Family Practice Vol. 21, No. 1, 51-53
© Oxford University Press 2004, all rights reserved.
Article |
GPs' perceptions of the role of DEXA scanning: an exploratory study
a Primary Care Sciences Research Centre, Hornbeam Building, Keele University, Keele, Staffordshire ST5 5BG and b Staffordshire Rheumatology Centre, The Haywood Hospital, Burslem, Stoke-on-Trent, Staffordshire ST6 7AG, UK
E-mail: j.c.richardson{at}keele.ac.uk or e.thomas{at}keele.ac.uk
Received 21 October 2002; Revised 20 May 2003; Accepted 8 September 2003.
Richardson JC, Hassell AB, Thomas E and Hay EM. GPs' perceptions of the role of DEXA scanning: an exploratory study. Family Practice 2004; 21: 51–53.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Background. Current recommendation are that women with clinical indicators of low bone mineral density should be offered a DEXA (dual energy X-ray absorptiometer) scan to help assess the need for treatment, but little is known about GPs' attitudes towards DEXA scans.
Objective. Our aim was to explore GPs' beliefs about diagnosis and management of osteoporosis, including the role that DEXA scanning can play.
Methods. Semi-structured interviews with five GPs in the North Staffordshire area were used to explore how GPs make decisions about diagnosis and treatment of osteoporosis, including the use of scans and the application of potential clinical risk factors to decisions about screening and treatment.
Results. The decision-making process about whether and who to scan is complex and was influenced by a range of factors including issues of diagnosis, treatment, patient pressure and ‘external’ factors such as practice protocol and the perceived local availability of scans.
Conclusions. GPs found it difficult to decide who and when to scan despite guidelines for primary care. Perceived local availability of DEXA scans is important and has implications for raising awareness.
Keywords. Decision making, DEXA scans, osteoporosis, primary care, qualitative study.
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Introduction |
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The economic and personal costs associated with the predicted rise in osteoporotic fractures have been well documented,1,2 but little is known about how GPs use DEXA (dual energy X-ray absorptiometer) scans—at the current time the "best available predictor of future fracture risk"3—in diagnosing and managing osteoporosis. The challenge is to identify women at risk of low bone mineral density (BMD) so that effective treatment can be implemented. One approach is for women with clinical indicators of low BMD to be offered a scan to assess their need for treatment.4 DEXA scans can also help in doctor and patient decision making.5–7
The aim of this study was to explore GPs' beliefs about and attitudes towards diagnosis and management of osteoporosis, including the role of DEXA scans.
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Methods |
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This research was part of a larger combined survey-based and qualitative study.8,9 Ethical approval was received from North Staffordshire LREC.
The interviews
A purposive sample of six GPs was selected using factors which might reflect differing beliefs about osteoporosis (age, sex, years of being a GP, practice type and socio-economic area served). Semi-structured interviews (with five GPs) were used to explore how GPs make decisions about diagnosis and treatment of osteoporosis. All interviews were tape-recorded and transcribed, and a systematic thematic analysis carried out.10
Setting and context
The GPs worked in an area supplied by a single large hospital, where DEXA scanning is available on an open access basis (with a current waiting time of 2 weeks).
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Results |
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The decision-making process about who to scan is complex and involves consideration of issues other than clinical risk factors, as outlined below.
The perceived importance of osteoporosis
All five GPs discussed osteoporosis in terms of its being a pathology, using phrases such as "thinning of the bones" and "loss of bone mass which leads to structural weakness of the bones". They all expressed the opinion that it was an important problem in terms of public health.
Identifying patients with osteoporosis
Important risk factors were identified as: menopause/ postmenopause, smoking, strong family history of osteoporosis, anorexia, being very thin, lack of exercise, chronic immobility, chronic steroid use, poor diet and metabolic disease. GPs would use these factors in order to evaluate an individual's risk. However, this was not seen as an exact science or as equivalent to diagnosis by scan, with three GPs considering that the only accurate way to evaluate risk was through a DEXA scan. The process of deciding whether, and who, to scan was not clear-cut (see Box 1: 1).
BOX 1 Quotations from GP interviews
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Some of the GPs expressed a lack of confidence in using DEXA scans as a tool, and felt that they would benefit from information about using them effectively.
Routes
The ‘guideline route’ indicates that an assessment is made of who is at risk, guidelines are used to decide who should be scanned, and the DEXA result is used to decide who to treat. However, the pathway taken by a GP does not necessarily follow this model. Alternative routes were identified within this study.
Treating without a DEXA. If treatment was straightforward on the basis of a number of strong risk factors, then confirmation through a DEXA scan was considered unnecessary, e.g. for an older woman happy to take hormone replacement therapy (HRT). Available evidence supports this stance. Potential treatment length influences consideration of a scan, e.g. for a younger woman with probable early menopause who is likely to be on long-term treatment. There is, however, no evidence available on whether monitoring treatment affects outcome.
Use of DEXA to influence other aspects of treatment. The DEXA scan was seen as useful in providing additional information to help in the joint decision-making process; in ‘persuading’ patients of the need for specific treatment; or in convincing patients that they had a problem (Box 1: 2).
Response to patient pressure. This was also a factor in the decision-making process and was linked to the type of area served by the practice (Box 1: 3). If a patient requested a scan, GPs would reassure them and then recommend a private scan, or, for one GP, an NHS scan, for their ‘mental well-being’. Again there was an emphasis on a joint process between patient and GP.
Response to local situation. This influenced the route taken by GPs. While four of the five GPs were aware of the local DEXA service, there were a number of misconceptions, e.g. of long waiting times or the need for formal rheumatology assessment. The influence of perception on practice can be seen clearly for the GP whose patients have private scans (Box 1: 4). This is also reflected in the number of scans seen in the past year by the GPs interviewed: 40 for GP1, compared with between one and ‘a handful’ for the other GPs.
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Discussion |
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Previous studies have highlighted the role that bone density scans can play in decision making for GPs and patients. This study adds to our knowledge of an earlier stage in that process, namely GPs' perceptions of the DEXA scan service and the factors influencing decisions about referral. Using current guidelines to inform decisions about individual patients is far from clear cut, and a range of factors influence GPs' decisions about offering scans, which have important implications for primary care. It is clear from this study that although guidelines might give a broad overview of the types of groups of patients that should be considered for scanning, they do not appear to be helpful at the individual level.
The perception of the local DEXA scan service is crucial to how GPs use it. In this study, many of the GPs' beliefs were based on misperceptions, despite a policy of active information provision. Although the sample may not be generalizable, the findings do illustrate the difficulties faced in convincing GPs that the service will meet their needs. The challenge for provides of health care is to develop strategies for disseminating information about a service in an way that results in equitable provision to an appropriate group of patients.
This study illustrates the need for ongoing dialogue between primary and secondary care to provide useful information for GPs on the role of DEXA scanning in various clinical scenarios, and in management of osteoporosis.
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Acknowledgments |
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We thank the GPs who took part in this study, and Dr Alison Irvine for her input into the initial project design.
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References |
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1 Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int 1992; 2: 285–289.[CrossRef][Web of Science][Medline]
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4 Royal College of Physicians. Osteoporosis: Clinical Guidelines for Prevention and Treatment. Suffolk: The Lavenham Press; 1999.
5 Barlow D. Advisory Group on Osteoporosis Report. London: Department of Health; 1994.
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8 Thomas E, Richardson JC, Irvine A, Hassell AB, Hay EM. Osteoporosis: what are the implications of DEXA scanning ‘high-risk’ women in primary care? Fam Pract 2003; 20: 289–293.
9 Richardson JC, Hassell AB, Hay, EM, Thomas E. ‘I'd rather go and know’: women's understanding and experience of DEXA scanning for osteoporosis. Health Expectations 2002; 5: 114–126.[CrossRef][Medline]
10 Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In Bryman A, Burgess RG (eds). Analysing Qualitative Data. London: Routledge; 1994; 173–194.
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