Effect of self-referral on bone mineral density testing and osteoporosis treatment

Abstract

Background: Despite national guidelines recommending bone mineral density screening with dual-energy x-ray absorptiometry (DXA) in women aged 65 years and older, many women do not receive initial screening.

Objective: To determine the effectiveness of health system and patient-level interventions designed to increase appropriate DXA testing and osteoporosis treatment through (1) an invitation to self-refer for DXA (self-referral); (2) self-referral plus patient educational materials; and (3) usual care (UC, physician referral).

Research design: Parallel, group-randomized, controlled trials performed at Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Georgia (KPG).

Subjects: Women aged 65 years and older without a DXA in past 5 years.

Measures: DXA completion rates 90 days after intervention mailing and osteoporosis medication receipt 180 days after initial intervention mailing.

Results: From >12,000 eligible women, those randomized to self-referral were significantly more likely to receive a DXA than UC (13.0%-24.1% self-referral vs. 4.9%-5.9% UC, P<0.05). DXA rates did not significantly increase with patient educational materials. Osteoporosis was detected in a greater proportion of self-referral women compared with UC (P<0.001). The number needed to receive an invitation to result in a DXA in KPNW and KPG regions was approximately 5 and 12, respectively. New osteoporosis prescription rates were low (0.8%-3.4%) but significantly greater among self-referral versus UC in KPNW.

Conclusions: DXA rates significantly improved with a mailed invitation to schedule a scan without physician referral. Providing women the opportunity to self-refer may be an effective, low-cost strategy to increase access for recommended osteoporosis screening.

Figure 1

Screening and Randomization CONSORT Diagram

Figure 2

Cumulative incidence of DXA receipt in Kaiser Permanente Northwest (KPNW) (2a) and Kaiser Permanente Georgia (KPG) (2b) after two intervention strategies compared to usual care.

Figure 3

Rates of DXA Testing (3a) and Osteoporosis Prescription Treatment (3b) stratified by Bone Mineral Density and Treatment Groups for Each Study Region. SELF: self-referral without patient educational materials; SELF+DVD: self-referral with patient educational materials; UC: Usual Care. KPNW: Kaiser Permanente Northwest. KPG: Kaiser Permanente Georgia