NEW YORK (Reuters Health)—Too many women who aren’t at risk for osteoporosis are being screened for the disease, and too many women who don’t need osteoporosis treatment are getting it, new research suggests.
“In our health system the overtreatment of osteoporosis was common, and this was partly due to the fact that a lot of women were screened who were younger than age 65 and low risk, and secondly, a lot of women who were treated despite having non-diagnostic abnormalities on their screening” by dual-energy x-ray absorptiometry (DXA), coauthor Dr. Joshua Fenton of the University of California, Davis, Medical Center in Sacramento told Reuters Health in a telephone interview.
The U.S. Preventive Services Task Force recommends DXA screening for women 65 and older, as well as younger women at high risk for fractures, Dr. Fenton and his colleagues note in their report, published online Jan. 4 in JAMA Internal Medicine.
Treatment should be based on whether a woman has clinically important DXA abnormalities, they add, as well as her personal fracture risk. However, they add, at their own center DXA reports include anatomic sites, such as lateral lumbar spine, that are not recommended for osteoporosis diagnosis.
To investigate how often osteoporosis overtreatment occurred at their regional healthcare system, the investigators reviewed electronic health and radiology records for 6,150 women age 40–85, who received initial DXA screening in 2006–2011. Screening found 53.1% had normal BMD or isolated osteopenia; 32.8% had non-main-site osteoporosis; and 14.2% had main-site osteoporosis.
Overall, 20.4% of the women screened had one or more osteoporosis risk factors, while 31.1% of the study participants received a new prescription for osteoporosis drug treatment.
About three-quarters of the women with main-site osteoporosis received drug therapy, while just under half of those with non-main-site osteoporosis were prescribed medication. Half of new prescriptions were written for patients without main-site osteoporosis.
Sixty percent of the DXA tests were performed in women younger than 65 with no osteoporosis risk factors, while half of the women who received drug treatment for osteoporosis were younger than 65 and had no risk factors.
Cases of non-main-site osteoporosis were disproportionately due to lateral lumbar spine osteoporosis, Dr. Fenton and his team note. The International Society for Clinical Densitometry does not recommend using lateral lumbar spine readings to diagnose osteoporosis, they add. These findings suggest that doctors may not be aware of these guidelines, or that they believe that osteoporosis identified at any site should be treated, according to the researchers.
“Physicians who are ordering screening tests should focus on screening women who are at risk for osteoporosis,” Dr. Fenton told Reuters Health. “Clinicians who are interpreting DXA results should focus on the specific anatomic sites that are recommended for osteoporosis diagnosis.”
At his own institution, the researcher added, DXA reports no longer include lateral lumbar spine T scores. “We also need to get the word out to the interpreting doctors, many of whom are primary care physicians, about what are the diagnostic criteria for osteoporosis, who are the best candidates for screening tests, and then how do you factor risk into treatment decisions.”
Although the findings suggest that overscreening and overtreatment of low-risk patients are taking place, the opposite is also true, with many high-risk patients going without screening or treatment, Dr. Anne Schafer, of the San Francisco Veterans Affairs Medical Center, told Reuters Health in a telephone interview. Dr. Schafer coauthored an editorial accompanying the study.
“We know that many people who have already had a fragility fracture don’t get bone mineral density testing,” Dr. Schafer added. “We must screen and treat the right people.”
The new study does seem to show overtreatment of younger women without risk factors, according to Dr. Schafer. “For the women who were included in the study who had those osteopenia-range T scores but were older and did have risk factors, we can’t really say from this study whether treatment was inappropriate or not,” she added.
Reporting only T scores at the femoral neck, total hip, and posterior-anterior lumbar spine will help address confusion, Dr. Schafer and her colleague Dr. Tiffany Kim, also of the San Francisco VA, state in the editorial. These results, along with clinical risk factors including previous fractures, “should be used in the evaluation for skeletal fragility and in decision-making about lifestyle and pharmacologic interventions,” they conclude.