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Perspective | Less Is More

A Dual-Energy X-ray Absorptiometry Scan Need to Know vs Nice to Know

Lorna A. Lynn, MD1
[+] Author Affiliations
1American Board of Internal Medicine, Philadelphia, Pennsylvania
JAMA Intern Med. 2014;174(2):183. doi:10.1001/jamainternmed.2013.12819.
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I know I am not alone in this. While making sure that my children and pets received all recommended vaccinations and medical care, it had been 8 years since I had seen a health care provider. My reasons for joining the ranks of the lost to follow-up are typical: I changed jobs, my gynecologist moved away, and I was embarrassed to have gone so long without having seen a physician. I had another reason for my absence: unlike most patients, I know what preventive care can and cannot do in terms of lengthening life, or at least improving its quality.

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Benefits and harms of screening tests
Posted on December 3, 2013
David L. Keller, MD
Conflict of Interest: None Declared

DEXA bone densitometry causes a small risk of harm due to ionizing radiation exposure, so I adhere to the recommended guidelines. The USPSTF recommends that routine DEXA screening begin at age 60 for women at increased risk for osteoporotic fractures, and at age 65 for women at average risk. I think your internist jumped the gun by ordering your first scan at age 50. On the other hand, I support her decision to obtain an "unnecessary" ECG, since this test causes no direct harm to the patient and is inexpensive. If the patient has a false-positive abnormality on ECG, it is better to learn about it when she is asymptomatic, rather than in the ER when she is presenting with an acute aortic dissection.

Manufactures of profits
Posted on February 4, 2014
Marc S. Frager MD
East Coast Medical Associates
Conflict of Interest: no conflicts of interest
I am astounded to see an ABIM employee criticize a clinical test and note that the main beneficiary is the \"manufacturers of the test.\"This may apply to the highly controversial maintenance of certification process and exam. There is little, if any, high quality data suggesting the MOC process accomplishes anything except serving as a source of revenue to the ABIM. About 50% of the revenue of the ABIM comes from the MOC process, which is likely detested by a majority of participants who are forced to participate. It is likely that the revenue used to pay the salary of the author comes from MOC at least in part. The hypocrisy of the ABIM and its employees is remarkable to me.
DXA testing in pre-menopausal women; a teachable moment
Posted on February 17, 2014
Andrew J Laster MD, John T Schousboe MD, PhD
Dr Laster: Chair Public Policy, ISCD; Arthritis & Osteoporosis of the Carolinas. Dr Schousboe: President of ISCD; Director, Osteoporosis Center , Park Nicollet Clinic
Conflict of Interest: Dr. Laster: consultant: Amgen, Eli Lilly; speakers bureau: Amgen, Eli Lilly, Novartis; Dr. Schousboe: contract research work for Bone Ultrasound Finland
The Choosing Wisely campaign, an initiative of the American Board of Internal Medicine (ABIM), “is focused on encouraging physicians, patients and other healthcare stakeholders to think and talk about medical tests and procedures that may be unnecessary and in some instances can cause harm” (1). The American Academy of Family Physicians (AAFP) as part of that campaign includes DXA testing in women younger than 65 with no risk factors on their list of “Fifteen Things Physicians and Patients Should Question” (2). So it is indeed surprising to see a physician (Dr Lynn) employed by ABIM not use this as a teachable moment with her internist on the first go round. The International Society for Clinical Densitometry (ISCD), the American Association of Clinical Endocrinologists (AACE) and the National Osteoporosis Foundation (NOF) do not recommend DXA testing in women younger than 65 unless they have a known secondary cause of osteoporosis or are postmenopausal and have additional risk factors (low BMI, prior steroid use, current smoker, excessive alcohol consumption, RA, family history of osteoporotic fracture). The author, age 50, lists coffee consumption and a positive family history but does not state she is post-menopausal so she would not likely warrant DXA testing at this time. Additionally, there is no data to support use of FDA approved drug therapies in a pre-menopausal woman without a secondary cause of osteoporosis. Moreover, current ISCD recommendations would not report a T-score or apply terms like “low bone mass”, “osteopenia” or “osteoporosis” to a pre-menopausal individual such as Dr Lynn. If her bone mineral density (BMD) was within 2 SD of age matched controls (Z-score) then she would have “normal bone mass for age”; if below 2 SD, then “low bone mass for age.” Finally, there is a perception that DXA testing is over used in women younger than 65 with no risk factors, but in fact this is not common. Kale et al, utilizing a cross-sectional analysis of data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), found that only 1.4% (95% CI, 0.9%-2.2%) of all DXA tests in women ages 40-64 were inappropriate(3). It’s nice to know that most pre-menopausal women don’t need to know.. their bone density. (1)American Board of Internal Medicine. Choosing Wisely. An Initiative of the ABIM Foundation. http://www.choosingwisely.org/(2) American Academy of Family Practice . Fifteen Things Physicians and Patients Should Question. http://www.choosingwisely.org/doctor-patient-lists/american-academy-of-family-physicians/(3)Kale MS, Bishop TF, Federman AD, Keyhani S. \"Top 5\" lists top $5 billion. Arch Intern Med. Nov 14 2011;171(20):1856-1858.
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