A long-term study of several thousand women over 65 who had baseline bone density testing was published in NEJM January 2012. The purpose was to try to determine how long it might take for a patient who does not have osteoporosis to develop it. In short, it depends how bad the bone density is to start with. What is making headlines seems to be the idea that if bone density is normal (or nearly so) at baseline that it might be reasonable to wait another 15 years before checking again. The authors make this conclusion because very few individuals will actually become osteoporotic in that timeframe if BMD is normal at baseline. That is certainly a long time. Health insurance plans may jump at the chance to further restrict access to this useful technology. And, I think if they do it thoughtfully that that might even be reasonable. On the other hand, this same study also concludes that patients who have more advanced osteopenia should be monitored more closely with repeat exams as soon as 1 year later. Other patients in-between could be re-examined in a more moderate time-frame of 3 to 5 years. So, from my perspective, if the health insurance plans appropriately liberalize access to use of DXA technology for bone density measurement on the patients with more advanced osteopenia, and allow us to use some clinical judgement on the others, restrictions on use of the technology for those with higher bone density to start with would not be met with much objection. Time will tell how this data will be handled and if it is done thoughtfully and with the best interests of the public health in mind.
Now, let’s talk more generally about testing. Health care costs in the US are rising unsustainably and have placed great burdens on family, employer and government budgets. Medical tests are a big part of health care costs. But, the same test may have great value for one situation and very little value in another. Judicious use of testing will improve quality of care and reflect responsible awareness of costs. We here at TEG welcome thoughtful discussion about use of various tests and interventions to promote high-value, cost-conscious care.