Overuse of short-interval bone densitometry: assessing rates of low-value care
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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.
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.
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).
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.
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.
KeywordsBone densitometry Health services research Medicare
This study was supported by grants from the National Institute on Aging (P01 AG019783 and K23 AG035030), the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) Initiative (#70729), and The Commonwealth Fund (#20130339). We are grateful to Kristen K. Bronner, M.A., of The Dartmouth Institute for Health Policy and Clinical Practice for assistance with mapping. Ms. Bronner received no compensation for this service.
Conflicts of interest
- 1.American College of Rheumatology (2012) Focus on patient care: choosing wisely. http://www.rheumatology.org/Practice/FiveThings/Focus_on_Patient_Care__Choosing_Wisely/. Accessed 5 Sept 2013
- 2.ABIM Foundation (2013) Choosing wisely: an initiative of the ABIM Foundation. http://www.choosingwisely.org. Accessed 12 Oct 2013
- 3.Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society (2010) Menopause (New York, NY) 17 (1):25–54; quiz 55–26. doi: 10.1097/gme.0b013e3181c617e6
- 4.Screening for osteoporosis: U.S. preventive services task force recommendation statement (2011). Ann Intern Med 154(5):356–364. doi: 10.7326/0003-4819-154-5-201103010-00307
- 6.Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, Burckhardt P, Cooper C, Christiansen C, Cummings S, Eisman JA, Fujiwara S, Gluer C, Goltzman D, Hans D, Krieg MA, La Croix A, McCloskey E, Mellstrom D, Melton LJ 3rd, Pols H, Reeve J, Sanders K, Schott AM, Silman A, Torgerson D, van Staa T, Watts NB, Yoshimura N (2007) The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18(8):1033–1046. doi: 10.1007/s00198-007-0343-y PubMedCrossRefGoogle Scholar
- 8.Hillier TA, Stone KL, Bauer DC, Rizzo JH, Pedula KL, Cauley JA, Ensrud KE, Hochberg MC, Cummings SR (2007) Evaluating the value of repeat bone mineral density measurement and prediction of fractures in older women: the study of osteoporotic fractures. Archives of Internal Medicine 167(2):155–160. doi: 10.1001/archinte.167.2.155 PubMedCrossRefGoogle Scholar
- 10.Centers for Medicare & Medicaid Services (2012) Medicare preventive services, quick reference information. http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf. Accessed 4 Nov 2013
- 11.Department of Health and Human Services CfMMS (2006) Federal Register Volume 71, Number 162 (Tuesday, August 22, 2006. http://www.gpo.gov/fdsys/pkg/FR-2006-08-22/html/06-6843.htm. Accessed 4 Nov 2013
- 13.The Patient Protection and Affordable Care Act (2010)Google Scholar
- 14.Zhang J, Delzell E, Zhao H, Laster AJ, Saag KG, Kilgore ML, Morrisey MA, Wright NC, Yun H, Curtis JR (2012) Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes. J Bone Miner Res 27(4):858–864. doi: 10.1002/jbmr.1534 PubMedCrossRefGoogle Scholar
- 17.Clinical Classifications Software (CCS) for ICD-9-CM. (2013) HCUP. http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp—overview. Accessed 1 Aug 2013
- 19.National Committee for Quality Assurance (2011) HEDIS and quality measures. http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx. Accessed 18 Jan 2012
- 20.The Dartmouth Atlas of Health Care Working Group (2013) The Dartmouth Atlas of Health Care. The Dartmouth Institute for Health Policy and Clinical Practice, Center for Health Policy Research. http://www.dartmouthatlas.org/. Accessed 4 Jan 2013
- 21.Cawthon PM, Ewing SK, Mackey DC, Fink HA, Cummings SR, Ensrud KE, Stefanick ML, Bauer DC, Cauley JA, Orwoll ES (2012) Change in hip bone mineral density and risk of subsequent fractures in older men. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research 27(10):2179–2188. doi: 10.1002/jbmr.1671 CrossRefGoogle Scholar
- 24.American Board of Internal Medicine Foundation (2012) ABIM FOUNDATION FORUMGoogle Scholar