Improving osteoporosis assessment follow ups

Dr David Rees

Many reports from the Osteoporosis Assessment (Dual Energy X-Ray Absorptiometry - DEXA) Service at the Southern General Hospital request re-referral by GPs for follow up DEXA scanning via DADS (direct access DEXA service).  Typically the gap before re-referral is due is 1-5 years. This creates logistical problems in that there is no automatic system for re-referring patients. In normal ad hoc practice, I had come across a number of requests for re-referral that had not been acted on so I thought it might be illuminating to audit this and hopefully create an administrative solution to the problem of flagging up when these re-referrals were due, and making the referrals as recommended.

I used a search technique in Vision to identify patients who had had an Osteoporosis Assessment done in a 6 month period between Oct 2012 and April 2013. This period was chosen as it was felt it was sufficiently long ago such that it would be demonstrable that scans were or were not being appropriately re-referred for.

In this period, there were 41 patients who were coded as having had DEXA scans. 4 of these patients were no longer registered at the practice and these patients were excluded from the audit. Of the 37 patients left, 19 had had no follow-up requested.  The remaining 18 patients had been recommended to be re-referred for DEXA scanning in anything from 1-10 years. Of these 18 recommended re-referrals, 16 were not yet due.  Of the 2 patients who had been due re-referral for repeat scan, neither had in fact been re-referred. Only one of the 18 patients who had been recommended re-referral had had a “reminder” placed in the yellow box in Vision. It seemed unlikely therefore that the other 17 patients would later be re-referred for follow up scans.

The findings were discussed at a practice meeting and everyone agreed that there was likely to be a significant shortfall in the re-referring of these patients for repeat DEXA scanning. It was agreed that the best way around this problem would be to keep a paper-based diary. A patient-label would be placed on the page of a folder corresponding to the due date of the re-referral. A GP would periodically go through the folder and submit re-referrals for all of the appropriate patients. A computerised reminder system was setup so that admin staff would be alerted to remind a doctor to do this once per quarter.

I was concerned that many repeat DEXA scans may have already been missed so I searched for all patients who had had a DEXA scan in the last 7 years. 415 patients were identified. Of these patients, 192 patients had been recommended for re-referral. 46 of these patients were already overdue and these patients were re-referred. The patients were notified. The large number of referrals was discussed with the osteoporosis assessment service prior to sending the referrals – they approved. The remaining 146 patients were entered into the folder at the page corresponding to the date in which their referral was due. An email was sent out to all of the doctors in the surgery to explain the purpose of the new folder. Instructions for the doctor sending the re-referrals were placed in the folder.

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