DXA prescription: in Italy, the age of 65 is enough for guidelines, but just a minor criterion for reimbursement law. Which might be the effect on clinical practice?

Andrea Virga, Sonia Zenari, Giulio Rigon, Francesco Del Zotti, Giovanni Merlino

Keywords: DXA, Densitometry, BMD, Osteoporosis, EBM, Healthcare Policy, Audit

Background:

Detecting BMD is necessary to define fracture risk in postmenopausal women and consequently treat the high-risk ones.
Italian SIOMMMS guideline, in line with USPSTF recommendations, states that age ≥65 years is a sufficient criterion for prescribing at least one DXA scan.
In the Italian Law, the “Essential Levels of Assistance” (LEAs) define the specific conditions for a fully reimbursed DXA: age ≥65 years is just a minor criterion among other 30 elements.

Research questions:

Considering the proportion of DXA prescriptions by primary care physicians in all women aged ≥65 years: are GPs following the Italian SIOMMMS Consensus, despite discordant and complex reimbursement criteria?

Method:

Audit process with SQL queries, anonymization of data, and analysis performed by 29 Italian GPs from the “NetAudit” group.
The number of DXA prescriptions recorded in the Electronic Clinical Record was collected among women aged ≥65 years.

Results:

DXA was requested in 3015/6091 (49.5%) women aged ≥65 years.
The GP with the least amount had 6%, the one with the most had 83%.
Median was 52%, Coefficient of Variability was 42%.

Conclusions:

Only half of the women aged 65 years and older had a DXA prescribed following the SIOMMMS Guideline, that agrees with USPSTF guideline.
A poor result, considering a target of at least 70% according to audit standards.
Probably, both the complexity of the LEAs and the fact that the age criterion is minor, thus not sufficient to have the DXA reimbursed, have contributed greatly to the low number of prescriptions.

Points for discussion:

How can GPs decide between a clear single criterion (age ≥ 65) and a complex regulation for reimbursement (LEAs), if they conflict?

How to avoid prescriptive omission with the risk of lawsuits from patients or overprescribing the exam by not following administrative authority?

How to communicate this contradiction to decision makers?

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