Indiana Decision on Osteoporosis Screening Based on Task Force Recommendations
The U.S. Preventive Services Task Force (USPSTF) recommendations and research conducted at Stanford—among other evidence-based resources on osteoporosis screening—influenced the Indiana State Department of Health to end a free bone density screening program in June 2006. The program had been in existence since 2000.
The State's Office of Women's Health had offered the free tests, which involved ultrasound scans of the heel. Tests had been given to about 51,000 women in Indiana over the six-year period and cost the state approximately $600,000.
In deciding to end the free screening program, State Health Commissioner Judith Monroe, MD, cited concerns that the tests could be inaccurate. Her office reviewed the program and learned that the use of heel ultrasound technology is not as reliable as the dual-energy x-ray absorptiometry; that tests were conducted on any woman 18 years or older who wanted one; and tests were conducted without taking the women's risk factors into account. Risk factors were not considered until the test was finished.
In Monroe's memo explaining the decision to end the free screenings, she stated that "The U.S. Preventive Services Task Force recommends that all women over age 65 be screened for osteoporosis and that routine screening begin at age 60 for women with risk factors... Currently there is no direct evidence that population screening for osteoporosis is effective, and general consensus recommends that screening be individualized."
Furthermore, research conducted at Stanford University's Center for Primary Care and Outcomes Research and other facilities found that heel screening was less accurate than other methods at detecting osteoporosis. Most problems with osteoporosis involve the back, hip, and wrists, and results from heel testing, in most cases, cannot be generalized to other parts of the body.
The likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test, the number of sites tested, the brand of densitometer, and the relevance of the reference range.
In her decision, Monroe cited the concerns that the heel scans could be inaccurate and lead to false positives, in addition to missing the diagnosis and thus giving false assurances. The studies cited showed the scans missed the disease 21 percent of the time and that additional research is needed before use of this test can be recommended in evidence-based screening programs for osteoporosis.
In place of the heel scan screenings, Monroe called for a comprehensive strategy emphasizing education and primary prevention. She recommended that women talk to their physicians to decide whether they should be tested using one of the other methods. A 2003 State survey found only 28 percent of 18- to 24-year-olds and 38 percent of women 75 or older in Indiana have received advice on preventing osteoporosis. Monroe also emphasized the need to ensure children get proper nutrition and enough exercise to build bone mass.
Nayak S, Olkin I, Liu H, et al. Meta-Analysis: Accuracy of quantitative ultrasound for identifying patients with osteoporosis. Annals of Internal Medicine June 2006; 144 (11):832-841. (AHRQ institutional research training grant HS000028)