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