Skip to main content


Log in

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

  • Short Communication
  • Published:
Osteoporosis International Aims and scope Submit manuscript



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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1


  1. American College of Rheumatology (2012) Focus on patient care: choosing wisely. Accessed 5 Sept 2013

  2. ABIM Foundation (2013) Choosing wisely: an initiative of the ABIM Foundation. 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

  5. Gluer CC (1999) Monitoring skeletal changes by radiological techniques. J Bone Miner Res 14(11):1952–1962. doi:10.1359/jbmr.1999.14.11.1952

    Article  CAS  PubMed  Google Scholar 

  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

    Article  CAS  PubMed  Google Scholar 

  7. Berry SD, Samelson EJ, Pencina MJ, McLean RR, Cupples LA, Broe KE, Kiel DP (2013) Repeat bone mineral density screening and prediction of hip and major osteoporotic fracture. JAMA 310(12):1256–1262. doi:10.1001/jama.2013.277817

    Article  CAS  PubMed Central  PubMed  Google 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

    Article  PubMed  Google Scholar 

  9. Leslie WD, Morin SN, Lix LM, Manitoba Bone Density P (2012) Rate of bone density change does not enhance fracture prediction in routine clinical practice. J Clin Endocrinol Metab 97(4):1211–1218. doi:10.1210/jc.2011-2871

    Article  CAS  PubMed  Google Scholar 

  10. Centers for Medicare & Medicaid Services (2012) Medicare preventive services, quick reference information. Accessed 4 Nov 2013

  11. Department of Health and Human Services CfMMS (2006) Federal Register Volume 71, Number 162 (Tuesday, August 22, 2006. Accessed 4 Nov 2013

  12. McAdam-Marx C, Unni S, Ye X, Nelson S, Nickman NA (2012) Effect of Medicare reimbursement reduction for imaging services on osteoporosis screening rates. Journal of the American Geriatrics Society 60(3):511–516. doi:10.1111/j.1532-5415.2011.03837.x

    Article  PubMed Central  PubMed  Google Scholar 

  13. The Patient Protection and Affordable Care Act (2010)

  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

    Article  PubMed  Google Scholar 

  15. King AB, Fiorentino DM (2011) Medicare payment cuts for osteoporosis testing reduced use despite Tests’ benefit in reducing fractures. Health affairs (Project Hope) 30(12):2362–2370. doi:10.1377/hlthaff.2011.0233

    Article  Google Scholar 

  16. O’Malley CD, Johnston SS, Lenhart G, Cherkowski G, Palmer L, Morgan SL (2011) Trends in dual-energy X-ray absorptiometry in the United States, 2000–2009. J Clin Densitom 14(2):100–107. doi:10.1016/j.jocd.2011.03.003

    Article  PubMed  Google Scholar 

  17. Clinical Classifications Software (CCS) for ICD-9-CM. (2013) HCUP.—overview. Accessed 1 Aug 2013

  18. Chien AJ, Goss PE (2006) Aromatase inhibitors and bone health in women with breast cancer. J Clin Oncol 24(33):5305–5312. doi:10.1200/JCO.2006.07.5382

    Article  CAS  PubMed  Google Scholar 

  19. National Committee for Quality Assurance (2011) HEDIS and quality measures. 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. 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

    Article  Google Scholar 

  22. Cummings SR, Bates D, Black DM (2002) Clinical use of bone densitometry: scientific review. JAMA 288(15):1889–1897

    Article  PubMed  Google Scholar 

  23. U. S. Preventive Services Task Force (2011) Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Annals of internal medicine 154(5):356–364. doi:10.7326/0003-4819-154-5-201103010-00307

    Article  Google Scholar 

  24. American Board of Internal Medicine Foundation (2012) ABIM FOUNDATION FORUM

Download references


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


Author information

Authors and Affiliations


Corresponding author

Correspondence to N. E. Morden.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Morden, N.E., Schpero, W.L., Zaha, R. et al. Overuse of short-interval bone densitometry: assessing rates of low-value care. Osteoporos Int 25, 2307–2311 (2014).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: