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

Abstract

Summary 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. Introduction 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. Methods 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). Results 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. Conclusions 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.

Measuring the effect of Choosing Wisely: an integrated framework to assess campaign impact on low-value care

“…Another study used Medicare claims data to assess the prevalence of cardiac testing in low-risk patients and found that 13% received cardiac tests without a clear indication.,8 while Kerr et al 23 showed that stress tests before low-risk surgery are very rarely performed. Morden and colleagues24 also used claims data to show that 1 out of 10 bone mineral density tests was done more frequently than recommended by Choosing Wisely.…”

DXA Utilization Between 2006 and 2012 in Commercially Insured Younger Postmenopausal Women

“…In the Medicare fee-for-service population DXA utilization has been shown to increase from 2002 until 2008 or 2009 depending on study before small declines in 2010 and 2011. (6, 11, 12) In patients with commercial insurance, decreases between 2005 and 2008 were reported for patients with Medicare Supplementary Insurance and increases between 2000 and 2009 for commercially insured patients less than age 64. (13, 14) Overall, and based on these reports that describe a diverse population including Medicare and/or commercially insured patients and covering time periods wherein reimbursement cuts were being phased in, DXA utilization appears to have slowed and in some reports slightly declined.…”

Variations in Radiographic Procedure Use for Medicare Patients With Rheumatoid Arthritis

“…8 Our study found a slightly higher rate of short-interval DXA scans (13%), perhaps because we did not exclude patients with a history of fracture or potentially because of more aggressive osteoporosis screening in this group of patients with RA, who may be more likely to be receiving glucocorticoids.…”

“…Claims for DXA scans were similarly assessed, but only among women, in order to compare our results with previously published estimates using a 100% Medicare sample. 4 …”