Trends and Disparities in Osteoporosis Screening Among Women in the United States, 2008-2014

The United States Preventive Services Task Force recommends universal osteoporosis screening among women ages 65+ and targeted screening of younger women, but historically, adherence to these evidence-based recommendations has been suboptimal.

To describe contemporary patterns of osteoporosis screening, we conducted a retrospective analysis using the OptumLabs™ Data Warehouse, a database of de-identified administrative claims, which includes medical and eligibility information for over 100 million Medicare Advantage and commercial enrollees. Study participants included 1,638,454 women ages 50+ with no prior history of osteoporosis diagnosis, osteoporosis drug use, or hip fracture. Osteoporosis screening during the most recent 2-year period of continuous enrollment was assessed via medical claims. Patient sociodemographics, comorbidities, and utilization of other services were also determined using health insurance files.

Overall screening rates were low: 21.1%, 26.5%, and 12.8% among women ages 50-64, 65-79, and 80+ years, respectively. Secular trends differed significantly by age (P <.001). Between 2008 and 2014, utilization among women ages 50-64 years declined 31.4%, changed little among women 65-79, and increased 37.7% among women 80+ years. Even after accounting for socioeconomic status, health status, and health care utilization patterns, non-Hispanic black women were least likely to be screened, whereas non-Hispanic Asian and Hispanic women were most likely to undergo screening. Marked socioeconomic gradients in screening probabilities narrowed substantially over time, decreasing by 44.5%, 71.9%, and 59.7% among women ages 50-64, 65-79 and 80+ years, respectively.

Despite significant changes in utilization of osteoporosis screening among women ages 50-64 and 80+, in line with national recommendations, tremendous deficiencies among women 65+ remain.

The prevalence of osteoporosis—a leading cause of disability and loss of independence among older Americans—increases substantially with age,1 and the medical and economic consequences of osteoporotic fracture can be severe. Half of all postmenopausal women will suffer osteoporotic fracture at some point during their lifetime; 15% will fracture a hip.2, 3 Approximately 10%-20% of hip fracture patients die in the first year following the injury2 and risk of premature mortality may remain elevated for at least 10 years.4 Just 40% of patients experiencing hip fracture regain their baseline level of independence.2

Although common, osteoporosis is preventable and treatable. Once diagnosed, fracture risk can be substantially mitigated with lifestyle modification and an array of US Food and Drug Administration-approved pharmacologic therapies.3, 5, 6 Given substantial evidence of the benefits of available treatments for osteoporosis among women, the United States Preventive Services Task Force (USPSTF) has recommended universal osteoporosis screening among women 65 years and older at 2-year intervals, and targeted screening of women 60-64 years based on individualized risk assessments since 2002.7 In 2011, the USPSTF eliminated the lower age limit to include targeted screening for all younger women with identified risk factors.3 In an effort to address cost barriers, Medicare has covered osteoporosis screening for qualified individuals at 2-year intervals since 1998.8Additionally, preventive care provisions in the Affordable Care Act eliminated cost sharing for the USPSTF-recommended service among privately insured women beginning in September 2010, and for qualified Medicare beneficiaries beginning in January 2011.9

In the first decade following the initiation of Medicare reimbursement for this service, rates of osteoporosis screening remained consistently low. One study of early adoption of bone density testing based on administrative claims data found that fewer than 21% of nearly 36,000 female Medicare beneficiaries ages 65-89 years living in three states, who subsequently experienced hip fractures, had undergone screening during a 2-year window beginning in 1999, 2000, or 2001.10 Another study, based on claims data from a 5% random sample of Medicare beneficiaries nationwide, found that fewer than 10% of women ages 65 years and older underwent screening during any given year from 2002 to 2009.11 Lastly, an analysis of claims from more than 400,000 geographically diverse women ages 65 years and older with employer-sponsored Medicare supplemental coverage showed that just 11%-13% of women were screened in any given year between 2005 and 2008 (38% were screened at least once during this 4-year interval).12 The impact of the recent expansion in coverage for consumers is unknown.

National quality reporting efforts track disparities in self-reported lifetime screening behaviors,13, 14 but few contemporary, population-based estimates of screening disparities based on administrative claims exist. Thus, we sought to evaluate trends in osteoporosis screening from 2008 to 2014 and to identify patient-level characteristics associated with screening among a large, nationwide cohort of privately insured women aged 50 years and older.