A Quality Improvement Project to Increase the Rate of Age Appropriate Dxa Screening for Female Patients in a Harris Health Internal Medicine Resident Clinic

Osteoporosis is common and carries a significant burden of morbidity and mortality. Early pharmacologic therapy for osteoporosis can reduce osteoporotic fractures. Thus, the USPSTF recommends dual energy x-ray absorptiometry (DXA) screening for osteoporosis in women above the age of 65. Screening for osteoporosis is often seen as a responsibility of the primary care provider. When caring for patients with multiple medical comorbidities, health maintenance exams, including DXA scans, are often overlooked. This study aimed to determine the rate at which DXA screening was being ordered in women aged 65 years or older receiving care from internal medicine residents in an outpatient primary care clinic and increase the rate of osteoporosis screening to 30%.

A retrospective chart review was conducted from July 2014 to September 2014 to identify baseline osteoporosis screening rates in age appropriate women. Over the following two months, two Plan-Do-Study-Act (PDSA) cycles were conducted. PDSA cycle 1 involved posting osteoporosis awareness signs aimed at both patients and physicians in the clinic. PDSA cycle 2 involved a presentation to residents and staff that included baseline DXA screening rates, logistics of obtaining a DXA scan within the Harris Health system, and instructions to modify current clinic templates. Patient charts were reviewed following each intervention to reassess screening rates. Results were recorded in both tables and run charts.

A baseline chart review of all patients seen in resident clinic between July and September 2014 resulted in the identification of 666 female patients. Of these patients, 84 (12.6%) met USPSTF criteria for osteoporosis screening. Of these patients, 50 women had not been previously screened. This baseline data showed that 1 of the 50 women eligible for screening (2%) was screened. Following the implementation of awareness posters during PDSA cycle 1, we improved resident driven screening rates to 5/47 (10.6%).  Following PDSA cycle 2, 5/61 (8.2%) of patients were screened.  The rates of screening were plotted on a run chart and no significant patterns emerged.

Although our project did not produce statistically significant results, our interventions resulted in screening additional patients who otherwise may not have been screened. Our results suggest that educational interventions alone do not produce a significant impact. Thus, we suggest that future efforts be directed towards stronger and more sustainable interventions, such as standardized note templates, electronic order sets, and electronic reminders.