Background/Purpose: Rheumatoid Arthritis (RA) is associated with an increased risk of osteopenia and osteoporosis, which may result in fragility fractures and significant cost and morbidity.  Bone density assessments are often overlooked in routine clinical practice, resulting in missed opportunities for early interventions and prevention of disease progression.  In the first phase of this multi-phase quality improvement project, a “Bone Health” prompt was added to the RA note template to remind physicians to document bone health status, Fracture Risk Assessment Tool scores, and management.  Initial documentation rate of bone health (ie, osteoporosis, osteopenia, normal bone density) was 65%.  We found that post-intervention documentation rates improved among residents (70%) and rheumatology fellows (82%).  It was unclear whether these changes could be sustained and, importantly, if the intervention would improve the quality of bone health management for RA patients.  The aim of this second phase of the project is to evaluate the sustainability of bone health documentation and the impact on clinical management in Veterans with RA in an academic clinic.

Methods: Pre-intervention documentation rates of bone health and appropriate management (defined as evaluation with DEXA or use of pharmacotherapy) were measured by reviewing 50 residents’ (internal medicine, PM&R) and 50 rheumatology fellows’ notes from August-October of 2017.  The “Bone Health” prompt (intervention) in the note template was implemented in December of 2017.  We reviewed 50 resident and 50 fellow notes from January-March of 2019 to evaluate the sustainability of bone health documentation and the rate of appropriate management 12 months after intervention implementation.

Results: One year after the original template intervention was introduced, the post-intervention documentation rate of bone health was sustained in both residents’ (88%) and fellows’ (82%) notes.  For bone health management, in the pre-intervention group, documentation was higher among residents (70%) than fellows (62%).  Twelve months after the intervention, rates of documentation of appropriate management dropped among residents (68%) but improved among fellows (74%).  Among the Veterans, three had significant medical comorbidities requiring emergency care or discontinuation of therapy, therefore, documenting bone health was less of a priority during these encounters.  A subgroup analysis including only Veterans with reduced bone density demonstrated documentation of appropriate management of 84% and 73% in the resident and fellow notes, respectively.

Conclusion: Adding a “Bone Health” prompt demonstrated sustained improvement of assessment over 12 months.  As compared to the pre-intervention data, documentation of management of bone disease improved in the fellow group but dropped in the resident group (possibly because they rotate more frequently); however, if Veterans with normal bone density were excluded, documentation of appropriate management improved in both groups.  Future projects can evaluate if prompting trainees to document bone health results in fewer fragility fractures. 

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/documenting-bone-health-for-veterans-with-rheumatoid-arthritis-in-an-outpatient-academic-clinic-a-multiphase-quality-improvement-project/