title: Effect of self-referral on bone mineral density testing and osteoporosis treatment.
abstract: BACKGROUND
  Despite national guidelines recommending bone mineral density screening with dual-energy x-ray absorptiometry (DXA) in women aged 65 years and older, many women do not receive initial screening.
  
  
  OBJECTIVE
  To determine the effectiveness of health system and patient-level interventions designed to increase appropriate DXA testing and osteoporosis treatment through (1) an invitation to self-refer for DXA (self-referral); (2) self-referral plus patient educational materials; and (3) usual care (UC, physician referral).
  
  
  METHODS
  Parallel, group-randomized, controlled trials performed at Kaiser Permanente Northwest (KPNW) and Kaiser Permanente Georgia (KPG).
  
  
  METHODS
  Women aged 65 years and older without a DXA in past 5 years.
  
  
  METHODS
  DXA completion rates 90 days after intervention mailing and osteoporosis medication receipt 180 days after initial intervention mailing.
  
  
  RESULTS
  From >12,000 eligible women, those randomized to self-referral were significantly more likely to receive a DXA than UC (13.0%-24.1% self-referral vs. 4.9%-5.9% UC, P<0.05). DXA rates did not significantly increase with patient educational materials. Osteoporosis was detected in a greater proportion of self-referral women compared with UC (P<0.001). The number needed to receive an invitation to result in a DXA in KPNW and KPG regions was approximately 5 and 12, respectively. New osteoporosis prescription rates were low (0.8%-3.4%) but significantly greater among self-referral versus UC in KPNW.
  
  
  CONCLUSIONS
  DXA rates significantly improved with a mailed invitation to schedule a scan without physician referral. Providing women the opportunity to self-refer may be an effective, low-cost strategy to increase access for recommended osteoporosis screening.
authors.affiliation: Divisions of *Endocrinology, Diabetes and Metabolism †Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL ‡Kaiser Permanente Center for Health Research/Northwest, Portland, OR §Kaiser Permanente Center for Health Research/Southeast, Atlanta, GA ∥Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA ¶Division of Clinical Immunology and Rheumatology #Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL.
authors.forename: Amy H
authors.initials: AH
authors.lastname: Warriner
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Outman
authors.forename: Adrianne C
authors.initials: AC
authors.lastname: Feldstein
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Roblin
authors.forename: Jeroan J
authors.initials: JJ
authors.lastname: Allison
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Curtis
authors.forename: David T
authors.initials: DT
authors.lastname: Redden
authors.forename: Mary M
authors.initials: MM
authors.lastname: Rix
authors.forename: Brandi E
authors.initials: BE
authors.lastname: Robinson
authors.forename: Ana G
authors.initials: AG
authors.lastname: Rosales
authors.forename: Monika M
authors.initials: MM
authors.lastname: Safford
authors.forename: Kenneth G
authors.initials: KG
authors.lastname: Saag
mesh_terms: D015502:Absorptiometry, Photon; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density; D015897:Comorbidity; D059026:Diagnostic Self Evaluation; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000706:statistics & numerical data*; D010024:Osteoporosis / Q000175:diagnosis*; D010353:Patient Education as Topic / Q000706:statistics & numerical data*; D044469:Racial Groups