DXA Best Practices 50 80 70 40 60 Ten Year 30 Fracture 50 - PDF document

9/29/2017 BMD Predicts Fracture Risk Age DXA Best Practices 50 80 70 40 60 Ten Year 30 Fracture 50 20 Probability (%) 10 0 1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0 Femoral Neck T-score E. Michael Lewiecki, MD Probability of first fracture of hip, Director, New Mexico Clinical Research & Osteoporosis Center distal forearm, proximal humerus, Director, Bone TeleHealth ECHO University of New Mexico Health Sciences Center and symptomatic vertebral fracture Adapted from Kanis JA et al. Albuquerque, New Mexico, USA in women of Malmö, Sweden. Osteoporosis Int. 2001;12:989-995. Dual-energy X-ray Absorptiometry: DXA • Bone Mineral Density (BMD) – Diagnosis What is the problem? – Fracture Risk (including FRAX/TBS) – Monitor • Vertebral Fracture Assessment (VFA) Too many bad DXAs • Trabecular Bone Score (TBS) • Hip Structural Analysis (HSA) Bad DXAs can harm patients • Body Composition (Body Comp) 1

9/29/2017 US Hip Fracture Trends 2002-2015 DXA Quality Gap Leads to 26% Hip Fracture Rates 900 14,391 additional hip fractures Adverse Clinical Outcomes $576 million additional expenses 884 Age-adjusted to the 2014 Age Distribution 24% 850 2,878 additional deaths Fractures per 100,000 Women Age 65+ • Watts NB. 2004. Fundamentals and pitfalls of bone densitometry using Percent of Women Age 65+ 22% 800 DXA Medicare Payments dual-energy X-ray absorptiometry (DXA). Osteoporos Int. 15:847–854. $139 738 20% 750 • Lewiecki EM, Binkley N, Petak SM. 2006. DXA quality matters. J Clin Densitom. 9:388–392. 18% Osteoporosis Diagnosis 700 • Lewiecki EM, Lane NE. 2008. Common mistakes in the clinical use of 17.9% 693 bone mineral density testing. Nat Clin Pract Rheumatol. 4:667–674. 16% $82 650 • Messina C, Bandirali M, Sconfienza LM et al. 2015. Prevalence and 14.8% type of errors in dual-energy X-ray absorptiometry. Eur Radiol. 14% 600 25:1504–1511. $42 13.2% DXA Testing 12% 550 • Binkley N et al. 2016. Error prevalence in DXA performance and reporting: Improving DXA quality is essential. ISCD Annual Meeting. 11.3% Galway, Ireland. Poster presentation. 10% 500 • Borges JLC, Haddad LP, Lewiecki EM. 2016. Bone Loss or a Case of Mistaken Gender? J Clin Exp Orthop. 2:20. Lewiecki EM et al. ASBMR Oral Presentation #1077. 2016. Low DXA Reimbursement Leads to Poor DXA Quality No No Losing Losing Inappropriate Inappropriate investment in investment in Suboptimal Suboptimal money with money with clinical clinical education education DXA studies DXA studies DXA DXA decisions decisions and training and training Potential harm to patients: higher medical Open access: download FREE expenses, unnecessary lab tests, wrong treatment, fractures that might have been prevented at www.iscd.org DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. 2

9/29/2017 DXA Quality DXA Best Practices is NOT . . . “the degree to which DXA measurements • A comprehensive list of all features that and interpretation are consistent with characterize a high quality DXA facility current professional standards to facilitate • A substitute for appropriate education, desired health outcomes” certification, and accreditation • The only means of addressing the many unmet needs in the care of patients with osteoporosis DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices is . . . Methodology • A guide and expectation for DXA supervisors, • ISCD Position Development Conferences held regularly since 2001, with rigorous reviews of best technologists, interpreters, and clinicians medical evidence evaluated by international panels • A set of essential markers that are consistent of experts with high quality DXA • Intended to aid patients, referring providers, and • ISCD Official Positions, developed with modified payers in recognizing high quality DXA services RAND Corporation and UCLA method (RAM) for • Applicable worldwide for adult and pediatric DXA recent PDCs (according to local circumstances and country- specific standards) • Written, reviewed, and vetted by numerous experts • Expected to evolve over time as new data in adult and pediatric DXA worldwide, including the emerge and new standards are developed ISCD Scientific Advisory Committee, and approved by the ISCD DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. 3

9/29/2017 How to use DXA Best Practices if you are NOT a bone densitometrist • Ask about the following – Certification for DXA tech and interpreter – Facility accreditation – Precision assessment has been done and least significant change is known • Look at the report – Make and model of DXA instrument are identified – One diagnosis per patient, not different diagnosis for each skeletal site – One fracture risk assessment per patient, not different one for each skeletal site • Look at the images – Spine positioning and vertebral body labeling – Hip positioning – Comparing “apples with apples” DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices How to use DXA Best Practices Scan Acquisition and Analysis if you are a bone densitometrist • Download DXA Best Practices 1.1. At least one practicing DXA • Be familiar with it technologist, and preferably all, has a • Follow the recommendations valid certification in bone densitometry. • Be trained and stay updated • Get certified (if not already) • Facility accreditation is the best way to demonstrate that high quality DXA is being performed DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. 4

9/29/2017 DXA Best Practices DXA Best Practices Scan Acquisition and Analysis Scan Acquisition and Analysis 1.2. Each DXA technologist has access to 1.4. The DXA facility must comply with all the manufacturer’s manual of technical applicable radiation safety requirements. standards and applies these standards for BMD measurement. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices DXA Best Practices Scan Acquisition and Analysis Scan Acquisition and Analysis 1.3. Each DXA facility has detailed 1.5. Spine phantom BMD measurement is standard operating procedures for DXA performed at least once weekly to performance that are updated when document stability of DXA performance appropriate and available for review by all over time. BMD values must be maintained within a tolerance of ± 1.5%, key personnel. with a defined ongoing monitoring plan that defines a correction approach when the tolerance has been exceeded. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. 5

9/29/2017 DXA Best Practices DXA Best Practices Scan Acquisition and Analysis Interpretation and Reporting 1.6. Each DXA technologist has 2.1. At least 1 practicing DXA interpreter, performed in vivo precision assessment and preferably all, has a valid certification according to standard methods and the in bone densitometry. facility LSC has been calculated. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices DXA Best Practices Scan Acquisition and Analysis Interpretation and Reporting 1.7. The LSC for each DXA technologist 2.2. The DXA manufacturer and model should not exceed 5.3% for the lumbar are noted on the report. spine, 5.0% for the total proximal femur, and 6.9% for the femoral neck. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. 6

9/29/2017 DXA Best Practices DXA Best Practices Interpretation and Reporting Interpretation and Reporting 2.3. The DXA report includes a statement 2.5. There is a single diagnosis reported regarding scan factors that may adversely for each patient, not a different diagnosis affect acquisition/analysis quality for each skeletal site measured. and artifacts/confounders, if present. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices DXA Best Practices Interpretation and Reporting Interpretation and Reporting 2.4. The DXA report identifies the skeletal 2.6. A fracture risk assessment tool is site, region of interest, and body side for used appropriately. each technically valid BMD measurement. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. DXA Best Practices. Lewiecki EM et al. J Clin Densitom. 2016;19(2):127-140. 7