Our systematic review of three categories of articles from the osteoporosis screening literature found that osteoporosis screening guidelines lack uniformity in their development and content. In populations for which there was agreement in guidelines about the utility of performing BMD screening, such as older patients with fractures and oral glucocorticoid users, we found low screening rates across multiple studies. Several patient and physician characteristics were associated with BMD testing, yet few articles carefully assessed correlates of screening using adjusted analyses. Only a small number of interventions to improve osteoporosis screening have been undertaken, and none of the findings have been reproduced.
There is concern that bone densitometry is performed infrequently in at-risk populations, and our findings may provide insight into this underutilization. Differing methods for guideline development, from evidence selection and grading to the degree of pharmaceutical support, may affect their credibility. In addition, variable recommendations across different practice guidelines limit the effectiveness of such recommendations. For example, while many guidelines endorsed screening all postmenopausal women under 65 with an additional risk factor for osteoporosis, there was little agreement on what those risk factors were. This lack of consensus may lead physicians to conclude there is no convincing evidence for any screening strategy. Recommendations were discrepant for other groups, including older postmenopausal women, men, and oral glucocorticoid users. Such heterogeneity of practice guidelines may produce confusion among physicians and patients and impair decision making regarding osteoporosis. Confusion about appropriate populations on which to conduct BMD testing may extend even to high-risk groups for whom there is clinical agreement. The low rates of BMD screening reported in oral glucocorticoid users and postfracture populations may in part be due to conflicting practice guidelines.
Almost all of the studies reported low rates of BMD testing: less than one tenth of postfracture or glucocorticoid-using patients, most of whom were postmenopausal women, received BMD testing. While not entirely comparable, these average screening rates are far lower than those for other diseases with accepted screening strategies including prostate cancer and hypercholesterolemia.58–60
Few predictors of BMD testing beyond patient gender, physician specialty, physician gender, and dose of oral glucocorticoids have been examined or identified. The limited information related to correlates of bone densitometry use prevents understanding which patient subgroups are more or less likely to undergo recommended screening. Equally important is the possibility that unrecognized groups of low-risk patients may be receiving BMD unnecessarily.
Improving the identification of individuals with osteoporosis through BMD testing requires a better understanding of how and where to intervene. The lack of well-defined strategies for improving rates of BMD testing prevents physicians, administrators, and health policy advocates from addressing the needs of at-risk populations. The lack of well-designed controlled trials of interventions to improve rates of BMD testing hampers quality improvement in this area.
The findings of this review may be subject to several limitations. It is possible our search strategy failed to identify published articles that would have been relevant to our analysis. Hospitals, clinics, insurers, and other health care organizations produce their own practice guidelines that were not included for review. While we did collect information on the content of guidelines, our review was not a meta-analysis or a “meta-summary.” It was not intended as a comprehensive synthesis of the recommendations of all available practice guidelines. Various studies correlated BMD testing data from different sources, possibly confusing the interpretation of a weighted average of BMD testing rates. We did not collect data on treatment rates in this analysis. High rates of treatment could partially explain low rates of BMD testing if physicians opted to initiate therapy for high-risk patients without documentation of low bone density. While some evidence supports this approach,61,62
a review we conducted of osteoporosis treatment found low rates of pharmacological therapy in similar populations.6
Further research is necessary to better determine the factors that predict BMD testing, and how best to optimize the rate at which at-risk populations undergo screening. There is a need to clarify patterns of BMD use across less-studied populations: nonwhite postmenopausal women, premenopausal women with multiple risk factors, hospitalized patients, and men. Studies that report screening rates should include analyses that adjust for relevant patient and physician characteristics, and assess awareness of osteoporosis and its risk factors, accessibility of densitometry equipment, reimbursement of testing, and familiarity with reports and therapeutic options. A better understanding of factors that predict osteoporosis screening is critical for the development of effective interventions.