A 30-Day Adjunct Wellness Intervention for the Management of Extra-Articular Symptoms of Rheumatoid Arthritis: A Formative Study.

Individuals with rheumatoid arthritis (RA) continually fall short of treatment targets using standard drug therapies alone. There is growing evidence that emphasizing physical and mental wellness is equally crucial for improving functioning among people with RA. The purpose of this formative study is to examine the feasibility of offering the wellness-based intervention ("KickStart30") in patients with RA. Thirteen individuals with RA on targeted immune modulators (a biologic or JAK inhibitor) enrolled in the KickStart30 program. Participants completed self-report measures of RA-specific disability (eg, pain) and other functional areas (eg, mood) in a pre- versus post- intervention design. Paired samples t-tests (and Related-Samples Wilcoxon Signed Rank Tests for non-normal distributions) detected statistically significant results for 10 of 12 measures, including reductions in pain (M = 4.54 to M = 3.54; p = .025; BPI), functional disability (M = 0.94 to M = 0.73, p = .032; HAQ-II), cognitive and physical dysfunction (M = 25.46 to M = 13.54, p < .001; CPFQ), depressive symptoms (M = 9.31 to M = 5.54, p = .003; PHQ-9), anxiety (M = 5.69 to M = 3.23, p = .005; GAD-7), insomnia (M = 11.62 to M = 17.32, p = .007; Note: higher scores on the SCI indicate less insomnia), stress-related eating (M = 75.46 to M = 84.54, p = .021; Note: higher scores on the EADES indicate less stress-related eating), along with significant increases in mindfulness (M = 62.54 to M = 67.85, p = .040; MAAS), mental wellness (M = 4.46 to M = 5.69; HERO), and well-being (Md = 8.00 to Md = 5.00, p = .004; WHO-5). All significant measures had medium to large effect sizes (Cohen's d). The study gives preliminary support for the possibility that the adjunct intervention may have an effect.

Dual-energy x-ray absorptiometry: overused, neglected, or just misunderstood?

Assessment of bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) plays a vital role in the diagnosis of osteoporosis and in monitoring a patient's response to drug therapy. This commentary will discuss controversies surrounding the use of DXA for screening and monitoring of BMD in women.

Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes.

In the United States, Medicare gradually reduced payments for central dual-energy X-ray absorptiometry (DXA) performed at physician offices (or other nonhospital settings) from an average of $139 in 2006 to about $82 in 2007 and 2008 and $72 in 2009. Reimbursement for hospital outpatient DXA service was unchanged. We investigated the utilization of hip and spine (central) DXA in the Medicare population before and after the reduction. We identified individuals from the national 5% random sample of Medicare beneficiaries who were ≥65 years of age and enrolled in Medicare Parts A and B but not in a Medicare Advantage plan from 2002 through 2009. For each calendar year, we calculated the proportion of beneficiaries who submitted claims for DXA, the proportions of DXAs performed in hospitals and in physician offices and the number of physician office-based practices that discontinued or started to provide DXA services. From 2002 to 2006, the proportion of beneficiaries who had at least one central DXA increased from 7.9% to 9.6% at an annual increase of 0.4% and from 2006 to 2009, the annual increase dropped to 0.1%. The number of DXAs performed in physician offices dropped from 1,643,720 (69% of 2,363,500 total DXAs) in 2006 to 1,534,240 (66% of 2,338,240) in 2009. This decline was offset by an increase in the number of DXAs performed in hospitals, which increased from 719,780 (31%) in 2006 to 804,000 (34%) in 2009. Among physician office-based practices, more practices initiated than discontinued DXA service each year from 2002 to 2006. However, the trend was reversed since 2007 such that in 2009, 1876 practices discontinued and only 1394 initiated DXA service. The reduction in DXA reimbursement was associated with a decrease in the number of DXAs performed in physician offices and fewer physician offices that provided DXA services.

Duration of treatment in postmenopausal osteoporosis: how long to treat and what are the consequences of cessation of treatment?

Although a variety of medications are effective for the treatment of postmenopausal osteoporosis, there is concern that long-term use may incur side effects. Consequently, some have proposed discontinuing or temporarily suspending treatment after a defined period of time. As the benefits of fracture risk reduction may recede during this "drug holiday", the clinician may be faced with deciding when to resume therapy (and with which agent) while avoiding the possible cumulative risk of side effects. This article summarizes data regarding length of treatment and the effects of cessation of treatment on bone density, bone turnover markers, and fracture risk.

2009 Santa Fe Bone symposium.

Osteoporosis is a common skeletal disease with serious clinical consequences because of fractures. Despite the availability of clinical tools to diagnose osteoporosis and assess fracture risk, and drugs proven to reduce fracture risk, it remains a disease that is underdiagnosed and undertreated. When treatment is started, it is commonly not taken correctly or long enough to be effective. Recent advances in understanding of the regulators and mediators of bone remodeling have led to new therapeutic targets and the development of drugs that may offer advantages over current agents in reducing the burden of osteoporotic fractures. Many genetic factors that play a role in the pathogenesis of osteoporosis and metabolic bone disease have now been identified. At the 2009 Santa Fe Bone Symposium, held in Santa Fe, New Mexico, USA, the links between advances in genetics, basic bone science, recent clinical trials, and new and emerging therapeutic agents were presented and explored. Socioeconomic challenges and opportunities in the care of osteoporosis were discussed. This is a collection of medical essays based on key presentations at the 2009 Santa Fe Bone Symposium.

Regional variation in the denial of reimbursement for bone mineral density testing among US Medicare beneficiaries.

Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician's office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age > or =65 yr with part A+B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.

Vertebral Fracture Assessment by dual-energy X-ray absorptiometry: insurance coverage issues in the United States. A White Paper of the International Society for Clinical Densitometry.

Clinical trial data and fracture risk prediction models unequivocally demonstrate the utility of identifying prevalent vertebral fractures to predict future fractures of all types. Knowledge of prevalent vertebral fractures can alter patient management decisions and result in initiation of therapy to reduce fracture risk in some patients who would not otherwise be treated. Cost-benefit analysis demonstrates that identifying and treating patients with vertebral fractures, even those with a densitometric classification of osteopenia, is cost effective. Vertebral fractures can be readily identified in the office setting using standard radiography or Vertebral Fracture Assessment (VFA), a software addition to a central dual-energy X-ray absorptiometry (DXA) machine. In the United States, VFA was assigned a Current Procedural Terminology (CPT) code in January 2005. Nevertheless, coverage of VFA has not been uniformly embraced by Medicare carriers, companies that contract with the federal government to administer Medicare coverage and process claims for a region of the United States. Unlike DXA, for which uniform national coverage of qualified Medicare beneficiaries is mandated by the Balanced Budget Act of 1997, VFA coverage policies are determined by the local Medicare carriers. Third-party insurers are also variable in their coverage of VFA. This International Society for Clinical Densitometry (ISCD) White Paper documents the role of VFA in the evaluation and treatment of women with postmenopausal osteoporosis and compares it with standard spine radiography. Arguments used by some Medicare carriers and insurers to deny coverage of VFA in the United States are analyzed and critiqued. For health care providers within the United States, this White Paper may serve as a resource to respond to insurers who deny coverage of VFA. For health care providers regardless of their country, this article underscores the value of VFA as an alternative to spine radiography in the evaluation and management of postmenopausal women with suspected osteoporosis.

Clinical review: Clinical applications of vertebral fracture assessment by dual-energy x-ray absorptiometry.

CONTEXT: Vertebral fracture (VF) is the most common type of fragility fracture, yet most VFs are not clinically apparent. VFs are associated with a significant increase in morbidity, mortality, and risk of future fracture. Many patients with VFs do not have T-scores classified as osteoporosis. Knowledge of VFs may change diagnostic classification, estimation of future fracture risk, and clinical management. VF assessment (VFA) by dual-energy x-ray absorptiometry is a method for imaging the spine to diagnose VFs. EVIDENCE ACQUISITION: Background information and medical evidence on the technology and clinical applications of VFA was acquired by electronic searching of PubMed for appropriate terms that included vertebral fracture, imaging, diagnosis, dual-energy x-ray absorptiometry, and cost effectiveness. Matches with the highest levels of medical evidence were selected for review, recognizing that the new and evolving nature of the field required inclusion of some material that relied partly on expert opinion. EVIDENCE SYNTHESIS: The sensitivity and specificity of VFA compare favorably with spine radiographs in the ability to diagnose grade 2 and 3 VFs. VFA involves less radiation, lower cost, and often greater patient convenience than spine radiography. Cost effectiveness modeling suggests that imaging of the spine in selected patients provides essential diagnostic and therapeutic information at a nominal cost. Patients with T-scores that are classified as low bone mass (osteopenia) who are selected for pharmacological therapy based on the presence of a VF benefit by reduction in fracture risk. Guidelines for the clinical application of VFA have been developed by the International Society for Clinical Densitometry. CONCLUSIONS: VFA is a technology for diagnosing VFs that may alter diagnostic classification, improve fracture risk stratification, and identify patients likely to benefit from pharmacological therapy who otherwise might not be treated.