Improve Screening for Osteoporosis with a Simple Intervention

November 11, 2009 ‐ Patton McGinley

November / December 2009

Quality Improvement

By Alicia Appel, MD; Thomas Mackenzie, MD, MSPH, FAC

Osteoporosis is a common disease characterized by low bone mass with microarchitectural disruption and skeletal fragility, resulting in an increased risk of fracture. In the United States today, an estimated 10 million individuals have the disease, and almost 34 million more have low bone mass, placing them at increased risk for osteoporosis. In 2005, osteoporosis-related fractures were responsible for an estimated $17 billion in costs By 2040, experts predict that these costs may double or triple due to the aging population (NOF, 2008).

Screening for and treating osteoporosis among asymptomatic women over age 65 costs about $55,000 per quality-adjusted life year saved placing this service in a cost-effectiveness range similar to accepted preventive health services such as mammography screening for breast cancer (Mobley et al., 2006).

Intervention
In 2007, we queried our electronic clinical database for all active primary care patients older than age 60 years who had one or more risk factors for osteoporosis and had never had a bone density test or dual-energy x-ray absorptiometry (DEXA) performed at our integrated public health system. Risk factors included low body weight (< 127 lbs), current smoking, and history of vertebral, wrist, radial or hip fracture. We used ICD-9 codes for fracture data and were therefore unable to distinguish traumatic from non-traumatic fractures. Risk fracture frequencies by age are listed in Table 1.

Risk Factor Groups	Age (years)					Total
Risk Factor Groups	60-64	65-69	70-74	75-80	80+	Total
A. – Fracture / – Smoker / Wt > 127	1531	1114	706	461	343	4155
B. – Fracture / – Smoker / Wt <= 127	139	123	90	96	165	613
C. + Fracture / – Smoker / Wt > 127	1	3	1	2	3	10
D. + Fracture / – Smoker / Wt <= 127	0	1	1	0	2	4
E. + Fracture / + Smoker / Wt > 127	2	0	2	0	0	4
F. + Fracture / + Smoker / Wt <= 127	2	0	2	0	0	4
G. – Fracture / + Smoker / Wt > 127	549	268	144	61	28	1050
H. – Fracture / + Smoker / Wt <= 127	81	63	30	24	20	218
Total	2305	1572	974	644	562	6057

Table 1. Active primary care patients age 60 years and older with no electronic documentation of bone-density testing, by age and risk factor status.

Patient Letter

   {pt full name}
   {pt address}

   Medical Record Number: {pt mrn}
   Date of Birth: {dob}
   Primary Care Provider: {pcp full name or “none”}

   Dear {pt full name},

   At Denver Health, we are trying to improve our care for people who may
be at high risk for osteoporosis, a condition that causes thinning and
weakening of the bones. Based on information in our computers, we
think that you may have risk factors for this condition called
osteoporosis. There is a simple X-ray test called a bone density test
(or “DEXA Scan”) which can be done to check for this condition. Please
make an appointment with your primary care doctor to discuss getting
this test. We are enclosing a handout with information on osteoporosis
which may answer some of your questions. We have also sent a similar
to your primary care doctor listed above on this letter. If you have
more questions about this letter or about how to get the test, please
call 303-436-5211. Thank you.

   Sincerely,

   Alicia Appel, MD
   Thomas Mackenzie, MD, MSPH, FACP

We elected to intervene on the 239 patients at
highest risk for an osteoporotic fracture (highlighted in the table).
This group included 21 patients with previous fracture, regardless of
weight or smoking status, and 218 patients who were both smokers and
underweight. We sent letters to both patients and providers (see
above), excluding 4 patients due to death or homelessness.

We advised the patients and providers to order
a bone density test on these patients. Approximately 3 months later, 20
patients (9%) had received a bone density test. Of the 20 patients, 11
had osteoporosis (55%), and 5 had osteopenia (25%). The remaining 20%
were normal. From both chart review and direct contact with providers,
we determined that the letter prompted the order for the DEXA in 14 of
the cases. In 4 of the patients, it could not be determined. While some
of the bone-density testing among the intervention patients might have
been ordered without the letter prompt, the majority of the providers
did report that the letter prompted them to order the study.

Provider Letter

   Patient Name:
   Medical Record Number: {pt mrn}
   Date of Birth: {dob}

Dear Provider:

As part of a quality improvement project, we have pulled the names of those patients at high risk for osteoporosis. These patients are all 60 years of age or older and have had a previous fracture, are smokers, have low body weight or have some combination of these risk factors and have not had a DEXA scan in the Denver Health system. As you are probably aware, there are 700,000 spine fractures and 250,000 hip fractures each year in the US leading to a great deal of morbidity and mortality. I hope you will consider ordering a bone density test on this patient. A similar letter has also been sent to the patient. If this patient is not yours, please try to direct this letter to the appropriate provider.

Sincerely,

Alicia Appel, MD
Thomas Mackenzie, MD, MSPH, FACP

Summary
This project demonstrates that rates of osteoporosis screening among
particularly high-risk individuals can be improved in a short window of
time by a simple and low-cost intervention. Clinical data warehouses,
which combine financial data (ICD-9 and CPT codes) with clinical
measures (smoking status, weight, age), can be valuable tools for
quality improvement interventions.

Thomas Mackenzie is the director of general internal medicine and director of quality improvement at DHHA.

References
National Osteoporosis Foundation. (2002). America’s bone health: The state of osteoporosis and low bone mass in our nation. Washington, DC: National Osteopororis Foundation.

Mobley, L. R., Hoerger, T. J., Wittenborn, J. S., Galuska, D. A., & Rao, J. K. (2006). Cost-effectiveness of osteoporosis screening and treatment with hormone replacement therapy, raloxifene, or alendronate. Medical Decision Making, 26(2), 194-206.

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