Dual Energy X-ray Absorptiometry (DXA) Services in Ireland – how do we fare? M O’Connor(Dept of Public Health, Dr Steevens’ Hospital, Dublin 8) S Van Der Kamp (St Vincent’s Hospital, Dublin 4) Introduction: The clinical significance of Osteoporosis (OP) resides in fracture related morbidity & mortality. Measurements of bone mineral density (BMD), via DXA are central to the diagnosis & assessment of OP. The European Commission in 1998 recommended that access to bone densitometry should be universal for people with accepted clinical indicators. 1 Kanis et al in 2003 compared DXA needs of various European countries to their current supply. 2 Figures for Ireland were not available. The aim of this survey was to provide a baseline view of current DXA services in Ireland. Methodology: DXA locations were identified by the personal knowledge & networking of the two investigators. DXA service providers in these locations were invited to complete a pre-piloted telephone questionnaire which covered aspects of DXA scan +/- Osteoporosis service, in late October-early December 2006. Results: Sixty one locations (63 scanners) were identified. Of these, two locations were not in operation as staff had not been assigned. Of the 59 staffed locations, 53 (89%) participated. Responses reflect a range of service provision from solely providing a DXA scan to complete Osteoporosis services which included DXA scans. Table 1 a below shows data on scanner locations and numbers of scanners per population, based on hospital network area. The DXA machine density ranged from 1/46, 000 to 1/122, 000. Given the variability in the number of scans done by each scanner, in table 1 b the approximate annual number of scans at a population level is shown. This ranged from 1, 025/100, 000 to 3, 053/100, 000. Table 1 a: DXA Scanners – locations, numbers – Hospital Network Population Table: 1 b Annual DXA Scans (approx) vs Population (Hospital Network Base) Table 3 Waiting Times for Scans (n=53) HSE Region Available on Request South 8 West 8 Dublin/North East 10 Dublin/Midleinster 8 Waiting Time > 2 weeks 6 3 4 6 HSE Networks Annual DXA Scans Population Scans/100, 000 (Approx) South East* South 4, 720 12, 940 460, 474 620, 525 1, 025 2, 085 West/North West Mid West** 9, 350 4, 690 651, 249 360, 651 1, 436 1, 300 Sources of referral to the scan service were multiple. All but one accepted referrals from GPs. Referrals from OPD were received by 38(71. 8%) while 18 (34%) accepted self referrals but for half of these certain criteria had to be met. Dublin North East 10, 920 4, 100 534, 233 392, 082 2, 044 1, 046 Dublin. East/SW*** SWest/M’land**** 14, 650 8, 360 479, 855 735, 856 3, 053 1, 136 In most services sites scanned routinely included the spine (51, 96%). In 50% of services both hips were scanned. If for particular patients, the hip or spine couldn’t be scanned, 7 (13. 2%) were not able to scan the forearm or equivalent. Of the services providing other than fracture liaison (52), 25 (48%) used lateral vertebral assessment. Total***** 69, 730 4, 234, 925 1, 647 In addition to the DXA scan service, all but two provided educational materials to patients. Two thirds included a formal lifestyle questionnaire and slightly fewer a formal discussion of risk factors as part of the DXA service. The scan report varied from scanner print-out to written interpretation with respect to risk factors & advice on therapy. Excludes 1 estimate from new (mixed) service, plus 2 (private) non responders, ** Excludes 2 non responders, *** Excludes 1 (private) non responder, ****Excludes 1 estimate from new (private) service, plus 1 (private) non responder, ***** Excludes: as above Of the 59 locations, 21 (35. 6%) were in Public Hospitals, while 15 (25. 4%) were in Primary Care Setting. Location in a Public Hospital did not equate with a service free to all users. In addition to the respondents, for five of the six non respondents information was available on charges to patients. Nine (15. 5%) services were free to all users, 13 (22. 4%) were mixed, while 36 (62. 1%) charged all users ( table 2). The service included ranged from DXA scan only to full work-up for Osteoporosis with commencement on appropriate bone health programme. For those where a mixed service was provided the free%: charge% ranged from 10%: 90% to 80%: 20%. Where there were patient charges these ranged from E 20 to E 140. Table 2: DXA scan – Charges to Patient HSERegion Network Scanners/ population South East South 10** 6 1/46, 047 1/103, 420 Free to all West/N West Mid West 8(+1) 5** 9(+1) 6** 1/72, 361 1/60, 108 Mix Dublin North East 11 3 1/48, 566 1/130, 694 Cost to all Dublin. East/SW SWest/M’lands 10(+&)* 6*(+1) 1/47, 985 1/122, 642 Total****** Inclds no info 59 (+2 not in op)(&) 61(+2)(+&new ie not incld as no patients yet seen) 1/69, 425 Dublin/ Mid leinster 2(16. 7%) 1(7. 1%) 4(25. 0%) 2 - 1 - 3 1 3 (18. 75%) 2(16. 7%) 6(42. 8%) 2(12. 5%) 1 1 5 1 11(68. 75%) 8(66. 6%) 7(50. 0%) 10(62. 5%) 7 4 Scanners Dublin/NEast N Dublin North East 2 1 Locations West S East South W/NWest 2 (12. 5%) 1 1 HSE Networks South 5 3 5 2 Written protocols were in place in thirty two locations (60%). Of the remaining 21 settings, sixteen had verbal procedures addressing most of the aspects covered by written procedures in other locations, one had them for self referrals, three were in the process of developing their own written protocols while the remaining one was interested in obtaining protocols from other locations so as to adapt for local use. Conclusion DXAs play a pivotal role in the management at risk of OP and in its diagnosis. Given a prevalence of OP of 1/3 women and 1/5 men over 50 years of age 1, with the associated risk of fractures with their attendant morbidity, mortality and impact on health services as well as quality of life, DXA service provision is a core health service, the delivery of which should be in a planned manner. 6 4 Mid. West Dublin. ESW M’lands/Dub. SW Waiting times(WT) for scan are shown in table 3. Over one third (19) of services had WT longer than two weeks. All but one of these were in public settings. Of these 13 had a system of prioritising referrals. Delays ranged from 4 -52 weeks with a median of 16 weeks. The European Commission in 1998 recommended that access to bone densitometry should be universal for people with accepted clinical indicators 1. By virtue of theses indicators most if not all of these patients are already in contact with health services either at primary care or secondary care level. Kanis et al 2 in their survey reported wide variability in the availability of DXAs in European countries other than Ireland. The survey reported here indicates inequity in terms of geography, waiting time, cost and access to DXAs in Ireland. In addition to accessibility to DXAs to meet the needs of those in known risk groups, the requirements are for a quality DXA services. Respondents identified the need for recognised standardised training for DXA providers & national standards and guidelines for all aspects of the OP service including the DXA scan itself, the referral mechanism, the actual services provided around the scan and the reporting and follow-up structures. References 1 Policy Report 1998 Report on Osteoporosis in European Community Action for Prevention 2 Kanis JA, Johnell O, Requirements for the Management of Osteoporosis in Europe Osteoporosis International (2005) 16: 229 -238
HSE Region Available on Request Waiting Time > 2 weeks South 8 6 West 8 3 Dublin/North Eats 10 4 Dublin/Midleinster 8 6
HSE Region South West Dublin/ North East Dublin/ Mid leinster Free to all users 2 2 1 4 Mix 3 2 6 2 Cost to all users 11 8 7 10
HSE Networks Locations Scanners/population South East South 10** 6 1/46, 047 1/103, 420 West/North West Mid West 8(+1) 5** 9(+1) 6** 1/72, 361 1/60, 108 Dublin North East 11 3 1/48, 566 1/130, 694 Dublin East/SWest/Midlands 10(+&)* 6*(+1) 1/47, 985 1/122, 642 Total ******inclds no info 59 (+2 not in op)(&) 61(+2)(+&new in op ie not included as no patients yet seen 1/69, 425
HSE Networks Annual DXA Scans Population Scans/100, 0 00 (Approx) Caveats South East* 4, 720 460, 474 1, 025 Excludes 1 estimate from new (mixed) service, plus 2 (private) non responders South 12, 940 620, 525 2, 085 West/North West Mid West** 9, 350 4, 690 651, 249 360, 651 1, 436 1, 300 Dublin North East 10, 920 4, 100 534, 233 392, 082 2, 044 1, 046 Dublin. East/SW*** SWest/M’land**** 14, 650 8, 360 479, 855 735, 856 3, 053 1, 136 Excludes 1 (private) non responder Excludes 1 estimate from new (private) service, plus 1 (private) non responder Total***** 69, 730 4, 234, 925 1, 647 Excludes: as above - Excludes 2 non responders
HSE Networks Annual DXA Scans Population Scans/100, 000 (Approx) South East* South 4, 720 12, 940 460, 474 620, 525 1, 025 2, 085 West/North West Mid West** 9, 350 4, 690 651, 249 360, 651 1, 436 1, 300 Dublin North East 10, 920 4, 100 534, 233 392, 082 2, 044 1, 046 Dublin. East/SW*** SWest/M’land**** 14, 650 8, 360 479, 855 735, 856 3, 053 1, 136 Total***** 69, 730 4, 234, 925 1, 647
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