Although dual-energy X-ray absorptiometry (DXA) is recommended for all women ≥65 and is covered by Medicare, 40 % of women on Medicare report never having had a DXA. In a longitudinal cohort of 3492 women followed for two decades, we identified several risk factors that should be targeted to improve DXA testing rates.
DXA is used to measure bone mineral density, screen for osteoporosis, and assess fracture risk. DXA is recommended for all women ≥65 years old. Although Medicare covers DXA every 24 months for women, about 40 % report never having had a DXA test, and little is known from prospective cohort studies about which subgroups of women have low use rates and should be targeted for interventions. Our objective was to identify predictors of DXA use in a nationally representative cohort of women on Medicare.
We used baseline and biennial follow-up survey data (1993–2012) for 3492 women ≥70 years old from the nationally representative closed cohort known as the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The survey data for these women were then linked to their Medicare claims (1991–2012), yielding 17,345 person years of observation. DXA tests were identified from the Medicare claims, and Cox proportional hazard regression models were used with both fixed and time-dependent predictors from the survey interviews including demographic characteristics, socioeconomic factors, health status, health habits, and the living environment.
DXA use was positively associated with being Hispanic American, better cognition, higher income, having arthritis, using other preventative services, and living in Florida or other southern states. DXA use was negatively associated with age, being African-American, being overweight or obese, having mobility limitations, and smoking.
Interventions to increase DXA use should target the characteristics that were observed here to be negatively associated with such screening.
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Klibanski A, Adams-Campbell L, Bassford TL, Blair SN, Boden SD, Dickersin K, Gifford DR, Glasse L, Goldring SR, Hruska K (2001) Osteoporosis prevention, diagnosis, and therapy. JAMA 285(6):785–795
Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17(12):1726–1733
US Preventive Services Task Force (2011) Screening for osteoporosis: US preventive services task force recommendation statement. Ann Intern Med 154(5):356
Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, Dawson-Hughes B (2014) The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res 29:2520–2526
Office of the Surgeon General (US) (2004) Bone health and osteoporosis: a report of the Surgeon General. Office of the Surgeon General (US), Rockville (MD). Available at: http://www.ncbi.nlm.nih.gov/books/NBK45513/. Accessed June 2016
U.S. Preventive Services Task Force (2002) Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 137(6):526
Centers for Disease Control and Prevention (2007) Dual energy X-ray absorptiometry (DXA) procedures manual. National Health and Nutrition Examination Survey (NHANES). Available at: www.cdc.gov/nchs/data/nhanes/nhanes_07_08/manual_dexa.pdf. Accessed June 2016
Healthy People 2020 Arthritis, osteoporosis, and chronic back conditions. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at https://www.healthypeople.gov/2020/topics-objectives/topic/Arthritis-Osteoporosis-and-Chronic-Back-Conditions. Accessed June 2016
Genant HK, Engelke K, Fuerst T, Gluer CC, Grampp S, Harris ST, Jergas M, Lang T, Lu Y, Majumdar S, Mathur A, Takada M (1996) Noninvasive assessment of bone mineral and structure: state of the art. J Bone Miner Res 11(6):707–730
Kanis JA (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 4(6):368–381
U.S. Preventive Services Task Force (1996) Guide to clinical preventive services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion, U.S. Government Printing Office. Available at: http://www.ncbi.nlm.nih.gov/books/NBK61778/. Accessed June 2016
Cosman F, De Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25(10):2359–2381
Blake GM, Fogelman I (2007) The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgrad Med J 83(982):509–517
Binkley N, Bilezikian JP, Kendler DL, Leib ES, Lewiecki EM, Petak SM (2007) Summary of the international society for clinical densitometry 2005 position development conference. J Bone Miner Res 22(5):643–645
Menopause Guidelines Revision Task Force A (2006) American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of menopause. Endocr Pract 12(3):315–337
Medicare program (1998) Medicare coverage of and payment for bone mass measurements—HCFA. Interim final rule with comment period. Fed Regist 63 (121):34320–34328. Available at: https://www.gpo.gov/fdsys/pkg/FR-1998-06-24/html/98-16783.htm. Accessed June 2016
Centers for Disease Control and Prevention Administration on Aging, Agency for Healthcare Research and Quality (2016) Enhancing use of clinical preventive services among older adults: closing the gap. Available at: http://www.cdc.gov/aging/pdf/clinical_preventive_services_closing_the_gap_report.pdf. Accessed June 2016
Association of State and Territorial Health Officials (2015) Healthy aging and public health—position statement. Washington DC: ASTHO. Available at: http://www.astho.org/Policy-and-Position-Statements/Healthy-Aging-and-Public-Health-Position-Statement/. Accessed June 2016
Amarnath AL, Franks P, Robbins JA, Xing G, Fenton JJ (2015) Underuse and overuse of osteoporosis screening in a regional health system: a retrospective cohort study. J Gen Intern Med 30(12):1733–1740
Cummings SR, Black D (1995) Bone mass measurements and risk of fracture in Caucasian women: a review of findings from prospective studies. Am J Med 98(2a):24s–28s
Ensrud KE, Lipschutz RC, Cauley JA, Seeley D, Nevitt MC, Scott J, Orwoll ES, Genant HK, Cummings SR (1997) Body size and hip fracture risk in older women: a prospective study. Study of osteoporotic fractures research group. Am J Med 103(4):274–280
Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A (2005) Alcohol intake as a risk factor for fracture. Osteoporos Int 16(7):737–742
Kung AW, Lee KK, Ho AY, Tang G, Luk KD (2007) Ten-year risk of osteoporotic fractures in postmenopausal Chinese women according to clinical risk factors and BMD T-scores: a prospective study. J Bone Miner Res 22(7):1080–1087
Robbins J, Aragaki AK, Kooperberg C, Watts N, Wactawski-Wende J, Jackson RD, LeBoff MS, Lewis CE, Chen Z, Stefanick ML, Cauley J (2007) Factors associated with 5-year risk of hip fracture in postmenopausal women. JAMA 298(20):2389–2398
Stevenson J, Lees B, Devenport M, Cust M, Ganger K (1989) Determinants of bone density in normal women: risk factors for future osteoporosis? BMJ 298(6678):924–928
Ward KD, Klesges RC (2001) A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcif Tissue Int 68(5):259–270
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
King AB, Fiorentino DM (2011) Medicare payment cuts for osteoporosis testing reduced use despite tests’ benefit in reducing fractures. Health Aff 30(12):2362–2370
Curtis J, Laster A, Becker DJ, Carbone L, Gary LC, Kilgore ML, Matthews RS, Morrisey MA, Saag KG, Tanner SB (2009) The geographic availability and associated utilization of dual-energy X-ray absorptiometry (DXA) testing among older persons in the United States. Osteoporos Int 20(9):1553–1561
Overman RA, Farley JF, Curtis JR, Zhang J, Gourlay ML, Deal CL (2015) DXA utilization between 2006 and 2012 in commercially insured younger postmenopausal women. J Clin Densitom 18(2):145–149
Juster FT, Suzman R (1995) An overview of the health and retirement study. J Hum Resour 40:S7–S56
Becker MH (1974) The health behavior model and personal health behavior. Health Educ Monogr 2:324–508
McArdle JJ, Smith JP, Willis R (2009) Cognition and economic outcomes in the health and retirement survey (No. w15266). National Bureau of Economic Research. Available at: http://www.rand.org/content/dam/rand/www/external/labor/aging/rsi/rsi_papers/2012/mcardle6.pdf. Accessed June 2016
Fonda S, Herzog A (2004) HRS/AHEAD documentation report: documentation of physical functioning measured in the health and retirement study and the asset and health dynamics among the oldest old study. Ann Arbor: University of Michigan. Available at: http://hrsonline.isr.umich.edu/sitedocs/userg/dr-008.pdf. Accessed June 2016
Hetzel L, Smith A (2001) 65 Years and over population: 2000: census 2000 brief. Washington, DC: U.S. Census Bureau. Available at: https://www.census.gov/prod/2001pubs/c2kbr01-10.pdf. Accessed June 2016
Healthy People 2020 (2011) Older Adults. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults. Accessed June 2016
NIH Osteoporosis and Related Bone Diseases National Resource Center (2015) Osteoporosis and Hispanic Women, NIH Publication Number 15–7924. Bethesda, MD: NIH. Available at: http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Background/hispanic_women.pdf. Accessed June 2016
This work was partially supported by Patient-Centered Outcomes Research Institute (PCORI) Pilot Project Award IP2 PI000659 to Dr. Wolinsky.
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PCORI had no role in the design and conduct of the study; collection, management, analysis, and interpretation of data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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Lou, Y., Edmonds, S.W., Jones, M.P. et al. Predictors of bone mineral density testing among older women on Medicare. Osteoporos Int 27, 3577–3586 (2016). https://doi.org/10.1007/s00198-016-3688-2