The Osteoporosis Centre, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
SIR, There is no policy for osteoporosis screening in the UK. It is generally recommended that bone density measurements be targeted towards high-risk groups [1] since it is not appropriate or effective to treat on the basis of clinical risk factors alone [2].
We offer an open access bone densitometry service measuring lumbar spine and total hip bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA). Patients are also asked to complete a risk-assessment questionnaire. Using information from the referral form, BMD measurement and patient questionnaire an individualized report is issued by a metabolic bone physician giving an interpretation of the BMD result and advice regarding management and follow-up. In approximately 10% of cases an appointment in the metabolic bone clinic is offered for detailed assessment on the basis of clinical need. In the remainder, the patient is advised to obtain the result of their scan from the referring physician. In cases where the referral is made from another hospital speciality, a copy of the BMD report is also sent to the patient's GP.
Our objective was to evaluate the information given to those patients who did not attend the metabolic bone clinic and identify whether they received appropriate treatment and lifestyle advice.
We retrospectively identified 295 patients who had undergone BMD scanning over a 2-month period a year earlier. Patients were sent a covering explanatory letter, questionnaire and pre-paid envelope. Consent was implied if patients responded. Non-responders were sent a reminder at 1 month. The actual report form presents a graphical and tabular summary of the BMD results with free text comments and for the purposes of this audit we classified BMD results on the basis of the lower Z score from the two measured sites as: normal (Z>-1); borderline (Z -1 to -2); and low (Z<-2). This simplified classification enabled comparison with the patient's recollection of the results using kappa statistics.
Two hundred and forty-three (82%) patients responded, 218 patient responses were suitable for analysis. One hundred and twenty-six patients (58%) had been referred by their GP, of these 118 (94%) had received their results, 112 (95%) via GP, four (3%) by a hospital doctor, three (2%) at the time of their scan. Of the remaining patients referred by a hospital consultant, 75 (82%) had received their results, 50 (67%) by hospital physician, 22 (29%) by GP, three (4%) by post. In total, 87% had received their results, 71% via their GP. Of the 189 patients who had received their results 20 (11%) were unable to recall the results given.
The comparison between the patients' understanding of their results and the actual BMD, resulted in a kappa score of 0.43 (95% CI 0.310.55).
Medication for the prevention or treatment of osteoporosis was commenced in 72 patients, this was appropriate in all cases. However, 17 patients did not receive treatment when this had been advised and of these seven had also not received their results (kappa score of 0.83, 95% CI 0.750.90). Eighty-two percent of patients were still taking treatment at 1 yr.
One hundred and eleven (51%) reports advised lifestyle advice as being appropriate. Only 36% recorded receiving some form of lifestyle advice, and only 30% of smokers recalled receiving advice to stop smoking.
Our questionnaire-based study involved 218 patients attending for DXA scan over a 2-month period. We found that 87% of our study population had received their results, mainly through their GPs and that, of these, 64% correctly recalled their result. Patient demographics, understanding of results and treatment implementation did not vary depending on who had been responsible for delivering their results.
A limitation of this project was the difficulty in classifying BMD measurements to compare with the patient's perceptions of their result. Our report forms take both T and Z scores into account in recommending treatment, together with the influence of risk factors acting independently of BMD such as family history of fractures. Therefore, it is difficult to categorize patients into simple groupings and we would not have expected to find more than a moderate agreement between BMD and the patient's understanding of the measurement. Generally, treatment was commenced appropriately in the 75% of those in whom it had been advised. In cases where treatment was started without specific advice this was mainly preventative in nature in patients with osteopenia and therefore appropriate. We were particularly encouraged to find that 82% of patients who had started treatment were still taking it 1 yr later. This is in contrast to previous studies, which suggest that persistence with osteoporosis therapy, particularly HRT, is very poor [3].
We found that many patients with lifestyle risk factors for osteoporosis had not been advised about these, or did not recall receiving this advice. This may be due in part to the wording on the report forms. As a result of this audit we now report lifestyle risk factors and advice to modify these in a more consistent manner and with greater emphasis.
To our knowledge this is the first audit of an open access bone densitometry report system. We specifically evaluated patients' understanding of their results, the treatment started and lifestyle advice received. We related this to the information given on the report forms. This has enabled us to assess the efficacy of an open access system and has highlighted areas where improvements could be made.
In conclusion, we believe the report form we have developed appears to be an effective way of delivering results of DXA scans to patients. As a result of this, treatment is in general being commenced appropriately and continued for at least 1 yr.
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