Journal of General Internal Medicine

, Volume 19, Issue 7, pp 783–790 | Cite as

Patterns of bone mineral density testing

Current guidelines, testing rates, and interventions
  • Charles A. Morris
  • Danielle Cabral
  • Hailu Cheng
  • Jeffrey N. Katz
  • Joel S. Finkelstein
  • Jerry Avorn
  • Daniel H. Solomon
Reviews

Abstract

OBJECTIVES: To identify potential obstacles to bone mineral density (BMD) testing, we performed a structured review of current osteoporosis screening guidelines, studies of BMD testing patterns, and interventions to increase BMD testing.

DESIGN: We searched medline and HealthSTAR from 1992 through 2002 using appropriate search terms. Two authors examined all retrieved articles, and relevant studies were reviewed with a structured data abstraction form.

MEASUREMENTS AND MAIN RESULTS: A total of 235 articles were identified, and 51 met criteria for review: 24 practice guidelines, 22 studies of screening patterns, and 5 interventions designed to increase BMD rates. Of the practice guidelines, almost one half (47%) lacked a formal description of how they were developed, and recommendations for populations to screen varied widely. Screening frequencies among at-risk patients were low, ranging from 1% to 47%. Only eight studies assessed factors associated with BMD testing. Female patient gender, glucocorticoid dose, and rheumatologist care were positively associated with BMD testing; female physicians, rheumatologists, and physicians caring for more postmenopausal patients were more likely to test patients. Five articles described interventions to increase BMD testing rates, but only two tested for statistical significance and no firm conclusions can be drawn.

CONCLUSIONS: This systematic review identified several possible contributors to suboptimal BMD testing rates. Osteoporosis screening guidelines lack uniformity in their development and content. While some patient and physician characteristics were found to be associated with BMD testing, few articles carefully assessed correlates of testing. Almost no interventions to improve BMD testing to screen for osteoporosis have been rigorously evaluated.

Key words

osteoporosis research methods diagnosis clinical reviews 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Marshall D, Joyhnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254–9.PubMedGoogle Scholar
  2. 2.
    Woodhouse A, Black DM. BMD at various sites for the prediction of hip fracture: a meta-analysis. J Bone Miner Res. 2002;15:S145.Google Scholar
  3. 3.
    Cummings SR, Black DM, Nevitt MC, et al. Bone density at various sites for prediction of hip fractures. Lancet. 1993;341:72–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Centers for Disease Control and Prevention. Healthy People 2010. Available at: http://www.health.gov/healthypeople/, volume1/02Arthritis.htm@_Toc49053811. Accessed April 30, 2004Google Scholar
  5. 5.
    Consensus Development Panel. National Institutes of Health Consensus Development Conference Statement: Osteoporosis Prevention, Diagnosis, and Therapy. Rockville, Md: National Institutes of Health; 2000:27.Google Scholar
  6. 6.
    Solomon DH, Morris CA, Cheng H, et al. A structured review of treatment guidelines, osteoporosis treatment rates, and quality improvement interventions. Under review.Google Scholar
  7. 7.
    American Association of Clinical Endocrinologists. American Association of Clinical Endocrinologists 2001 medical guidelines for clinical practice for the prevention and management of postmenopausal osteoporosis. Endocr Pract. 2001;7:294–312.Google Scholar
  8. 8.
    Hodgson SF, Johnston CC, Avioli LV, et al. AACE clinical practice guidelines for the prevention and treatment of postmenopausal osteoporosis. Endocr Pract. 1996;2:157–71.Google Scholar
  9. 9.
    American College of Rheumatology Ad Hoc Committee on Glucocorticoid-induced Osteoporosis. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. Arthritis Rheum. 2001;44:1496–503.CrossRefGoogle Scholar
  10. 10.
    American College of Rheumatology Task Force on Osteoporosis Guidelines. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Rheum. 1996;39:1791–801.CrossRefGoogle Scholar
  11. 11.
    Collier JD, Ninkovic M, Compston JE. Guidelines on the management of osteoporosis associated with chronic liver disease. Gut. 2002;50(suppl 1):1–9.CrossRefGoogle Scholar
  12. 12.
    Compston J. Prevention and treatment of osteoporosis: clinical guidelines and new evidence. J R Coll Physicians Lond. 2000;34:518–21.PubMedGoogle Scholar
  13. 13.
    Guideline Development Group of the Royal College of Physicians. Osteoporosis: Clinical Guidelines for Prevention and Treatment. London: Royal College of Physicians; 1999.Google Scholar
  14. 14.
    Eastell R, Boyle IT, Compston J, et al. Management of male osteoporosis: report of the UK Consensus Group. QJM. 1998;91:71–92.PubMedCrossRefGoogle Scholar
  15. 15.
    Eastell R, Reid DM, Compston J, et al. A UK Consensus Group on management of glucocorticoid-induced osteoporosis: an update. J Intern Med. 1998;244:271–92.PubMedCrossRefGoogle Scholar
  16. 16.
    National Osteoporosis Society. Guidance on the Prevention and Management of Corticosteroid-induced Osteoporosis. Bath, UK: National Osteoporosis Society; 1998.Google Scholar
  17. 17.
    Kanis JA, Delmas P, Burckhardt P, et al. The European Foundation for Osteoporosis and Bone Disease, for guidelines for diagnosis and management of osteoporosis. Osteoporos Int. 1997;7:390–406.PubMedCrossRefGoogle Scholar
  18. 18.
    Meunier PJ, Delmas PD, Eastell R, et al. Diagnosis and management of osteoporosis in postmenopausal women: clinical guidelines. International Committee for Osteoporosis Clinical Guidelines. Clin Ther. 1999;21:1025–44.PubMedCrossRefGoogle Scholar
  19. 19.
    National Osteoporosis Foundation. Osteoporosis: Review of the Evidence for Prevention, Diagnosis, and Treatment and Cost-effectiveness Analysis. Washington, DC: The Foundation; 1998.Google Scholar
  20. 20.
    National Osteoporosis Foundation. Physician’s Guide to the Prevention and Treatment of Osteoporosis. Available at: http://www.nof.org. Accessed July 18, 2002.Google Scholar
  21. 21.
    Osteoporosis Clinical Practice Guideline. American Medical Directors Association, Columbia, Md, and American Health Care Association, Washington, DC; 1998.Google Scholar
  22. 22.
    Sturtridge W, Lentle B, Hanley D. The use of bone density measurement in the diagnosis and management of osteoporosis. CMAJ. 1996;155:924–9.PubMedGoogle Scholar
  23. 23.
    The prevention and management of osteoporosis: consensus statement. Australian National Consensus Conference 1996. Med J Aust. 1997;167(suppl):S1-S15.Google Scholar
  24. 24.
    U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. Baltimore, Md: Williams & Wilkins; 1996.Google Scholar
  25. 25.
    U.S. Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med. 2002;137:526–8.Google Scholar
  26. 26.
    Adachi JD, Olszynski WP, Hanley DA, et al. Management of corticosteroid-induced osteoporosis. Semin Arthritis Rheum. 2000;29:228–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Foundation for Osteoporosis Research and Education. Guidelines of Care on Osteoporosis for the Primary Care Physician. Oakland, Calif: Foundation for Osteoporosis Research and Education; 1998.Google Scholar
  28. 28.
    Sambrook PN, Seeman E, Phillips SR, et al. Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit. Med J Aust. 2002;176:S1-S16.PubMedGoogle Scholar
  29. 29.
    Brown JP, Josse RG. Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167(10 suppl):S1-S34.PubMedGoogle Scholar
  30. 30.
    Scientific Advisory Board, Osteoporosis Society of Canada. Clinical practice guidelines for the diagnosis and management of osteoporosis. CMAJ. 1996;155:1113–29.Google Scholar
  31. 31.
    Sahota O, Worley A, Hosking DJ. An audit of current clinical practice in the management of osteoporosis in Nottingham. J Public Health Med. 2000;22:466–72.PubMedCrossRefGoogle Scholar
  32. 32.
    Gallagher TC, Geling O, Comite F. Missed opportunities for prevention of osteoporosis fracture. Arch Intern Med. 2002;162:450–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Colon-Emeric C, Yballe L, Sloane R, Pieper CF, Lyles KW. Expert physician recommendations and current practice patterns for evaluating and treating men with osteoporotic hip fracture. J Am Geriatr Soc. 2000;48:1261–3.PubMedGoogle Scholar
  34. 34.
    Ridout R, Hawker GA. Use of bone densitometry by Ontario family physicians. Osteoporos Int. 2000;11:393–9.PubMedCrossRefGoogle Scholar
  35. 35.
    Solomon CG, Connelly MT, Collins K, Okamura K, Seely EW. Provider characteristics: impact on bone density utilization at a health maintenance organization. Menopause. 2000;7:391–4.PubMedCrossRefGoogle Scholar
  36. 36.
    Papa LJ, Weber BE. Physician characteristics associated with the use of bone densitometry. J Gen Intern Med. 1997;12:781–3.PubMedCrossRefGoogle Scholar
  37. 37.
    Jaglal SB, McIsaac WJ, Hawker G, Jaakkimainene L, Cadarette SM, Chan BTB. Patterns of use of the bone mineral density test in Ontario, 1992–1998. CMAJ. 2000;163:1139–43.PubMedGoogle Scholar
  38. 38.
    Harrington JT, Bory SB, DeRosa AM, et al. Hip fracture patients are not treated for osteoporosis: a call for action. Arthritis Care Res. 2002;47:651–4.CrossRefGoogle Scholar
  39. 39.
    Kiebzak GM, Beinart GA, Perser K, et al. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med. 2002;162:2217–22.PubMedCrossRefGoogle Scholar
  40. 40.
    Riley RL, Carnes ML, Gudmundsson A, Elliott ME. Outcomes and secondary prevention strategies for male hip fractures. Ann Pharmacother. 2002;36:17–23.PubMedCrossRefGoogle Scholar
  41. 41.
    Smith MD, Ross W, Ahern MJ. Missing a therapeutic window of opportunity: an audit of patients attending a tertiary teaching hospital with potentially osteoporotic hip and wrist fractures. J Rheumatol. 2001;28:2504–8.PubMedGoogle Scholar
  42. 42.
    Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am. 2000;82-A:1063–70.PubMedGoogle Scholar
  43. 43.
    Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment of osteoporosis in patients with fragility fractures. CMAJ. 2000;163:819–22.PubMedGoogle Scholar
  44. 44.
    Kamel HK, Hussain MS, Tariq S, Perry HM III, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109:326–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Gudbjornsson B, Juliusson UI, Gudjonsson FV. Prevalence of long term steroid treatment and the frequency of decision making to prevent steroid induced osteoporosis in daily clinical practice. Ann Rheum Dis. 2002;61:32–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Solomon DH, Katz JN, Jacobs JP, La Tourette AM, Coblyn J. Management of glucocorticoid-induced osteoporosis in patients with rheumatoid arthritis—rates and predictors of care in an academic rheumatology practice. Arthritis Rheum. 2002;46:3136–42.PubMedCrossRefGoogle Scholar
  47. 47.
    Ettinger B, Chidambaran P, Pressman A. Prevalence and determinants of oteoporosis drug prescription among patients with high exposure to glucocorticoid drugs. Am J Manag Care. 2001;7:597–605.PubMedGoogle Scholar
  48. 48.
    Mudano A, Allison J, Hill J, Rothermel T, Saag K. Variations in glucocorticoid-induced osteoporosis prevention in a managed care cohort. J Rheumatol. 2001;28:1298–305.PubMedGoogle Scholar
  49. 49.
    Smith MD, Cheah SP, Taylor K, Ahern MJ. Prevention of corticosteroid induced osteoporosis in inpatients recently discharged from a tertiary teaching hospital. J Rheumatol. 2001;28:566–70.PubMedGoogle Scholar
  50. 50.
    Yood RA, Harrold LR, Fish L, et al. Prevention of glucocorticoid-induced osteoporosis: experience in a managed care setting. Arch Intern Med. 2001;161:1322–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Osiri M, Saag KG, Ford AM, Moreland LW. Practice pattern variation among internal medicine specialists in the prevention of glucocorticoid-induced osteoporosis. J Clin Rheumatol. 2000;6:117–22.CrossRefGoogle Scholar
  52. 52.
    Buckley LM, Marquez M, Feezor R, Ruffin DM, Benson LL. Prevention of corticosteroid induced osteoporosis: results of a patient survey. Arthritis Rheum. 1999;42:1736–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Chevalley T, Hoffmeyer T, Bonjour JP. An osteoporosis clinical pathway for the medical management of patients with low-trauma fracture. Osteoporosis Int. 2002;13:450–5.CrossRefGoogle Scholar
  54. 54.
    Wroe A, Salkovskis PM, Rimes KA. The effect of nondirective questioning on women’s decisions whether to undergo bone density screening: an experimental study. Health Psychol. 2000;19:181–91.PubMedCrossRefGoogle Scholar
  55. 55.
    Newman ED, Starkey RH, Ayoub WT, et al. Osteoporosis disease management: best practices from the Penn State Geisinger Health System. J Clin Outcomes Manage. 2000;7:23–8.Google Scholar
  56. 56.
    Pazirandeh M. Does patient partnership in continuing medical education (CME) improve the outcome in osteoporosis management? J Contin Educ Health Prof. 2002;22:142–51.PubMedCrossRefGoogle Scholar
  57. 57.
    Stock JL, Waud CE, Corderre JA, et al. Clinical reporting to primary care physicians leads to increased use and understanding of bone densitometry and affects the management of osteoporosis. Ann Intern Med. 1998;128:996–9.PubMedGoogle Scholar
  58. 58.
    Etzioni R, Bery KM, Legler JM, Shaw P. Prostate-specific antigen testing in black and white men: an analysis of Medicare claims from 1991–1998. Urology. 2002;59:251–5.PubMedCrossRefGoogle Scholar
  59. 59.
    Ruffin MT, Gorenflo DW, Woodman B. Predictors of screening for breast, cervical, colorectal, and prostatic cancer among community-based primary care practices. J Am Board Fam Pract. 2000;13:1–10.PubMedGoogle Scholar
  60. 60.
    Anonymous. State-specific cholesterol screening trends—United States, 1991–1999. MMWR Morb Mortal Wkly Rep. 2000;49:750–5.Google Scholar
  61. 61.
    Moss K, Keen R. Usefulness of bone densitometry in post-menopausal women with clinically diagnosed vertebral fractures (letter). Ann Rheum Dis. 2002;61:667–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Nolla JM, Gomez-Vaquero C, Fiter C, et al. Usefulness of bone densitometry in postmenopausal women with clinically diagnosed vertebral fractures. Ann Rheum Dis. 2002;61:73–5.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Charles A. Morris
    • 5
    • 1
  • Danielle Cabral
    • 5
  • Hailu Cheng
    • 5
  • Jeffrey N. Katz
    • 2
  • Joel S. Finkelstein
    • 3
    • 4
  • Jerry Avorn
    • 5
  • Daniel H. Solomon
    • 5
    • 2
  1. 1.Division of General MedicineBrigham and Women’s HospitalBoston
  2. 2.Division of Rheumatology, Immunology, and AllergyBrigham and Women’s HospitalBoston
  3. 3.Department of MedicineBrigham and Women’s HospitalBoston
  4. 4.Endocrine UnitMassachusetts General HospitalBoston
  5. 5.Division of Pharmacoepidemiology and PharmacoeconomicsBrigham and Women’s HospitalBoston

Personalised recommendations