DXA Scan, Bone Density Screening — Inpatient, Outpatient Specialty Care and Primary Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Related Pathway

Steroid Stress Dose

Patient Who May Benefit from a DXA Bone Scan

Diagnosed or Significant Risk
for Low Bone Mineral Density

At Risk for Bone Disease

Low Risk for Bone Disease

Primary bone disorders
Clinically Significant Fractures
Previous abnormal DXA scan

Diseases associated with:
- Immobilization
- Malabsorption
- Inflammation
- Gonadal hormone imbalance
- High-risk medications:
  - Chronic Steroid Exposure

Clinical recommendations by body system/clinical disorder

Vitamin D deficiency
Obesity
Malnutrition not due to eating disorder or chronic disease

Obtain DXA Scan

Consider DXA Scan

DXA Scan NOT Indicated

Before ordering a DXA scan, use clinical judgement to
consider how the results will change patient care

Information about DXA Scans/Imaging Recommendations

DXA Scan Interpretation Based on Z-Score
Find Results in EPIC within DXA Encounter

Imaging Recommendations
Patient Age	3 - 18 yrs	≥ 18 yrs
Standard Scan Sites	Lumbar Whole body	Lumbar Whole body Hip
Alternative Scan Sites If spinal disease, hardware, positional challenges	5 - 18 yrs	Lateral Distal Femur
	Distal Forearm Lateral Distal Femur	Lateral Distal Femur

Z-score ≤ -2
Low Bone Mineral Density

Z-score > -2 up to +2
Normal Bone Mineral Density

Factors interfering with accurate interpretation:
- Barium studies in the
  7 days prior DXA scan
- Contrast materials within the
  last 7 days
- Calcium supplements within the
  last 24 hours
Other Ordering Considerations
Spinal disease or positional challenges
Hardware in scan sites
Ventilator dependence

Presence of

Primary Bone Disorder
Clinically Significant Fractures

Absence of

Primary Bone Disorder
Clinically Significant Fractures

Reassess bone mineral density
if clinical situation changes

Referral to Bone Health Specialist

Treatment, DXA scan monitoring as indicated per specialist recommendations

Optimize treatment and management of underlying disease

Repeat DXA scan as clinically indicated and/or guidance by body system, DXA Scan Interpretation

Consider referral to bone health specialist

Posted: September 2018
Authors: Mascarenhas, M. MD; Webster, J. MD; Barsky, D. MD; Jannelli, F. RN; Calabria, A. MD; Downing, M. MHA

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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