Variations in Radiographic Procedure Use for Medicare Patients With Rheumatoid Arthritis

Abstract

Background In 2013, the American College of Rheumatology published its Choosing Wisely list, which identified 2 radiographic procedures (peripheral joint MRI and DXA scans) that were at risk for being overused. Methods We performed a retrospective cross-sectional cohort study to measure the use of peripheral joint MRI, peripheral joint x-rays, and DXA scans in a national cohort of Medicare patients with rheumatoid arthritis (RA) during 2008–2009, before the start of the Choosing Wisely campaign. Diagnoses were identified via ICD9 codes; utilization was calculated using CPT codes. Utilization was analyzed at the individual and regional level (hospital referral region (HRR)). Results 8,051 patients with rheumatoid arthritis were included: 81% were women, mean age was 76 years. Over a 2-year period, the mean number of peripheral joint MRIs per beneficiary was 0.3 (median 0, range 0–50), peripheral joint x-rays per beneficiary was 2.6 (median 1, range 0–33), and DXA scans per beneficiary was 0.7 (median 0, range 0–11). Only 6.8% of patients received more than 1 peripheral joint MRI, and 6% of HRRs had a mean number of peripheral joint MRIs of greater than 1. Conclusions There is variation in the use of peripheral joint MRI, peripheral joint x-rays, and DXA scans among Medicare patients with rheumatoid arthritis, although only a small number of HRRs have consistently high utilization. Although we cannot judge the appropriateness of each procedure, variations in use across regions signal the need for investigations to examine potential overutilization.

Osteoporosis and fractures in rheumatoid arthritis

“…Despite the observation that patients with RA are at high risk for osteoporosis, screening is underperformed [5]. Screening should involve DXA testing if available.…”

“…Rheumatoid arthritis (RA) is a chronic inflammatory disease that damages the joints and causes bone demineralization [1], thereby doubling the risk of osteoporotic fractures compared to the general population [2]. Osteoporotic fractures in people with RA are associated with greater mortality [3,4], yet bone mineral density (BMD) screening rates are low patients with RA [5]. Osteoporosis is common in RA, affecting nearly one-third of the RA population [6,7].…”

“…Traditional osteoporosis risk factors must also be considered in the RA population and are detailed in Table 1. There is evidence that with improved RA therapies and less dependence on glucocorticoids (GCs), osteoporosis rates may be on the decline [17 ▪ ], however, these studies may be confounded by the lack of adequate osteoporosis testing [5]. Unfortunately, findings from a meta-analysis including all published studies through 2017 suggest that fracture risk in RA remains high, compared to the general population [18], and a study from Spain found increasing hip fracture rates from 1999 to 2015 [19]…”