Journal of Clinical TJensilomf'try: As.sessmml & Management of M1u1:11loskelelal Health. vol. a, no. a, 1-14, 2016 ~) Copyrig.hl 2016 hy The fntcrn:iliunal So..:icly for C:lini,;al fknsilornclry t094-69so1a :1-141S36.00 hltp://dx.doi.org/10. t016/j.jocd.2016.03.003

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Best Practices for Dual-Energy X-ray Absorptiometry Measurement an.d Reporting: International Society for Clinical Densitometry Guidance

E. Michael Lewiecki, *' 1 Neil Binkley, 2 Sarah L. Morgan/ Christopher R. Shuhart, 4 Bruno Muzzi Camargos, 5 John J. Carey, 6 Catherine M. Gordon, 7 Lawrence G. Jankowski, 8 Joon-Kio11g Lee, 9 and William D. Leslie1° on behalfof the International Society for Clinical Densitometry 'New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA; 20steoporosis Clinical Center and Research Program, University ofWisconsin., Madison, WI, USA; 3Division of Clinical Immunology and Rheumatology, Department ofMedicine, UAB Osteoporosis Prevention and Treatment Clinic, University ofAlabama at Birmingham, Birmingham, AL, USA;"Swedish Medical Group, Seattle, WA, USA;sRede Mater Dei de Sau.de - Densimater, Belo Horizome, Braz.i~· 6Galway University Hospitals, National University of Ireland, Galway, Ireland; 7Cmcinnati Children's Hospital Medical Center, University ofCincinnati College of Medicine, Cincinnati, 0 H, USA; 8/llinois Bone and Join/ Institute, LLC, Morton Grove, IL, USA; 9JK Lee Orthopaedics & Traumatology, Petaling Jayo, Malaysia; and 10University of Manitoba, Winnipeg, Manitoba, Canada

Abstract

Dual-energy X-ray absorptiometry (DXA) is a technology that is widely used to diagnose osteoporosis, assess fraclure risk, and monitor changes in bone mineral density (BMD). The clinical utility of DXA is highly dependent on the quality of the scan acquisition, analysis, and interpretation. Clinicians are best equipped to manage patients when BtviD measurements are correct and interpretation follows well-established stan­ dards. Poor-quality acquisition, analysis, or interpretation of DX/\ data may mislead referring clinicians, re• suiting in unnecessary diagnostic evaluations, failure to evaluate when needed, inappropriate treatment, or failure to provide medical treatment, with potentially ineffective, harmful, or costly consequences. Misallo­ cation of limited healthcare resources and poor treatment decisions can be minimized, and patient care op­ timi1.ed, through meticulous attention to DXA instrument calihration, data acqui,;ition and analysiR,interpretation, and reporting. This document from the International Society for Clinical Densitometry describes quality stan­ dards for BMD testing at DXA facilities worldwide to provide guidance for DXA supervisors, technologists, interpreters, and clinicians. High-quality DXA testing is necessary for correct diagnostic classification and optimal fracture risk assessment, and is essential for BMD monitoring.

Received 03/7/16; Accepted 03/8/16. Disclosure: EML has served on scientific advisory boards for Amgen, Merck, 'Eli Lilly, Radius Health, AgNovos Healthcare, Alexion, Shire, and AbbVie-. NB has served on scientific advisory boards for Amgen, Merck, and Eli Lllly. CRS serves on scientific and com­ mercial advisory boards for Amgen. WDL has received speaker fees from Amgen, Eli Lily, and Novartis. BMC has ·received speaker fees from GE, Hologic, Ache, E.MS. Hypermarcas and Medimaps. EML has received institutional grant/research support from Amgen. Merck, and F.li Tilly. NB has received institutional grant/research support from Amgen, Merck, F.li T.illy, and GR Healthcare.WDT. received research granls from Amgen (all paid to the institution). JJC was served oo scientific advisory boards for MSD, Abbvie,Amgen, Prcoter & Gamhle, Hospira,Servier, Pfizer, Bristol Myers Squihh, and Roche, and received speaker fee.s from MSD, Roche, Ahhvie, Eli-Lilly, Bristol Myers Squibb. Hospira, and Pfizer. Research Grants: Abbvie, MSD. P&G, and Centocor. ~ Address correspondence to: E. Michael r .ewiecki, MD, New Mexico Clinical Research & Osteoporo~s Center, 300 Oak St. NF., Alhuquerque, NM 87106. F.-mail: mlcwiccki@.>gmail.com

1 2 Lewiecki et al.

Key Words: Accreditation; certification; DXA; osteoporosis; quality.

Introduction stale and local regulalions du not rc::q ufre any specific quali­ ncations for DXA interpretation (25), despite the impor­ Dual-energy X-ray absorptiometty (DXA) is a quanti­ tant technical aspects of the test discussed here. US Medicare tative radiological procedure for meai:uring hone mineral regulations only require some qualifications of supervi,;­ density (UMD). a major determinant of bone strength (l ). ing physicians in independent diagnostic testing faci lities DXA mtasuremc::nts am used lo diagnose osteoporosis (2), (26), but nol in hospital facilities ur privale clinical prac­ monitor changes inBMD over lime (3),and estimate frac­ tices. In Canada, 3 provinces currently have a requirement ture risk, (4) and, as such, are often integral to therapeutic for International Society for Clinical Densitometry (JSCD) intervention recommendations. Indeed. BMD hy DXA is certification for physicians who are reporting or supervis­ a component of osteoporosis treatment guidelines in the· ing a DX/\ facility. rn Brazil, ccrtificalion by the Brazilian United Stales (5,6) , Canada (7),Europe (8), Unil~ Kingdom Radiology Society (Colegio Brasileiro hip structural analysis (14), and trabecu­ requiremenlS for training, perforroing,and interpretingDXA lar bone score determination (15). Physicians rely on DXA scans by healthcare professionals are variable. measurements to manage patient,; with skeletal disorders. The generation of high-quality DXA reports requires Poor-quality DX/\ acquisition/analysis and/or incorrect re­ an understanding of potential sources of errors, including porling uf lhe results may result in tl1e or

.Touma! of Clinical Densitometry: Assessment & Management of Mu.sculoskeleral Health Volume a, 2016 DXA Best Practices 3

Box. DXA Best Practices Scan Acquisition and Analysis 1.1. At least one practicing DXA technologist, and preferably all, has a valid certification in bone densitometry. 1.2. Each DXA technologist has access to the manufacturer's manual of technical standards and applies these stan- dards for BMD measurement. 1.3. Each DXA facility has detailed standard operating procedures for DXA performance that are update

Interpretation and Reporting 2.1. At least 1 practicing DXA interpreter, and preferably all, has a valid certification in bone densitometry. 2.2. The DXA manufacturer and model are noted on the report. 2.3. TheDXA report includes a statement regarding scan factors that may adversely affect acquisition/analysis quality and artifacts/confounders, if present. 2.4. The DXA report identifies the skeletal site, region of interest, and body side for each technically valid BMD measurement. 2.5. There is a single diagnosis reported for each patient, not a different diagnosis for each skeletal site measured. 2.6. A fracture risk assessment tool is used appropriately. 2.7. When reporting differences in BMD with serial measurements. only those changes that meet or exceed the l.SC are reported as a change. B:MD, boni:: mini::ral density; DXA, dual-energy X-ray absorpLiomelry; LSC, leasl significant changi::.

health outcomes. These DXA Best Practices are intended hnplementation of DXA Best Praciices to serve as a guide and expectation for DXA supervisors, technologists, interpreters, and clinicians. Following these The ISCD recommends that DXA facilities establish DXA Bc~t Practices aids patients, referring healthcare pro­ standard operating procedures (SOPs) as a guide for ad· viders, and payers by facililaling n~cognition of high­ herence to DXA Best Practices. For others (e.g., patients, quality DXA services. DXA Best Practices are applicable referring physicians, and payers) interested in assessing com­ worldwide for adult and pediatric DXA testing, recogniz­ pe ten{.;y of I.hose responsible for bone

Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume • , 2016 4 Lewiecki et al.

rigorous review of lhe best medical evidence by Failure to follow standard procedures may result in internationally recogni1.ed experts in sk eletal health invalid data, which can he misleading and potentially assessment, often in collaboration with other stakeholder harmful for patient care (76.17,19,37,38). Examples of DXA organizations. Evaluation of the evidence when develop­ errors abound. These include incorrecL pal.ienl posiliu.n­ ing Official Positions is conducted using a modification of ing and/or analysis, failure to consider confounding arti­ the RA.ND Corporation and U1tiversity of California at facts Lhat affect BMD values, and inappropriate reference 1.os Angeles method (RAM) (35). This method has heen datahase use for T-seore derivation. Additional errors used worldwide to determine whether medical proce­ include failure to recognize densitometer drift or shift that dures are expecled to provicfo a specific health benefit could lead Lo reporting an inappropriaLc BMD change, lhus that exceeds the potential negative consequences by such. leading to alteration of therapy, failure to change therapy, a wide margin that the procedure or indication is worth and/or unnecessary diagnostic studies. Another common doing. The rationale for use of the RAM in the develop­ error is failure to perform precision asliessment, rei.ulting mcn t of the TSCD Official Positions is based on its ability in inability to distinguish between an apparent BMD dif­ lo tX)mbine the best available scienl.ific eviden(;(:! with Lht: Jt:re::nce that is simply within the range:: of etror of the lt:st collective judgment of the expert panel consisting of a vs one that is statistically significant. broad range of professionals within and outside of the DXA certi.fication provides evidence that a basic body ISCD. of knowledge bas heen acquired. A "valid" certification ii; one that is currently active (i.e., not expired). Certifica­ tion shoult.l be:: maint.aine

Journal of Clinical Densitometry: Asses.rmenl & Management u/ Musluloslceletal Hen/th Volume a, :W16 D XA Best Practices 5

of a nonstandard phantom (41), failure to recognize and mittees; the scrutiny of clinical and research protocols is correct changes in instrument calibration (17), and non­ often stricter than that for adults. standard patient positioning (42). Three concepts related to DXA scanning should be con­ sidered in protecting lhe public an

Journnl of" Clinical Densitometry: Assessment & Management of Musculoskeletal Health Volume a, 2016 6 Lewiecki et al

delineates the upper and lower limits (47,49). U tbe phantom average LSC of all technologists be used (24). If a DXA value falls o ut<:ide the upper or lower control limit, the facility has not performed precision assessment, then quan­ phantom should be rescanned. Tf the rescan value also falls titative comparison of serial BMD measurements is not outside oJ acceptable ranges, them putienl scanning should p ossible. be postponed until machine service occurs. The Shewhart plots should be reviewed regularly to assure that there is The LSC for Eacli DXA Tecl,nologist Should Not no sborl-term shift or long-term drift in RMD values. Fol­ Exceed 5.3%/or the Lumbar Spi11e, 5.0%/or the lowins routine preventive or oth er scanner maintenance, Total Hip, and 6.9% for the Femoral Neck th e:: phan1om should be scan nc::cJ 10 lim c::s wilhout repositioning between scans. If the mean BMD of these 10 Rationale. BMD precision error values acceptable for scans differs from the mean of prior daily phantom scans clinical practice were determined by a meta-analysis of pub­ by more than the estahlished limit<;, then the roachioe,c;hould lished B MD precision studies (55). In the studies compris­ be recalibrated and a new mean of 10 further scans is es­ ing this meta-analysis, precision values were reported as tablished (47,49). D epending on the DXA manufacturer, percent coefficient of variation (%CV) rather than abso­ the Shewhart plot may be automatically generated or may lute SD values in gram per square centimeter, the latter need to be created manually. Facilities may wish to invoke of which is recommended in clinical practice (56). more rigorous phantom scanning protocols (i.e., daily Comments:Tecbnologisc precision and quantitative BMD phantom scannins and tishtcr phantom limits), as many fa­ comparisons in clinical pr~ctice should use the LSC ex­ cilities have:: long-term CVs <0.5%. pressed as an absolute value in gram per square centime­ ter (53). This is preferable to using %CV as it is less affected by the baseline BMD value; as an example, the same ab­ Each IJX'A Technologist Has Performed In Vivo solute change in BMD with a very low baseline BMD would Precision Assessment According to Standard represent a greater 111::rcentagc change comparnn with a Methods a11d the Facility Least Significant Cha,ige higher baseline BMD. DXA precision calculators that are (LSC) Has Been Calculated available online (54) can be set to express precision as either Rationale. All quantitative tests in medicine have in­ gram per square centimeter or %CV. As such, it is pos­ herent uncertainty. With DXA RMD measurement, the sible to determine whether the technologists are meeting main sources of variability arc patient factors, the tech­ the preci,c;ion standards. If a technologist ba,; exceeded the.,;e nologist, an

JourMl of Clinical Densitometry: Assessment & Murwgement of MusculoskeletuJ, Health Volume II, 2016 DXA Best Practices 7

recommendations are continually evolving. Examples of The DXA Report Includes a Statement Regarding conumm mistakes (16,17,JY,37,38) that could result in an Sca11 Factors That May Adversely Affect incorrect interpretation of DXA include the following: A cquisitionlAnalysis Quality and Artifacts/ failure tu rei;ognize the presence of an arlifai;L that invali­ dates BMD measurement, use of an invalid skeletal site for Co,,jounden, ifPrese,it diagnostic classification, reporting a different diagnosis and Ralionale. DXA results depend greally on lhe skills of fracture risk for each skeletal site and region of interest the technologist to properly position the patient and sub­ (ROT) measured, reporting T-seorcs when Z-scorcs should sequently analyze the data for interpretation and report· be used, using an incorn:i;l reference bone age, lo ensure that the Z-score fied as internal (intrinsic to the patient when disrobed) or is not confounded by delayed skeletal growth and/or matu­ external {ahle to be removed). . ration (36). Comments. Acquisition and analysis errors may require DXA certification provides evidence that a basic hody repeat analysis, repeat scanning, or having the patient of knowledge has been acquired. A "valid" certification is relum for scan of an additional likeletal site. Important one that is currenlly ai;Live (i.e., not e.xpire

Joumal of Clinical Den.~itometry: A.~sessment & Management of Musculoskeletal Health Volume•, 2016 8 Lewiecki et al.

healthcare providers Lo document that the same skeletal female normative database to derive T·scores for women sites were used to monitor RMD change over time. and men of all ethnic groups (24). This convention should Comment An important component of DXA interpre­ be used in reporting DX/\ scans; however, application of tation involves scrutinizing the skeletal images Lo assess this rewmmendation may vary according to loc.;al require­ patient positioning, correctness of edge detection, poten­ men ts (24). Manufacturers are advised to use National tially confounding artifacts, and placement of margins to Health and Nutrition Examination Survey III young­ delineate ROis (49). If scanning of any skeletal site is not adult Caucasian female RMD data as the reference Rtan­ technically valid, the values for that site should not be re­ dard for femoral neck and total proximal femur T-scorc pone15 yr), with total proximal femur being pre­ Rationale. In some locations, the therapeutic interven­ ferred. However, in children and young adole.~cents, the hip tion tbre.,;hold (i.e., the cul-point at which pharmacoJogic should generally be excluded as a skeletal assessment site, therapy is recommended) historically was based on the BMD as posiLioning in this age group is c.;ballenging and skel­ T-score alone. However, the majority of "osleoporosis­ etal landmarks that guide consistent positioning are not well related" fractures occur in individuals with low bone mass developed. For forearm DXA measurements, use of the (osteopenia) or normal BMD (62,6}). To improve target­ 33% radius (one-third radius) of the nondominant forearm ing of intervention,c; to those most likely to s ustain frac­ is recommended for diagnosis; other forearm ROTs arc not tures, various fracture risk assessment tools have been rcwmmendcbone health. The whole body many country-specific versions. FR.AX utilizes clirucal risk scan a)lio provides a measurement of hody composition, factors with or without femoral neck BMD to estimate the which may be hcipful in ii,l; ongoing evaluation of youth 1 Q..yr risk for major osteoporosis-related fractures (clini­ with chronic diseases. cal spine, forearm, hip, or shouhlt:r) and for hip fra~tUrt! alone. Other calculators exist; for example, the Garvan cal­ There Is a Single Diagnosis Reported for Each culator allows inclusion of the number of prior fractures and falls (M). In some regions of the world, therapeutic in­ Patien~. Nol a Different Diagnosis fnr Each tervention thresholds arc linked to fracture risk estimates. Skeletal Site Measured Like all tools, il is imporlanl lo use these calculators as in­ Rationale. The densitometrjc diagnosis of osteoporosis tended; for example, FRAX is intended to assess fracture in clinicaJ practice is made by applying the WHO criteria risk and to assist in treatment decisions in individuals between (2) to each approprjate patient using a limited number of the ages of 40 and 90 yr. Additionally, it is important to rec­ skeletal sites {24). This allows for a consistent diagnostic ognize when to check "yes" in the r-R/\X calculator for a classilkalion for application lo Lrealment gw

Journol of Cliniwl Densitometry: Assessment & Management of Musculoske/etal Health Volume • , 2016 c5' i:::, l ~ ~ Table 1 0:, [ Examples of Resources for DXA Training and Certification/ Accreditation ~.... ~ i Organization Description Weblinl- I:) t, ("') (1: :::t, a American Bone Health Limited permit X-ray technician https'i/americanbonehealth.org/timited-permit-x-ray-techniciao-school ("') §' -bone-densitometry · ~ 3i American College of Practice parameter for the performance of http://www.acr.org/-/media/e b34da2f786d4f8e96a70b7 5ee035992, pdf ~ Radiology ~ DXA :t,.. American Registry of Ttaining and certification for technologists https://www.arrt.org/pdfs/DiscipllnesiHandbool::s/BD-Handbook .pdf ~ Radiologic Technologists https://www.atrt.org/pdfs/disciplines/clinical-experience/bd-clin.ical "'~ -experience. pd( :! American Society of 'Jtaining and certification for technologists http://www.asrt.org/students/study-guides/bone-c1ensitometry "' i! Radiologic Technologists https:/lwww.asrt.org/docs/default-&ource/educators/ Ro, bonedensitometrycurriculum.pdf ~ http://www.asrt.org/events-and-conferences/event-calendar ;:::i Auntminnie.com Bone densitometry course for http://www.auntminnie.com/(F(AiaAhFY):'F2NipZ technologists -LQYAK9zBSaE53uNbrdw8TMEotZJ4C_aaBzpJsKf51OZTxmu NjXb9031JaUqAs9rhc5QxVyVpLx:TkY0MGovcJoYp 1 Yo Y40DAE80cW6rOWGxQOr8qjHkOA557w2) )/ ~ illdeK.aspx?sec=lin&sub.. def&erd:a83 ~ CAR CAR Bone Mineral Densitometry http://www.car.ca/en/accreditatioo/bmd.aspx 1;; g_ Accreditation Program DEXA Solutions Link to training and certification h ttp://www.dexasolutions.com/Resources/Certification.aspx ~ [ GE Healthcare (Lunar) O:XA training http://www3.gehealthcare.com/en/education/prodnct_education_- _technical/Iunar_bone_densilometry i Tlologic DXA training http://www.h otogic.com/ttainin g/dxa-101 ~basics-bone-densitometry Swissray (Norland) DXA training bttp://www.swi~sray.com/product.php?ac:tion=view&cid=l6 International Society for Training courses for DXA certification for http-J/www.iscd.or'l)education/cmece-live•courses/o5teoporosis-essentials/ i Clinical Densitometry clinicians and technologists, facility http://www.iscd.org/certification/ accreditation http://www.iscd.org/accredita lion/ Medical Technology Bone densitometry training course http://www.mtmi.net/courses/reg_BD.php Management Institute OAR Accredited Densitometry Technologist https://cme.oarinfo.ca/cme/uploadedf2015-CBMD-Tech-ADT-2016 CME -brochure.pd{ OAR OAR Canadian Bone .Mineral http://cbmd.ca/ . Densitometry Facility Accreditation Study.com Bone density technicilm training and http://study.com/article-s/Bone_Density_Technician_Training_and_Degree degree program options _Frogram_Options.html

~ Nore: This is not an all-inchisive list. O ther organizations in othc.r countries may have uullent re5ources as well Inclusion of programs in this table does not represent an endorsement of the ISCD; the quality of training in preparation fot certification and/or accreditation may vary. [ Abbr: DXA, dual-energy X-ray absorptiom.etey; CAR, Canadian Association of Radiologists; CME, continuing medical education; OAR, Ootario Assoc1atiou of Radiologists. "'

t,,j ~·0.~ \0 10 [,ewiecki et al.

Tablc2 Examples of Helpful Books on Bone Densitometry

Bonnick SL, Lewis LA. Bone Densitometry forTechnologists,Springer, New York, NY. 2012. Genanl KH. Bone Deosilometry and Osteoporosis, Springer, New York, NY. 2011. Guglielmi G (ed.). Osteoporosis and Bone D ensitometry Measurements (Medical Radiology), Springer-Verlag Berlin Heidelberg. 2013. Hamdy RC, T.ewiecki F.M. Osteoporosis, Oxford University Press, New York, NY. 2013. Licata AA, Williams SE. A DXA Primer for the T'raclicing C linician: a Case-Base Manual for Understanding and Interpreting Bone Densitomt!Lry, Springer, Nt!W York, NY. 2013. Sawyer AJ, Bachrach LK, Fung E. Bone Densitometry in Growing Patients: Guidelines for Clinical Practice, Humana Press, Totowa, NJ. 2007. Saag KG.Morgan SL, Clines GA. Diagnosis and Management of Osteoporosis, Professional Communications Inc, West Islip, NY. 2013. TheAmeri1;an Sodely for Bone and Mineral Research, Primer on Lhe Metabolic Bone Diseases and Disorders o( MineraJ Metabolism , 8th ed, John Wiley & Sons, Ames, IA. 2013. Dual energy X ray absorptiometry for bone mineral density and body composition assessment. IAEA Human Health Series. No.15. Vienna: International Atomic Energy Agency. 2010. Body Composition assessment from birth to two years of age. TATIA Human Health Series. No, 22. Vienna: International Atomic Energy Agency. 2013. Note: This li sting of examples is not· exhaustive and is only representative; this does not indicate an endorsement of the JSCD.

fracture risk calculators are a substantial step forward, they proximal femur, and femoral neck), the LSC values shoilld are not without limitations. For example, the FR.AX cal­ he applied to serial scans. The T.SC should he calculated culator requires dichotomous (i.e., yes or no) answers for for other ROis (e.g., L2-lA, L3-lA, 33% radius, and total risk factors, which are actually associated with a range of radius) if serial comparison for any of these is desired. risks depending on modifying factors sucb as dose, length The lSCD Official Positions include operational details of cxposur~, or severity. Additionally, as the number of prior on LSC calculation and reporling (24)). For comparison, osteoporosis-related fractures increases or the dose of glu­ lhe currenl RMD measurement is subtracted from the cocorticoids rises, the risk of future fractures increases, yet prior scan and the absolute difference is assessed. If the these considerations are not included in Lhe FRAX algo­ difference is less than the LSC, this is simply measure­ rithm. In cb.ildren, the correlation beLween HMD and frac­ ment variance and should not be identified as a change. ture risk is not well established; a FRAX algorithm for the Simply put, a "change" that is not statistically signiticant pediatric population doe.<; not yet exist. is oo change and should he reported as such. When tb.e difference between scans is greater than the facility LSC, When Reporting Dijfere11ces in BMD With Serial this change should be reported as an increase or decrease Measurements, Only Those L'hanges That Meet or inBMD. Exceed the LSC Are Reported as a Change Resources to Support DXA Quality Rationale. To deteonine when a difference in UXA mea­ sured BMD reflects a true biological change vs a simple Resources for education in bone densitometry and the measurement variability, each facility needs to calculate its conditions evaluated with DXt\ technology include scicn­ individual LS<.:. Brit:ily, Lhis is acwmpJished by m~asur­ lilk journals (e.g.,Journai of Clinical Densitometry, Joumal ing a patient Lwice on the same day using the same instru­ of Bone and Mineral Research, Osteoporosis Interna­ ment with the scans being performed by the same tional, Bone, Calcified Tissue lntemational, and Journal of technologist. When 30 patients (60 scans) have been ob­ Clinical R11dncrinolo,:y and Metaholi,ftn), instructional tained, the LSC can be calculated using the root mean courses (Table 1), and books (Table 2). A glossary of DXA square siandard deviation approach. The LSC.: can aJso be terminology and common acronyms is provided in Table 3. calculated using 3 scans obtained on 15 patients. The ISCD The ISCD has a selection of instructional courses devoted and others have developed online calculators to facilitate to various uses of DXA (e.g., vertebral fracture recogni­ this process (54). Although calculation of LSC by this tion, pediatric DXA, and body composition testing) and col­ method may underestimate Jong-term measurement v_ari­ laborates with the International Osteoporosis Foundation ability (65,66), it is a widely used pragmatic approach to lo regularly update a course {Ostt:oporosis .Essentials) in patient care. bone densitometry and osteoporosis treatment. Comment. Once a center has determined LSC values Certification is a procedure by which a third party gives for the clinically relevant sites (usually Ll-U spine, total written assurance that a product, process, or service lourtwl of Clinical Densitom1Ury: Assessrmm.! & Management of J,of1.1sr:uloskelelul Ilea/th Volume • , 2016 0 •

DXA Best Practices ll

Table3 Glossary

Terminology

Acquisition. The process of positioning and scanning the patient on the DX/\ table. Aca-editalion of a certification program. Declaralion by a neutral lhir

ANSI. American National Standards Institute ARRT. American Registry of Radiologic Technologists ASRT. American Sode Ly of Radiologic Technologists BMD. Bone mineral density DXA. Dual-energy X-ray absorptiometry FR.AX. WHO fracture risk assessment tool ISCD. International Society for Clinical Densitometry ISO. International Organization fur Standardizalion LSC. Least significant change NCCA. National Commission for Certifying Agencies NHANES. National Health and Nutrition Examination Survey ROI. Region of interest SOPs. Standard operating procedures Sv. Sievert WHO. World Health Organization

Joumal of Clinical Densitometry: Assessment & Management of M~culoskeletal Health Volume • , 2016 12 Lewiecki et al.

conforms to specified requirements. Certification io. bone 7. Papaioannou A, Murin S. Cbc::ungAM. c::l al. 2010 2010 Clini­ densitometry is provided hy organizations such as the cal practice guidelines for the diagnosis and management of American Registry of Radiologic Technologists (for radio­ oslc::oporosis in Canada: summary. CMAJ 182:1864-1873. 8. Kanis JA. McCloskey EV, Johansson H, el al. 2013 logical technologists) anJ!rnge.s in osteororosi.~ evaluation. JAMA Intern Med 1. Bouxsein ML. Seeman E. 2009 Quantifying tJ1e material and 176:393-395. structural detcrminan1s of hone s1rengi.h. Besl Pracl Res Oin 21. Fenton .JJ, Rohhins JA, A01arnal11 AT., Franks P. 20Hi Os­ Rhcumatol 23:741-75:3. teoporosis overtreatment in a regional health care system. 2. Kanis JA. 1994 Assessment of fracture risk and its applica­ JAMA Intern Med 176:391-393. tion lo screening (or po:;Lmenopaus,11 osteoporosis: synopsis 22. Gafui RI. Baron J. 2004 Overcliagnosis of osteoporosis in of a WHO report. Wl-IO S1udy Group. Usteoporo:; Int4:368- childrr.n due to misinterpret al ion of dual-energy X-ray 381. absorptiomdry (DBXA). J Pc::cJiatr 144:253-257. 3. Miller PO, Bonnick SL, Rosen CJ. 1996 Consensus of an 23. Bonnick SL, Lewis LA. 2013 Bone Densitometry for Tech­ illtcmalional panel on Lhc dinii.:al utilily o( bunt: mass mea­ nologists. New York, I .uodon: Springer. surements in Lhe detection of low bone mass in the adull popu­ 24. Shepherd JA, Schousboe JT, Broy SB, et al. 2015 Executive lation. Culcif Tissu~ Tnt 58:207-214. summary o! Lhc 2015 ISCD position development 4. Marshall D , Johnell 0, Wedel H . l996 Meta-analysis of how conference on advanced measures from DXA and QCT: frac­ well measures of bone mineral density predict occurrence of tu re prediction beyond BMD. J Clin Densitom 18:274- ostcoporoUc fractures. BMJ 312:1254-1259. 286. 5. Cosman P',dc 13cur SJ, Lclloff MS,cl al. 2014 Clinician's guide 25. MulliStalc Associates Incorporated. Semi-weekly reports to to prevention and Lreaunenl of osteoporosis. Osteoporos lnt the lntcmalional Society for Clinica.l Densitometry on state 25:2359-2381. legislative and regulatory activity relating to DX/\ or bone 6. Grossman JM, Gordon R, Ranganath VK et al. 2010 Amcri- density studies. 2006-2015; Data on file. 1.an College of Rhrumatolo{!y 2010 recommendations for the 26. Centers for Medicare & Medicare Services. 20'11 Code or prevention and treatmen1 of glucocorticoid-induced ostou­ Federal Register. Billing and Enrollment Guideline for PHYS- porosis. Arlhritis Care Res (Hoboken) 62:1515-1526 . 078 Independent Diagnostic Tes1ing l•ac1llties (IDTF).

.foumal of Clinical Densitometry: Assessment & Management of Musculoskelctal Health Volume • . 2016 .. DXA Best Practices 13

Available at: hllps://downloads.crns.gov/medkare-coveragc­ 43. D onnelly Ll', Dickerson J~ Goudfrit:nd MA, Muel.l1ing SB. da labase/lcd_attachments/23448_6/CBGPHYSMED078 2009 lmprovi:ng patient safety: effects of a safety program on April09.psorptiomctry. J Clin Densitom 7:27-36. chilJoint official posi­ Ostl:oporos Int 7:338-343. tions of I.he tmernalional Soddy for Clinical Densilomclry 51. Bonnick SL. 2010 Bone Densilomelry in CHnical Praclicc:: and Inlemational Osteoporosis Foundation on FRAX((R)) Application and Interprecatioo. New York, NY: Humana. execulive summary of l11c:: 2010 Position Development 52. Bt:nnetl HS, Dienslt:rey A, Hudson LT. el al. 2006 Stan­ Conference on Interpretation and Use of FRAX((R)) in Clio.i­ dards and measurements for assessing bone health-workshop cal Pradice. J Clin Densilum 14:171-180. report co-sponsored by lhe Inl crnational Socit:Ly for Cllni­ 33. Schousboe JT, Shepherd .TA, Bilezikian JP, Baim S. 2013 caJ Densitometry (ISCD) and the National Institute of Stan­ Executive summary of the 2013 International Society for Oini­ dards and Technology (NIST). J Clin Densitom 'J:399--405. cal Densitometry Position Development Conference on Bone 53. Lenchik L, IGebz.ak GM, Blunt BA, International Society for Densitometry. J Clin Densitom 16:455-466. Clinical Densi tometry, Position D evelopment Panel, Scien­ 34. Crabtree NJ, Arabi A, Bachrach LK, et al. 20l4 T>ual­ tific Advisory Committee. 2002 What is the role of serial bone encrgy X-ray absorptiomctry interpretation and reporting in mineral density measurements in patient management'! I Clio children and adolescents: the revised 20J3 ISCD pediatric of­ Densitum 5(Suppl):S29-S38. fi<.ial positions. J Clin Densitom 17:225-242. 54. Tntcrnational Society for Clinical Densitometry. 2015 TSCD 35. Filch K, Bernstein SJ. Aguilar B, e< al. 2001 The RAND/ Calculator.t Available at: http://www.igcd.org/resou:rces/ UCLA Appropriateness Method User's Manual. Sant~ calcul ators/. Accessed March LS, 2016. Monica, California: 11,e RAND Corporation. 55. S11epherd JA, Lu Y, Wilson K, ct al. 2006 Cross-calibration 36. Gordon CM, T.eonard MR, Zemel HS, International .Society and minimum precision standards for dual-energy X-ray for Oinieal Densitometry. 2014 2013 Pediatric po~ition de· absorp!iometry: Lh.e 2005 ISCD of!icial positions. J Clin vclopmcnt conference: executive summary and reflections. J Dcnsitom 9::11-:!6. Clio Dcusitom 17:219-224. 56. Leslie WD, Manitoba Bone Density Program. 2006 The im­ 37. Morgan ST., T.ope~-Ren R, Nunnally N, et al. 200R The effect portance of spectrum hias on hone density mooitoring in clini­ of common artifacts lateral to the spine on bun~ mineral cal practice. Bone 39:361-368. density in the lumbar spine. J Clin Densitom 11:243-249. 57. Boonen S, Kaufman JM, Reginster JY, D evogelaer JP. 38. El Maghraoui A, Roux C. 2008 DXA scanning in cli.J1ical prac­ 2003 Patient assessment using slandard.ized bone mineral tice. QJM 101:605-617. densit)' vitlues and a n.ttionat reference database: imple­ 39. Institute for Cn:denlialling Excdlencc. 2014 NCCA Accredi­ men Ling uniform thresholus rur the reimbursemenl or tation. Available at: http://www.credentialingexcellenct: osteoporosis treatments in Belgium. Ostcoporos Int 14:lH~ . org/ncca. Accessed March 1.'i. 2016. 115 . 40. American National Standards Institute. 2016 Accreditation 58. Shepherd JA, Morgan SL.Lu Y. 2008 Comparing BMD results Servic~s. Available at: hllps://www.ansica.org/wwwversion2/ helwecn two similar DXA syslems using U1e generalized Je:.ist outside/Default.a.~p. Accessed March 15, 2016. significant change. J Clin Densitom 11 :237-242. 41. Frimcth J, Oaliano E, Webstel D. 2010 Some physical and clini­ 59. Peel NF, Johnson A, Barringtou NA, el al. 1993 Impact of cal factors influcndng the measurement of precision error, anomalous verlebral segm entation on measurements of bone least significant change, and bone mineral density in mineral density. J Bone Miner Res 8:719-723. dual-energy X-ray ahsorptiometry. J Clin Dt:nsitom 13:29- 60. Rinl

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Journal of Ct,mcal Den1·itvmetry: Assessment ~ Management of M1415cuJoskeleral Health Volume a, 2016