Factors influencing screening

In spite of what appear to be advanced screening methods for osteoporosis, the rate of screening is still very low among postmenopausal women. In a survey of Medicare claims from 2005 involving women aged 65 years and older, only 12.9% were given a diagnostic BMD exam.28,29 At this point, the reasons for this low usage rate can only be speculated on. In all likelihood, several factors are compounded to produce this phenomenon.

Confusion. Many different organizations worldwide have promulgated criteria for osteoporosis screening and the threshold at which a person is considered to have osteoporosis.30 The WHO, USPSTF, and IOF are the most prominent groups whose work permeates current literature. Although most of the recommendations set forth by these organizations are similar, variations can be found in such areas as the age at initial screening and the levels of bone density that define osteoporosis.22 When regulatory bodies disagree and each set of authors recommend something different than the last, the result is often inaction.31

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If health-care practitioners are unsure of the true standard of care, it is unlikely that their patients will be any more confident. Public-health education, thanks largely to the pharmaceutical industry, has improved greatly over the past 10 years with respect to raising awareness of osteoporosis. However, the television advertisements always end with a disclaimer instructing patients to “discuss this with a health-care provider.” Once practitioners have reviewed information about calcium, vitamin D, weight-bearing exercise, and estrogen supplementation, the discussion may be over. If the practitioner and the patient are both unclear about the need for BMD testing, it is doubtful that the practitioner will recommend or order the test.

Finances. Financial concerns affect provider and patient alike. For the patient, the issue is affordability or insurance coverage. For the practitioner, it is reimbursement, either from the patient or a third-party payer.32

The typical DEXA scan in 2007 cost the providing facility $137.32 Medicare and Medicaid reimbursement for this procedure at that time was $139.46.33,34 Obviously, this was not an income-generating test, but it at least provided break-even reimbursement. However, the Centers for Medicare & Medicaid Services have proposed cuts that would take the reimbursement to a low of $55 per test by the end of this year.33,34 This action will impact BMD testing from two directions: (1) Practitioners who depend solely on Medicare for revenue will stop ordering the test or bill the patient for the difference; and (2) patients will be hesitant to request the test if they have to pay out-of-pocket.

Availability. Ready access to a BMD-testing facility is not usually a problem. All medium and large population areas have multiple facilities, and two thirds of DEXA scans are performed in private community offices, making the test available in most outlying areas.35

The small, portable ultrasound densitometer that tests calcaneal bone is frequently used in community health fairs or retail health clinics. While the overall accuracy of this test is not equal to a composite DEXA scan, it at least provides a basis for decisions about further screening.7 The advantages of densitometry are its low cost, portability, and ease of use.

Patient education and awareness. Regardless of any other concerns, patient education and awareness are the most important factors in osteoporosis screening for postmenopausal women. No practitioner can be responsible for all aspects of an individual’s wellness, especially when the person is not an active participant in the process. Becoming informed and proactive about their own health is absolutely essential for women. In women’s journals, authors of health articles often discuss osteoporosis and associated risk factors. Even if a patient opts not to pursue formal screening in the form of a DEXA scan, she can at least become familiar with her risk profile and take basic steps to counteract the disease process.10

Dr. Sego is a staff clinician at the VA Hospital in Kansas City, Mo., where she practices adult medicine and women’s health. She has no relationship to disclose relating to the content of this article.

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All electronic documents accessed September 15, 2010.

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