Repeat Bone Mineral Density Screening and Prediction of Hip and Major Osteoporotic Fracture

Abstract

IMPORTANCE Screening for osteoporosis with bone mineral density (BMD) is recommended for older adults. It is unclear whether repeating a BMD screening test improves fracture risk assessment.OBJECTIVES To determine whether changes in BMD after 4 years provide additional information on fracture risk beyond baseline BMD and to quantify the change in fracture risk classification after a second BMD measure. DESIGN, SETTING, AND PARTICIPANTSPopulation-based cohort study involving 310 men and 492 women from the Framingham Osteoporosis Study with 2 measures of femoral neck BMD taken from 1987 through 1999.MAIN OUTCOMES AND MEASURES Risk of hip or major osteoporotic fracture through 2009 or 12 years following the second BMD measure.RESULTS Mean age was 74.8 years. The mean (SD) BMD change was −0.6% per year (1.8%). Throughout a median follow-up of 9.6 years, 76 participants experienced an incident hip fracture and 113 participants experienced a major osteoporotic fracture. Annual percent BMD change per SD decrease was associated with risk of hip fracture (hazard ratio [HR], 1.43 [95% CI, 1.16 to 1.78]) and major osteoporotic fracture (HR, 1.21 [95% CI, 1.01 to 1.45]) after adjusting for baseline BMD. At 10 years' follow-up, 1 SD decrease in annual percent BMD change compared with the mean BMD change was associated with 3.9 excess hip fractures per 100 persons. In receiver operating characteristic (ROC) curve analyses, the addition of BMD change to a model with baseline BMD did not meaningfully improve performance. The area under the curve (AUC) was 0.71 (95% CI, 0.65 to 0.78) for the baseline BMD model compared with 0.68 (95% CI, 0.62 to 0.75) for the BMD percent change model. Moreover, the addition of BMD change to a model with baseline BMD did not meaningfully improve performance (AUC, 0.72 [95% CI, 0.66 to 0.79]). Using the net reclassification index, a second BMD measure increased the proportion of participants reclassified as high risk of hip fracture by 3.9% (95% CI, −2.2% to 9.9%), whereas it decreased the proportion classified as low risk by −2.2% (95% CI, −4.5% to 0.1%). CONCLUSIONS AND RELEVANCEIn untreated men and women of mean age 75 years, a second BMD measure after 4 years did not meaningfully improve the prediction of hip or major osteoporotic fracture. Repeating a BMD measure within 4 years to improve fracture risk stratification may not be necessary in adults this age untreated for osteoporosis.

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

“…Medicare policies have reflected this understanding, but enforcement efforts appear insufficient [11]. Recent studies suggest the minimum meaningful intertest interval may be many years for average risk patients [7, 23, 6]. Our results (spanning 2008 to 2011) reflect practice before the time rheumatologists elected to include short-interval DXAs on their Choosing Wisely list and thus portray the starting point from which we hope use of this care will decline in response to the Choosing Wisely initiative.…”

Associations between the 2007 Medicare reimbursement reduction for bone mineral density testing and osteoporosis drug therapy patterns of female Medicare beneficiaries

“…Frequent, timely BMD testing could therefore improve the quality and outcomes of osteoporosis treatment through early detection of least significant change and minimization of extended gaps 9,13. Previous reports on the limited value of repeat BMD testing included healthy and untreated older females – a different population than reviewed in this study 27,28…”

Fracture prediction from repeat BMD measurements in clinical practice

“…However, prior to our current study, the utility of repeat BMD measurements vs. the first BMD measurement to predict fractures in adults aged 50 years and above was not well understood. In older populations, data from the Framingham Study showed that, in 802 (61.3 % female) untreated adults (mean age 75 years), a repeat BMD measure after 4 years did not meaningfully improve the prediction of MOF or hip fracture [14]. Similar observations were reported by the US-based Study of Osteoporotic Fractures, whereby in 4124 healthy women (mean age 72 years), repeating a BMD measurement up to 8 years later had little additional value for fracture prediction compared to the initial BMD value itself [11].…”

“…However, the role of repeat BMD measurement remains controversial [7,8], and the effectiveness for fracture prediction has not been established in clinical populations which differ from population-based cohorts and the clinical trial setting. Furthermore, conflicting data exist regarding the clinical utility of rate of BMD loss as an indicator of fracture risk [9][10][11][12] with recent data suggesting that fracture prediction is not enhanced by rate of BMD change [9,13,14]. Although we have previously investigated the effectiveness of the initial BMD measurement for predicting osteoporotic fractures in clinical populations [15], it remains uncertain whether repeat BMD measurements are as clinically useful for fracture risk assessment as the first measurement and whether fracture risk is affected by preceding change in BMD or recent osteoporosis therapy.…”