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Screening for osteoporosis among high-risk populations, including postmenopausal women, is essential. Women found to have low bone density due to osteoporosis or osteopenia (a precursor to osteoporosis) can reduce their risk of future bone fracture with lifestyle changes and drug therapies. The United States Preventive Services Task Force (USPSTF) recommends that all women ages 65 years and older undergo bone density testing to screen for osteoporosis, and that some younger women receive targeted screening based on individual risk assessments.
In addition, fragility fracture events, when they do occur, represent important opportunities to identify and treat previously undiagnosed osteoporosis in order to prevent subsequent fractures. In fact, the National Committee for Quality Assurance (NCQA) tracks utilization of bone density testing and initiation of osteoporosis pharmacotherapy among women within six months of hip fracture as a key indicator of health system performance.
Unfortunately, these guidelines are often not followed. Despite osteoporosis being a leading cause of disability and loss of independence among older Americans, especially women, this bone disease frequently goes unrecognized and untreated. A colleague and I recently investigated these missed opportunities.
Although poor adherence to evidence-based guidelines for osteoporosis screening and post-fracture management has been previously documented among some populations, few studies have looked at contemporary trends in utilization of these services among a nationwide sample or have considered patient-level predictors of utilization other than age.
Findings show guidelines collect dust
Pam Morin of OptumLabs and I recently published two reports looking at trends and disparities in utilization of osteoporosis-related health services between 2008 and 2014. Our research focused on American women age 50 and older who have medical and prescription drug coverage through private commercial or Medicare Advantage plans. We found that evidence-based guidelines for both the prevention and treatment of osteoporosis are not being widely implemented in practice. Below are some of the key insights from our investigations of osteoporosis screening 1 and post-fracture care 2:
- Fewer than one in four privately insured women age 65-plus utilized osteoporosis screening for primary prevention during a two-year period, despite USPSTF recommendations for universal routine screening in this age group.
- Between 2008 and 2014, there was almost no improvement in osteoporosis screening among women ages 65-79, and while screening rates increased 38 percent among women 80 and older, they remain unacceptably low in this age group.
- Fewer than 1 in 5 privately insured women age 50-plus receive recommended osteoporosis care within six months of a hip fracture, contrary to guidelines.
- Hip fractures disproportionately occur among women age 80 and older, yet this group is least likely to receive recommended care, thus remaining at unnecessarily high risk for subsequent fracture. In fact, Pam and I previously reported findings3 linking failure to adhere to recommendations for post-fracture care to a significantly higher risk of second hip fracture among women in this age group.
But our research uncovered good news, too:
- Between 2008 and 2014, osteoporosis screening among women 50-64 declined 31 percent — in line with the Choosing Wisely campaign, which highlighted the lack of cost-effectiveness of universal screening among this younger age group.
- Disparities in screening utilization based on sociodemographic characteristics, though apparent, narrowed substantially over time.
- There were no significant disparities in post-fracture care by race/ethnicity, although women of lower socioeconomic status in our cohort were somewhat less likely to receive the recommended services.
- Primary care played a key role. Having any primary care encounters within the six-month period following fracture was the strongest and most consistent predictor of recommended post-fracture services.
For more details, please see the full text of our papers, which are available to the public using the links in this blog post.
- Gillespie CW, Morin PE. Trends and disparities in osteoporosis screening among women in the United States, 2008-2014. American Journal of Medicine. November 2016:(epub ahead of print). doi:10.1016/j.amjmed.2016.10.018. Available online.
- Gillespie CW, Morin PE. Osteoporosis-related health services utilization following first hip fracture among a cohort of privately-insured women in the United States, 2008-2014: An observational study. Journal of Bone and Mineral Research. February 2017:(epub ahead of print). doi:10.1002/jbmr.3079. Available online.
- Gillespie CW, Morin PE. Few Hip Fracture Patients Receive Osteoporosis Care. Washington, DC: AARP Public Policy Institute; 2016. Available online.
Kate Gillespie is an epidemiologist and senior adviser at the AARP Public Policy Institute. She spends much of her time studying health services utilization in order to identify opportunities to improve health care delivery in the United States.