DXA Quality Matters

doi:10.1016/j.jocd.2006.07.002

Journal of Clinical Densitometry

Volume 9, Issue 4, October–December 2006, Pages 388-392

https://doi.org/10.1016/j.jocd.2006.07.002 Get rights and content

Abstract

The proliferation of devices to measure bone mineral density (BMD), with large numbers of technologists operating these instruments and numerous physicians interpreting/reporting the results, raises concern regarding the quality of the studies. High quality BMD measurement and reporting is essential, since referring healthcare providers rely on these reports to make patient care decisions that include additional medical evaluation (laboratory or imaging tests), drug therapy (starting, stopping, or changing), and possibly referral to an osteoporosis specialist. Incorrect BMD acquisition or reporting may generate unnecessary medical expenses and result in therapeutic decisions that could be harmful to patients. Contrary to the common misperception that BMD measurement and interpretation is a simple procedure requiring no special expertise, densitometer maintenance/operation, data acquisition, and interpretation/reporting of the results are skills that must be acquired and maintained. We recommend that technologists and clinicians involved with performing or interpreting BMD tests be educated and trained in bone densitometry and that they update their skills regularly. We also suggest that they provide demonstration of proficiency in bone densitometry in order to assure patients, referring healthcare providers, and payers of medical services that these skills have been acquired and maintained.

Section snippets

Background

Osteoporosis is a disease characterized by diminished bone strength and increased risk of fracture. It is a common disease with serious clinical consequences. In the USA, there are about 44 million people with osteoporosis or low bone mass (osteopenia), with 1.5 million fragility fractures per year (1). Fractures of the spine and hip are associated with increased morbidity (e.g., diminished quality of life, loss of independence, chronic pain) and an excess mortality of about 20% (2). About 50%

Perceptions of DXA Quality

It is our experience that errors in DXA acquisition and reporting are not rare. To investigate this perception, a survey of members of the International Society for Clinical Densitometry (ISCD) was undertaken (5). In the spring of 2006, clinician and technologist members of the ISCD were asked to complete an online survey evaluating the quality of DXA studies and reports received from other DXA facilities. Of the 3488 clinicians and 2362 technologist members who were sent an email request to

Patient Scenarios

Potential adverse effects of poor quality bone density testing are illustrated by the following patient case histories, each of which describes a real patient, or composite of patients, seen by the authors. In our opinion, these cases are representative of scenarios where poor quality BMD testing can result in inappropriate clinical decisions that generate unnecessary medical expenses and may harm patients. These are divided in categories of quality control, acquisition, analysis, and

Discussion

DXA is widely considered to be the “gold standard” technology for BMD measurement. This is appropriate as DXA-measured BMD is highly correlated with biomechanical strength (6) and in epidemiological studies is strongly related with fracture risk (7). Moreover, most randomized clinical trials showing a benefit with drug therapy have selected subjects based on BMD measured by DXA (8). There is a relationship between decreases in fracture risk with drug therapy and increases in BMD measured by DXA

Summary

BMD testing is an important component in the management of osteoporosis. High quality, cost-effective patient care depends on healthcare providers receiving valid reports from trained clinicians for BMD tests done by skilled technologists on instruments that are properly maintained. We recommend that technologists and clinicians involved with BMD testing receive dedicated education and training on the necessary skills to perform and interpret these tests, that they update these skills regularly

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Introduction: Bone mineral density, measured by dual X-ray absorptiometry (DXA), is the gold standard for diagnosis of osteoporosis. The utility of DXA relies on the accuracy of scan acquisition, interpretation of data, and the adequacy of reports. The International Society for Clinical Densitometry (ISCD) has published guidelines regarding minimum reporting guidelines. This study assessed whether DXA reports for patients receiving care at an academic teaching hospital adhere to these reporting standards, and determine whether differences exist depending on patient factors and the imaging service. Methods: Patients aged ≥18 years, receiving care at specialist outpatient clinics between January 1, 2018 and December 31, 2019, with a DXA report available, were eligible for inclusion. DXA reports were manually reviewed for adherence to ISCD guidelines, with each criterion scored as one point, giving a total score of 14 for baseline DXA scans and 18 for repeat DXA scans. The score was then converted to a percentage. Results: Of 459 DXA scans included, 214 were performed internally at our hospital and 245 performed at 23 external imaging services. Mean (SD) patient age was 60 (16.3) years, and 75.8% were female. The overall median (IQR) report score was 57.1% (42.9, 82.4). ISCD criteria with the lowest scores were recommendation and timing of future DXA scans (included in 1.1% of reports) and investigation for secondary causes of osteoporosis (included in 1.2% of reports). Reports performed internally had significantly higher scores than those performed externally, after adjusting for age, sex, indication, and type of scan (incidence rate ratio 1.83, 95% confidence interval 1.77, 1.89). Baseline DXA reports had slightly higher scores than repeat DXA scans, and, among external imaging services, rural services had higher scores than metropolitan services. Conclusion: This study, the largest comprehensive evaluation of DXA reports, highlights significant deficiencies and variation in report standards between imaging services. This has potential implications for osteoporosis diagnosis and management.
DXA: 30 years and counting: Introduction to the 30th anniversary issue
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Dual-energy X-ray absorptiometry (DXA) is the gold standard for measuring bone mineral density (BMD), making the diagnosis of osteoporosis, and for monitoring changes in BMD over time. DXA data are also used in the determination of fracture risk. Procedural steps in DXA scanning can be broken down into scan acquisition, analysis, interpretation, and reporting. Careful attention to quality control pertaining to these procedural steps should theoretically be beneficial in patient management. Inattention to procedural steps and errors that may occur at each step has the possibility of providing information that would inform inappropriate clinical decisions, generating unnecessary healthcare expenses and ultimately causing avoidable harm to patients. This article reviews errors in DXA scanning that affect trueness and precision related to the machine, the patient, and the technologist and reviews articles which document problems with DXA quality in clinical and research settings. An understanding of DXA errors is critical for DXA quality; programs such as certification of DXA technologists and interpreters help in assuring quality bone densitometry. As DXA errors are common, pay for performance requiring DXA technologists and interpreters to be certified and follow quality indicators is indicated.
Evaluation of Automated Fracture Risk Assessment Based on the Canadian Association of Radiologists and Osteoporosis Canada Assessment Tool
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Fracture risk assessments are not always clearly communicated on bone mineral density (BMD) reports; evidence suggests that structured reporting (SR) tools may improve report clarity. The aim of this study is to compare fracture risk assessments automatically assigned by SR software in accordance with Canadian Association of Radiologists and Osteoporosis Canada (CAROC) recommendations to assessments from experts on narrative BMD reports. Charts for 500 adult patients who recently received a BMD exam were sampled from across University of Toronto's Joint Department of Medical Imaging. BMD measures and clinical details were manually abstracted from charts and were used to create structured reports with assessments generated by a software implementation of CAROC recommendations. CAROC calculations were statistically compared to experts' original assessments using percentage agreement (PA) and Krippendorff's alpha. Canadian FRAX calculations were also compared to experts', where possible. A total of 25 (5.0%) reported assessments did not conform to categorizations recommended by Canadian guidelines. Across the remainder, the Krippendorff's alpha relating software assigned assessments to physicians was high at 0.918; PA was 94.3%. Lower agreement was associated with reports for patients with documented modifying factors (alpha = 0.860, PA = 90.2%). Similar patterns of agreement related expert assessments to FRAX calculations, although statistics of agreement were lower. Categories of disagreement were defined by (1) gray areas in current guidelines, (2) margins of assessment categorizations, (3) dictation/transcription errors, (4) patients on low doses of steroids, and (5) ambiguous documentation of modifying factors. Results suggest that SR software can produce fracture risk assessments that agree with experts on most routine, adult BMD exams. Results also highlight situations where experts tend to diverge from guidelines and illustrate the potential for SR software to (1) reduce variability in, (2) ameliorate errors in, and (3) improve clarity of routine adult BMD exam reports.
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The incidence of osteoporosis and osteoporotic-related fractures continues to increase with the aging population. Early diagnosis of low bone mineral density with dual-energy absorptiometry (DXA) and appropriate treatment can prevent fractures. Accurate DXA imaging and patient education regarding the importance of DXA screening play a critical role in patient management. Recognition of osteoporotic fractures on X-ray at the time of an injury or incidentally during imaging for other indications can lead to early treatment and prevention of future fractures. Radiology nurses and other providers are strategically positioned to impact patient outcomes. An overview of osteoporosis, diagnosis, screening guidelines, and nuances of DXA imaging are provided. Case studies provide the clinician with a summary and application of content.
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Dual-energy X-ray absorptiometry (DXA) is a technology that is widely used to diagnose osteoporosis, assess fracture risk, and monitor changes in bone mineral density (BMD). The clinical utility of DXA is highly dependent on the quality of the scan acquisition, analysis, and interpretation. Clinicians are best equipped to manage patients when BMD measurements are correct and interpretation follows well-established standards. Poor-quality acquisition, analysis, or interpretation of DXA data may mislead referring clinicians, resulting in unnecessary diagnostic evaluations, failure to evaluate when needed, inappropriate treatment, or failure to provide medical treatment, with potentially ineffective, harmful, or costly consequences. Misallocation of limited healthcare resources and poor treatment decisions can be minimized, and patient care optimized, through meticulous attention to DXA instrument calibration, data acquisition and analysis, interpretation, and reporting. This document from the International Society for Clinical Densitometry describes quality standards for BMD testing at DXA facilities worldwide to provide guidance for DXA supervisors, technologists, interpreters, and clinicians. High-quality DXA testing is necessary for correct diagnostic classification and optimal fracture risk assessment, and is essential for BMD monitoring.

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Original ArticleDXA Quality Matters

Abstract

Section snippets

Background

Perceptions of DXA Quality

Patient Scenarios

Discussion

Summary

Applied Radiation & Isotopes

America's bone health: the state of osteoporosis and low bone mass in our nation

Population-based study of survival after osteoporotic fractures

Am J Epidemiol

The worldwide problem of osteoporosis: insights afforded by epidemiology

Bone

Meta-analyses of therapies for postmenopausal osteoporosis. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis

Endocr Rev

Impact of DXA quality on patient care: clinician and technologist perceptions

J Bone Miner Res

Original Article
DXA Quality Matters