Andrew J. Laster

Longitudinal Trends in Use of Bone Mass Measurement Among Older Americans, 1999–2005

Bone mass measurement (BMM) is useful to identify persons with low bone mass who are at increased risk for fracture. Given the increased emphasis that is being placed on preventive services such as screening for osteoporosis, we evaluated trends in BMM among Medicare beneficiaries. We studied a 5% sample of Medicare beneficiaries ≥65 yr of age in 1999–2005. We identified claims for BMM tests performed in both facility and nonfacility settings, evaluated temporal trends in use of these tests, and described the proportion of tests attributable to each specialty of physicians submitting claims. We also assessed patterns of serial testing among individuals who were tested more than once. Claims data from all years were pooled to describe the proportion of persons in the population ever tested. From 1999 to 2005, use of central DXA increased by ∼50%, and use of peripheral DXA declined. The greatest increases in central DXA occurred among internists, family practitioners, and gynecologists. In 1999, the proportion of 65‐yr‐old women tested was 8.4%; this increased to 12.9% in 2005. Corresponding proportions for men were 0.6% and 1.7%, respectively. Between 40% and 73% of persons receiving central DXA were retested, most at ∼2‐yr intervals. Aggregating data across all years for whites and blacks, 30.0% of women and 4.4% of men underwent central DXA at least once. We conclude that, although use of DXA steadily increased from 1999 to 2005, only ∼30% of women and 4% of men at least 65 yr old had a central DXA study. Given the importance of central DXA to assess the risk of osteoporotic fractures, strategies to increase central DXA use to test at‐risk persons are warranted.

Clinical Value of Monitoring BMD in Patients Treated With Bisphosphonates for Osteoporosis

Osteoporosis is a common disease with serious medical and economic consequences. Despite great efforts to educate healthcare professionals and the public, it remains underdiagnosed and undertreated. BMD testing by DXA is an extraordinarily useful clinical tool for assessment of fracture risk and to diagnose osteoporosis before the first fracture occurs. DXA is the only technology for measuring BMD that can be used with FRAX, the World Health Organization fracture risk assessment algorithm that is becoming widely used throughout the world. Several organizations recommend serial DXA testing for monitoring pharmacologic therapy of osteoporosis. The utility of BMD testing to monitor therapy was questioned almost a decade ago when the concept of ‘‘regression to the mean’’ was raised. Although this concept has relevance at a population level, it was subsequently refuted as misleading and irrelevant to the clinical management of individual patients. A study published recently in BMJ by Bell et al. raises the question anew. Despite the title, ‘‘Value of Routine Monitoring of Bone Mineral Density after Starting Bisphosphonate Treatment: Secondary Analysis of Trial Data,’’ the authors conclude that monitoring BMD ‘‘in postmenopausal women in the first three years after starting treatment with a potent bisphosphonate is unnecessary and may be misleading.’’ The authors go on to state that ‘‘routine monitoring should be avoided in this early period.’’ These conclusions are based on a secondary analysis of pooled data from the two arms of the Fracture Intervention Trial (FIT) in which postmenopausal women with low BMD were randomized to alendronate or placebo. They conclude that using BMD to monitor response to treatment with alendronate was of no value because (1) >97% of the patients on treatment ultimately showed an increase in BMD and (2) the withinsubject variability was considerable. Several of the same authors used a similar approach in a post hoc analysis of the Perindopril Protection Against Recurrent Stroke Study (PROGRESS) to conclude that monitoring the initial blood pressure response after perindopril (an angiotensinconverting enzyme inhibitor) therapy was unnecessary. The purpose of this commentary is to address issues raised by Bell et al. and to place the need for BMD monitoring into an appropriate clinical context. Whereas we applaud all efforts to apply the best available medical evidence to clinical decision-making, the validity and applicability of evidence should be closely scrutinized before making recommendations. The conclusion of the recent BMJ article, that monitoring therapy with BMD testing is unnecessary, rests on four assumptions: (1) the goal of monitoring is to document effectiveness by showing an increase in BMD, (2) the increase in BMD in virtually all treated subjects in FIT can be expected to occur in patients in clinical practice, (3) the response to one bisphosphonate in a clinical trial is indicative of the response to all bisphosphonates in clinical practice, and (4) within-person

Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes

In the United States, Medicare gradually reduced payments for central dual‐energy X‐ray absorptiometry (DXA) performed at physician offices (or other nonhospital settings) from an average of

More bone density testing is needed, not less

139 in 2006 to about

2009 Santa Fe Bone Symposium

82 in 2007 and 2008 and

Regional Variation in the Denial of Reimbursement for Bone Mineral Density Testing Among US Medicare Beneficiaries

72 in 2009. Reimbursement for hospital outpatient DXA service was unchanged. We investigated the utilization of hip and spine (central) DXA in the Medicare population before and after the reduction. We identified individuals from the national 5% random sample of Medicare beneficiaries who were ≥65 years of age and enrolled in Medicare Parts A and B but not in a Medicare Advantage plan from 2002 through 2009. For each calendar year, we calculated the proportion of beneficiaries who submitted claims for DXA, the proportions of DXAs performed in hospitals and in physician offices and the number of physician office‐based practices that discontinued or started to provide DXA services. From 2002 to 2006, the proportion of beneficiaries who had at least one central DXA increased from 7.9% to 9.6% at an annual increase of 0.4% and from 2006 to 2009, the annual increase dropped to 0.1%. The number of DXAs performed in physician offices dropped from 1,643,720 (69% of 2,363,500 total DXAs) in 2006 to 1,534,240 (66% of 2,338,240) in 2009. This decline was offset by an increase in the number of DXAs performed in hospitals, which increased from 719,780 (31%) in 2006 to 804,000 (34%) in 2009. Among physician office‐based practices, more practices initiated than discontinued DXA service each year from 2002 to 2006. However, the trend was reversed since 2007 such that in 2009, 1876 practices discontinued and only 1394 initiated DXA service. The reduction in DXA reimbursement was associated with a decrease in the number of DXAs performed in physician offices and fewer physician offices that provided DXA services.

“Evidence-based” or “logic-based” medicine?

E Michael Lewiecki , Andrew J Laster , Paul D Miller , and John P Bilezikian New Mexico Clinical Research & Osteoporosis Center, University of New Mexico School of Medicine, Albuquerque, NM, USA Arthritis & Osteoporosis Consultants of the Carolinas, Charlotte, NC, USA Colorado Center for Bone Research, University of Colorado Health Sciences Center, Lakewood, CO, USA Metabolic Bone Diseases Units, Department of Medicine, College of Physicians and Surgeons, New York, NY, USA

Clinical review: Clinical applications of vertebral fracture assessment by dual-energy x-ray absorptiometry.

Osteoporosis is a common skeletal disease with serious clinical consequences because of fractures. Despite the availability of clinical tools to diagnose osteoporosis and assess fracture risk, and drugs proven to reduce fracture risk, it remains a disease that is underdiagnosed and undertreated. When treatment is started, it is commonly not taken correctly or long enough to be effective. Recent advances in understanding of the regulators and mediators of bone remodeling have led to new therapeutic targets and the development of drugs that may offer advantages over current agents in reducing the burden of osteoporotic fractures. Many genetic factors that play a role in the pathogenesis of osteoporosis and metabolic bone disease have now been identified. At the 2009 Santa Fe Bone Symposium, held in Santa Fe, New Mexico, USA, the links between advances in genetics, basic bone science, recent clinical trials, and new and emerging therapeutic agents were presented and explored. Socioeconomic challenges and opportunities in the care of osteoporosis were discussed. This is a collection of medical essays based on key presentations at the 2009 Santa Fe Bone Symposium.

The geographic availability and associated utilization of dual-energy X-ray absorptiometry (DXA) testing among older persons in the United States

Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physicians office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age > or =65 yr with part A+B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.

Vertebral Fracture Assessment by Dual-Energy X-ray Absorptiometry: Insurance Coverage Issues in the United States A White Paper of the International Society for Clinical Densitometry

Low trauma fractures are the cardinal manifestation of osteoporosis. Their occurrence supersedes bone mineral density in deciding whether specific therapy is warranted. We therefore disagree with the notion that a densitometric threshold for treatment should be applied to patients over age 50 who suffer low trauma distal radius fracture.