1. Scanning and reporting:
Best Practice in DXA-
Scanning and reporting:
Who, What and Why?
Tuesday 24th April 2018
Mrs Jill Griffin
Consultant Practitioner,
Healthy Bones Service, Derriford Hospital Plymouth

2. Topics DXA Pathways Who? Unscrambling Who’s Who
What? Best Practice in:
DXA BMD
DXA reporting
DXA VFA

3. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

4. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

5. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

6. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

7. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

8. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

9. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

10. DXA Pathways? DXA Scan FLS Primary Care GP & Practice nurses Referral:
Symptoms
Well Woman
Primary Care
GP & Practice nurses
New patient
Well Man
Referral:
Imaging, nuclear medicine, medical physics,
Health Check/ initiative QOF
NEWS story
DXA Scan
Medication Review
Osteo/ met bone clinic
Incidental finding on imaging
Rheumatology
Symptoms #
Fracture clinic
FLS
Oncology, gastro-enterology, respiratory medicine

11. DXA Pathways Complex Local Protocol Driven
Availability
Specialist interest/skills
Protocol Driven
Regulated under ionising radiation regulations (IRR/IRMER)

12. Who? Unscrambling Who’s Who
Regulated under ionising radiation regulations (IRR/IRMER)
Statutory duties
Justification
Optimisation
Audit
Training

13. Who? Unscrambling Who’s Who
Patient
Employer
Referrer
Practitioner
Operator
Reporter

14. Who? Unscrambling Who’s Who
Who is our Patient?
RCR
iRefer: Making the best use of clinical radiology
ISCD
Official Positions 2015 Adults
NICE
CG146 Fracture risk assessment
-- FRAX/NOGG /QFracture

15. Who? Unscrambling Who’s Who
Patient
Clinical Indications:
As part of fracture risk assessment:
In all women aged 65 years and over and all men aged 75 (70) years and over (NICE CG146/ISCD)

16. Who? Unscrambling Who’s Who
Women aged 65 and older
For post-menopausal women younger than age 65 a bone density test is indicated if they have a risk factor for low bone mass such as;
Low body weight
Prior fracture
High risk medication use
Disease or condition associated with bone loss.
Women during the menopausal transition with clinical risk factors for fracture, such as low body weight, prior fracture, or high-risk medication use.
(ISCD 2015)

17. Who? Unscrambling Who’s Who
For men < 70 years of age a bone density test is indicated if they have a risk factor for low bone mass such as;
Low body weight
Prior fracture
High risk medication use
Disease or condition associated with bone loss.
Adults with a fragility fracture
(ISCD 2015)

18. Who? Unscrambling Who’s Who
Adults with a fragility fracture.
Adults with a disease or condition associated with low bone mass or bone loss.
Adults taking medications associated with low bone mass or bone loss.
Anyone being considered for pharmacologic therapy.
Anyone being treated, to monitor treatment effect.
Anyone not receiving therapy in whom evidence of bone loss would lead to treatment.
(ISCD 2015)

19. Who? Unscrambling Who’s Who
Patient
Clinical Indications:
Those over 65 at risk of fragility fracture
Those over 50 with a fragility fracture
Those with an underlying condition or treatment known to decrease bone mass or increase risk of fragility fracture
Those on treatment with bone sparing therapies
Those with a known low bone mass where intervention is indicated by bone loss

20. Who? Unscrambling Who’s Who
Age and gender
Clinical risks for fragility fracture
BMI
Fragility Fracture
Parental hip Fracture
Current smoking
Current steroids RA
Alcohol >3units BD
Secondary factors

21. Who? Unscrambling Who’s Who
Age and gender
Clinical risks for fragility fracture
BMI
Fragility Fracture
Parental hip Fracture
Current smoking
Current steroids
BMD RA
Alcohol >3units BD
Secondary factors

22. Who? Unscrambling Who’s Who

23. Who? Unscrambling Who’s Who

24. Who? Unscrambling Who’s Who

25. Who? Unscrambling Who’s Who
Patient
Clinical Indications:
Those over 65 at risk of fragility fracture
Those over 50 with a fragility fracture
Those with an underlying condition or treatment known to increase risk of fragility fracture
Those on treatment with bone sparing therapies
Those with a known low bone mass where intervention is indicated by bone loss

26. Who? Unscrambling Who’s Who
Who can be the Referrer?
‘A registered medical practitioner, dental practitioner or other health professional who is entitled in accordance with the employers procedures to refer individuals for medical exposure to a practitioner’
IR(ME)R 2 (1) Interpretation

27. Who? Unscrambling Who’s Who
Referrer
Qualified medical doctor
Qualified dentist
Registered health professional (HCPC/RN) who is entitled to refer under employers procedures

28. Who? Unscrambling Who’s Who
1 Definition
Under the Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006, (IR(ME)R), a non-medical referrer is a registered healthcare professional who is entitled to refer individuals for medical exposures to a practitioner.
2 Responsibilities
2.1 The referrer must be competent in assessing the patient, and has responsibility for, and must be able to provide sufficient and necessary clinical data for the practitioner to justify the exposure.
2.2 The referrer must understand his or her responsibilities under IR(ME)R.
2.3 The referrer must understand their professional accountability arising from their professional body’s code of conduct and any medico-legal issues related to their scope of practice.
2.4 Any non-medical referrer referring patients to Anyhospital NHS Trust for DXA scanning must:
have attended a Radiation Protection and IR(ME)R training session,
work to a protocol approved by the Directorate of Diagnostic Imaging (appendix 1A.1)
have attended Healthy Bones Training delivered by the Anyhospital Osteoporosis Service

29. Who? Unscrambling Who’s Who
The referrer must be competent in assessing the patient, and has responsibility for, and must be able to provide sufficient and necessary clinical data for the practitioner to justify the exposure.

30. Who? Unscrambling Who’s Who
Who is this ‘Practitioner’?
Entitled in Employers procedures…(4(1)
Be adequately trained… (11(1))
The practitioner is responsible for the justification of a medical exposure…(5 (2))
No person shall carry out a medical exposure unless- it has been justified by the practitioner as showing a sufficient net benefit… ( 6 1a)
The ‘operator’ may authorise an exposure as required in accordance with guidelines issued by the Practitioner...(6 (5)

31. Justification ‘v’ Authorisation
Practitioner
Trained within field of specialism
Authorisation criteria
(pre-justified)
Operator
YES!
authorisation NO
justification

32. Justification ‘v’ Authorisation
Any Hospital DXA Authorisation criteria:
>50 year old with fragility fracture
High dose steroids >3mo
Parental hip fracture
Amenorrhoea >6mo (in absence of pregnancy or breast feeding
Author: A. Practitioner Esq.
Practitioner
Trained within field of specialism
Authorisation criteria
(pre-justified)
Operator
YES!
authorisation NO
justification
Any Hospital DXA referral
Patient: Mrs Smith
Age: 60
Clinical indication:
Colles fracture left wrist following fall
Signed: Dr Bones (GMC )
Who can Authorise this referral?

33. Justification ‘v’ Authorisation
Any Hospital DXA Authorisation criteria:
>50 year old with fragility fracture
High does steroids >3mo
Parental hip fracture
Amenorrhoea >6mo (in absence of pregnancy or breast feeding
Author: A. Practitioner Esq.
Practitioner
Trained within field of specialism
Authorisation criteria
(pre-justified)
Operator
YES!
authorisation NO
justification
Practitioner or Operator
Any Hospital DXA referral
Patient: Mrs Smith
Age: 60
Clinical indication:
Colles fracture left wrist following fall
Signed: Dr Bones (GMC )
Who can Authorise this referral?

34. Who? Unscrambling Who’s Who
Who is an ‘Operator’?
Entitled in Employers procedures…(4(1))
Be adequately trained… (11(1))
The operator is responsible for the practical aspects of a medical exposure…(5 (2)) as well as any ‘authorisation’ under regulation 6 (5)
The ‘operator’ may authorise an exposure as required in accordance with guidelines issued by the Practitioner...(6 (5)
The operator must comply with ‘employers procedures’
Practically ID and patient pregnancy

35. Who? Unscrambling Who’s Who
Who is an ‘Operator’?
Be adequately trained… (11(1))
‘A certificate issued by an institute or person competent to award degrees or diploma as…adequately trained’
BSc/DCR Radiographer/AHP (HCPC registered) Or
‘under the supervision of a person who is adequately trained
AP supervised by Radiographer
- Schedule 2- training in specific area of practice

36. Who? Unscrambling Who’s Who
Who should report DXA scans?
Why report?
‘…a clinical evaluation of the outcome of each medical exposure, is recorded…’ (7 (8))
Direct onward management of patient
Evidence treatment decisions
Improve fracture risk prediction

37. Who? Unscrambling Who’s Who
Who should report DXA scans?
Registered healthcare professionals working in the field with additional training in speciality
radiologists, radiographers, nurses, rheumatologists
ISCD- those reporting DXA should have a valid certificate in bone densitometry

38. Who? Unscrambling Who’s Who
Who should report DXA scans?
Registered healthcare professionals working in the field with additional training in speciality
radiologists, radiographers, nurses, rheumatologists
ISCD- those reporting DXA should have a valid certificate in bone densitometry

39. Who? Unscrambling Who’s Who
Who should report DXA scans?
RCR
Standards for interpretation and reporting of imaging investigations
Standards for the reporting of imaging investigations by non-radiologist medically qualified practitioners
SOR
Radiographers are responsible and accountable
Must undertake regular CPD and engage with robust audit
Receive acredited post graduate training

40. Who? Unscrambling Who’s Who
Non-radiologists
Timing and training
Permanently recorded report
Provision of resources
Expertise of reporters
Identification of reporter
Clinical audit or reports

41. BMD by DXA The measure by which osteoporosis may be diagnosed (1)
An independent clinical risk factor for fragility fracture (2)
WHO 1994
FRAX ® /Qfracture
Dual Energy X-ray absorbtiometry (DXA) remains the gold standard diagnostic tool for diagnosis and evaluation of osteoporosis
We know that a low bone mineral density (BMD) is an important clinical risk factor for fragility fracture and inclusion of BMD improves the predictive capacity of fracture risk assessment tools such as FRAX ®.
It is important to have a basic grasp of the DXA technique and its capability- and crucially its limitations, in order to understand and appreciate BMD measurements obtained this way.

42. What? DXA BMD & VFA
WHO 1994
Lumbar spine, proximal femur & distal forearm validated sites for diagnosis

43. What? DXA BMD & VFA ISCD 2015 Lumbar spine & proximal femur Forearm
where spine or femur cannot be interpreted
In hyperparathryroidism
Very obese patients over the scanner weight limit

44. Centre laser 5cm superior to the ASIS in the patients midline
What? DXA BMD & VFA
Centre laser 5cm superior to the ASIS in the patients midline
To start in the body of L5

45. What? DXA BMD & VFA

46. What? DXA BMD & VFA

47. What? DXA BMD & VFA

48. What? DXA BMD & VFA

49. What? DXA BMD & VFA
GE Lunar
& Hologic scanner
differences

50. What? DXA BMD & VFA
GE Lunar
& Hologic scanner
differences

51. What? DXA BMD & VFA

52. What? DXA BMD & VFA WHO 1994 ISCD 2015
Osteoporosis is diagnosed when the BMD T-score is greater than -2.5 SD’s below the mean of the peak bone mass.
Applicable to lumbar spine, proximal femur, femoral neck or distal forearm
Applicable only to post menopausal white women
ISCD 2015
Osteoporosis may be diagnosed in postmenopausal women and in men age 50 and older if the T-score of the lumbar spine, total hip, or femoral neck is -2.5 or less
In certain circumstances the 33% radius (also called 1/3 radius) may be utilized

53. What? DXA BMD & VFA
Pre-menopausal females and males under 50 years ISCD 2015:
Use Z-scores
A Z-score of -2.0 or lower is defined as “below the expected range for age”, and a Z-score above -2.0 is “within the expected range for age.”
Osteoporosis cannot be diagnosed in men under age 50 on the basis of BMD alone
The WHO diagnostic criteria may be applied to women in the menopausal transition

54. What? DXA BMD & VFA Quality
Only as good as the quality of the scan and analysis

55. What? DXA BMD & VFA Region BMD g/cm2 T-score L1-L4 0.963 -2.1 Region
1.029
-1.6

56. What? DXA BMD & VFA Must haves: Patient identification
Clinical question to be answered- what is this report about?
What happened- what is this report about?
Measurements
Validity of measurements
Diagnostic outcome
Follow up advice
Who is reporting

57. What? DXA BMD & VFA Might haves:
Rate of change between scans and statistical or clinical significance
Follow up test advice
Onward referral advice
Lifestyle advice
Treatment advice

58. Example report Scan centre ID Patient ID Clinical indications/factures
BMD measurements
Assessment/diagnosis
Fracture risk
Recommendations/ treatment/lifestyle/bloods
Follow up scan date/interval
Reporting clinician ID
WHO thresholds

59. What? DXA BMD & VFA Rationale for identifying VFX
Most common osteoporotic fracture
Increased morbidity and mortality
Strongly predict future fracture risk
Under-diagnosed
Black et al., JBMR 1999; Melton et al., OI 1999; Lindsay et al., JAMA 2001

60. What? DXA BMD & VFA Rationale for using VFA
Clinical risk profiles have limited predictive ability
High index of suspicion required to justify spine radiographs
Radiation dose
Cost
Patient inconvenience
VFA can be obtained at same time as BMD measurement

61. What? DXA BMD & VFA Rationale for using VFA
Clinical risk profiles have limited predictive ability
High index of suspicion required to justify spine radiographs
Radiation dose
Cost
Patient inconvenience
VFA can be obtained at same time as BMD measurement
Presence of fracture may access anabolic treatments

62. What? DXA BMD & VFA Indications for VFA:
T-score < -1.0 SD + 1 or more:
Woman aged > 70 or man >80
Historical height loss > 4 cm
Self reported but undocumented prior vertebral fracture
Glucocorticoid therapy >5 mg BD > 3 mo
ISCD 2015

63. What? DXA BMD & VFA Indications for VFA:
T-score < -1.0 SD + 1 or more:
Woman aged > 70 or man >80
> 50% women
aged 70

64. What? DXA BMD & VFA Locally agreed Indications for VFA:
Women > 65 & Men > 70 with osteoporosis
Adults > 50 on long term steroids
Appearance of vertebral height loss on DXA
Documented height loss
Kyphosis
Hip fracture

65. What? DXA BMD & VFA

66. What? DXA BMD & VFA Should include part of L5 to top of T4
Lateral – should be seen as rectangular boxes with only one edge.
L5 should usually sit between the iliac crests
L4 is frequently bisected by the iliac crests
Thoracic vertebrae shorter, square and have rib articulations.

67. What? DXA BMD & VFA

68. What? DXA BMD & VFA

69. What? DXA BMD & VFA

70. What? DXA BMD & VFA

71. What? Have we learned? Unscrambled some pathways Identified the who?
Looked at what we should be doing

72. Answered some of the whys along the way
But why can’t I?