Archives of Osteoporosis

, 13:133 | Cite as

Referral pattern for DXA scanning in a tertiary care centre from southern India

  • Aditya John Binu
  • Kripa Elizabeth Cherian
  • Nitin KapoorEmail author
  • Nihal Thomas
  • Thomas V. Paul
Original Article



Referral patterns for bone mineral density testing by dual energy X-ray absorptiometry (DXA) scanning are seldom studied. In our study, the overall proportion of referrals from specialties remained low. This highlights the need for adequate utilisation of DXA by specialties treating subjects at risk for osteoporosis.


The knowledge of referral patterns for DXA scanning (dual energy X-ray absorptiometry) for bone mineral density (BMD) measurement is relevant in a developing country like India. We studied the referral source and clinical and densitometric profile of patients referred for DXA scanning at a south Indian tertiary care centre.


We conducted a cross-sectional study over 3 months and included subjects referred during this period for BMD assessment (lumbar spine and femoral neck) by DXA scan. Details regarding referring departments and reasons for referral were collected. The number of patients seen in individual departments was obtained during the study period and respective proportions of patients referred were calculated.


Of the 1932 subjects included in the study, we observed a definite female preponderance (90.2%), with a mean (SD) age of 51.6 (13.3) years. The greatest number of referrals came from the departments of rheumatology (37%; n = 724) and endocrinology (20%; n = 382). Overall, 36% were referred for inflammatory arthritis or systemic inflammatory disorders (n = 696) and 34% for postmenopausal state screening (n = 657). In relation to the individual outpatient strength, the departments who referred the highest proportion of their patients were rheumatology (6.8%), endocrinology (1.76%) and geriatrics (1.05%). A diagnosis of osteoporosis at any one site was made in 41% (448 of 1107) and the BMD was below the expected range for age in 37% (304 of 825) of the referrals.


Most referrals for DXA scanning were from rheumatology. Among the referred patients, about two fifth had osteoporosis and over one third had BMD below expected range for age. Although referrals by rheumatology were relatively higher, overall referrals from all departments remained low. This underscores the need for adequate utilisation of DXA by specialties treating subjects at risk for osteoporosis.


DXA referral Osteoporosis Southern India BMD 


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Khadilkar AV, Mandlik RM (2015) Epidemiology and treatment of osteoporosis in women: an Indian perspective. Int J Womens Health 7:841–850CrossRefGoogle Scholar
  2. 2.
    Paul TV, Thomas N, Seshadri MS, Oommen R, Jose A, Mahendri NV (2008) Prevalence of osteoporosis in ambulatory postmenopausal women from a semiurban region in southern India: relationship to calcium nutrition and vitamin D status. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol 14(6):665–671Google Scholar
  3. 3.
    Shetty S, Kapoor N, Naik D, Asha HS, Prabu S, Thomas N et al (2014) Osteoporosis in healthy South Indian males and the influence of life style factors and vitamin d status on bone mineral density. J Osteoporos 2014:723238CrossRefGoogle Scholar
  4. 4.
    Carey JJ, Delaney MF (2017) Utility of DXA for monitoring, technical aspects of DXA BMD measurement and precision testing. Bone 104:44–53CrossRefGoogle Scholar
  5. 5.
    Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE (2015) Diagnosis and Management of Osteoporosis. Am Fam Physician 92(4):261–268PubMedGoogle Scholar
  6. 6.
    Shane ES, Dempster DW (2001) Bone quantification and dynamics of bone turnover by histomorphometric analysis- principles and practice of endocrinology and metabolism, Third edn. Lippincott Williams and Wilkins, Baltimore,USA, pp 541–548Google Scholar
  7. 7.
    Shepherd JA, Schousboe JT, Broy SB, Engelke K, Leslie WD (2015) Executive summary of the 2015 ISCD position development conference on advanced measures from DXA and QCT: fracture prediction beyond BMD. J Clin Densitom Off J Int Soc Clin Densitom 18(3):274–286CrossRefGoogle Scholar
  8. 8.
    Paul TV, Selvan SA, Asha HS, Thomas N, Venkatesh K, Oommen AT et al (2015) Hypovitaminosis D and other risk factors of femoral neck fracture in South Indian postmenopausal women: a pilot study. J Clin Diagn Res:JCDR 9(6):OC19–OC22PubMedGoogle Scholar
  9. 9.
    Jha RM, Mithal A, Malhotra N, Brown EM (2010) Pilot case-control investigation of risk factors for hip fractures in the urban Indian population. BMC Musculoskelet Disord 11:49CrossRefGoogle Scholar
  10. 10.
    Varthakavi PK, Joshi AS, Bhagwat NM, Chadha MD (2014) Osteoporosis treatment in India: call for action. Indian J Endocrinol Metab 18(4):441–442CrossRefGoogle Scholar
  11. 11.
    Satyaraddi A, Shetty S, Kapoor N, Cherian KE, Naik D, Thomas N, Paul TV (2017) Performance of risk assessment tools for predicting osteoporosis in south Indian rural elderly men. Arch Osteoporos 12(1):35CrossRefGoogle Scholar
  12. 12.
    Malhotra N, Mithal A (2008) Osteoporosis in Indians. Indian J Med Res 127(3):263–268PubMedGoogle Scholar
  13. 13.
    Shivane VK, Sarathi V, Lila AR, Bandgar T, Joshi SR, Menon PS, Shah NS (2012) Peak bone mineral density and its determinants in an Asian Indian population. J Clin Densitom Off J Int Soc Clin Densitom 15(2):152–158CrossRefGoogle Scholar
  14. 14.
    Torpy AMJ, Brennan SL, Kotowicz MA, Pasco JA (2012) Reasons for referral to bone densitometry in men and women aged 20-49 years: population-based data. Arch Osteoporos 7:173–178CrossRefGoogle Scholar
  15. 15.
    Health Quality Ontario (2006) Utilization of DXA bone mineral densitometry in Ontario: an evidence-based analysis. Ont Health Technol Assess Ser 6(20):1–180PubMedCentralGoogle Scholar
  16. 16.
    Hayes BL, Curtis JR, Laster A, Saag K, Tanner SB, Liu C, Womack C, Johnson KC, Khaliq F, Carbone LD (2010) Osteoporosis care in the United States after declines in reimbursements for DXA. J Clin Densitom Off J Int Soc Clin Densitom 13(4):352–360CrossRefGoogle Scholar
  17. 17.
    Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R, National Osteoporosis Foundation (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int J Establ Result Coop Eur Found Osteoporos Natl Osteoporos Found USA 25(10):2359–2381CrossRefGoogle Scholar
  18. 18.
    Shetty S, Kapoor N, Dian Bondu J, Antonisamy B, Thomas N, Paul TV (2016) Bone turnover markers and bone mineral density in healthy mother-daughter pairs from South India. Clin Endocrinol 85(5):725–732CrossRefGoogle Scholar
  19. 19.
    Kim SY, Schneeweiss S, Liu J, Solomon DH (2012) Effects of disease-modifying antirheumatic drugs on non-vertebral fracture risk in rheumatoid arthritis: a population-based cohort study. J Bone Miner Res Off J Am Soc Bone Miner Res 27(4):789–796CrossRefGoogle Scholar
  20. 20.
    Yamamoto Y, Turkiewicz A, Wingstrand H, Englund M (2015) Fragility fractures in patients with rheumatoid arthritis and osteoarthritis compared with the general population. J Rheumatol 42(11):2055–2058CrossRefGoogle Scholar
  21. 21.
    Dubrovsky AM, Lim MJ, Lane NE (2018) Osteoporosis in rheumatic diseases: anti-rheumatic drugs and the skeleton. Calcif Tissue Int 102(5):607–618CrossRefGoogle Scholar
  22. 22.
    Tanner SB, Moore CF (2012) A review of the use of dual-energy X-ray absorptiometry (DXA) in rheumatology. Open Access Rheumatol Res Rev 4:99–107Google Scholar
  23. 23.
    Zerbini CAF, Clark P, Mendez-Sanchez L, Pereira RMR, Messina OD, Uña CR et al (2017) Biologic therapies and bone loss in rheumatoid arthritis. Osteoporos Int J Establ Result Coop Eur Found Osteoporos Natl Osteoporos Found USA 28(2):429–446CrossRefGoogle Scholar
  24. 24.
    Dobbins AG, Brennan SL, Williams LJ, Kotowicz MA, Sarah B, Birch Y, Pasco JA (2014) Who are the older Australians referred for a bone density scan? Data from the Barwon region. Arch Osteoporos 9:196CrossRefGoogle Scholar
  25. 25.
    Lewiecki EM, Laster AJ, Miller PD, Bilezikian JP (2012) More bone density testing is needed, not less. J Bone Miner Res Off J Am Soc Bone Miner Res 27(4):739–742CrossRefGoogle Scholar
  26. 26.
    Amin S, Felson DT (2001) Osteoporosis in men. Rheum Dis Clin N Am 27(1):19–47CrossRefGoogle Scholar
  27. 27.
    Al Attia H, Adams B (2007) Osteoporosis in men: are we referring enough for DXA and how? Clin Rheumatol 26(7):1123–1126CrossRefGoogle Scholar
  28. 28.
    Gopinathan NR, Sen RK, Behera P, Aggarwal S, Khandelwal N, Sen M (2016) Awareness of osteoporosis in postmenopausal Indian women: an evaluation of osteoporosis health belief scale. J -Life Health 7(4):180–184CrossRefGoogle Scholar
  29. 29.
    Pande K, Pande S, Tripathi S, Kanoi R, Thakur A, Patle S (2005) Poor knowledge about osteoporosis in learned Indian women. J Assoc Physicians India 53:433–436PubMedGoogle Scholar
  30. 30.
    Warriner AH, Outman RC, Feldstein AC, Roblin DW, Allison JJ, Curtis JR, Redden DT, Rix MM, Robinson BE, Rosales AG, Safford MM, Saag KG (2014) Effect of self-referral on bone mineral density testing and osteoporosis treatment. Med Care 52(8):743–750CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  • Aditya John Binu
    • 1
  • Kripa Elizabeth Cherian
    • 2
  • Nitin Kapoor
    • 2
    Email author
  • Nihal Thomas
    • 2
  • Thomas V. Paul
    • 2
  1. 1.Department of Internal MedicineChristian Medical CollegeVelloreIndia
  2. 2.Department of EndocrinologyChristian Medical CollegeVelloreIndia

Personalised recommendations