The study reported on here found that the DXA screening test for osteoporosis was underused among women older than 65 who are at higher risk, but was overused among younger women who have no osteoporosis risk factors. That’s a newsworthy finding, and with the help of a related news release (which the story draws from liberally), the story does convey the basic outlines of what the study found. However, the story fails to dig any deeper to examine questions such as: What would be the benefit of more effective screening — and is inappropriate screening causing harm? Why are the recommendations not being followed? What do other experts in the field think about these findings? And what’s our current approach to screening costing us?
As the story points out, more than 10 million Americans have osteoporosis, which is blamed for more than 2 million fractures per year at a cost exceeding $17 billion. Once identified as being at risk for fracture, a person can take measures to lower that risk.
The study makes no mention of the cost of the screening test or whether it’s typically covered by insurance. That’s what we’d look for here to warrant a bare-minimum Satisfactory grade. We also wonder how much money is being wasted on tests for women who don’t need them, or how much money could be saved by screening more smartly.
The story notes that the US Preventive Services Task Force recommends the screening test for women without other risk factors beginning at age 65. And it provides some statistics to document the possible overuse of scanning in younger women and underuse in older women. That’s all good reporting. But what’s missing is why the reader should care about these numbers. The story does not say that drugs are available that can reduce the risk of fracture among those at high risk. It wouldn’t have take much space or many words to deliver that important context.
We’re also a little concerned about how some of the findings are framed by the story– for example, the fact that certain risk factors “had only a slight effect on a woman’s decision to get her bones tested.” That sounds a little bit like the women are being blamed for the inappropriate testing found in this study. While it is probably true that patient demand drives some inappropriate bone density testing in younger women, the majority of screening decisions are likely to be made by the physician, not the woman.
The story does not mention a potential harm common to all screening tests — the risk of a false-positive result that can lead to more tests and unnecessary treatment. And while the dose they provide is small, DXA tests do involve radiation exposure. The story makes no mention of any possible downside to that exposure.
The original journal article describing this observational study notes that the study has several potential limitations, including unmeasured confounding and possible measurement error (e.g. the researchers may not have identified all women who did in fact receive DXA screening, which would potentially lead to exaggeration of the extent of underuse in older women). The results also came from electronic health records of one medical system, which may not be representative of practices more generally. The story describes how the observational study was carried out, but makes no mention of these possible limitations. Consulting an independent expert may have uncovered some of this context.
The story does not overstate the prevalence or impact of osteoporosis. In fact, it makes no mention at all of how many people it affects or its cost.
The story offers no independent voices to put the findings in context. It makes no mention of funding, though there appear to be no conflicts of interest.
We’ll rate this Not Applicable. The story does not say whether alternatives to the DXA test exist (e.g. ultrasound) or how these methods stack up against each other. But DXA is well established as the evidence-based choice for bone scanning — so we’re not sure it would’ve helped much to get into these other methods.
The story does not say how commonly available the screening test is, but provides the impression that it’s widely used. Since the test has been widely available for many years, we’ll give the story a pass here.
The study notes that, “to our knowledge, the degree of DXA overuse across an entire screening population has not been reported.” But the story does not tell us that.
The story draws liberally from a news release about the study, which is also the source of all of the story’s quotes. Although the story alerts readers to this fact, which is good practice, it doesn’t provide any other evidence of original reporting — so we’ll have to award a Not Satisfactory grade here.