Population rates of bone densitometry use in Australia, 2001–2005, by sex and rural versus urban location

Dan P Ewald, John A Eisman, Ben D Ewald, Tania M Winzenberg, Markus J Seibel, Peter R Ebeling, Leon A Flicker and Peter T Nash
Med J Aust 2009; 190 (3): 126-128. || doi: 10.5694/j.1326-5377.2009.tb02310.x
Published online: 2 February 2009

This novel analysis of longitudinal national data shows that bone densitometry use in Australia is markedly lower in rural areas compared with urban areas, and in men compared with women. While use of the investigation increased between 2001 and 2005, these differences have persisted. The results suggest that rural communities and men potentially have inequitable access to the gold-standard investigation for the detection of osteoporosis. This in turn has implications for the implementation of best practice care, potential targeting of interventions to improve clinical care, and the setting of future policy affecting access to bone densitometry.

Rates of osteoporosis investigation and care after minimal trauma fractures in older patients in Australian hospitals are poor,1,2 and the evidence–practice gap is well recognised.3,4 Our study suggests particular problems with this evidence–practice gap in rural areas and in men.

While some difference in bone densitometry use between the sexes would be expected because of the lower incidence and prevalence of osteoporosis in men compared with women, the difference we observed was far greater than the population-wide ratio for prevalence of osteoporosis. A previous Australian study showed that the true incidence of fractures in men aged over 60 years is 1940 per 100 000 person-years, compared with 3250 for women. This gives a crude sex ratio of about 1.7 : 1. For fracture of femur, the corresponding crude incidence ratio is 2.9.4 There is an estimated residual lifetime fracture risk of 44% for women and 27% for men aged over 50 years,5 again a sex ratio of about 2 : 1. Men may sustain higher levels of high trauma fractures, but the vast majority of symptomatic fractures in men and women aged over 60 years are osteoporotic fractures,4 and a small sex difference in causes of fracture would not greatly change this estimated expected ratio. These data suggest the “correct” ratio of bone densitometry use would be about 2 : 1 (women to men) (Box 3). Therefore, other factors must be contributing to the differences we observed. These might include a relative underactivity of health services for detecting and managing osteoporosis in men, which would be consistent with other Australian reports that osteoporosis is likely to be underdiagnosed and undertreated in men.6

A likely contributor to the gradient across RRMA categories is limited access, both to primary health care7 and to bone densitometry. Competition between health care priorities may also be more severe in rural areas. It is no surprise that there are lower rates of a “specialised” radiological investigation in rural and remote settings. Currently only 14% of radiologists are based outside metropolitan locations,8 but serve 30% of the population aged over 45 years.

Osteoporosis and related fractures are so common that they should be managed by decentralised services that include rural and remote Australia. Ways of improving access to appropriate osteoporosis care in rural areas require further exploration and review of policy and education.

Although lower rates of osteoporotic fracture in rural areas might also contribute to the lower utilisation, the reported 15%–65% increase in relative risk of fracture in urban compared with rural areas9,10 cannot fully account for the 240% to 450% higher bone densitometry usage rates in urban areas seen in our analysis.

This study has several limitations. There may be a significant number of ad-hoc non-Medicare “screening” measurements outside the population considered to yield the highest health benefit. Accordingly, this analysis most closely relates to public expenditure rather than total activity for bone densitometry. We do not have data to enable more detailed assessment of other markers of osteoporosis care, and further research should similarly examine prescribing data for the use of osteoporosis medications, such as bisphosphonates and strontium, to describe the evidence–practice gaps further. Nonetheless, we consider that these results demonstrate reason to be concerned about potential access and equity issues for osteoporosis care in Australia.

These results show relative underuse of bone densitometry in rural areas and in men, likely to reflect poorer access to these services in rural areas and consistent with known undertreatment of osteoporosis in men. These problems should be highlighted in osteoporosis treatment guidelines and emphasised in interventions to improve the detection and management of osteoporosis. This information could also be used to inform policy development addressing urban–rural health inequalities. Further research is needed to explore barriers to bone densitometry use and to confirm whether other components of osteoporosis management show similar inequities.

  • Dan P Ewald1
  • John A Eisman2,3
  • Ben D Ewald4
  • Tania M Winzenberg5
  • Markus J Seibel6
  • Peter R Ebeling7
  • Leon A Flicker8
  • Peter T Nash9

  • 1 Northern Rivers General Practice Network, Lismore, NSW.
  • 2 Bone and Mineral Research Program, Garvan Institute of Medical Research, St Vincent’s Hospital, Sydney, NSW.
  • 3 University of New South Wales, Sydney, NSW.
  • 4 Centre for Clinical Epidemiology and Biostatistics, Newcastle, NSW.
  • 5 Menzies Research Institute, Hobart, TAS.
  • 6 Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW.
  • 7 University of Melbourne, Western Hospital, Melbourne, VIC.
  • 8 School of Medicine and Pharmacology, University of Western Australia, Perth, WA.
  • 9 University of Queensland, Brisbane, QLD.


Competing interests:

John Eisman, Markus Seibel, Peter Ebeling and Peter Nash have received research and other support and honoraria from multiple sources, including numerous pharmaceutical companies (details available on request from the Journal).

  • 1. Kelly AM, Clooney M, Kerr D, Ebeling PR. When continuity of care breaks down: a systems failure in identification of osteoporosis risk in older patients treated for minimal trauma fractures. Med J Aust 2008; 188: 389-391. <MJA full text>
  • 2. Teede HJ, Jaysuriya IA, Gilfillan CP. Fracture prevention strategies in patients presenting to Australian hospitals with minimal trauma fractures: a major treatment gap. Intern Med J 2007; 37: 674-679.
  • 3. National Institute of Clinical Studies. Evidence-Practice Gaps Report Vol 2. Melbourne: NICS, 2005.
  • 4. Eisman JA, Clapham S, Kehoe L; Australian BoneCare Study. Osteoporosis prevalence and levels of treatment in primary care: the Australian BoneCare Study. J Bone Miner Res 2004; 19: 1969-1975.
  • 5. Jones G, Nguyen T, Sambrook PN, et al. Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 1994; 4: 277-282.
  • 6. Ebeling PR. Osteoporosis in men. N Engl J Med 2008; 358: 1474-1482.
  • 7. The general practice workforce in Australia; supply and requirements to 2013, AMWAC Report 2005.2. Sydney: Australian Medical Workforce Advisory Committee, 2005.
  • 8. Jones DN. 2002 Australian radiology workforce report. Australas Radiol 2002; 46: 231-248.
  • 9. Cooley H, Jones G. A population based study of fracture incidence in southern Tasmania: lifetime fracture risk and evidence for geographic variations within the same country. Osteoporos Int 2001; 12: 124-130.
  • 10. Sanders KM, Nicholson GC, Ugoni AM, et al. Fracture rates lower in rural than urban communities: the Geelong Osteoporosis Study. J Epidemiol Community Health 2002; 56: 466-470.


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