Elsevier

Journal of Clinical Densitometry

Volume 15, Issue 2, April–June 2012, Pages 165-175
Journal of Clinical Densitometry

Original Article
Social Determinants of Bone Densitometry Uptake for Osteoporosis Risk in Patients Aged 50 Yr and Older: A Systematic Review

https://doi.org/10.1016/j.jocd.2011.12.005Get rights and content

Abstract

The World Health Organization identifies that osteoporosis is one of the leading health problems in the Western world. An increased risk of fragility fracture is observed in more socially disadvantaged individuals in most Western countries. Dual-energy X-ray absorptiometry (DXA) is currently the procedure of choice to diagnose osteoporosis and assess fracture risk. We systematically reviewed the literature regarding social determinants of DXA utilization for osteoporosis detection in patients aged 50 yr and older using a computer-aided search of MEDLINE, EMBASE, CINAHL, and PsychINFO from January 1994 to December 2010. Five cross-sectional studies, incorporating 16 separate analyses, were identified for inclusion in this review. The best evidence analysis identified limited evidence for a positive association between either income or education with DXA utilization; furthermore, the best evidence analysis found no evidence for an association between either marital status or working status and DXA utilization. Further research is required to identify whether a relationship exists and elucidate reasons for disparities in DXA utilization between different social groups, such as choice and referral processes, as a necessary precursor in identifying modifiable determinants and appropriate strategies to promote preventive screening to identify fracture risk.

Introduction

Osteoporosis is one of the leading health problems in the Western world because of its high prevalence, social and health implications, and financial burden on society 1, 2, 3, 4. Characterized by a progressive loss of bone mass and increased skeletal fragility (5), the high prevalence of osteoporosis means that 1 in 2 women and 1 in 3 men aged 60 yr and older will experience an osteoporotic fracture, resulting in reduced quality of life and increased mortality for elderly patients 6, 7.

Bone densitometry using dual-energy X-ray absorptiometry (DXA) is the reference procedure to diagnose osteoporosis and fracture risk (8). DXA is an essential tool to identify fracture risk, and, used in combination with the country-specific World Health Organization (WHO) fracture risk assessment FRAX model (9) or the FRISK (10) or Garvan nomogram (11) for the Australian context, provides a more accurate indication of fracture risk. Yet, there remains a gap between actual and ideal rates of DXA testing of high-risk individuals 12, 13, 14, 15; a clear concern for public health policy and preventive behaviors.

The association between poorer musculoskeletal health and social disadvantage has recently been documented. Individuals of lower socioeconomic status (SES) have poorer lifestyle behaviors and this has been associated with osteoporosis 16, 17, and increased fracture risk has been observed for those of greater social disadvantage when measured by individual parameters, such as income, education, and occupation (18), and by area-based aggregate scores (19). The largest benefit derived from DXA is for those at greater fracture risk, and therefore, an inverse association between SES and DXA would be expected (20). Paradoxically, individuals of lower SES are reported to be less likely to undertake preventive DXA testing, both before (20) and after fragility fracture (21); a pattern of association, which is also seen with regard to other diagnostic imaging, such as angiography (22), mammography (23), computed tomography (CT), and magnetic resonance imaging (MRI) (24). Lower uptake, or delayed uptake, of preventive strategies by individuals of lower education has been shown in relation to other diseases, including diabetes, hypertension, heart disease, chronic respiratory disease, urological diseases, arthritis, and psychiatric disturbances (25).

Taken in context, the importance of elucidating the relationship between SES and DXA utilization cannot be underestimated. Yet, no systematic review is available that examines the social determinants of DXA uptake. The goals of this systematic review are 3-fold: (1) to describe the study designs, constructs of SES, and analytical methods used; (2) to describe the association between area-based SES or individual parameters of SES in DXA utilization of individuals aged 50 yr and older; and (3) to summarize and discuss available data.

Section snippets

Materials and Methods

This systematic review adheres to the preferred reporting processes outlined within the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement 2009 (26).

Description of the Studies

An overview of the included studies (n = 5) is presented in Table 3. All studies were cross sectional in design 20, 21, 33, 38, 39. Sample sizes ranged from 871 (33) to 107,944 (20). Two of the studies used data linkage techniques 20, 21, whereas 2 used self-report data 38, 39, and 1 used a standardized telephone interview with validation of self-reported DXA use (33). Four of the studies examined only female populations 20, 21, 33, 39, and 1 examined males only (38). Area-based parameters of SES

Discussion

This review identified only a small number of studies investigating the relationship between social determinants and DXA utilization, with only 5 available cross-sectional studies eligible for inclusion. However, within the 5 studies identified for inclusion, there were a total of 16 separate analyses to be examined. The best evidence analysis identified a consistent yet limited level of evidence for the contention that income or education plays a role in DXA utilization; interestingly, these

Acknowledgments

Excluded for blinded peer review.

References (60)

  • E. Seeman

    The dilemma of osteoporosis in men

    Am J Med

    (1995)
  • World Health Organization

    Prevention and management of osteoporosis: report of a WHO scientific group. World Health Organisation Scientific Group on the prevention and management of osteoporosis

    (2007)
  • WHO

    Assessment of fracture risk and its application to screening for postmenopausal osteoporosis

    (1994)
  • IOF

    The burden of brittle bones: epidemiology, costs and burden of osteoporosis in Australia

    (2007)
  • P.N. Sambrook et al.

    Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit

    Med J Aust

    (2002)
  • D. Bliuc et al.

    Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women

    JAMA

    (2009)
  • S. Morin et al.

    Mortality rates after incident non-traumatic fractures in older men and women

    Osteoporos Int

    (2011)
  • J. Kanis et al.

    FRAX trade mark and the assessment of fracture probability in men and women from the UK

    Osteoporos Int

    (2008)
  • M. Henry et al.

    Fracture risk (FRISK) score: Geelong Osteoporosis Study

    Radiology

    (2006)
  • S. Sandhu et al.

    Prognosis of fracture: evaluation of predictive accuracy of the FRAX algorithm and Garvan nomogram

    Osteoporos Int

    (2010)
  • Medicare Services Advisory Committee: an application for increasing the availability for bone mineral densitometry (BMD) testing to at-risk groups by Osteoporosis Australia

    (2006)
  • E.M. Lewiecki et al.

    Osteoporosis care at risk in the United States

    Osteoporos Int

    (2008)
  • J.R. Curtis et al.

    Longitudinal patterns in bone mass measurement among U.S. Medicare beneficiaries

    J Bone Miner Res

    (2007)
  • S. Demeter et al.

    The effect of socioeconomic status on bone density testing in a public health-care system

    Osteoporos Int

    (2007)
  • J.M. Neuner et al.

    Racial and socioeconomic disparities in bone density testing before and after hip fracture

    J Gen Intern Med

    (2007)
  • D. Alter et al.

    Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction

    CMAJ

    (2003)
  • M.M. Finkelstein

    Preventive screening. What factors influence testing?

    Can Fam Physician

    (2002)
  • C. la Vecchia et al.

    Education, prevalence of disease, and frequency of health care utilisation. The 1983 Italian National Health Survey

    J Epidemiol Community Health

    (1987)
  • D. Moher et al.

    Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

    (2009)
  • United Nations Development Programme. 2007 Human development report 2007/2008. Available at:...
  • Cited by (12)

    • A novel photocrosslinked phosphate functionalized Chitosan-Sr<inf>5</inf>(PO<inf>4</inf>)<inf>2</inf>SiO<inf>4</inf> composite hydrogels and in vitro biomineralization, osteogenesis, angiogenesis for bone regeneration application

      2021, Composites Part B: Engineering
      Citation Excerpt :

      As global life span expectancy and the aging population continue to rise, so too will the number of bone-related health problems, such as critical-sized bone defect that will negatively impact the quality of life while increasing associated economic costs within society [1–3].

    • The epidemiology of hip fractures across western Victoria, Australia

      2018, Bone
      Citation Excerpt :

      However, one study of indigenous and non-indigenous individuals residing in Western Australia [43] reported the same result as the current study; those living in non-metropolitan areas had higher rates of hip fractures (175.0; 95% CI 168.1–81.9 per 100,000 person-years for non-indigenous persons) than metropolitan areas (141.7; 95% CI 138.8–144.7 per 100,000 person years for non-indigenous persons). There are a number of risk factors associated with lower SES that impact hip fracture risk including lifestyle factors leading to lower BMD such as poor diet, lower physical activity, higher levels of smoking and alcohol consumption, as well as healthcare factors such as less BMD testing, poor accessibility to healthcare, inadequate built environment and lower uptake of treatment [18,21,44–46]. One study by Byberg et al. [44] reported that diet plays an important role in hip fracture risk.

    • The clinical consequences of an ageing world and preventive strategies

      2013, Best Practice and Research: Clinical Obstetrics and Gynaecology
      Citation Excerpt :

      Despite recent advances in osteoporosis care, additional action is urgently needed to improve the quality of life of people with osteoporosis in general and of elderly people, in particular, as fracture outcomes are typically poorer in older than in younger people.80 Dual-energy X-ray absorptiometry is currently the procedure of choice to diagnose osteoporosis and assess fracture risk.81 Recent evidence suggests that optimal intervals for rescreening to detect osteoporosis in older, postmenopausal women with normal bone density or mild osteopaenia is 15 years, 5 years for those with moderate osteopaenia, and 1 year for women with advanced osteopaenia.82

    View all citing articles on Scopus
    View full text