Osteoporosis can be a difficult disease to detect. It is a “silent” disease, meaning that it lacks obvious signs and symptoms. People with osteoporosis generally don’t feel anything out of the ordinary. Often a fracture is the first overt sign that someone has osteoporosis, which can be a costly and debilitating way of realizing there’s a problem. Fortunately, osteoporosis is detectable before it reaches this stage.

Risk Factors

Detecting osteoporosis begins with one simple step: knowing whether or not you are at risk. Knowledge of the risk factors associated with osteoporosis can help a physician make decisions about the need for more advanced tests and detection methods, and can help a patient talk with their doctor about these tests. For certain fractures, risk factor assessment may be even more effective than medical tests for determining that a fracture occurred.¹

Some risk factors are related to genetics and can’t be changed, while others involve modifiable lifestyle decisions.² Non-modifiable risk factors include:
     • Age
     • Being a woman, especially post-menopausal
     • Family history of fractures
     • Low body weight and/or being thin

Modifiable risk factors include:
     • Tobacco use
     • High alcohol consumption (more than two drinks a day)
     • Insufficient calcium and/or vitamin D intake
     • Sedentary lifestyle

Unfortunately, studies indicate that knowledge of these factors among at-risk populations is relatively poor.³

Evaluating fracture risk is an important step in deciding to pursue further tests to detect osteoporosis. American Bone Health provides an online risk calculator based on World Health Organization criteria, available at http://www.americanbonehealth.org/tools-and-resources/risk-calculator.

Screening Tests

A variety of quick and painless tests are available to measure bone density mass (BMD), which is an excellent indicator of osteoporosis. The National Osteoporosis Foundation recommends screening for the following populations: women over 65; men over 70; anyone over 50 who experiences a fracture; women of menopausal age with risk factors; postmenopausal women under 65 with risk factors; and men 50-69 with risk factors.

BMD tests fall into two broad categories, peripheral screening tests which test the heel or wrist, and central tests which test the hip and spine. The central test provides the most thorough picture of bone density and is the preferred tool for diagnosing osteoporosis and monitoring treatment, though there is a high degree of correlation between peripheral bone tests and central bone tests for most people. These tests often utilize a technique called dual-energy X ray absorptiometry (DXA). DXA tests are quick, safe, painless, and effective. These tests allow a physician to determine their patient’s T-score, which is a measure of their BMD compared to a healthy adult. T-scores below -2.5 indicate osteoporosis.⁴

Despite the ease and importance of DXA tests for measuring BMD and detecting osteoporosis, evidence indicates that these tests are underutilized. Though DXA tests are covered for at-risk people by most insurance plans and Medicare, only 30 percent of eligible women and four percent of eligible men had a central DXA test from 1999 to 2005.⁵

Of those tests, the majority were conducted at nonfacility sites, such as a physician’s office, as opposed to facility sites like hospital radiology departments. Nonfacility sites are particularly important for people living in rural communities who might not have easy access to hospitals.

Unfortunately, in 2007 the Medicare reimbursement rate for nonfacility DXA tests was reduced, though the passage of the Patient Protection and Affordable Care Act in March 2010 included a provision to restore this rate to its 70 percent of its previous level for two years. This provision expires in 2012. Though the impact of this rate reduction on DXA utilization is not clearly understood, studies indicate that as travel time to DXA screening sites increases, rural populations are less likely to seek these tests.⁶ This could help explain why the utilization of these services is so low.

Sources:
1. Tsang SWY, Bow CH, Chu EYW, Yeung SC, Soong CC, Kung AWC. “Clinical risk factor assessment had better discriminative ability than bone mineral density in identifying subjects with vertebral fracture.” Osteoporosis International online publication (2010). DOI: 10.1007/s00198-010-1260-z. Accessed March 8, 2011.
2. National Osteoporosis Foundation website – “Factors that Put You at Risk.” http://www.nof.org/aboutosteoporosis/bonebasics/riskfactors
3. Giangregorio L, Thabane L, Cranney A, Adili A, deBeer J, Dolovich L, Adachi JD, Papaioannou A. “Osteoporosis Knowledge Among Individuals With Recent Fragility Fracture.” Orthopaedic Nursing 29 No. 2 (2010): 99-107.
4. American Bone Health website – “About T-scores.” http://www.americanbonehealth.org/what-you-should-know/about-t-scores
5. Curtis JR, Carbone L, Cheng H, Hayes B, Laster A, Matthews R, Saag KS, Sepanski R, Tanner SB, Delzell E. “Longitudinal Trends in Use of Bone Mass Measurement Among Older Americans, 1999-2005.” Journal of Bone and Mineral Research 23 No. 7 (2008): 1061-1067.
6. Curtis JR, Laster A, Becer DJ, Carbone L, Gary LC, Kilgore ML, Matthews RS, Morrisey MA, Saag KG, Tanner SB, Delzell E. “The geographic availability and associated utilization of dual-energy X-ray absorptiometry (DXA) testing among older persons in the United States.” Osteoporosis International 20 (2009): 1553-1561.

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