Osteoporosis is a growing health concern in the United States and access to high quality bone mineral density evaluation is a priority to large care organizations, such as the Veterans Health Administration1. Dual energy x-ray absorptiometry (DXA) is the “gold standard” to measure bone mineral density (BMD) and is necessary to diagnose osteoporosis before a fragility fracture occurs, to monitor patients’ response to therapy, and is used to predict fracture risk2. The quality of the DXA images, accuracy, and reproducibility of measurements on baseline and follow-up studies are extremely important2.

Multiple aspects of the process prior to, during, and after the DXA scan impact the quality and therefore the clinical utility of DXA results. Prior to a DXA appointment two elements of care can affect quality: 1) the information collected and provided to the DXA center by the ordering provider; and 2) the instructions given to the patient, such as general patient preparation for the study2,3. During the DXA assessment, multiple factors can impact the quality of the scan, including the skill and training of the technologist performing the study, the way information is collected from patients, and the condition of the DXA scanner itself. Once a DXA scan is complete, the quality of the information included in the report to the ordering provider, such as details of the equipment used for the scan, scanning mode, or limitations of the data collected, is vital to interpreting the results and ultimately providing appropriate patient care2, 3, 4, 5. Despite widespread recognition of the importance of technical and operational quality to the clinical utility of DXA scans, there are few studies which characterize the quality of DXA practice, and all indicate much room for improvement in the process of care. An early study focused on BMD reporting practices of bone densitometry centers found inconsistent use of evidenced based reporting practices, a lack of clinical information included in the report, and variability across geography and specialty6. Two previous studies reviewed existing DXA scans or reports to assess for errors compared to the International Society for Clinical Densitometry (ISCD) guidelines, finding errors related to data analysis, technical quality, and interpretations in 80-93% of scans7,8. Most recently, a worldwide survey of fracture liaison services found “significant variability” in the quality of care and inconsistent adherence to the ISCD and International Osteoporosis Foundation standards including accreditation/education, phantom calibration, and methods used for reporting9.

Our team developed and conducted a nationwide survey of Veterans Health Administration (VHA) DXA centers to assess the availability and quality of DXA services. The VHA is the largest integrated healthcare system in the United States, serving over 9 million patients10, slightly less than half of whom are age 65 or older11. The objective of this study was to characterize DXA scan processes of care within the VHA and to inform VHA healthcare operations and research focused upon improving access to skeletal health care for persons with fracture risk.