Is it Possible to Educate Your Healthcare Provider About REMS?

The answer is ……a definite maybe! Obviously, all provider-patient relationships are different and depend not only on the provider and the patient, but the type of relationship you can have with your provider often depends on the setting where the healthcare is being delivered. In the body of this post we hope to provide insight into what we as providers consider when we review information that a patient has brought to us. We want to offer some suggestions on how to encourage and increase the likelihood that your provider will read what you have provided to them.

Know thy provider!!!!! - Everyone is different and you probably will already know whether or not your provider is amenable to receiving information from patients. If it is not your provider’s style to be receptive - don’t push the issue because it will not work and it may just set up feelings of frustration and possibly even unnecessary animosity which is counter-productive to any provider-patient relationship. Let it go and look for other options!

Respect your provider’s time!!!! - Even if your provider is willing to look at information that you bring in to help you determine if it is reasonable and even possibly beneficial for you it will take up time. Time is a problem in our modern health care system - modern medicine has had to become a “lean and mean fighting machine.” As insurance reimbursement levels continue to fall in order to stay open medical practices have to be “efficient”. Your provider has mandatory objectives that need to be completed during your visit in order to “close the loop” that include identifying your medical issue, addressing it and providing treatment all within in either 10, 15 or 20 minutes, whatever time your provider’s business overlords have allotted (very few providers are in their own practices). After they have completed your visit, they have 20-30 more visits to complete! You may have to book additional time (the question is whether insurance will pay for that time) to discuss an educational issue in any significant detail.

Understand that your provider may be skeptical of internet-based information that you bring in order to help keep you safe!!!!! - The internet is fantastic in many ways and there is a wealth of knowledge just a click away! However, there are also scams, misinformation and deceptive practices flourishing, often dressed up to look legitimate and wholesome. When your provider reviews something that you bring in, there should be a level of caution on their part. 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 to their attention because it is important to you. You may want to even point out how important it is to you for them to evaluate what you have brought to them and that you really respect their opinion - otherwise you wouldn’t be putting your health into their hands!

Understand what “standards of care” means and implies!!! - How a provider practices is based on her/his knowledge-base which is a composite of education/school, training and experience. However, “standards of care” are the region specific medical care standards practiced by surrounding providers in similar practice situations. Obviously, the “standards of care” will be different between a University Medical Center and a small community hospital. However, both “standards” should still deliver an acceptable level of health care. In order to maintain practice with an accepted “standard of care” a provider may stay with acceptable methods of providing care and not venture out of that “standard of care” comfort zone. Cutting edge is often what brings about innovation in health care but it is possibly a risky proposition - that goes back to the premise that it is your provider's responsibility to keep you safe. In regards to our topic - DXA is considered “standard of care”; REMS has not yet achieved that designation (but we are working on it!)

Show your provider that you respect their advice and recommendations, but if you disagree, tell them why you don’t agree and what alternative plan you would prefer that they consider. Be sure to be able to explain your opinion and having a valid reference at hand will go a long way!!!! Understand that your provider wants to keep you safe, but they also want to provide the highest level of healthcare that they can - 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. For example, every so often there will be a patient in my ortho practice who declines a cast. If splinting is a reasonable alternative, then I will explain to the patient why I think that casting is a better treatment choice; 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 declination of my recommendations, and then apply the splint and continue to monitor their progress. In most cases, it’s not a big deal - but sometimes it may be so it has to be case-by-case!

With REMS, since many providers know nothing about it, you will have to be knowledgeable. Make sure that you understand the results of your report and the specific information that REMS provides that DXA does not (Fragility Score). To assist you in this challenge, the second portion of this post is an outline of the major properties of REMS with included references. If your provider is willing to accept it, or better yet to look it over in your presence, that may be the first step in the process of breaking through their first line of defenses and possibly raising their curiosity. You can only hope!



We at the Bone Matrix accepted REMS technology early on - but not blindly and only after investigation and assessment of the available information. However, other providers may be slower in coming around to new technology for all of the above stated reasons. It goes back to knowing your provider, respecting their time, and understanding where they are coming from. However, your provider also has the responsibility of providing the best level of care that is available to you and so we recommend that you remain patient but be persistent and always, always respectful. Obviously, bone health is an important issue to all of you, so make sure that your provider understands that point and they should address it with you the same way that they address your weight or your blood pressure.

SHORT REMS LIST:

REMS is equivalent to DXA in determining BMD according to the World Health Organization standards

REMS can be used to diagnose and to monitor osteoporosis

REMS is radiation free - it is ultrasound-based

REMS is done in a provider’s office and results are immediately available

REMS is portable (significant public health value)

REMS learning curve is not steep - REMS is not prone to user error

REMS is not prone to artifact error or patient positioning error

REMS has a low LSC (0.5-1.0% - error rate) can be used to monitor bone over short periods of time

REMS measures BMD and also provides a Fragility Score

Fragility Score is a measure of BONE QUALITY

FDA approved in the US in 2018

REMS is used in the European Union and multiple other countries: Italy, Belgium. France. United Kingdom, Poland, Australia, Japan, India, Brazil, Canada, Spain, United States.

REMS was designated the Official method for bone densitometry in Italy in 2020.

Please feel free to copy this list!

Referenced DXA/REMS Fact Sheet - compiled by Andy Bush, MD, FAAOS, CWSP and Kim Zambito, MD, FAOA, FAAOS:

Osteoporosis is diagnosed based on the WHO standard of measuring BMD at axial Regions of Interest (spine and hips) and then determining the T-score. A T-score of (-)2.5 or lower has been defined as 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 densitometry:

DXA (Dual Energy Xray Absorptiometry) has been historically the standard method to measure BMD at the appropriate Regions of Interest and it is the main method in the United States used 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)

Error rates in DXA can be up to 90%! - that includes all errors. The established error rate in BMD determination is 40-50%! LSC for a calibrated DXA is 5%. - therefore, only if the change between two DXA bone BMD measurements is 5% or greater then should the results be considered clinically significant (Lecture #6, Can you Trust this DXA Report?, IOF/ISCD Clinician Course, US version December 2020).

Heel ultrasound (QUS) is another historical method to assess bone. QUS measurements were found to be predictive of fracture risk. However, because of technical issues, QUS could not provide axial BMD measurements; therefore, it could not be used to diagnose and/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 - novel method of bone densitometry:

REMS (Radiofrequency Echographic Multi Spectrometry) is a novel sonographic (ultrasound) method of determining BMD. REMS is echogenic - it analyzes the soundwaves that have been reflected from the bone (the echo). Therefore, it is technically different from QUS which analyzes transmitted sound waves. Because of the technological improvements over QUS, REMS can be used for axial bone assessment. REMS has been determined to be a method that 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. It 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 US for the determination of osteoporosis and to monitor its treatment and to provide a FRAX-based fracture risk. (FDA 501(k) premarket notification of intent to market, October 19, 2018).

Sources of error in densitometry:

DXA accuracy is affected by arthritis or other artifacts including patient positioning all of which can affect and modify how x-rays penetrate tissues (attenuation differential) leading to inaccurate BMD determination.

REMS is not susceptible to the effects of artifacts or by patient positioning. In a REMS assessment, the sound waves will interact with the tissues (bone) that they insonify and the information about the properties of that tissue will be contained in the “echo”. The echographic waves are analyzed and only the waveforms that are 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 are significantly less than DXA (0.5 - 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 and that is the reason why REMS is not susceptible to artifact error. The basic physics of insonified bone and how the reflected sound waves are analyzed 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 to fracture risk can be best described as associative, and 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 just BMD, which are 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 a novel way to determine fracture risk:

REMS provides the Fragility Score (FS). The FS is a value that is derived from the identification and analysis of a particular sound wave that contains information on 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 - this aspect of REMS is 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).

Hopefully, the information in this post will help at least some of you in your Bone Health journey. Remember that healthcare is a team effort and your provider is a member or YOUR team. They are 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.