Our results show that a system-based change, in which allied health staff work at their maximum level of licensure, can significantly improve the rate of osteoporosis screening with minimal involvement of the primary care provider. In our study, appointment secretaries identified patients due for osteoporosis screening through a population-based informatics system (PRECARES). The identified patients in the intervention group were then sent one letter requesting that they call to set up a DEXA scan. Three months after the letters were sent, the rate of osteoporosis screening was significantly improved in the intervention group compared with that in the control group. In the intervention group, 25% of the patients who received the letter responded and completed osteoporosis screening. In a prior study on breast cancer screening at Mayo Clinic, the percentage improvement with use of two reminder letters was greater than that observed in this study using only one letter.8
Therefore, more than one reminder letter for a preventive service may have an added benefit at a population level.
For the 44 patients who had their first DEXA scan as a result of the intervention, 82% received a diagnosis of osteopenia or osteoporosis. Review of their charts showed that most of these patients received appropriate treatment for low bone density. Among patients who had a repeat DEXA scan as a result of the intervention, very few (16%) had worsening of their bone density. This finding is consistent with those of a prior study showing that for healthy women aged 65 years and older, a repeat DEXA scan adds little value to initial bone mineral density measurement.9
However, in 36% of the patients in our study, repeat DEXA did result in the addition of calcium and vitamin D supplementation and/or the addition of a bisphosphonate.
The combination of short, 15 to 20 min primary care visits and an expanding list of clinical recommendations leads to significant pressure on the provider to address preventive care while also attempting to manage chronic diseases and acute needs.7
Therefore, population-based systems that can accurately identify the preventive needs of patients have considerable potential. If accurate and easy-to-use systems are available, allied health staff can provide timely reminders to patients due for preventive services, and protocols can enable them to order the tests on behalf of the primary care provider.10
Without PRECARES, population management would not be possible in our practice. The appointment staff would have to review the electronic medical record for all of the 5259 women patients aged 65 years and older in our practice to determine who had already completed osteoporosis screening and who was eligible for screening. Although it was still substantial, the effort needed to review the records of 772 patients to determine if they truly were eligible for screening was much less than it would have been for 5259 patients. For our study, our two appointment secretaries required less than 5 days to review the records and determine which patients were eligible for screening. We have now enhanced our population management system to further automate some of the prior manual processes.
A limitation of our study is the small number of patients who underwent initial osteoporosis screening. However, we were encouraged that among the patients who had their first DEXA scan, the intervention enabled us to identify a large percentage of patients who had osteopenia or osteoporosis and to begin appropriate treatment.
By developing information systems that serve the needs of patients who have not been seen in the office or who will not need a visit in the near future, we can ensure that their preventive care needs continue to be addressed. Information systems must be developed to support the workflow of the primary care practice and enable physicians to provide care for their population of patients. Population-based surveillance and delivery systems have the most promise to allow care for many patients who otherwise might not be receiving services.
As seen in our control group, many patients currently depend on receiving preventive services only through face-to-face contact with a provider. However, if patients have confidence that primary care practices have available the information systems and processes to address their needs for future preventive services, they might not request unnecessary visits to receive those services. If preventive services are being addressed by allied health staff using information systems, this will allow physicians more time to focus on acute care issues and chronic disease management. This holds especially true as we face a crisis in healthcare, with a future shortage of primary care physicians.12
Within our organization, the demonstrable early successes we had with breast cancer screening, osteoporosis screening, and population management of patients with diabetes mellitus helped us to convince our institutional leadership to invest further in the development of population management systems. We now also have dedicated staff in our appointment office to proactively manage not only our division's patient population, but also those of family medicine and pediatrics. Future reports will describe the ongoing initiatives we have for the management of diabetes mellitus and other conditions at a population level for all of our primary care patients.