Educating Health Care Providers About REMS Technology


Is it possible to educate your health care provider about REMS? And what is the best way to accomplish that?

The answer to the first question…a definite maybe! Obviously, all provider-patient relationships are different. They depend not only on the unique provider and the unique patient, but also the setting where the healthcare is being delivered. 

In this blog, we hope to provide insight into what we – as providers – consider when we review information that a patient has brought to us. We will offer suggestions on how to increase the likelihood that your provider will read information you have provided them.
 

1) Know your provider. 


Every health care provider is different. You can probably already tell whether your provider is open to receiving information from patients. If it is not your provider’s style to be receptive, don’t push the issue. It will not work and may just set you up for frustration and possibly even create unnecessary animosity – which is counter-productive to any provider-patient relationship. Try to let it go, and look for other health care options!
 

2) Respect your provider’s time.


Even if your provider is willing to look at information you bring in order to help you determine whether it is reasonable or beneficial for you, doing so will take up time. 

Time is a significant problem in our modern health care system. Modern medicine has had to become a “lean, mean fighting machine.” As insurance reimbursement levels continue to fall, medical practices have had to find ways to be “efficient” in order to keep doors open. 

Your health care provider has mandatory objectives that need to be met during your visit in order to “close the loop.” They need to identify your medical issue, address it. and provide treatment all within 10 to 20 minutes (or whatever time your provider’s organization has allotted). After they complete your visit, they have 20 to 30 more visits to complete! 

Therefore, you may have to book another appointment to discuss an educational issue in detail. The question then becomes whether your insurance will pay for that time.
 

3) Understand your provider may be skeptical.


To keep you safe, health care providers tend to approach internet-based information with a certain degree of skepticism. 

The internet is fantastic in many ways, providing a wealth of knowledge just one click away! However, it is also flourishing with scams, misinformation, and deceptive practices often dressed up to look legitimate and wholesome. 

When your provider reviews information you show them, they should take a level of caution. However, providing patients with education is a big part of the healing process, so your provider should be willing to critically evaluate what you have brought them and realize that you are bringing it to their attention because it is IMPORTANT TO YOU. 

To encourage your provider’s receptivity, you may even want to point out exactly “why” the information is important to you and remind them that you really do respect their opinion (otherwise, you would not be putting your health into their hands).
 

4) Understand what “standards of care” means and implies.


How a health care provider practices is based on her or his knowledge-base – a composite of education and schooling, training, and experience. However, when we talk about “standards of care,” we are referring to the region-specific medical care standards practiced by surrounding providers in similar practices. 

Obviously, the “standards of care” will be different between a University Medical Center and a small community hospital. However, both sets of standards should still deliver an acceptable level of health care. 

To maintain a practice with an adequate “standard of care,” your health care provider may stick with the widely-accepted methods of care, without venturing out of that “standard of care” comfort zone. While cutting edge practices often bring about innovation in health care, adopting such practices carry significant risk for a provider. This goes back to the premise that it is your provider's responsibility to keep you safe. 

Regarding the topic of innovative REMS technology, DXA (Dual Energy X-Ray Absorptiometry) is considered the current “standard of care” while REMS (Radiofrequency Echographic Multi Spectrometry) has not yet achieved that designation. But we are working on it!
 

5) Show your provider respect.


Respectfully consider your health care provider’s advice and recommendations. If you disagree, tell them why you do not agree and what alternative plan you would prefer that they consider. Make sure you are able to explain your opinion (with valid references). 

Remember, your provider wants to keep you safe, but they also want to provide the highest level of health care possible in 10 minutes. 

Ultimately, YOUR health care is YOUR decision! Ask your physician to partner with you and offer their guidance. This is not an unreasonable request to make to your provider. 

Every so often, a patient will come into the Central Carolina Orthopaedics office and decline a cast. If splinting is a reasonable alternative, I – Dr. Bush – will explain to the patient why I think that casting is a better treatment choice. Then, I will discuss explicit instructions for splint use and document the patient’s preference in the medical record – as well as their statement of understanding of risks and rejection of my recommendations. Then, I will apply the splint per the patient’s request and continue to monitor their progress. In most cases, fulfilling such a request is not a big deal, but in certain cases, the choice may be far more significant – your provider may address each unique case differently!
 

6) Come prepared with adequate knowledge.


Since many providers know nothing about the REMS technology, you will have to have a strong understanding of it. Make sure that you understand the results of your report and the specific information that REMS provides that DXA does not (i.e. Fragility Score). 

To assist you with this challenge, the second portion of this post outlines the major properties of REMS (with included references).
 

WHAT YOU SHOULD KNOW ABOUT REMS


Central Carolina Orthopaedics Associates accepted the REMS technology early on – but not blindly, and only after thorough investigation and assessment of the available information. 

However, other health care providers may be slower to come around to new technology for many of the reasons stated above. It goes back to knowing your provider, respecting their time, and understanding where they are coming from. However, your provider also has the responsibility to provide the best level of care available, so we recommend that you remain patient, persistent, and ALWAYS respectful. 

Make sure your provider understands how important your bone health is to you. They should address it the same way they would address your weight or your blood pressure.
 

BASIC REMS FACT LIST:


Please feel free to copy this list and bring it to your health care provider.
 

  • REMS is equivalent to DXA in determining bone mineral density (BMD), according to World Health Organization standards.
  • REMS can be used to diagnose and monitor osteoporosis.
  • REMS is ultrasound-based and radiation-free.
  • REMS assessments are done in a provider’s office, producing immediate results.
  • REMS is portable (and thus, of significant public health value).
  • The REMS learning curve is not steep, as the technology is not prone to user error.
  • REMS is not prone to artifact error or patient positioning error.
  • REMS has a low LSC (0.5% to 1.0% error rate) and can be used to monitor bone over short periods of time.
  • REMS not only measures BMD, but it also provides a Fragility Score .
  • Fragility Score is a measure of bone “quality.”
  • The FDA approved REMS technology in the U.S. in 2018.
  • REMS is used in the European Union and multiple other countries, including Italy, Belgium, France, the United Kingdom, Poland, Australia, Japan, India, Brazil, Canada, Spain, and the United States.
  • REMS was designated the official method for bone densitometry in Italy in 2020.


REFERENCED DXA/REMS FACT SHEET (compiled by Andy Bush, MD, FAAOS, CWSP and Kim Zambito, MD, FAOA, FAAOS.)


Osteoporosis is diagnosed based on the World Health Organization (WHO) standard of measuring BMD at axial regions of interest (spine and hips) and determining the T-score. A T-score of -2.5 or lower has been defined as the threshold for the diagnosis of osteoporosis. (Tümay S, et al, An overview and management of osteoporosis, Eur J Rheumatol 2017; 4: 46-56)
 

HISTORICAL METHODS OF PERFORMING BONE DENSITOMETRY


DXA (Dual Energy X-Ray Absorptiometry) has historically been the standard method to measure BMD at the appropriate regions of interest. It is the primary method used in the United States to diagnose and monitor osteoporosis per WHO standards. (Lewiecki, M, et al, Best Practices for Dual-Energy X-ray Absorptiometry Measurement and Reporting: International Society for Clinical Densitometry Guidance, Journal of Clinical Densitometry: Assessment & Management of Musculoskeletal Health, Volume 19, 2016, 127-140) 

DXA error rates can be up to 90% . Meanwhile, the established error rate in BMD determination is 40% to 50%. The least significant change (LSC) for a calibrated DXA is 5%. Therefore, results should be considered clinically significant ONLY if the change between two DXA BMD measurements is 5% or greater. (Lecture #6, Can you Trust this DXA Report? IOF/ISCD Clinician Course, US version December 2020)

Heel ultrasound (QUS) is another historical method of bone assessment. QUS measurements were found to be predictive of fracture risk. However, because of technical issues, QUS could not provide axial BMD measurements. Therefore, it can not be used to diagnose or monitor osteoporosis based on WHO standards. (Krieg D, Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD, Official Positions, J Clinical Densit, 2008 Jan-Mar;11(1):163-87)
 

REMS – A NOVEL METHOD OF BONE DENSITOMETRY


REMS (Radiofrequency Echographic Multi Spectrometry) is a novel sonographic (ultrasound) method of determining BMD. REMS is echogenic, meaning it analyzes sound waves reflected off the bone (the echo). Therefore, it is technically different from QUS, which analyzes transmitted sound waves. 

With significant technological improvement from QUS, REMS can be used for axial bone assessment. The WHO established that REMS is equivalent to DXA in determining BMD at axial regions of interest (spine and hips). Therefore, REMS is a clinically acceptable method to diagnose and monitor osteoporosis per WHO standards. REMS technology has been used for almost ten years in the European Union to determine BMD. (Cortet B, et al, Radiofrequency Echographic Multi Spectrometry (REMS) for the diagnosis of osteoporosis in a European multicenter clinical context, Bone, (2021) 143:115786)

REMS is FDA-approved for use in the U.S. for the purposes of determining osteoporosis, monitoring its treatment, and providing FRAX-based fracture risk assessments. (FDA 501(k) premarket notification of intent to market, October 19, 2018)
 

SOURCES OF ERROR IN DENSITOMETRY


Arthritis or other artifacts affects the accuracy of DXA results, such as patient positioning – all of which can affect and modify how x-rays penetrate tissues (attenuation differential) and lead to inaccurate BMD determination.

Meanwhile, REMS is not susceptible to the effects of artifacts or patient positioning. In a REMS assessment, the sound waves interact with the bone tissues they insonify, and the important information about the tissue properties will be contained in the “echo.” The echographic waves are analyzed, and only the waveforms determined to be quantitatively similar to bone will be used for BMD and Fragility Score determination. ( Giovanni Adami, et al, Radiofrequency Echographic Multis Spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study, Bone, (2020) 134:115297)

The reported LSC, intra-operator, and inter-operator repeatability for REMS is significantly less than DXA (0.5 to 1.05%). ( Marco Di Paola, et al, Radiofrequency Echographic Multi Spectrometry compared with Dual X-ray Absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck, Osteoporosis International, (2019) 30(2):391-402)

DXA testing requires uniformity of testing methods to minimize error rates. When performing a series of tests with DXA, it is imperative that all DXA scans are performed on the same machine, preferably by the same examiner. The results of DXA tests performed on different machines and by different examiners should not be considered diagnostically useful. (Lecture #6, Can you Trust this DXA Report?, IOF/ISCD Clinician Course, US version December 2020)

REMS testing is echogenic – precisely the reason REMS is not susceptible to artifact error. The basic physics of insonified bone and method of analysis of the reflected sound waves eliminates the effects of arthritis, bone pathology, and the presence of foreign material on the results of the REMS assessment. This is in significant contrast to DXA. ( Marco Di Paola, et al, Radiofrequency Echographic Multi Spectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck, Osteoporosis International, (2019) 30(2):391-402)
 

DXA-DERIVED BMD IS NOT A VERY ACCURATE WAY TO DETERMINE FRACTURE RISK


DXA-derived BMD fracture risk determination is imperfect. The correlation of BMD with fracture risk can be best described as associative (not determinative). Low BMD values are associated with an increase in fracture risk. However, it is estimated that approximately 50% of all fragility-type fractures occur in individuals with BMD values that are either normal or near-normal. It is now understood that the structural properties of bone other than BMD – commonly referred to as the “bone quality” – factor into the determination of fracture risk. ( Leslie W, et al, Why Does Rate of Bone Density Loss Not Predict Fracture Risk? J of Clin Endo & Metab, 2015, 100(2); 679–683)
 

REMS OFFERS AN INNOVATIVE WAY OF DETERMINING FRACTURE RISK


In addition to BMD, REMS provides the Fragility Score (FS). The FS is a value derived from the identification and analysis of a particular sound wave containing information about the structural properties of the bone. The analysis of this sound wave yields a measure of bone quality. Therefore, FS is a method to quantify fracture risk, an aspect similar to the established capability of QUS. (Paola Pisani, et al, A quantitative ultrasound approach to estimate bone fragility: A first comparison with dual X-ray absorptiometry, Measurement (2017) 101: 243-249)
 

CENTRAL CAROLINA ORTHOPAEDICS ASSOCIATES | REMS TECHNOLOGY HEALTH CARE PROVIDER


Hopefully, the information in this post will help you in your bone health journey. Remember, health care is a team effort shared between you and your provider. Your provider is there to give you advice and guidance, but the person who makes the ultimate decision for your healthcare is YOU! 

Please feel free to copy and paste the above information into a Word Document of PDF and take it along to your appointment. Your provider may be willing to look at it, and it may open the door to a REMS discussion with them.

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