Adding Ancillaries: Bone density testing

Osteoporosis is a major public health threat, responsible for more than 1.5 million fractures annually, according to the National Osteoporosis Foundation. Ten million Americans are estimated to have the disease and almost 34 million have osteopenia.

Bone mineral density (BMD) testing can have a measurable impact on those numbers and on a primary care physician's earnings.

Equipment

The central DEXA machines are the gold standard for diagnosing osteoporosis and monitoring response to medication. Their measurements best predict the risk of hip and vertebral fractures.

The peripheral ultrasound machines, which are smaller and less costly, have been approved by the FDA because studies have shown that low bone mass at any site is associated with a substantial risk of fracture. These devices are sometimes used for prescreening purposes (patients with low scores are referred for DEXA assessment) or in settings where DEXA screening would be impractical, such as health fairs. Colleen Heniff and her partner, family practitioners in Oak Park, IL, received an ultrasound machine as a bonus for buying a Hologic central DEXA. They now screen-for free-every woman who comes in for a Pap test because it tells them whether she needs the DEXA measurement.

Despite the cost of the DEXA equipment, all three of the major manufacturers (Hologic of Bedford, MA, GE Healthcare Lunar of Madison, WI, and Norland, part of CooperSurgical in Trumbull, CT) say that the DEXA machines far outsell the ultrasound models, even among primary care physicians.

Space

All of the models fit in a standard exam room. DEXA machines range from six to nine feet long; if space is tight, some of them are designed so you can push the scanning equipment out of the way and use the table for exams. Most states don't require shielding, nor is any special support necessary for the floor structure. If your state requires shielding, however (check with your state department of health to see if this is the case), you'll need extra space for that. The machines run off standard 120-volt outlets.

Ultrasound machines are highly portable; they range from backpack- to suitcase-size, and weigh between 10 and 20 pounds.

Staff/training

All three manufacturers send trainers into the office for a day or two to show staff how to calibrate the operating system, position the patient, conduct an exam, and observe radiation safety.

For interpretation of results, it's recommended that physicians take a certification course from the International Society for Clinical Densitometry (see http://www.iscd.org). The ISCD has certification exams for radiographic technologists, also, to verify that they're qualified to do bone density testing. Only physicians can interpret results.

Because ultrasound machines don't use radiation, it's not necessary for your clinical staffers who operate the equipment to have radiology training. But state law may require that techs who operate X-ray based axial densitometers have radiation safety training, a limited radiography license, or a full RT license. Check your state's rules at http://www.iscd.org/Visitors/reimbursement/reimbursement.cfm.

Costs

The central DEXA units cost from $40,000 for a no-frills scanner to $160,000 for a high-end clinical research unit. The pricier units are faster and yield sharper images. Leasing arrangements include the option of buying the machine or getting a newer model when the lease is up. The smaller ultrasound units cost between $10,000 and $20,000.