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Use of a performance algorithm improves utilization of vertebral fracture assessment in clinical practice

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Abstract

Summary

A performance algorithm can be successfully used by bone density technologists at the time of a bone density test to identify patients with an indication for vertebral fracture assessment (VFA). Doing so appropriately increases physician prescription of fracture prevention medication.

Introduction

Densitometric spine imaging (vertebral fracture assessment, VFA) can identify prevalent vertebral fracture but is underutilized. We developed an algorithm by which DXA technologists identify patients for whom VFA should be performed. Following this algorithm, VFA was performed in patients whose lowest T-score (lumbar spine, total hip, or femoral neck) was between −1.5 and −2.4 inclusive and with one of the following: age, ≥65 years; height loss, ≥1.5 in.; or current systemic glucocorticoid therapy. Our main objectives were to assess change in VFA utilization at two other healthcare organizations after algorithm implementation, and to estimate the association of VFA results with prescription of fracture prevention medication.

Methods

The proportions of patients with an indication for VFA who had one performed before and after algorithm implementation were compared. Logistic regression was used to estimate the multivariable-adjusted association of VFA results with subsequent prescription of fracture prevention medication adjusted for healthcare organization (study site).

Results

After algorithm introduction, appropriate VFA use rose significantly Patients with a VFA positive for vertebral fracture had an odds ratio of 3.2 (95 % C.I., 2.1–5.1) for being prescribed new fracture prevention medication, adjusted for age, sex, prior clinical fracture, use of glucocorticoid medication, femoral neck bone mineral density T-score, and study site.

Conclusions

An algorithm to identify those for whom VFA is indicated can successfully be implemented by DXA technologists. Documentation of vertebral fracture increases prescription of fracture prevention medication for patients who otherwise lack an apparent indication for such therapy.

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Acknowledgments

This study was funded by the University of Minnesota and University of Clinical Translational Science Institutes T2 Partnership Collaborative Grant under grant number CTSI-OCEH-2010-001.

We would also like to acknowledge Derek E. Fuerbringer, CNMT, at the University of Wisconsin and Matthew K. Breitenstein, MS, at Park Nicollet Clinic for their work retrieving bone density and electronic health record data for this study.

Conflicts of interest

Dr. Schousboe is the president of the International Society for Clinical Densitometry; Dr. McKiernan received a research grant from OPKO Health, Alexion; Mr. Fuehrer has nothing to disclose; and Dr. Binkley received research support from Amgen, Lilly, Merck, OPKO. Advisory board, Merck, Lilly.

Author information

Authors and Affiliations

  1. Health Research Center, Park Nicollet Clinic, 3800 Park Nicollet Blvd., Minneapolis, MN, 55416, USA

    J. T. Schousboe

  2. Division of Health Policy and Management, University of Minnesota, Minnesota, MN, USA

    J. T. Schousboe

  3. Marshfield Clinic Research Foundation, Marshfield, WI, USA

    F. McKiernan & J. T. Fuehrer

  4. University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

    N. Binkley

Authors
  1. J. T. Schousboe
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  2. F. McKiernan
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  3. J. T. Fuehrer
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  4. N. Binkley
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Corresponding author

Correspondence to J. T. Schousboe.

Appendix: Diagnosis and procedure codes used to characterize the study population at all three institutions

Appendix: Diagnosis and procedure codes used to characterize the study population at all three institutions

Those who had a bone density test were identified in EHR billing record by a CPT-4 code for a bone density test using dual energy X-ray absorptiometry (76075 or 76076 between 1 July 2005 and 31 December 2006, and 77080 or 77081 between 1 January 2007 and 30 June 2010). Those who also had a VFA were identified from encounters that also had a CPT-4 billing code of 76077 (on or before 31 December 2006) or 77080 (after 1 January 2007).

Those who had a clinical vertebral fracture were identified by any outpatient encounter with the one of the following ICD-9 diagnosis codes, or any inpatient hospital stay with one of the following primary or secondary discharge codes;

  1. (a)

    Spine 805.2, 805.4, 805.8, 733.13

  2. (b)

    Hip 820–820.32, 733.14

  3. (c)

    Pelvis 805.6, 808.0, 808.2, 808.4x, 808.8

  4. (d)

    Proximal humerus 812.0x, 812.2x, 733.11

  5. (e)

    Distal radius 813.4x, 813.5x, 813.8x, 733.12.

Downstream utilization of additional spine imaging was identified in EHR billing records as any encounter with one of the following CPT-4 codes;

  1. (a)

    Thoracic spine radiographs: 72070, 72072,72074,72080

  2. (b)

    Lumbar spine radiographs: 72100, 72110, 72114, 72120

  3. (c)

    CT scan of thoracic spine: 72128, 72129, 72130,

  4. (d)

    CT scan of lumbar spine: 72131, 72132, 72133

  5. (e)

    MRI thoracic spine: 72146, 72147, 72157

  6. (f)

    MRI lumbar spine: 72148, 72149, 72158

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Schousboe, J.T., McKiernan, F., Fuehrer, J.T. et al. Use of a performance algorithm improves utilization of vertebral fracture assessment in clinical practice. Osteoporos Int 25, 965–972 (2014). https://doi.org/10.1007/s00198-013-2519-y

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  • DOI: https://doi.org/10.1007/s00198-013-2519-y

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