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Running head: OSTEOPOROSIS SCREENING 1

A Quality Improvement Project:

Increasing Osteoporosis Screening in Women 65 Years and Older

A Scholarly Project Presented to

The Faculty of the Maryville University

Catherine McAuley School of Nursing

In Fulfillment of the Requirements

For the Degree of Doctor of Nursing Practice

Lori Johnson

August 1, 2018

OSTEOPOROSIS SCREENING

TABLE OF CONTENTS

Title Page 1

Table of Contents 2

Abstract 3

Chapter 1: Introduction 4

Chapter II: Review of Related Literature 11

Chapter III: Methods 26

Chapter IV: Findings 30

Chapter V: Discussion 33

References 40

Appendix 47

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ABSTRACT

A Quality Improvement Project: Increasing Osteoporosis Screening in Women 65 Years and Older

Background: Osteoporosis affects 16.2% of female adults greater than 65 years of age (Centers for Disease Control & Prevention [CDC], 2015). Complications associated with osteoporosis place a substantial financial burden on the healthcare system, cause debilitating chronic pain, and result in loss of function in patients with the disease. Although national guidelines exist for osteoporosis screening, adequate screening scores have not been reached in general practice.

Objective: The purpose of this pilot project was to determine if implementation of a quality improvement program increased the screening rate for osteoporosis in women 65 and older in a rural primary care clinic in the Midwest region of the United States.

Design: The pilot project utilized a quantitative, exploratory design. Several interventions were implemented including an educational intervention and procedural changes to improve osteoporosis screening scores. A nonprobability, convenience sampling was utilized for data collection. Following implementation of the program, 75 records were retrospectively reviewed of women 65 years and older who visited the clinic over a six-week period.

Results: Overall screening rates were low. Despite improving provider knowledge and implementing steps to remove perceived barriers of osteoporosis screening, overall dual energy X-ray absorptiometry (DXA) screening scores in women aged 65 and older remained low at 50%. Although the results are limited due to a small sample of wellness visits, osteoporosis screening was initiated at a much higher rate when the patient was scheduled for a wellness exam.

Conclusions: This pilot study is the first step in an improvement process to increase osteoporosis screening numbers. The study illustrates that despite improved provider knowledge and the implemented practice changes, a deficit in osteoporosis screening still exists. The findings suggest that scheduling a visit that is dedicated to wellness may be a key component in improving preventive clinical services.

Key words: Bone Mineral Density, Diagnosis, DXA, Guidelines, Osteoporosis, Prevention, Screening

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A Quality Improvement Project: Increasing Osteoporosis Screening in Women 65 Years and

Older

Chapter I: Introduction

Introduction to the Problem

Osteoporosis is a skeletal disease in which the density of the bone and the structural

integrity is impaired thus increasing the risk of fracture (National Institutes of Health [NIH],

2017). According to the Centers for Disease Control and Prevention (CDC) (n.d.), the quality

and the bone mass or bone mineral density (BMD) determine the strength of the bone.

Throughout life new bone is added to the skeleton (formation) and old bone is removed from the

skeleton (resorption). This process is mediated at the cellular level where osteoblasts are

involved in bone formation, and osteoclasts remove old bone (Gass & Dawson-Hughes, 2006).

During the younger years, the rate of formation is greater than the rate of resorption, making the

skeleton denser and stronger (NIH, 2017). This equilibrium shifts dramatically in the first years

after menopause and continues over time (Gass & Dawson-Hughes, 2006). As a result, bone is

not replaced, and the bone becomes thinner and more porous resulting in a loss of density.

Osteoporosis develops when this remodeling cycle is disrupted, and an imbalance occurs

resulting in impaired structural integrity of the bone (Toson, 2017).

Osteoporosis is highly prevalent. Globally, osteoporosis affects over 200 million people

(Nayak, Edwards, Salch & Greenspan, 2015). According to the U.S. Preventive Services Task

Force (USPSTF) (2011a), approximately 12 million Americans aged 50 and older were expected

to have osteoporosis by the year 2012. In 2005-2010, the Centers for Disease Control and

Prevention (CDC, 2015) report that osteoporosis affected 16.2% of adults greater than or equal to

65 years of age. During the same time frame, 48.3% of the same population had osteopenia at

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the lumbar spine or femur (CDC, 2015).

Throughout the world, a fracture strikes every three seconds with more than 8.9 million

fractures occurring annually (International Osteoporosis Foundation [IOF], 2015a). In patients

over the age of 50, the incidence of an osteoporotic fracture is higher in women (one in three)

compared to one in five in men (IOF, 2015a). Kling, Clarke, & Sandhu (2014) reported that

women have roughly a 40% to 50% lifetime risk of an osteoporotic fracture with men ranging

from 13% to 22%. In those seeking clinical evaluation, the IOF (2015a) reports a combined

lifetime risk for hip, forearm and vertebral fractures at approximately 40%. This risk is

comparable to the threat of cardiovascular disease.

Costs related to osteoporosis-related fractures are high. The National Osteoporosis

Foundation (NOF) (2018) reports that two million broken bones and $19 billion in related costs

per year are attributable to osteoporosis. By 2025, experts predict that those figures will rise

respectively to approximately three million fractures and $25.3 billion in costs annually. (NOF,

2018). The IOF (2015a) reported that women over 45 years of age spend more days in the

hospital from osteoporosis than diabetes, myocardial infarction, and breast cancer. In 2005, 2.5

million office visits, 180,000 nursing home admissions, and 432,000 hospital admissions were a

result of osteoporosis related illness (Kling et al., 2014).

Osteoporosis-related fractures affect patients’ quality of life. Many fractures result in

hospitalization and increased mortality. In addition, in women 50 years and older, nearly 40%

will suffer a hip, spine or wrist fracture in their ensuing years (Gass & Dawson-Hughes, 2006).

According to Gillespie and Morin (2017), approximately 10% - 20% of patients experiencing a

hip fracture will die within the first year following the injury and only 40% of patients will return

to their baseline level of independence. Fractures may also result in chronic pain, spinal

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deformity, diminished functioning, and the inability to perform normal activities of daily living

(Gass & Dawson-Hughes, 2006). Osteoporosis is preventable and treatable. Following

osteoporosis diagnosis, lifestyle modifications and pharmacologic treatment can significantly

decrease fracture risk (Gillispie & Morin, 2017). The fact that osteoporosis can be “silent” until

a fracture occurs makes screening the at-risk population essential. Existing research shows that

current screening levels are suboptimal. By improving osteoporosis screening, preventative

measures can be implemented in patients to help reduce the incidence of fracture.

Purpose and Aims

The overarching goal of this Doctorate of Nursing Practice (DNP) quality improvement

project is to improve osteoporosis screening in primary care. Without screening, osteoporosis

may go undetected until a fracture occurs. Osteoporosis related complications can place a

substantial financial burden on our healthcare system and cause debilitating effects with chronic

pain and loss of function in the osteoporotic patient. To address this growing concern, guidelines

for screening have been recommended to prevent serious health consequences and to provide

optimal care to patients. However, despite the recommendations, the screening rate remains

suboptimal. Provider confusion of the recommendations and time constraints of the provider

have been indicated as barriers to adequate screening.

Studies have shown that implementation of change strategies including a broad approach

are more effective in sustaining change. This was a pilot study that included an educational

intervention that encompassed the most current evidence-based practice guidelines of

osteoporosis to improve provider knowledge. In addition, several additional interventions were

implemented to facilitate change. The medical assistant flagged all women over the age of 65

when rooming patients. Prior to the intervention, the screening results were found under the

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diagnostic imaging tab in the medical record. To access the information, the provider had to go

out of the current record and review the diagnostic images to find a screening DXA report. A

new tab within the current record was adopted to store screening DXA results. This information

now carries forward to each subsequent note so the provider does not have to go out of the

current record to access results. The Fracture Risk Algorithm (FRAX®) tool is now located on

each computer to facilitate calculating a risk assessment. Following the quality improvement

initiative, a chart review was completed to evaluate change. The question of this study was: Did

the implementation of a quality improvement program increase the screening rate for

osteoporosis in women 65 and older?

A systematic review by Prior, Guerin and Grimmer-Somers (2008) revealed that

multifaceted intervention strategies resulted in greater effectiveness when compared to single

intervention strategies. The Institute for Healthcare Improvement (2017) supports utilizing the

Plan-Do-Study-Act (PDSA) cycle to determine if a small proposed change will lead to the

desired improvement. This was a pilot study to determine the effectiveness of change. Following

the intervention, screening scores were reassessed to determine if the implemented changes

improved screening scores. The facility plans to continue monitoring the change effect as a

quality indicator following the completion of this project. Educating healthcare workers about

osteoporosis and facility changes to improve clinical efficiency in practice were utilized to

improve practice.

Background of Problem of Interest

According to Kling et al. (2014), many primary and secondary interventions may be

utilized to reduce fracture risk. These strategies include calcium/vitamin D supplementation,

weight bearing exercise, tobacco avoidance, limiting alcohol, avoiding falls and trip hazards, and

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pharmacologic therapy. Screening for osteoporosis may expedite treatment before a fracture

occurs.

A risk assessment should be completed on patients to determine the need for BMD

testing (Cosman et al., 2014; IOF, 2017; NOF, 2014). A detailed medical history, family history,

physical examination including height measurement, review of medications, and fall history are

essential components of the risk evaluation.

There are many osteoporosis risk assessment tools available that have been validated for

use in postmenopausal women. According to Wright and Saag (2012), for fracture prediction, the

World Health Organization’s FRAX® tool has become the standard. This tool is a computerized

fracture-risk algorithm that was developed to calculate major osteoporotic and hip fracture risk

within 10 years. As the number of risk factors increases, the risk for osteoporosis also grows.

Kling et al. (2014) report that the most commonly used and validated method to measure

BMD is dual-energy X-ray absorptiometry (DXA). However, there is some variation in

recommended screening guidelines. The USPSTF, National Osteoporosis Foundation, and

American Association of Clinical Endocrinologists all include universal screening for women

over the age of 65 and others based on risk factors (Cosman, et al., 2014; Gass & Dawson-

Hughes, 2006; NOF, 2017; USPSTF, 2011a).

According to Kling et al. (2014), there are no current guidelines for screening intervals or

when to stop screening due to a lack of evidence. The USPSTF (2011a) also reports there is

insufficient data regarding ideal screening intervals. They do report that a minimum of two years

may be needed to accurately measure a change in BMD. The NOF recommends repeating BMD

evaluation 1 to 2 years after starting therapy for osteoporosis and then every two years (Cosman,

et al., 2014). No direct guidelines were found for repeat screening if the initial evaluation

8


revealed normal or higher bone mass. Further research regarding screening intervals and fracture

rates would be beneficial.

Although there are documented guidelines for osteoporosis screening, the adherence to

these evidence-based recommendations has been suboptimal. According to a study completed

by Gillespie and Morin (2017), between 2008 and 2014 less than one in four women aged 65 and

older had BMD screening completed. DeJesus et al. (2011) stated that despite the universal

screening recommendations for osteoporosis, the screening rate remained low at 12%-56%.

Curtis et al. (2008) completed a longitudinal study from 1999 to 2005 in patients 65 and older.

The study revealed that only about 30% of women and 4% of men in this age group had obtained

BMD screening. Furthermore, a study completed by Nayak, Roberts, and Greenspan (2008),

revealed that only 47.6% of surveyed patients (≥ 60 years old) reported their physician had

advised screening. These figures collectively indicate that the screening rates are suboptimal.

Significance

Nursing. The importance of education in nursing is crucial to ensure that quality

outcomes are achieved. Education will be utilized to instill the importance of screening at risk

patients for osteoporosis. Many variables may contribute to osteoporosis, but by screening

patients for osteoporosis, preventative measures can be implemented in patients to help reduce

the incidence of fracture.

Healthcare. Osteoporosis related fractures place a significant burden on our healthcare

system. The IOF (2015a) reported that women over 45 years of age spend more days in the

hospital from osteoporosis than diabetes, myocardial infarction, and breast cancer. Kling et al.

(2014) indicated that approximately 180,000 were admitted to nursing homes and 432,000 to the

hospital from osteoporosis related illness. By improving osteoporosis screening, preventative

9


measures can be implemented in patients before a fracture occurs, thus improving patients’

quality of life and decreasing the healthcare financial burden.

Advanced Practice Nursing. Advanced practice nurses have the opportunity to improve

outcomes by improving the screening process for osteoporosis. Osteoporotic related fractures

can cause detrimental lifestyle changes for a patient. By providing care at the tertiary level, the

advanced practice nurse has the ability to decrease the fracture related complications in the

osteoporotic patient. Osteoporosis is preventable and treatable. Early detection, lifestyle

modifications, and pharmacologic treatment can help prevent fractures (Gillispie & Morin,

2017), thus improving quality of life in our patients.

Practice Support for Project

The project was completed at a primary care practice in the rural Midwest. The practice

requested that the researcher provide an educational intervention on osteoporosis and current

screening guidelines. The practice administrator granted approval to complete the project in the

facility and the physician staff were supportive during the project.

Benefit of Project to Practice

The practice understood the importance of the project. The practice wanted to improve

osteoporosis screening scores within the practice and expressed the desire to implement

strategies to improve osteoporosis screening scores. The practice requested the researcher to

provide an educational intervention to review current screening guidelines. Evidence-based

practice guidelines were utilized to improve patient care. The results from this study are being

utilized to further improve osteoporosis screening scores and thus reduce the incidence of

fracture.

Conclusion

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Osteoporosis is a documented risk factor for fracture in older adults. Osteoporosis is

silent and may go undetected until a fracture occurs. Without screening, osteoporosis related

complications can place a substantial financial burden on our healthcare system and cause

debilitating effects with chronic pain and loss of function in the osteoporotic patient. To address

this growing concern, guidelines for screening have been recommended to prevent serious health

consequences, and to provide optimal care to patients. However, despite the recommendations,

the screening rate remains suboptimal. By improving osteoporosis screening, preventative

measures can be implemented in patients to help reduce the incidence of fracture.

Chapter II: Review of Related Literature

Search History

A variety of avenues were utilized to obtain resource information for this literature

search. The initial search of osteoporosis yielded expansive information requiring the search to

be narrowed. Osteoporosis pathophysiology, prevalence, statistics, epidemiology, prevention,

treatment, burden, screening guidelines, suboptimal screening and risk assessment were used to

obtain information on osteoporosis. Practice improvement, osteoporosis education, quality

improvement models, continuing education, and nursing knowledge were key terms utilized to

search for implementation of change processes. Organizational behavior and change theories

were utilized to initiate a search for theoretical frameworks. Articles were screened and limited

to those written in the English language. Computerized databases including ScienceDirect,

EBSCohost, ResearchGate and Google were utilized for the literature review search. Vital

statistics and screening guidelines were obtained from agencies including the Centers for Disease

Control and Prevention, United States Preventive Services Task Force, and World Health

Organization (WHO).

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Critical Analysis of Conceptual and Theoretical Literature

Fracture Prevention. Many primary and secondary interventions are utilized to reduce

fracture risk. These strategies include calcium/vitamin D supplementation, weight bearing

exercise, tobacco avoidance, limiting alcohol, avoiding falls and trip hazards, and pharmacologic

therapy. A review of the strategies is described below.

Calcium/Vitamin D Supplementation. Adequate levels of calcium and vitamin D have

been known for their role in bone health. There are guidelines for overall health and

recommended dietary intakes. However, there are conflicting results regarding their role in the

reduction of fractures. Further research would be helpful in further evaluating daily

supplementation of calcium and vitamin D and fracture incidence. Areas such as dosage,

comparative analysis of preparations, ethnicity, and age analysis when supplementation was

initiated, and future fracture incident are some areas that would be beneficial (USPSTF, 2011b).

There is also recent concern about potential risks of supplementation along with the unclear

balance of benefit versus harm leading to recent changes in the recommendations (Kling et al.,

2014).

U.S. Preventive Services Task Force. The USPSTF (2011b) reviewed six randomized

trials included in a meta-analysis to construct the 2011 guidelines for calcium and vitamin D

supplementation. These trials were completed in community-dwelling adults. When the results

were combined, a relative risk (RR) of 0.89 (95% Confidence Interval (CI), 0.76 to 1.04)

revealed no statistically significant reduction in fractures. The largest trial in this analysis was

the WHI trial. In this trial of postmenopausal women aged 50-79 years, a control group received

a placebo. The other group received vitamin D3 (400 international units [IU] daily) and calcium

(1,000 mg daily). No statistically significant reductions in hip fractures or total fractures were

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found. The USPSTF (2011b) could not generalize the findings beyond the parameters utilized in

the study.

After completing their review, the USPSTF (2011b) determined, with reasonable

certainty, that at these dosages of calcium and vitamin D3 or less, there was no clear benefit for

prevention of fractures. For noninstitutionalized postmenopausal women, they recommend

against these dosages. Additionally, they reported that there is a lack of evidence that higher

doses of calcium and vitamin D3 are helpful in preventing fractures. Based on this research, they

report that there is insufficient evidence to assess the balance of benefits and harm for primary

fracture prevention in premenopausal women or men with any daily dose of vitamin D3 and

calcium. Their earlier suggestions regarding vitamin D supplementation being effective in

preventing falls in community-dwelling adults aged 65 years and older with fall risks did not

change.

The report does note that following the USPSTF’s review concluded, an individual

patient meta-analysis was published. This review included 11 trials (some of which were

included in the USPSTF’s review) with 31,022 patients aged 65 and older. The study indicated

that higher doses of vitamin D (greater than or equal to 800 IU daily) may reduce fractures.

However, adjusted for subgroup analysis, the reduction was not considered statistically

significant. Given these findings, the USPSTF urges caution when considering these results.

Institute of Medicine. The Institute of Medicine (IOM) was asked to review the current

data regarding calcium and vitamin D supplementation by the U.S. and Canadian governments

(IOM, 2010). More than 1,000 studies and evidence from numerous scientists were examined.

They concluded that there was a strong body of evidence supporting bone health but the health

benefits beyond that could not be considered reliable (IOM, 2010). Furthermore, higher levels

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have not shown to provide an increased benefit and may actually be detrimental. Kidney stones

have been linked to too much supplementation of calcium and very high levels of vitamin D

(above 10,000 IUs/day) can cause kidney and tissue damage (IOM, 2010).

According to the IOM (2010), Recommended Dietary Allowances (RDA) are meant to be

utilized as a guide for proper nutrition in the U.S. and Canada. The RDA for calcium is

1,000mg/day for women 19-50 years and men 19-70 years. The RDA for calcium increases to

1,200 mg/day for females > 50 and men > 70 years of age. Assessing the recommended intake

for vitamin D is more difficult. Vitamin D comes from skin synthesis from sun exposure in

addition to dietary intake and patients have varied sun exposure. For this reason, minimal sun

exposure was utilized when constructing the recommendations. In the U.S. and Canada, the

IOM recommends the RDA for vitamin D at 600 IU/day for those less than 70 years, and 800

IU/day for those older than 70 (IOM, 2010).

National Osteoporosis Foundation. The National Osteoporosis Foundation convened an

expert panel from the foundation along with medical experts of bone health to develop The

Clinician’s Guide to Prevention and Treatment of Osteoporosis (Cosman, et al., 2014). The NOF

reports that the combination of calcium and vitamin D have demonstrated the reduction of

fracture risk (Cosman et al., 2014). The foundation recommends dietary supplementation if

adequate dietary intakes are not achieved.

Cosman et al. (2014) report the NOF advises 1,000 mg/day of calcium (men 50-70 years)

and 1,200 mg/day (women ≥ 51 and men ≥ 71 years). They also cite that there is no evidence

that increased doses promote any further bone strength but that excessive doses of calcium may

increase kidney stones, cardiovascular risk, and stroke, indicating controversial scientific

literature in this area.

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Vitamin D can help improve balance, performance of muscles, calcium absorption, bone

health and fall risk (Cosman et al., 2014). The NOF (2014) recommendations for vitamin D

intake are 800 to 1000 IU per day for adults age 50 and older. They also report that many

patients are at risk for vitamin D deficiency. They recommend checking serum 25(OH)D levels

in patients at risk of deficiency and correcting deficiency when needed (Cosman et al., 2014;

NOF, 2014).

Weight Bearing Exercise. Exercise has been widely recommended for a healthy lifestyle

as well as for osteoporosis prevention. Kling et al. (2014) report that weight-bearing and

muscle-strengthening exercise helps to improve agility, posture, balance, and strength. This may

help reduce the risk of falling. According to the IOF (2015b), physical activity can help reduce

the risk of osteoporosis and fracture.

The effect of women’s exercise interventions in preventing bone loss and fracture in

postmenopausal women was evaluated in a Cochrane review. Forty-three randomized controlled

trials and 4320 participants were included in the study (Howe et al., 2011). A small statistically

significant effect of exercise on bone density was observed. Non-weight bearing, high-force

exercise (e.g. progressive-resistance strength training of the lower limb) appeared to be the most

effective exercise on the bone density of the femur neck (MD 1.03; 95% CI 0.24 to 1.82). For

the spine, combination exercise programs were the most effective (MD 3.22; 95% CI 1.80 to

4.64). No effect on numbers of fractures was demonstrated.

Tobacco Avoidance. Numerous health organizations warn of the risks of smoking and

bone health (Cosman et al., 2014; IOF 2015b; NOF, 2014). Data from a landmark study by Law

and Hackshaw in 1997 are widely referenced. Law and Hackshaw’s (1997) meta-analysis

included 29 cross sectional studies that looked at bone density in relation to smoking habits and

15


age. The results revealed that roughly one in eight hip fractures could be linked to smoking.

Also, after menopause, the findings revealed that hip fractures are a significant adverse effect of

smoking. Furthermore, a substantial excess of bone loss occurs over decades increasing the

lifetime risk of hip fracture by half.

A second meta-analysis completed by Kanis et al. (2005), explored the relationship of

smoking with age, gender, and BMD. In this study, ten cohorts which included 59,232 men and

women (74% female) were studied. Results revealed that a smoking history accounted for a

statistically significant higher risk of fracture when compared to those without a smoking history

(RR 1.25; 95% CI 1.15–1.36).

Thirdly, a systematic review was completed by Vestergaard and Mosekilde (2003) to

assess the risk of fracture with smoking. Fifty studies including 512,399 subjects were included

in the study. The meta-analysis revealed that fracture risk was significantly increased in current

smokers for all fracture types combined (pooled relative risk 1.26, 95% CI 1.12–1.42).

Alcohol Moderation. Heavy alcohol consumption is widely discouraged by health

officials. According to the National Institutes of Health (2003), almost all epidemiologic studies

indicate that chronic heavy alcohol intake can adversely affect bone health. The IOF (2015b)

reports a 40% increased risk of an osteoporotic fracture in those that drink alcohol excessively (>

2 units/day) when compared to those with moderate or no alcohol intake. The IOF (2015b)

further reports that the high intake of alcohol affects the osteoblasts, calcium metabolism, and

can lead to poor nutritional status. However, the research regarding the association between

moderate alcohol consumption and BMD appears to be inconsistent.

A study completed by Hannan et al. (2000), evaluated risk factors in longitudinal changes

in bone density over four years. Eight hundred senior men and women from the population-

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based Framingham Osteoporosis Study were utilized. Multivariate regression analyses were

conducted for adjustment of all variables. The findings of this study may imply that for women

drinking 7 oz. or more of alcohol per week, a short-term bone loss may occur. Previous cross-

sectional findings implied a positive alcohol effect, but those findings were not duplicated.

Limitations to this study included bone density evaluation of only two points in time.

A meta-analysis was completed by Berg et al. (2008) to evaluate the association between

alcohol consumption and osteoporotic fracture and bone density. Internal validity criteria of the

U.S. Preventive Services Task Force was utilized to assess quality. When compared to

abstainers, a lower risk of hip fracture was found in those who consumed 0.5 to 1.0 drink per

day. There was no difference in those who drank 1 to 2 drinks per day compared to those who

did not drink. The highest risk was found in those who drank more than 2 drinks per day.

Often, the results were adjusted for smoking, age, and body mass index. However, few studies

adjusted for variables such as calcium intake, physical activity or exposure to estrogen. Further

research would be beneficial to address these variables and to determine the precise range of

alcohol that would be most beneficial to bone health.

Avoidance of Falls/Trip Hazards. A fall for an osteoporotic patient can be devastating.

Gass and Dawson-Hughes (2006) report that roughly 30 percent of people ≥ 60 years fall at least

once a year with an increased incidence in those ≥ 80 years. The literature collectively indicates

the importance of fall prevention in the older population. Cosman et al. (2014) recommend

incorporating home safety assessments into the plan of care for patients. Including trip and fall

hazards, correction of vision, balance training exercises, avoiding medications that cause central

nervous system depression, and vigilant monitoring of blood pressure lowering medications are

helpful. Kling et al. (2014) also included hearing correction and hip pad protectors for patients

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with significant risk.

Pharmacologic Therapy. According to the USPSTF 2011 Clinical Guidelines,

pharmacologic therapy can be administered for primary or secondary prevention (USPSTF,

2011a).

According to Cosman et al. (2014, p. 2), the NOF recommends pharmacologic treatment

in postmenopausal women and men age 50 and older:

- In those with hip or vertebral (clinical or asymptomatic) fractures

- In those with T-scores ≤ - 2.5 at the femoral neck, total hip, or lumbar spine by

DXA

- In postmenopausal women and men age 50 and older with low bone mass (T-

score between -1.0 and -2.5, osteopenia) at the femoral neck, total hip, or lumbar

spine by DXA [dual-energy X-ray absorptiometry] and a 10-year hip fracture

probability ≥3% or a 10-year major osteoporosis-related fracture probability

≥20% based on the USA-adapted WHO absolute facture risk model (Fracture

Risk Algorithm [FRAX®])

The NOF lists several Food and Drug Administration (FDA)-approved pharmacologic

options for osteoporosis (Cosman, et al., 2014; NOF, 2014). All patients being considered for

pharmacologic therapy should be advised on preventative measures. Secondary causes of

osteoporosis should be explored and patients should have diagnostic studies completed.

Decisions on the treatment plan should be based on clinical judgement after synthesizing the

current recommendations and available clinical information (Cosman et al., 2014).

The evidence demonstrates treatment can reduce postmenopausal osteoporosis fracture

risk (Kling et al., 2014). Seurer and Huntingon (2015) report that high-quality studies comparing

18


pharmacologic therapies are lacking. They add that the provider and patient should reach a

mutual decision regarding pharmacologic treatment after evaluating factors such as efficacy,

safety, and price. Further research would be helpful to further compare treatment regimens and

to expand the research in men.

Risk Assessment. A risk assessment should be completed on patients to determine the

need for BMD testing (Cosman et al., 2014). A detailed medical history, family history, social

history, physical examination including height measurement, review of medications, and fall

history are essential components of the risk evaluation. In addition, a 10-year estimated fracture

probability may be calculated. As the number of risk factors increases, the risk for osteoporosis

also grows.

There are many osteoporosis risk assessment tools available that have been validated for

use in postmenopausal women. According to Wright and Saag (2012), for fracture prediction,

the World Health Organization’s FRAX® tool has become the standard. This tool is a

computerized fracture-risk algorithm that was developed to calculate major osteoporotic and hip

fracture risk within 10 years. The tool utilizes the femoral neck BMD and clinical risk factors to

calculate the fracture risk.

Although FRAX® is the recommended screening tool by the WHO, the tool still has

limitations. Unnanuntana, Gladnick, Donnelly, and Lane (2010) discuss that the relationships

between risk factors and fracture risk incorporated into the FRAX® model may have been

underestimated as many fractures such as wrist fractures are treated as an outpatient and may not

have been included. Generalizability is another area that has been questioned. The data used to

design the FRAX® tool was based on predominantly white and higher educated subjects than the

population of the United States. Wright and Saag (2012) recommend further examination

19


regarding the performance in subpopulations. Other important factors such as 25-hydroxyvitamin

D levels are not included. Cosman, et al. (2014) also indicate that there may be other risk factors

that are not included in the FRAX® tool. Further research to address some of these areas would

be helpful.

According to the NOF, FRAX® was designed to be utilized only on postmenopausal

women and men over the age of 50 (Cosman et al., 2014; NOF, 2017). Kling et al. (2014) report

that despite the intended audience, the FRAX® model was validated for men and women ages

40-90. The FRAX® tool is not indicated for use on patients already receiving pharmacotherapy.

Femoral neck BMD or total hip BMD may be utilized to calculate FRAX® but femoral neck

BMD is preferred. The NOF further specifies that clinical judgment must be utilized when

deciding on treatment and there are risk factors that are not built in the FRAX® tool (Cosman et

al., 2014; NOF, 2017).

Screening Guidelines. Screening for osteoporosis may expedite treatment before a

fracture occurs. Kling et al. (2014) report that the most commonly used and validated method to

measure BMD is DXA. There is some variation in recommended screening guidelines but they

all include women ≥ 65 years. According to the NOF, these are guidelines only and clinical

judgment should be used with each individual case (Cosman, et al., 2014; NOF, 2017). Some of

the recommendations for screening BMD are outlined below.

National Osteoporosis Foundation.

• All women ≥ 65 years and men ≥ 70 years

• Postmenopausal women and men over age 50-69, based on risk factor

• Postmenopausal women and men ≥ 50 years with a history of adult age fracture

• Adults with a disorder or taking a medication that may result in decreased bone

20


mass/bone loss (Cosman et al., 2014; NOF, 2017)

USPSTF.

• Women ≥ 65 years and younger women that have the risk of fracture equal to or greater

than a white 65-year-old woman with no added risk fractures

• Men – existing evidence is inadequate to determine benefit/risk balance (USPSTF,

2011a)

American Association of Clinical Endocrinologists.

• Women ≥ 65 years

• Women - all peri- and postmenopausal women with risk factors for osteoporosis if

willing to consider pharmacologic treatment (Camacho, et al. 2016; Gass & Dawson-Hughes,

2006)

According to Kling et al. (2014), there are no current guidelines for screening intervals or

when to stop screening due to a lack of evidence. The USPSTF (2011a) also reports there is

insufficient data regarding ideal screening intervals. They do report that a minimum of two years

may be needed to accurately measure a change in BMD. The NOF recommends repeating BMD

evaluation 1 to 2 years after starting therapy for osteoporosis and then every two years (Cosman,

et al., 2014; NOF, 2017). No direct guidelines were found for repeat screening if the initial

evaluation revealed normal or higher bone mass. The NOF does discuss considering vertebral

imaging in patients with significant risk (Cosman, et al., 2014; NOF, 2017). Further research

regarding screening intervals and fracture rates would be beneficial.

Diagnosis of Osteoporosis. The WHO (2017) utilizes a T-score to define the categories

for diagnosis of osteoporosis. The T-score compares BMD to average values for young healthy

women. The diagnostic categories include:

21


• normal (T-score -1.0 and greater)

• low bone mass, osteopenia (T-score between -1.0 and -2.5)

• osteoporosis (T-score -2.5 and below)

• severe osteoporosis (T-score -2.5 and below with a fracture history)

Although criterion is needed to establish osteoporosis. They should not be the only determinant

in deciding on treatment.

Current Rate of Screening is Suboptimal. Although there are documented guidelines

for osteoporosis screening, the adherence to these evidence-based recommendations has been

suboptimal. According to a study completed by Gillespie and Morin (2017), between 2008 and

2014 less than one in four women aged 65 and older had BMD screening completed. DeJesus et

al. (2011) stated that despite the universal screening recommendations for osteoporosis, the

screening rate remained low at 12%-56%. Curtis et al. (2008) completed a longitudinal study

from 1999 to 2005 in patients 65 and older. The study revealed that only about 30% of women

and 4% of men in this age group had obtained BMD screening. Furthermore, a study completed

by Nayak, Roberts, and Greenspan (2008), revealed that only 47.6% of surveyed patients (≥ 60

years old) reported their physician had advised screening. These figures collectively indicate that

the screening rates are suboptimal. Given the importance of assessing the risk of osteoporotic

fractures, strategies to increase DXA use in at-risk persons are indicated.

Knowledge Gap. Studies regarding deficits of knowledge of current osteoporosis

guidelines by health care providers exist (Saag, 2011; Sabin & Sarter, 2014; Giangregoria,

Fisher, Papaioannou, & Adachi, 2016. The studies are limited, however, with regards to

knowledge deficits of primary care providers in the United States. Giangregorio, Fisher,

Papaioannou and Adachi (2016) evaluated osteoporosis knowledge and learning needs in

22


healthcare professionals in Canada working with patients who were at risk for a fracture or had

already sustained a fracture. An osteoporosis knowledge and learning needs questionnaire that

had been tested for validity was completed by the providers. The low scores on key questions

indicate gaps of knowledge specifically related to health promotion and management of patients.

One of the methods that providers indicated they would like to receive information was

presentations at their work setting.

A descriptive study evaluating the knowledge of primary health care providers in

Malatya, Turkey indicated that their knowledge base was very limited and that 87.9% of the

participants wanted to obtain further knowledge about osteoporosis (Yagmur, 2009). Another

descriptive study completed by Hannon and Murphy (2007) surveyed nurses’ and midwives’

knowledge of osteoporosis and assessed their education and training needs. Almost all

respondents indicated a need for further education on osteoporosis.

Literature Critique

The literature related to osteoporosis is expansive. After reviewing a large volume of

information, substantive information including evidence-based practice was obtained. Overall

the literature was well researched and thorough. However, there are some areas with gaps and

limitations in the research.

Strengths. Overall, the quality of research was well established and rigorous. When

looking at hierarchy of research studies, the studies ranged from single randomized control

studies to expert reviews with a concentration in the higher levels of research. One example is

the National Osteoporosis Foundation (2014). Cosman et al. (2014) reported that the NOF

utilized an expert panel in combination with medical experts of bone health. Berg et al. (2008)

completed a meta-analysis with Internal Validity Criteria by the USPSTF and a Cochrane review

23


was completed by Howe et al. (2011).

Weaknesses. The study completed by Hannan et al. (2000) was a longitudinal study that

evaluated changes in bone density in relation to alcohol intake. A noted weakness in this study

was that it only included bone density evaluation in two points of time and the results implied

that in women drinking 7 oz. or more of alcohol per week a short-term bone loss may occur.

Further research regarding alcohol would be helpful to adjust for variables such as exercise,

calcium, vitamin D intake, and estrogen therapy.

Gaps and Limitations. Seurer and Huntingon (2015) report that high-quality studies

comparing pharmacologic therapies are lacking. Further research would be helpful to further

evaluate and compare treatment regimens and the effectiveness of FDA-approved treatments for

patients with low bone density. Evaluating the effectiveness at specified time frames along with

side effects would be helpful to further define recommended length of treatment. In addition,

looking at combination therapies or sequential treatment to determine if there is any increase in

efficacy or if increased risks are associated with this treatment plan would also be advantageous.

Further research to identify recommended screening intervals would also be beneficial.

The FRAX® tool has not been validated in patients currently or previously treated with

pharmacotherapy for osteoporosis. It would also be helpful for the FRAX® algorithm to

incorporate information on lumbar spine BMD and 25-hydroxyvitamin D levels. Further studies

regarding secondary osteoporosis and risk assessment would be helpful. Much of the research is

limited in regards to men and ethnicity. Further studies to expand the research in this area would

be valuable.

Concepts and Definitions

The following definitions were utilized for this study:

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Bone density is the measurement of the mineral content in bone that is used to determine

the strength of the bone. (Merriam-Webster Medical Dictionary, 2017).

Dual-energy X-ray absorptiometry (DXA) is an enhanced form of x-ray technology that

uses low dose radiation to determine the bone density of the bone usually in the hip and spine

(NOF, 2017).

Epidemiology is “the study of the distribution and determinants of health-related states or

events in populations . . .” (Last, 1988).

Incidence is a measure that determines a person’s probability of being diagnosed with a

disease during a specific period of time (Department of Health, 1999, p. 159).

Menopause is the time in a woman’s life when the patient has stopped having menses for

12 months (CDC, 2017).

Morbidity is a term for illness (Department of Health, 1999).

Mortality is a term for death (Department of Health, 1999).

Primary prevention are health promotion activities that are utilized to prevent the

occurrence of an illness or disease and reduce risk factors (CDC, 1992)

Secondary prevention is a term that refers to promoting early detection, screening and

treatment of disease. (CDC, 1992)

T-score is a value of measurement of a person’s bone density when compared to a

healthy 30-year old adult. (NIH, 2015).

Tertiary prevention includes providing supportive and rehabilitative services to minimize

death and disability and improve quality of life. (CDC, 1992)

Theoretical Framework

The Theory of Planned Behavior (TPB) is a theory that was proposed by Icek Aizen in

25


the 1980s to explain the factors that mediate human behavior (Aizen, 1991). Boslaugh (2013)

explains that this theory is based on the assumption that people utilize information and reasoning

to guide their behavior. It describes three determinants that drive an individual’s intention to

perform a behavior. The three factors are attitude toward behavior, a social factor termed

subjective norm, and perceived behavioral control (Aizen, 1991).

According to Aizen (1991), the first variable is the individual’s intention to perform a

behavior. That intent involves the degree to which a person has a favorable or unfavorable

evaluation of the proposed response. The second variable includes the person’s social pressure to

perform or not perform the behavior. Perceived behavioral control is the final variable. Here the

person looks at the ability to perform the action. This includes looking at past experiences as

well as evaluating obstacles or anticipated impediments (Aizen, 1991).

This theory is relevant to this project as it will be used to plan interventions to promote

behavior changes in primary care providers. Staff members were included in reviewing the

current processes to identify key areas they felt were deterrents to improving screening scores.

The combination of awareness of the devastation that an osteoporotic fracture can cause and the

facility wide initiative to improve osteoporosis scores will stimulate social pressure within the

organization to facilitate change. An educational program with current evidence based practice

was presented to promote perceived behavioral control in order to initiate change. Facility

changes that included steps to improve clinical efficiency and decrease time constraints on

providers were implemented to make providers more receptive to the changes.

Chapter III: Methods

Methodology & Design

This study utilized an exploratory, quantitative design to determine the effectiveness of

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change. The Institute for Healthcare Improvement (2017) supports utilizing the Plan-Do-Study-

Act (PDSA) cycle to determine if a small proposed change will lead to the desired improvement.

During the development phase, providers and staff collaborated to identify some key components

of the intervention. An educational intervention including the most current evidence-based

practice guidelines of osteoporosis to improve provider knowledge combined with process

changes to improve efficiency was implemented. After a six-week trial period, a retrospective

chart review was conducted to determine if the guidelines and other strategies improved

screening and prompted treatment. The results of the retrospective chart audit provided

information to make revisions to the program.

Needs Assessment

Although there are documented guidelines for osteoporosis screening, numerous studies

have revealed that the adherence to these evidence-based recommendations has been suboptimal

(Curtis et al., 2008; DeJesus et al., 2011; Gillespie & Morin, 2017; Nayak, Roberts & Greenspan,

2008). The literature clearly indicates a need for change to improve osteoporosis screening.

Following the literature review, the clinic discovered that the rate of osteoporosis screening for

women 65 and older in this clinic was approximately 50%. Prior to this intervention, each

provider in the facility ordered DXA screening on a case-by-case basis. The current layout of

the chart made it difficult for providers to locate DXA results quickly. These results guided

educating healthcare providers about osteoporosis and quality improvement initiatives in an

effort to improve practice.

Research Question

This capstone project served to review the following question: Does implementation of a

quality improvement program increase the screening rate for osteoporosis in women 65 and

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older?

Data Collection Instruments

The data collection tool utilized in this project was developed by the researcher after an

extensive literature review. The following information was collected from the electronic medical

records and entered in listed columns onto the electronic data sheet: (a) visit type (wellness

exam, routine follow up, or acute); (b) DXA completed prior to October 6, 2017 (yes or no); (c)

chart flagged by medical assistant (yes or no); (d) DXA order initiated (yes or no); and (e) DXA

results documented in chart (yes or no). A sequential inclusion and exclusion process was

utilized until the determined 75 number of EMRs was achieved.

Analysis Plan

Descriptive statistics were used to describe information. Instead of collecting data from

an entire population, researchers usually study a carefully selected sample. By using descriptive

statistics, the researcher organized and described the data from that sample group. This allowed

large amounts of data to be simplified in a sensible way and presented in a manageable form.

The baseline percentage of osteoporosis screening for women 65 and older in the clinic

was 50%. A retrospective chart review was completed six weeks following the intervention.

Screening scores were reassessed to determine if the implemented changes improve screening

scores. Descriptive statistics summarized the results. To improve the project design, a z-score

was calculated to compare the screening rates. The results of the retrospective chart review

provided information to make revisions to the program if necessary, or continue the program if

found to be successful during the trial period. The facility plans to continue monitoring the

change effect as a quality indicator following the completion of this project.

Budget

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The expenses for this project were absorbed by the researcher. The time needed for

development of the educational component, presentation and data collection was waived by the

researcher. Equipment such as a password protected computer was already owned by the

researcher and there was no incurred expense for this. Copy paper for handouts to staff was

approximately $5. There was no expense for staff time as the educational intervention was

completed over lunch hour. There was no charge for use of the facility equipment for the

presentation. The total direct expense was minimal.

Protection of Human Subjects

One strategy researchers take to protect participants is a risk/benefit assessment

(Polit & Beck, 2017). The researcher completed formal training on ethical conduct and research

plans were submitted for Institutional Review Board (IRB) approval. This project did not have

any foreseeable threat for physical, psychological, social, economic or legal risk that would

result from this study. There was a potential but unlikely risk of a breach of confidentiality.

This was minimal and every effort was taken to maintain confidentiality.

A retrospective chart audit of electronic medical records was utilized to collect data. The

data was generated from these electronic records. To comply with the Health Insurance

Portability and Accountability Act Privacy Rule, the data collection sheet was stored on a

password protected computer that was located in the researcher’s locked office. Access was

limited to the author of the project. In this study, each medical record was assigned a numerical

number on the data collection sheet. The minimum necessary data was collected to achieve the

goals of the project. Potential identifiers were removed, and data has been presented in aggregate

form. All collected data for the project was destroyed with completion of the project.

The burden from the potential breach of confidentiality of the subjects was incidental and

29


did not exceed the benefit of the knowledge gained about the implementation of screening and

treatment for osteoporosis in this high-risk population. Thus, the potential benefits outweighed

the risk.

Resources

The resources needed for this project included the electronic medical record system,

equipment and available space to present the educational component, and staff participation.

The electronic medical record system at the clinic enabled the researcher to collect data from

patient charts. The data collection sheet that was developed kept the data organized and concise.

Time commitment from the researcher was required to retrieve the data. A password protected

computer was utilized to store the data worksheet and compile the data. Analysis of the data was

achieved by utilizing an Excel spreadsheet and statistical calculator. Facility staff with expertise

in the medical record system was needed to change the structure of the medical record to be able

to formulate a tab within the note to store DXA results. For the educational component of the

project, a conference room along with the technology to present a PowerPoint presentation

(included in Appendix A) was needed. Staff resources included the facility administrator,

providers and medical assistants.

Project Timeline

To track the timeline of the project, a Gantt Chart (Appendix B) was created to ensure

timely completion. Each milestone date was estimated and every step in the project depended on

timely completion of the previous steps. The timeline was also dependent upon IRB approval

and approval from the DNP project committee.

Chapter IV: Findings

Data Collection Method

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The study was a descriptive, quantitative pilot study. The data was collected from the

intended primary care clinic in the Midwest region of the United States. A retrospective chart

review was completed and included data from a six-week trial period (October 6, 2017 through

November 17, 2017) following the intervention. The intended seventy-five electronic medical

records (EMRs) were accessed by the researcher. The instrument utilized for data collection was

completed by the researcher after an extensive literature review. The data was collected in a

consistent manner over a one-week span following implementation of the program. Each EMR

was given a numerical number and entered on the data collection sheet. All patient identifiers

were removed. The information from the data collection sheet was entered onto an Excel

spreadsheet and the statistical analysis was then computed.

Target Variables

Data collection plans should yield accurate, valid and meaningful data (Polit & Beck,

2017). The data collection variables that were measured in this study included visit type, DXA

completed prior to visit, chart flagged by medical assistant, DXA order initiated at time of visit,

and correct documentation of the DXA results that were entered in the chart. Visit type was

identified as a wellness exam, follow-up appointment, or acute care visit. The intended sample

size of 75 EMRs was achieved. The variables were measured consistently and precisely after

completion of the program. The data collection followed the IRB approved proposal and was

congruent with the project design.

Study Replication

Replication of a study involves utilizing the same research plan and applying it to

different participants or subjects (Polit & Beck, 2017). Precise measurement is critical in

quantitative research. The detailed process of this research was thoroughly explained including

31


the IRB application, data collection plan, and descriptive statistics. Following the project

implementation, consistent data was obtained which will allow for recommendations for further

studies and replication of the data collection plan.

Validity and Reliability

The concepts of validity and reliability aid the researcher in evaluating measurement

tools utilized in research studies (Polit & Beck, 2017). The data collection instrument was

developed by the researcher after an extensive literature review. It consisted of five variables

with a coded response for each question. Content and face validity was achieved by having the

collection instrument evaluated by a panel of experts. They evaluated and confirmed that the

instrument was evaluating the intended items. To ensure consistency of results, the student

followed the data collection plan and was responsible for all of the data collection.

Reliability relates to how consistent a test can measure a variable (Kim & Mallory, 2017.

The instrument itself was developed to improve reliability. Pulling direct information from the

chart and utilizing specific coding increased the reliability of the instrument. However,

repetition would further improve the reliability of the instrument.

Descriptive Statistics

Descriptive statistics were utilized to describe and summarize the data from the sample

group. This enables the researcher to provide great detail about the characteristics of the study

sample and allows a large amount of data to be reduced into a simpler summary.

The sample consisted of 75 females aged 65 and older who were seen in the clinic from

October 6, 2017 through November 17, 2017. Exclusion criteria consisted of those who had

received a DXA scan prior to October 6, 2017. Forty-two (56%) of the visits were an acute type

visit, thirty-one (41.33%) were classified as a routine follow-up, and two (2.67%) were

32


scheduled as a wellness visit.

Of the 42 patients that had a visit for an acute type of service, one (2%) was flagged by

the medical assistant and one (2%) received an order for a DXA scan at the visit. In the 31

follow-up visits, one (3%) was flagged by the medical assistant and two participants (6%)

received an order for a DXA scan at the visit. The two participants that were scheduled for a

wellness visit, 100% were flagged by the medical assistant before the provider saw the patient,

an order for a DXA was initiated at the visit (100%), and the results were properly documented

in the chart (100%).

Results

Prior to the intervention, there were a total of 805 female patients aged 65 and older. Of

those patients, 404 (50%) had received a screening DXA. Following the intervention, there were

a total of 818 female patients aged 65 and older. Of those patients, 407 (50%) had received a

screening DXA. A z-score was computed utilizing a statistical calculator. The z-score result

was .1736; p=.865, which revealed no statistical significance. A z-score is an appropriate test

choice for this study, as it enables two scores from different normal distributions to be compared

(Kim & Mallory, 2017).

Chapter V: Discussion

Summary of Findings

Early detection and treatment of osteoporosis is critical in improving outcomes and

reducing disability. When comparing pre- and post-intervention screening scores, no statistical

significance was found. The computed z-score was .1736, p=.865. Improved knowledge did not

improve the screening rate of osteoporosis in the clinic. Although the results are limited due to a

small sample of wellness visits, osteoporosis screening was initiated at a much higher rate on

33


those patients scheduled for a wellness exam when compared to a follow-up examination or an

acute visit.

Interpretation of Findings

The statistical analysis was completed by utilizing a z-score. No statistical significance

was found in overall screening scores pre- and post- intervention. Seventy-five records were

evaluated. Descriptive statistics showed an improvement in screening score in those patients that

were scheduled for a wellness exam as compared to those that were scheduled for a follow-up or

acute visit.

The educational component and clinical changes did not significantly enhance the

effectiveness of osteoporosis screening. Gaps between evidence-based guidelines and medical

care in practice still exist. These findings suggest that improved knowledge does not change

behavior (improve practice). However, what was very important for future practice is the

improvement in screening scores in patients that were scheduled for a wellness exam.

Analysis

Immediately following the research, the data was analyzed. Since the project looked at

comparison, a z-score was the most logical statistical analysis. The z-score result was .1736;

p=.865, which revealed no statistical significance. When looking at descriptive statistics, in

those patients scheduled for a wellness exam, 100% had a DXA ordered, compared to 3% in

patients scheduled for a follow-up visit, and 2% in those scheduled for an acute visit.

Strengths and Limitations

A solid data collection plan is crucial to obtain dependable results in research. It is

important to obtain accurate, valid, and meaningful data in research (Polit & Beck, 2017). A

clear data collection plan will help achieve consistent results. When developing a data collection

34


plan, it is important to look at the quality of the data collection plan. In research, it is vital to

utilize a sample that is representative of the intended population. This will enable the researcher

to be able to generalize the findings beyond the sample used (Polit & Beck, 2017). The sample

utilized is representative of the desired population. A retrospective chart review was utilized to

collect data which is appropriate for this type of study.

The data collection instrument was developed by the researcher after an extensive

literature review. It consisted of five variables with a coded response for each question. It is also

important to measure the intended concept. In this project, to look at improvement of

osteoporosis screening scores, it is necessary to look at the number of patients who have received

a screening DXA which was done in the data collection. The data was further broken down by

visit type and the number of DXA tests ordered in the sample.

It was determined that seventy-five EMRs would be reviewed for this project. This

number of EMRs yielded a power of 0.80. The intended number of EMRs was reviewed. To

ensure consistency of results, the researcher followed the data collection plan and was

responsible for data collection. All of the data was collected from the proposed clinic following

implementation of a six-week trial after the implementation of the project. Data was collected

over a one-week period.

Limitations included utilizing a non-random sampling plan. The utilization of

convenience sampling can increase the risk of bias. This study only included patients from one

office during the designated time of the study. The sample size was limited due to the nature and

time constraints of the study which may impact the generalizability of the findings.

Implications for Research and Practice

Although statistical significance was not found in the research, important findings that

35


relate to practice were identified. Previous research did reveal suboptimal screening for

osteoporosis, lack of knowledge related to guidelines, and provider frustration regarding

management of health prevention due to lack of time. DeJesus et al. (2011) completed a study

that looked at predictors of osteoporosis screening completion. This study did note that patients

that were undergoing a full examination were more likely to be screened but did not statistically

compare that to other visit types. A similar retrospective study that looked at screening for

abdominal aortic aneurisms found that screening was more likely to be ordered at a general

medical examination versus an acute care visit or follow-up examination (Eaton et al., 2012).

Although provider knowledge deficits do exist, it appears that lack of knowledge is not

the greatest barrier to preventive services. It is becoming increasingly difficult to address the

array of preventive services in a routine office visit. It is estimated that it would take nearly a

full day of a provider’s time to address all of the Grade A and B preventive healthcare

recommendations from the US Preventive Services Task Force (Saag, 2011). Although

knowledge was a critical component to the change process and needed as a predecessor to

practice change, improved knowledge did not change behavior. Dedicating a visit to preventive

services may be key to improving screening scores for osteoporosis as well as other

recommended preventive services.

Nursing and Healthcare

Clinical preventive services are critical in improving patient’s health and reducing death

and disability. Outcomes can be improved by discovering certain diseases early and initiating

prompt treatment. Osteoporosis care specifically aims at early detection to prevent fractures and

ultimately improve health-related quality of life. This also helps decrease the healthcare

financial burden.

36


Advanced practice registered nurses (APRNs) are at the forefront of delivering

preventive care to patients. Early detection and treatment can help prevent fractures and improve

the quality of life in our patients. APRNs have the opportunity to improve outcomes by

improving the screening process for osteoporosis.

Benefit of Project to Practice

The purpose of this project was to implement a quality improvement program to increase

osteoporosis screening scores. The office has committed to improve preventive services,

specifically osteoporosis screening, and has included it as a quality indicator for the next year.

The educational component increased provider awareness of the recommended screening

guidelines as well as treatment recommendations to prevent fracture and further disability from

osteoporosis. Although the implemented strategies did not improve overall screening scores,

valuable information was obtained for further improvement initiatives with regards to preventive

services. Although the number of wellness visits in the sample size was low, screening scores

were much higher with a wellness visit when compared to an acute visit or a follow-up exam.

The literature has documented this as well.

Review of the findings of this study has stimulated further investigation of preventive

clinical services. The Office of Disease Prevention and Health Promotion (2014) developed

Healthy People 2020 which strives to identify nationwide health improvement priorities. The

initiative indicates that clinical preventive services, such as routine disease screening and

scheduled immunizations, are key to reducing death and disability and improving the Nation’s

health. They further indicate that although these services are covered by Medicare, Medicaid,

and many private insurance plans, millions of patients “go without clinical preventive services

that could protect them from developing a number of serious diseases or help them treat certain

37


health conditions before they worsen” (Office of Disease Prevention and Health Promotion,

2014, para.1). Getting patients into the office for a wellness exam may be the key to getting

preventive services completed.

The Welcome to Medicare Preventive Visit is a one-time initial visit that is covered

within the first 12 months that a patient is enrolled in Part B. Original Medicare covers this visit

with no coinsurance or deductible if you see providers who “take assignment” (The Official U.S.

Government Site for Medicare, 2018). The purpose of this exam is to introduce the beneficiary to

Medicare. Key components include discussing health promotion, early disease detection, and

preventive services that can help the patient stay well.

This was a pilot study and the results of this project have stimulated initiatives to increase

wellness exams in the office which in turn will help increase preventive services. The facility

has recently started contacting patients that turn 65 in the upcoming year by phone to schedule a

Welcome to Medicare Preventive Visit. During the current initial trial period, three dedicated

providers in the office including the researcher are providing these services. During this visit,

recommended clinical preventive services including immunizations, screenings and healthy

lifestyles are discussed. Recommended screenings are scheduled that day. Osteoporosis

screening will continue to be monitored quarterly as a quality indicator to determine if this

change is effective.

Recommendations

Further research regarding improving preventive clinical services including osteoporosis

screening should be studied. Studies to evaluate the long-term effects of interventions beyond

six weeks post-intervention would be beneficial. Larger sample sizes should be utilized to

enable a more accurate interpretation of statistical significance. This may increase the

38


generalizability of the results. Given the results of this study, further studies that look at how

increasing wellness exams affect preventive screening scores should be completed.

Conclusion

As the U.S. population continues to age, an increasing number of patients will be affected

by osteoporosis. Osteoporotic related fractures can result in chronic pain, loss of function,

decreased quality of life, and increased mortality. The fact that osteoporosis can be “silent” until

a fracture occurs makes screening the at-risk population essential. Existing research shows that

current screening levels are suboptimal. Barriers in the patient, provider and health system levels

have been recognized.

This study utilized a quantitative, exploratory design. An educational intervention and

procedural changes were implemented to improve osteoporosis screening scores. A convenience

sample of 75 records was reviewed from women 65 years and older who were seen at the clinic

over a six-week period following the intervention. A z-score was used to compare pre- and post-

intervention findings. The analysis did not reveal improvement in screening scores; however,

important practice information was obtained. Although the sample size was limited, screening

scores were much higher for those patients scheduled for a wellness exam. It is anticipated that

this pilot study can be utilized to further inspire research to evaluate promising practices to

increase osteoporosis screening.

39


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Appendix A

Educational Intervention Power Point Slides

47

OSTEOPOROSIS SCREENING 48


Appendix B

Projected Timeline

4/20

17

5/20

17

6/20

17

7/20

17

8/20

17

9/20

17

10/2

017

11

/201

7

01/2

018

2/20

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3/20

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3/20

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4/20

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5/20

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6/20

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7/20

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8/20

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Concept Analysis

X X

Comprehensive Literature Review

X X

Proposal XSubmission to IRB at Maryville

X

Program Implementation

X

Data Collection XData Analysis XData Interpretation

X

Discussion Section

X X

Final Paper X XDisseminationof project

X X

49

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