified from clinical data and used to create a low-energy fracture sub-cohort. At each skeletal site, bone mineral density (BMD) and finite element (FE)-estimated bone strength were determined. Logistic regression predicted fracture and receiver-operator characteristic curves analyzed prediction capabilities.

RESULTS

In participants with a fracture, low-energy fractures occurred in 88% of women and 79% of men. Fracture prediction by combining both BMD and FE-estimated bone strength was not statistically different than using either BMD or FE-estimated bone strength alone. Predicting low-energy fractures in women determined the greatest AUC of 0.710 by using both BMD and FE-estimated bone strength.

CONCLUSIONS

oCT screening using abdominal CT scans is effective at predicting individuals with previous fracture at major osteoporotic sites and offers a promising screening tool for skeletal health assessment.

Computer-Aided Detection of Incidental Lumbar Spine Fractures from Routine Dual-Energy X-Ray Absorptiometry (DEXA) Studies Using a Support Vector Machine (SVM) Classifier

To assess whether application of a support vector machine learning algorithm to ancillary data obtained from posterior-anterior dual-energy X-ray absorptiometry (DEXA) studies could identify patients with lumbar spine (L1-L4) vertebral body fractures without additional DEXA imaging or radiation. Three hundred seven patients (199 without any fractures of the spine, and 108 patients with at least one fracture of the L1, L2, L3, or L4 vertebral bodies) who had DEXA studies were evaluated. Ancillary data from DEXA output was analyzed. The dataset was split into training (80%) and test (20%) datasets. Support vector machines (SVMs) with 10-fold cross-validation and different kernels were used to identify the best kernel based on the greatest area under the curve (AUC) and the best training vectors in the training dataset. The SVM with the best kernel was then applied to the test dataset to assess the accuracy of the SVM. Receiver operating characteristic (ROC) curves of the SVMs using different kernels in the test dataset were compared using DeLong's test. The SVM classifier with the linear kernel had the greatest AUC in the training dataset (AUC = 0.9258). The AUC of the SVM classifier with the linear kernel in the test dataset was 0.8963. The SVM classifier with the linear kernel had an overall average accuracy of 91.8% in the test dataset. The sensitivity, specificity, positive predictive value, and negative predictive of the SVM classifier with the linear kernel to detect lumbar spine fractures were 81.8%, 97.4%, 94.7%, and 90.5%, respectively. The SVM classifier with the linear kernel ROC curve had a significantly better AUC than the SVM classifier with the cubic polynomial kernel (P = 0.034) for discriminating between patients with lumbar spine fractures and control patients, but not significantly different from the SVM classifier with a radial basis function (RBF) kernel (P = 0.317) or the SVM classifier with a sigmoid kernel (P = 0.729). All fractures identified by the SVM classifiers were not prospectively identified by the radiologist. SVM analysis of ancillary data obtained from routine DEXA studies can identify lumbar spine fractures without the use of vertebral fracture assessment (VFA) DEXA imaging or radiation, and identify fractures missed by radiologists.

Factors Associated With Osteoporosis Care of Men Hospitalized for Hip Fracture: A Retrospective Cohort Study

Rates of postfracture DXA and pharmacotherapy appear to be declining despite their known benefits in fracture reduction. We sought to identify factors associated with osteoporosis care among male veterans aged 50 years and older after hip fracture and to evaluate trends in rates of care with an observational cohort design using US Department of Veterans Affairs’ (VA) inpatient, pharmacy, and outpatient encounters and Centers for Medicare and Medicaid Services outpatient pharmacy claims (2007 to 2014) from men aged 50 years and older treated for hip fracture (N = 7317). We used the Cox proportional hazards model with random effects for the admitting facility. A sensitivity analysis was performed for a subset of patients aged 65 to 99 dually enrolled in Medicare ( N = 5821). Overall, approximately 13% of patients had evidence of osteoporosis care within one year of fracture. In the adjusted model, rural residence was associated with lower likelihood of care, and several comorbidities were associated with higher likelihood of receiving care. In sensitivity analyses of patients dually enrolled in Medicare, rural residence remained associated with lower likelihood of osteoporosis care. Overall rates of care decreased over time, but rates of DXA in the VA remained stable. These findings highlight the ongoing problem of low rates of postfracture care among a population with the highest risk of future fracture and its associated morbidity and mortality. The rural disparity in care and differences in rates of care across healthcare delivery systems illustrates the importance of healthcare delivery systems in promoting pharmacotherapy and DXA after sentinel events. Because the VA removes a majority of cost barriers to care, this integrated healthcare system may outperform the private sector in access to care. However, declining rates of pharmacotherapy imply knowledge gaps that undermine quality care. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Sex differences in osteoporosis self-efficacy among community-residing older adults presenting for DXA

The Osteoporosis Self Efficacy Scale was determined to equivalently measure calcium and exercise beliefs in both sexes. Despite data illustrating men's and women's similar self-efficacy, gender differences in clinical predictors of self-efficacy imply that efforts to improve care must account for more than self-efficacy.

INTRODUCTION

To understand the extent to which the Osteoporosis Self Efficacy (OSE) Scale is reliable for both men and women. A secondary objective was to evaluate sex differences in OSE.

METHODS

For this cross-sectional study, we analyzed data collected as part of the Patient Activation after DXA Result Notification (PAADRN) pragmatic trial which enrolled 7749 community-residing adults aged 50 and older reporting for bone densitometry. We used univariable methods, item analysis, exploratory and confirmatory factor analyses, and linear regression to evaluate sex differences in OSE responses and measurement.

RESULTS

In this sample, the confirmatory factor analysis model for OSE both overall and within groups indicated a poor fit. The sex differences in the measurement model, however, were minor and reflected configural invariance (i.e., constructs were measuring the same things in both men and women), confirming that the OSE was measuring the same constructs in men and women. Men overall had higher exercise self-efficacy and women higher calcium self-efficacy. Overall, education, hip fracture, and self-reported health status predicted exercise self-efficacy whereas prior DXA, self-reported osteoporosis, and history of pharmacotherapy use did not. Predictors of calcium self-efficacy differed by gender.

CONCLUSION

The OSE can be used to measure calcium and exercise self-efficacy in all older adults. However, gender differences in clinical predictors of self-efficacy and the lack of an association of prior DXA with self-efficacy imply that interventions to improve self-efficacy may be insufficient to drive significant improvement in rates of osteoporosis evaluation and treatment.

TRIAL REGISTRATION

Patient Activation after DXA Result Notification (PAADRN), NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.

Use of iDXA spine scans to evaluate total and visceral abdominal fat

OBJECTIVES

Abdominal fat may be a better predictor than body mass index (BMI) for risk of metabolically-related diseases, such as diabetes, cardiovascular disease, and some cancers. We sought to validate the percent fat reported on dual energy X-ray absorptiometry (DXA) regional spine scans (spine fat fraction, SFF) against abdominal fat obtained from total body scans using the iDXA machine (General Electric, Madison, WI), as previously done on the Prodigy model.

METHODS

Total body scans and regional spine scans were completed on the same day (N = 50). In alignment with the Prodigy-based study, the following regions of interest (ROI) were assessed from total body scans and compared to the SFF from regional spine scans: total abdominal fat at (1) lumbar vertebrae L2-L4 and (2) L2-Iliac Crest (L2-IC); (3) total trunk fat; and (4) visceral fat in the android region. Separate linear regression models were used to predict each total body scan ROI from SFF; models were validated by bootstrapping.

RESULTS

The sample was 84% female, a mean age of 38.5 ± 17.4 years, and mean BMI of 23.0 ± 3.8 kg/m² . The SFF, adjusted for BMI, predicted L2-L4 and L2-IC total abdominal fat (%; Adj. R² : 0.90) and total trunk fat (%; Adj. R² : 0.88) well; visceral fat (%) adjusted R² was 0.83. Linear regression models adjusted for additional participant characteristics resulted in similar adjusted R² values.

CONCLUSIONS

This replication of the strong correlation between SFF and abdominal fat measures on the iDXA in a new population confirms the previous Prodigy model findings and improves generalizability.

Trends in osteoporosis and low bone mass in older US adults, 2005-2006 through 2013-2014

This study examined trends in osteoporosis and low bone mass in older US adults between 2005 and 2014 using bone mineral density (BMD) data from the National Health and Nutrition Examination Survey (NHANES). Osteoporosis and low bone mass appear to have increased at the femur neck but not at the lumbar spine during this period.

INTRODUCTION

Recent preliminary data from Medicare suggest that the decline in hip fracture incidence among older US adults may have plateaued in 2013-2014, but comparable data on BMD trends for this time period are currently lacking. This study examined trends in the prevalence of osteoporosis and low bone mass since 2005 using BMD data from NHANES. The present study also updated prevalence estimates to 2013-2014 and included estimates for non-Hispanic Asians.

METHODS

Femur neck and lumbar spine BMD by DXA were available for 7954 adults aged 50 years and older from four NHANES survey cycles between 2005-2006 and 2013-2014.

RESULTS

Significant trends (quadratic or linear) were observed for the femur neck (mean T-score and osteoporosis in both sexes; low bone mass in women) but not for the lumbar spine. The trend in femur neck status was somewhat U-shaped, with prevalences being most consistently significantly higher (by 1.1-6.6 percentage points) in 2013-2014 than 2007-2008. Adjusting for changes in body mass index, smoking, milk intake, and physician's diagnosis of osteoporosis between surveys did not change femur neck trends. In 2013-2014, the percent of older adults with osteoporosis was 6% at the femur neck, 8% at the lumbar spine, and 11% at either site.

CONCLUSIONS

There was some evidence of a decline in femur neck BMD between 2005-2006 and 2013-2014, but not in lumbar spine BMD. Changes in the risk factors that could be examined did not explain the femur neck BMD trends.

Dual energy X-ray absorptiometry spine scans to determine abdominal fat in postmenopausal women

Body composition may be a better predictor of chronic disease risk than body mass index (BMI) in older populations.

OBJECTIVES

We sought to validate spine fat fraction (%) from dual energy X-ray absorptiometry (DXA) spine scans as a proxy for total abdominal fat.

METHODS

Total body DXA scan abdominal fat regions of interest (ROI) that have been previously validated by magnetic resonance imaging were assessed among healthy, postmenopausal women who also had antero-posterior spine scans (n = 103). ROIs were (1) lumbar vertebrae L2-L4 and (2) L2-Iliac Crest (L2-IC), manually selected by two independent raters, and (3) trunk, auto-selected by DXA software. Intra-class correlation coefficients evaluated intra and inter-rater reliability on a random subset (N = 25). Linear regression models, validated by bootstrapping, assessed the relationship between spine fat fraction (%) and total abdominal fat (%) ROIs.

RESULTS

Mean age, BMI, and total body fat were 66.1 ± 4.8 y, 25.8 ± 3.8 kg/m² and 40.0 ± 6.6%, respectively. There were no significant differences within or between raters. Linear regression models adjusted for several participant and scan characteristics were equivalent to using only BMI and spine fat fraction. The model predicted L2-L4 (Adj. R² : 0.83) and L2-IC (Adj. R² : 0.84) abdominal fat (%) well; the adjusted R² for trunk fat (%) was 0.78. Model validation demonstrated minimal over-fitting (Adj. R² : 0.82, 0.83, and 0.77 for L2-L4, L2-IC, and trunk fat, respectively).

CONCLUSIONS

The strong correlation between spine fat fraction and DXA abdominal fat measures make it suitable for further development in postmenopausal chronic disease risk prediction models. Am. J. Hum. Biol. 28:918-926, 2016. © 2016Wiley Periodicals, Inc.

Has Choosing Wisely® affected rates of dual-energy X-ray absorptiometry use?

Reducing overuse of tests such as dual-energy X-ray absorptiometry (DXA) scans in younger women is an important quality issue. We evaluated trends in DXA ordering before and after Choosing Wisely recommendations were released. We found no significant difference in ordering trends suggesting that other initiatives are needed to change behavior.

INTRODUCTION

Reducing overuse of tests such as dual-energy X-ray absorptiometry (DXA) scans in younger women is an important quality issue, but trends in care are difficult to change. We evaluated (1) trends in DXA ordering before and after the Choosing Wisely recommendation release and (2) patterns of key characteristics that indicate a potentially appropriate DXA scan order.

METHODS

We performed a retrospective longitudinal analysis of electronic health record data at a multi-specialty, ambulatory care network of 34 practices across Maryland and Washington, DC. Since the Choosing Wisely DXA recommendation was released April 2012, the study periods were April-December 2011 (pre-initiative) and April-December 2012 (post-initiative). Women between 50 and 64 years with primary care encounters, and primary care providers who saw ten or more women in the study population in both pre and post periods were included.

RESULTS

For 42,320 eligible patients, the mean provider ordering rate was 2.6 % pre-initiative and 2.0 % post-initiative; there was no significant difference in trend over time. Over 70 % of the population had no characteristics associated with potentially appropriate DXA ordering. Low body mass index, current smoker status, and osteopenia were the most common characteristics indicating potentially appropriate DXA orders. Patients with any of these three characteristics had DXA ordering rates between 3-20 %.

CONCLUSIONS

The trend in provider ordering rates of DXA scans did not decrease after the release of the DXA Choosing Wisely recommendation. Targeted initiatives addressing providers with high ordering rates will be needed to change behavior.

Annual incidence rates of herpes zoster among an immunocompetent population in the United States

BACKGROUND

Herpes zoster (HZ), also known as shingles, is a painful and commonly occurring condition in the United States. In spite of a universally recommended vaccine for use in immunocompetent adults aged 60 years and older, HZ continues to impact the American public, and a better understanding of its current incidence is needed. The objective of the current study is to estimate the overall and age- and gender-specific incidence rates (IRs) of HZ among an immunocompetent US population in 2011 following availability of a vaccine.

METHODS

Claims data from the Truven Health MarketScan® Research databases between 01/01/2011 and 12/31/2011 were extracted. Immunocompetent adult patients, enrolled as of January 1, 2011 were analyzed. The denominator was defined as eligible subjects who were immunocompetent, had no evidence of zoster vaccination, and no diagnosis of HZ (International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 053.xx) in the 90 days prior to January 1, 2011. Subjects contributed person-days to the denominator until the occurrence of one of the following events: end of continuous enrollment in the database, a claim for zoster vaccination, diagnosis of HZ or end of the observation period (December 31, 2011). The numerator was defined as enrollees within the denominator file exhibiting evidence of HZ. Annual IRs were calculated for the entire population in the database as well as by gender and age group; standardized IRs were also produced using the 2010 US Census data.

RESULTS

The overall annual IR of HZ across all ages was 4.47 per 1000 person-years (95% confidence interval [CI]: 4.44-4.50) which monotonically increased with age from 0.86 (95% CI: 0.84-0.88) for those aged ≤ 19 to 12.78 (95% CI: 12.49-13.07) for patients ≥ 80 years. The IR was 8.46 (95% CI: 8.39-8.52) among adults ≥ 50 years and 10.46 (95% CI: 10.35-10.56) among those aged ≥ 60 years. Women compared to men had higher HZ incidence (5.25, 95% CI: 5.21-5.29 vs. 3.66, 95% CI: 3.62-3.69) and this was seen across all age groups. When adjusted for age and gender using 2010 US Census data, the annual IR was 4.63 per 1000 person-years (95% CI: 4.61-4.66).

CONCLUSIONS

Despite the availability of a vaccine, HZ remains common among immunocompetent adults in the US with incidence rates of HZ observed to increase with age and be higher in women than men.

Cost-effectiveness of fracture prevention in rural women with limited access to dual-energy X-ray absorptiometry

A reduced reimbursement for office-based dual-energy X-ray absorptiometry (DXA) is likely to exacerbate the burden of fractures in rural areas. Our cost-effective analysis suggests that, in areas where access to DXA is limited, treatment for women at high clinical risk for fractures could both improve health and save money.

INTRODUCTION

To evaluate the cost-effectiveness of various fracture prevention strategies for rural women with limited access to dual-energy X-ray absorptiometry (DXA).

METHODS

A Markov model was developed using data from the published literature and the Manitoba Bone Density Program. The participants were a simulated cohort of rural women aged 65 years with travel distance between 10 and 24 mi to the nearest DXA site. The evaluated strategies were (1) watchful waiting, (2) bone mineral density (BMD)-based strategy (i.e., DXA screening followed by pharmacotherapy based on BMD), and (3) clinical risk factor (CRF)-based strategy (i.e., pharmacotherapy for women at high risk for fractures by the World Health Organization Fracture Risk Assessment Tool [FRAX]). The outcome was an incremental cost-effectiveness ratio (ICER) measured by cost per quality-adjusted life-year (QALY) gained. The analysis was preformed from a societal perspective over a lifetime horizon.

RESULTS

In the base-case analysis, the BMD-based strategy had an ICER of $6000 per QALY gained. For those with travel distance between 25 and 39 mi, the BMD-based strategy would have an ICER of $140,800 per QALY gained. For those with travel distance greater than 40 mi, the CRF-based strategy would be more effective and less costly than other strategies.

CONCLUSIONS

In areas where DXA is readily available, DXA screening followed by pharmacotherapy guided by BMD would be preferred. In areas with more limited access to DXA, pharmacotherapy for women at high clinical risk for fractures based on FRAX could both improve health and save money from the societal perspective.

DXA Utilization Between 2006 and 2012 in Commercially Insured Younger Postmenopausal Women

Reimbursement for dual-energy X-ray absorptiometry (DXA) scans in the outpatient setting has declined significantly since 2006. Research through 2011 has suggested reimbursement reductions for DXA scans have corresponded with an overall decreased utilization of DXA. This study updates utilization estimates for DXAs through 2012 in patients with commercial insurance and compares DXA rates before and after reimbursement changes. We evaluated DXA utilization for women aged 50-64 yr from Marketscan Commercial Claims and Encounter database between January 2006 and December 2012 based on CPT codes. We estimated utilization rates per 1000 person years (PY). We also used segmented regression analysis of monthly rates to evaluate the change in utilization rates after a proposed reimbursement reduction in July 2009. In women aged 50-64 yr, 451,656 DXAs were performed in 2006, a rate of 144 DXAs per 1000 PY. This rate increased to 149 DXAs per 1000 PY in 2009 before decreasing to 110 DXAs per 1000 PY or 667,982 scans in 2012. DXA utilization increased by 2.24 per 1000 PY until July 2009 then declined by 12.98 DXAs per 1000 persons, resulting in 37.5 DXAs per PY fewer performed in 2012 compared with 2006. Since July 2009 a significant decline in DXA utilization occurred in a younger postmenopausal commercially insured population. This decline corresponds with a time period of reductions in Medicare DXA reimbursement.

Overuse of short-interval bone densitometry: assessing rates of low-value care

We evaluated the prevalence and geographic variation of short-interval (repeated in under 2 years) dual-energy X-ray absorptiometry tests (DXAs) among Medicare beneficiaries. Short-interval DXA use varied across regions (coefficient of variation = 0.64), and unlike other DXAs, rates decreased with payment cuts.

INTRODUCTION

The American College of Rheumatology, through the Choosing Wisely initiative, identified measuring bone density more often than every 2 years as care "physicians and patients should question." We measured the prevalence and described the geographic variation of short-interval (repeated in under 2 years) DXAs among Medicare beneficiaries and estimated the cost of this testing and its responsiveness to payment change.

METHODS

Using 100 % Medicare claims data, 2006-2011, we identified DXAs and short-interval DXAs for female Medicare beneficiaries over age 66. We determined the population rate of DXAs and short-interval DXAs, as well as Medicare spending on short-interval DXAs, nationally and by hospital referral region (HRR).

RESULTS

DXA use was stable 2008-2011 (12.4 to 11.5 DXAs per 100 women). DXA use varied across HRRs: in 2011, overall DXA use ranged from 6.3 to 23.0 per 100 women (coefficient of variation = 0.18), and short-interval DXAs ranged from 0.3 to 8.0 per 100 women (coefficient of variation = 0.64). Short-interval DXA use fluctuated substantially with payment changes; other DXAs did not. Short-interval DXAs, which represented 10.1 % of all DXAs, cost Medicare approximately US$16 million in 2011.

CONCLUSIONS

One out of ten DXAs was administered in a time frame shorter than recommended and at a substantial cost to Medicare. DXA use varied across regions. Short-interval DXA use was responsive to reimbursement changes, suggesting carefully designed policy and payment reform may reduce this care identified by rheumatologists as low value.

Clinical impact of recent genetic discoveries in osteoporosis

Osteoporotic fracture carries an enormous public health burden in terms of mortality and morbidity. Current approaches to identify individuals at high risk for fracture are based on assessment of bone mineral density and presence of other osteoporosis risk factors. Bone mineral density and susceptibility to osteoporotic fractures are highly heritable, and over 60 loci have been robustly associated with one or both traits through genome-wide association studies carried out over the past 7 years. In this review, we discuss opportunities and challenges for incorporating these genetic discoveries into strategies to prevent osteoporotic fracture and translating new insights obtained from these discoveries into development of new therapeutic targets.

A review of the use of dual-energy X-ray absorptiometry (DXA) in rheumatology

The principal use of dual-energy X-ray absorptiometry (DXA) is to diagnose and monitor osteoporosis and therefore reduce fracture risk, associated morbidity, and mortality. In the field of rheumatology, DXA is an essential component of patient care because of both rheumatologists’ prescription of glucocorticoid treatment as well as the effects of rheumatological diseases on bone health. This review will summarize the use of DXA in the field of rheumatology, including the concern for glucocorticoid-induced osteoporosis, as well as the association of osteoporosis with a sampling of such rheumatologic conditions as rheumatoid arthritis (RA), systemic lupus erythematosus, ankylosing spondylitis, juvenile idiopathic arthritis, and scleroderma or systemic sclerosis. Medicare guidelines recognize the need to perform DXA studies in patients treated with glucocorticoids, and the World Health Organization FRAX tool uses data from DXA as well as the independent risk factors of RA and glucocorticoid use to predict fracture risk. However, patient access to DXA measurement in the US is in jeopardy as a result of reimbursement restrictions. DXA technology can simultaneously be used to discover vertebral fractures with vertebral fracture assessment and provide patients with a rapid, convenient, and low-radiation opportunity to clarify future fracture and comorbidity risks. An emerging use of DXA technology is the analysis of body composition of RA patients and thus the recognition of “rheumatoid cachexia,” in which patients are noted to have a worse prognosis even when the RA appears well controlled. Therefore, the use of DXA in rheumatology is an important tool for detecting osteoporosis, reducing fracture risk and unfavorable outcomes in rheumatological conditions. The widespread use of glucocorticoids and the underlying inflammatory conditions create a need for assessment with DXA. There are complications of conditions found in rheumatology that could be prevented with more widespread patient access to DXA.

Effect of reimbursement reductions on bone mineral density testing for female Medicare beneficiaries

BACKGROUND

We examined whether the recent reimbursement reductions on the bone mineral density (BMD) test affected BMD testing in female Medicare beneficiaries with or without supplemental private health insurance.

METHODS

Retrospectively analyzing hospital administrative and clinical data on female Medicare beneficiaries (n=1320), we reviewed whether participants received BMD testing before (January 2004-December 2006) or after (January 2007-December 2009) reimbursement reductions for BMD testing. After adjusting for demographics and clinical characteristics, we performed Cox proportional hazard regression analyses of the BMD test including data from all study participants; we then performed separate regression analyses using data with or without supplemental private health insurance.

RESULTS

In those without supplemental private health insurance (n=421), less frequent BMD testing occurred after reimbursement reductions for BMD testing (hazard ratio [HR] 0.67, 95% confidence intervals [CI] 0.34-0.98; p=0.03). By contrast, in the overall participants (n=1320) and those with supplemental private health insurance (n=899), the number of BMD tests did not change significantly after reimbursement reductions for BMD testing.

CONCLUSIONS

We found a significant association between reimbursement reductions and decrease in BMD tests in female Medicare beneficiaries without supplemental private health insurance.

Medicare payment cuts for osteoporosis testing reduced use despite tests' benefit in reducing fractures

Bone imaging known as DXA ("dexa")-dual energy x-ray absorptiometry of the central skeleton--is considered the "gold standard" test for osteoporosis, which affects more than fifty million Americans. The tests are associated with improved clinical outcomes through preventing bone fractures. Cuts in Medicare Part B reimbursement for the provision of this preventive imaging in a physician's office began in 2007 and reached 56 percent below the 2006 level in January 2010. To encourage the use of DXA testing, the Affordable Care Act of 2010 provided partial relief from the cuts for two years (2010-11). Our study found that after a decade of growth, DXA testing in all Part B settings plateaued in 2007-09, resulting in 800,000 fewer tests than expected for Medicare beneficiaries--tests that might have prevented approximately 12,000 fractures. Testing declined in 2010, when the start of reimbursement relief under the Affordable Care Act was delayed, and increased outpatient testing failed to offset reduced use in physician offices. Our findings strongly suggest that the payment cuts reduced beneficiary access and that the tests were underused by elderly female Medicare beneficiaries despite strong association with fracture prevention. We recommend that Congress extend the payment relief granted under the Affordable Care Act for at least another two years.

Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes

In the United States, Medicare gradually reduced payments for central dual-energy X-ray absorptiometry (DXA) performed at physician offices (or other nonhospital settings) from an average of $139 in 2006 to about $82 in 2007 and 2008 and $72 in 2009. Reimbursement for hospital outpatient DXA service was unchanged. We investigated the utilization of hip and spine (central) DXA in the Medicare population before and after the reduction. We identified individuals from the national 5% random sample of Medicare beneficiaries who were ≥65 years of age and enrolled in Medicare Parts A and B but not in a Medicare Advantage plan from 2002 through 2009. For each calendar year, we calculated the proportion of beneficiaries who submitted claims for DXA, the proportions of DXAs performed in hospitals and in physician offices and the number of physician office-based practices that discontinued or started to provide DXA services. From 2002 to 2006, the proportion of beneficiaries who had at least one central DXA increased from 7.9% to 9.6% at an annual increase of 0.4% and from 2006 to 2009, the annual increase dropped to 0.1%. The number of DXAs performed in physician offices dropped from 1,643,720 (69% of 2,363,500 total DXAs) in 2006 to 1,534,240 (66% of 2,338,240) in 2009. This decline was offset by an increase in the number of DXAs performed in hospitals, which increased from 719,780 (31%) in 2006 to 804,000 (34%) in 2009. Among physician office-based practices, more practices initiated than discontinued DXA service each year from 2002 to 2006. However, the trend was reversed since 2007 such that in 2009, 1876 practices discontinued and only 1394 initiated DXA service. The reduction in DXA reimbursement was associated with a decrease in the number of DXAs performed in physician offices and fewer physician offices that provided DXA services.

Effect of Medicare reimbursement reduction for imaging services on osteoporosis screening rates

OBJECTIVES

To determine bone mineral density (BMD) testing rates and the proportion of women diagnosed after BMD screening vs an osteoporosis-related fracture before and after reductions in Medicare reimbursement for office-based imaging services in 2007, which was projected to save $2.8B over 5 years.

DESIGN

Retrospective observational analysis of administrative medical claims reimbursement data.

SETTING

Analysis of data from a medical claims data set.

PARTICIPANTS

A cohort of 405,093 women (average age 74.1 ± 6.7) aged 65 and older with employer-sponsored Medicare supplemental coverage.

MEASUREMENTS

BMD testing and the incidence of participants whose first diagnosis for osteoporosis occurred with BMD screening vs as a result of osteoporosis-related fracture were identified by calendar year.

RESULTS

Thirty-eight percent of participants received one or more BMD tests during the study period. The proportion of women who received a BMD test was 12.9% in 2005, 11.4% in 2006, 11.8% in 2007, and 11.6% in 2008. Although testing rates varied, results were consistent with testing guidelines and did not decrease at a rate relative to reimbursement reductions, as had been anticipated.

CONCLUSION

BMD screening rates did not substantially decline in Medicare-eligible women in the 2 years after reimbursement reductions. Meanwhile, the proportion of women diagnosed after a fracture increased, although the nature of this increase is unclear.