Quality in Bone Densitometry

Additional Info

• Audio File:uab/ua044.mp3
• Doctors:Morgan, Sarah
• Featured Speaker:Sarah Morgan, MD
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4285
• Guest Bio:Sarah Morgan, MD, MS, RD/LD, FADA, FACP, CCD, is Professor of Nutrition Sciences and Medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham (UAB) School of Medicine.
  
  Learn more about Sarah Morgan, MD 
  
  Release Date: November 6, 2017
  Reissue Date: November 6, 2020
  Expiration Date: November 6, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Sarah L. Morgan, MD, RD, FADA, FACP, CCD
  Professor in Internal Medicine and Nutrition
  
  Dr. Morgan has disclosed the following commercial interests:
  Consulting Fee – Amgen
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host): According to the National Osteoporosis Foundation, approximately 54 million Americans have osteoporosis and low bone mass; placing them at an increased risk for osteoporosis. Studies suggest that approximately one in two women and up to one in four men aged 50 and older will break a bone due to osteoporosis. My guest today is Dr. Sarah Morgan. She’s a professor of Nutrition Sciences and Medicine in the Division of Clinical Immunology and Rheumatology at UAB Medicine. Welcome to the show Dr. Morgan. So, explain a little bit about bone density and osteoporosis and why it’s important to measure this.
  
  Dr. Sarah Morgan, MD, RC, FADA, FACP, CCD (Guest): Osteoporosis is a condition that can be caused by many things where the bones are thin and the problem with having osteoporosis is it predisposes you to have fractures. This is not fractures – traumatic fracture, this is a fall when you have a fall from a standing height, you might have a fracture, so we call that an insufficiency fracture. So, that’s the problem with having osteoporosis. A bone densitometry test which is also called DEXA, which is dual energy x-ray absorptiometry, right now is one of the state of the art measurements that help us to determine how thick your bones are. So, it’s a very nice test to help us to make the diagnosis and we use it for a lot of things; to follow you and also determine your fracture risk.
  
  Melanie: So, tell us about some of those valuable prognostic tools to aid in early diagnosis of osteoporosis because that is so important. Are there different types of bone density tests?
  
  Dr. Morgan: There is really one – there are probably two different types of bone density tests. There is a peripheral one where you might go to a screening health fair and you could stick your heel or your forearm into a machine. The one that we use in our clinic, is a table unit where we would measure bone density on the lumbar spine, the hip and we could also measure the forearm. We can also do total body evaluation which also can tell us about body composition analysis. For the most part, when you come to our clinic, we will be doing the DEXA scan of the hip, the spine, and sometimes adding on a wrist scan.
  
  Melanie: So, are the any shortcomings of bone mineral density testing?
  
  Dr. Morgan: I can’t think of many shortcomings. Really a bone mineral density test is more predictive of whether somebody will have a fracture that is a cholesterol level of whether somebody will have a heart attack or a stroke. That being said, there may be things that confound the bone density testing. For example, as we get older, in our spine, we may get degenerative arthritis in our spine and that will tend to overestimate bone mineral density in the spine. Therefore, that’s one of the reasons that we do other sites such as the hip and the forearm to provide us with other data.
  
  Melanie: Well, as we are speaking about data, does denser bone necessarily mean stronger bone?
  
  Dr. Morgan: We measure bone densitometry, we measure your bone mineral density which is in T-scores and in Z-scores and there is categorization of these T-scores and Z-scores. We use a T-score and Z-score which are standard deviations to give us benchmarks for diagnosis. A T-score that is in a postmenopausal woman for example, that is above -1 or above is normal bone mineral density. A T-score that is below -1 to just above -2.5 is osteopenia and a score of -2.5 is osteoporosis. To specifically address your question, we do have metabolic bone diseases that have thicker bones that necessarily may not be stronger bones, but in the context of osteoporosis; generally having higher bone mineral density means you are less likely to have a fracture.
  
  Melanie: So, speak about patient selection criteria and some clinical indications for the institution of this test. Who should have it?
  
  Dr. Morgan: Well, there are a wide variety of people that have come up with guidelines related to this for example, the National Osteoporosis Foundation. Generally, and I also will add, that Medicare/Medicaid has criteria for paying for that test. So, those are some of the benchmarks we use. But generally, I think that we do these studies in people who have had insufficiency fractures looking for their bone mineral density. We may do them for people that are on steroids because steroids are examples of medications that can lower bone mineral density. We often do them in postmenopausal women because we know women at menopause who chose not to continue to take hormones lose bone mineral density. So, there are some categories like that of people in whom we generally recommend that they have a bone density test. Another good example is hyperparathyroidism. In hyperparathyroidism, you lose bone mineral density. So, there are a whole host of reasons that your physician may decide to order a bone density test.
  
  Melanie: So, what are some current issues in medical management, assess for us the appropriateness of specific treatments you might engage with the patient if you determine that they have osteopenia and on to osteoporosis.
  
  Dr. Morgan: If somebody has osteopenia, that’s the category that is above osteoporosis, so generally the bone mineral density is higher than osteoporosis. One of the uses of bone mineral density is to use a tool called FRAX in osteopenia which is a fracture risk algorithm that gives somebody their ten-year risk of having a major osteoporotic fracture or a hip fracture. So, we can combine the information with bone mineral density, the bone mineral density generally at the femoral neck with risk factors in the patient and that can help us to determine their fracture risk. So, we oftentimes do that in somebody with osteopenia and the National Osteoporosis Foundation has established cutoffs for when the fracture risk is high enough to use medical therapies and the National Osteoporosis Foundation generally would certainly recommend therapy in somebody with an insufficiency fracture, if you have a T-score of -2.5 or below at the lumbar spine and in the hip.
  
  Melanie: So, tell us about the UAB Osteoporosis Prevention and Treatment Clinic.
  
  Dr. Morgan: I’m very proud of this clinic. This is a long-term clinic we have had is a multidisciplinary clinic. So, I feel that the best care of patients with metabolic bone disease is multidisciplinary. So, in ort clinic, we have a physical therapist, so a new patient may have a physical therapy screen. This helps me with fall prevention, gait analysis, back pain. We have nurses, nurse practitioners. We have physicians that are many different types of specialties; internal medicine, nutrition, endocrinology, rheumatology, geriatrics. We all practice together. We have a nurse practitioner that we all work together. We have a radiologist that works with us on our team to read bone densities. So, a new patient that would come to our clinic, might come in the morning and see the physical therapist first. They would then go on to have a DEXA scan completed and then we; one day of the week we have a two-hour class that our patient educator, who I should mention is a PhD level nutritionist, so we have dieticians that are part of our team. We have a two-hour class for all of our new patients. In this class, we discuss calcium, calcium stores, you learn how to read a label, we talk about fall prevention, we talk about how to read your DEXA scan and we talk about therapeutic options. Then all of us see our new patients, generally in the afternoons so all of our patients have been educated and our wonderful patient educator is there in the afternoon and she helps us to do calcium and vitamin D instructions. If I want to put somebody on a low sodium diet, because of hypercalciuria, she also would instruct people on how to take bisphosphonate medicine correctly, she would also instruct on how to give an injectable medicine like teriparatide.
  Melanie: So, how can someone schedule a bone density test?
  
  Dr. Morgan: A bone density test in our health system; can be scheduled by any physician. It’s part of the radiology order set and you just click on the bone densitometry and you can order it.
  
  Melanie: And what can a physician expect from your team after referral, if they refer someone to you, insofar as communication with the referring physician and your team approach?
  
  Dr. Morgan: With our team approach, let me talk about clinic first; we would generate a report of our consultation and that would be sent to a physician who requested the consultation. It would be available on our electronic medical record. A DEXA scan we rotate reading DEXA scans, all of the physicians within the clinic and our radiologists and those are reported out and one of the things I will mention is that DEXA quality is very important and our DEXA facility is accredited by the International Society for Clinical Densitometry. We are one of about 50 or 60 in the country right now. And so, I’m very proud of that, because that means we do all of the quality control and you can also count that our report that we generate about the DEXA scan has all of the recommended required elements that the International Society for Densitometry deems to be important in communicating our DEXA results.
  
  Melanie: So, to wrap up in summary Dr., tell other physicians what you would like them to know about quality in bone densitometry and when to refer to a specialist.
  
  Dr. Morgan: Quality is extremely important in bone densitometry. The clinician who reads a bone densitometry report should be certified. I have the letters CCD after my name, which means Certified Clinical Densitometrist, this is through the International Society for Clinical Densitometry. And my bone density, my DEXA technologists, are radiographic technologists who have the letters CBDT, they are certified bone density technologists. And so, I think that is very important to have people that have been educated about correctly doing the test, correctly reading the test and evaluating the test. So, that’s one thing I’d like to leave with everybody is that quality in DEXA scans is very important and so you want to make sure that the facility that is performing the DEXA scan has certified individuals and also is hopefully accredited.
  
  Melanie: Thank you so much Dr. Morgan for being with us today. And a community physician can refer a patient to UAB Medicine by calling the Mist line at 1-800-UAB-MIST. That’s 1-800-822-6478. You are listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to UABmedicine.org/physician. That’s UABmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
• Hosts:Melanie Cole, MS