Background

Recent years have seen a dramatic new focus on an old disease - osteoporosis.  Formerly osteoporosis was seen as an inevitable part of aging, and consequently little effort was expended in its early detection or treatment.  This situation has altered radically.  There have been great advances in our knowledge of the pathophysiology and the risk factors of osteoporosis.  Accurate, non-invasive techniques are available for measuring bone mass and strength, and these have been prospectively validated in large clinical trials as fracture-risk predictors.  New treatments are available for the treatment of osteoporosis which, in large randomized controlled trials, have been proven safe and effective.  In short, there has been a complete philosophical transformation of our approach to osteoporosis.

Not surprisingly, increased attention to osteoporosis as a treatable disease has resulted in substantial increases in utilization of associated medical resources.  It is estimated that currently only a small fraction of patients with osteoporosis are being treated.  The scope of the problem is enormous.  At age 50, a healthy woman has almost a 50% risk of sustaining an osteoporotic fracture during the remainder of her lifetime, and 15% will sustain a hip fracture with significant excess risk of death, institutionalization and loss of independence.  Although traditionally considered a disease of females, males can also sustain osteoporotic fractures and are estimated to have approximately one-half the rate of females.  Each year more than 1,200 Manitobans sustain a hip fracture, virtually all of which are related to osteoporosis.  Even more will develop non-hip osteoporotic fractures.  The financial implications, life-years lost and morbidity from these fractures is enormous.

Program Description

Bone density testing is currently operated as a single program in Manitoba.  This program reports through the Chair of the Department of Radiology, Winnipeg Regional Health Authority, who in turn reports to Manitoba Health.

Responsibilities of the bone density program:

(A) Clinical protocols for bone density measurements.

• Clearly define situations in which bone density measurements are appropriate, inappropriate or unproven.
• Define the optimal timing of initial and/or follow-up measurements.
• Ensure that bone density of protocols are integrated into clinical management guidelines.

(B) Needs assessment for bone density services in Manitoba.

• Determine the bone density needs based upon the clinical protocols and demographics of the province of Manitoba (to be updated to reflect new medical evidence and/or changes to the population of Manitoba).
• Determine the optimal way of providing the services identified by the needs assessment.
• Ensure a consistent approach to bone density measurement by overseeing the selection and distribution of bone density equipment in Manitoba.

(C) Assessment of current and emerging bone density technologies.

• Develop guidelines for technologist training to ensure safe and effective operation of bone density equipment.
• Develop criteria for physician training to ensure accurate interpretation of bone density measurements.
• Establish a quality assurance program to be followed by each bone density facility.
• Assess new bone measurement technologies and incorporate these into clinical protocols when judged to be appropriate.

(D) Monitor the bone density program.

• Track utilization of bone density testing as well as clinical indications and patient demographics.
• Assess the impact of the bone density on patient management and outcome.
• Ensure that the operation of bone density units contributes to research and other academic activities that benefit the residents of the province of Manitoba.
• Act as an educational resource for the public, for specialist and nonspecialist medical practitioners, and for other allied health personnel.

Guidelines for Testing

Specific criteria have been identified which allow targeted testing to be performed. These are as follows:

• Vertebral low-trauma (fragility) fracture proven by x-ray (Note: Bone density testing is not required for diagnosis of osteoporosis as active treatment is usually indicated.)
• Non-vertebral fragility fracture proven by x-ray
• Osteopenia or osteoporosis identified on x-ray
• Systemic corticosteroid therapy for more than 3 months per year
• Prolonged amenorrhea prior to age 45 (includes surgical menopause or premature menopause) if results needed to decide on hormonal or drug therapy
• Woman age 65 or older if results needed to decide on hormonal or drug therapy.
• Follow up of a previous bone density measurement (initial recommended interval 3 years for most patients, 1 year in patient on systemic corticosteroid therapy)

Other indications may be considered if appropriate clinical justification is provided. (Testing in men, and in women younger than age 65, are not approved indications unless there are additional risk factors.  The "Fracture INDEX Self-Assessment Aid" printed on the reverse side of the test requisition may be helpful in selecting people for testing.)

• Requisition for Bone Mineral Density Testing  52Kb