Osteoporosis Screening in a Resident-Driven Clinic of a Large Academic Hospital. Do we know enough?

From the 2019 HVPAA National Conference

Dr. Anam Umar (Morehouse School of Medicine), Dr. Titilope Olanipekun (Morehouse School of Medicine), Dr. Chelsy Harris (Morehouse School of Medicine), Dr. Hiu Sze Kwong (Morehouse School of Medicine), Dr. Muhammad Bilal (Morehouse School of Medicine), Dr. Claudia Fotzeu (Morehouse School of Medicine)

Introduction

Osteoporosis is associated with fragility fractures and represents a significant public health problem. The United States Preventive Services Task Forces (USPSTF) recommend dual-energy x-ray absorptiometry (DEXA Scan) of the hip and lumbar spine for osteoporosis screening in females aged 65 years and older. However, despite these recommendations, studies show that the screening rate remains suboptimal. Additionally, African-American females relative to other ethnic groups have been shown to have lower screening rates despite the higher risk of mortality following hip fractures. In teaching hospitals, internal medicine resident form an integral component of patient care and provide consultations to a significant proportion of patients in the primary care clinic.

Objective

Determine the screening rate for osteoporosis among women aged 65 years and older and identify factors that affect screening.

Method

We selected through simple random sampling, 1,118 female patients aged 65 and older that visited one of the out-patient departments of Grady Memorial Hospital, Atlanta between July 1, 2017, and June 30th, 2018. Data was extracted from the electronic medical record (EMR) system. Osteoporosis screening rate was determined using proportions and percentages. Patients were asked to complete a questionnaire on reasons for not getting screened. We surveyed 20 internal medicine residents that were involved in patient care regarding their knowledge of osteoporosis screening and factors that influence their decisions. STATA software was used and two-sided P-value < 0.05 was considered statistically significant.

Results

Osteoporosis screening rate using DEXA scan was 37%(n=402). However, there was a disparity in screening rates by ethnic groups; 33% in African Americans, 78% in Asians, 69% in Caucasians and 80% in Hispanics. Patients aged 65-75 years were more likely to have screening compared with age >75 (AOR 1.47 CI 1.04-3.16, P value<0.005). Also, Caucasians, Asians, and Hispanics were more likely to have screening compared to African Americans (AOR 1.29, CI 1.16-4.23, P value <0.005). 81% (n=583/716) of the patients without screening did not have DEXA scan ordered by their physicians. In cases where scan was ordered but not done, identified reasons included lack of patients’ knowledge on the importance of screening (43%), DEXA scan scheduling and transportation issues(52%), and inability to afford the test (3%). More than 50% of surveyed residents cited inadequate knowledge of the screening recommendations and not remembering to discuss screening with patients and subsequently placing the order.

Conclusion

Our study provides information on the osteoporosis screening rate in a resident-driven clinic of a large academic hospital. We found the presence of racial disparities consistent with what has been previously reported in the literature. Interestingly, it appears that resident physician provider-related factors primarily drive the sub-optimal osteoporosis screening rates. We propose that education on the screening guidelines should be consistently provided to resident physicians involved in the care of these patients. Also, incorporating reminder alerts and patient education materials on osteoporosis screening in the EMR system might improve the screening uptake and rate.

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