The knowledge that a densitometrist must bring to bear on the quantitative assessment of bone density to interpret the findings and place them in the appropriate clinical context is considerable. But the conclusions must be carefully crafted in the most succinct fashion possible. Long reports are simply not read. Vague statements will not be understood or appreciated. At present, it is not sufficient to simply say that the patient does or does not have osteoporosis or is or is not at increased risk for fracture. For the densitometry report to be useful it must be accurate, clear, and complete but also concise. Even though some have said that densitometrists should restrict their statements to a simple review of the numbers, referring physicians want and require more from the experienced densitometrist to better serve their patients' needs.
The best format for conveying this information is a matter of opinion. Narrations in the form of a letter may evoke a sense of frustration on the part of the busy clinician who feels he or she must search the letter for information relevant to the care of the patient. Shorter narrations that are followed by numbered conclusions may result in only the numbered conclusions being read. Any important information contained in the narration may be lost. It would also seem clear that the longer the letter or the greater the number of conclusions, the less likely it is that the pertinent information will be
12 See Chapters 3 and 11 for a discussion of the RMS-SD.
read. Addressing these issues at present is primarily a matter of trial and error and personal opinion. To meet the needs and requests of the primary care physician regarding reporting and to ensure that all the relevant information is reviewed and understood is a challenge. With these issues in mind, a reporting format that combines a very brief narrative paragraph describing pertinent technical issues with a brief series of numbered conclusions that clearly address the specific clinical issues raised by primary care physicians would seem to be the best approach. The issues addressed by the numbered conclusions should be clearly identified and always given in the same order, from report to report. For example, Figs. 12-1A and B are a PA lumbar spine and proximal femur bone density study on a 67-year-old Caucasian woman. Prior to undergoing the study, the woman completed the patient questionnaire found in Appendix XIII. From the questionnaire, it was noted that she had never taken hormone replacement, she weighed only 105 lb, and her mother had osteoporosis. This was her first bone density study. The patient was referred by her physician for testing because she met the NOF Guidelines for testing described in Chapter 7. The report from the densitometrist to the referring physician might read as follows:
January 15, 2003
Dear Dr. Smith:
Ms. Jane Doe, dob 2/7/35, underwent PA lumbar spine and proximal femur DXA bone density studies on a Lunar Prodigy, software version 5.5 on 1/15/03. No technical difficulties were encountered. A review of the bone density images did not suggest fracture, degenerative change or artifact that would affect the interpretation of the numerical results.
1. Diagnosis: Osteoporosis, based on the T-score of -3.3 at L2-L4, applying World Health Organization Criteria for the diagnosis of osteoporosis.
2. Fracture Risk: Markedly increased.
3. Historical risk factors: Postmenopausal estrogen deficiency, low body weight, family history of osteoporosis.
a. Secondary causes of bone loss should be excluded clinically.
b. The patient meets National Osteoporosis Foundation guidelines for prescription intervention to treat osteoporosis. She should obtain 1200 mg of elemental calcium and 400IU of vitamin D per day. The following antiresorptive medications are FDA-approved for the treatment of postmenopausal osteoporosis: alendronate, 10 mg po daily or 70 mg po once weekly; risedronate, 5 mg po daily or 35 mg po once weekly; and raloxifene in a dose of 60 mg po daily. Salmon calcitonin is approved for treatment in women more than 5 years postmenopausal in a dose of 100 IU injected subq daily or 200 IU in one nasal spray daily. The anabolic agent teripartide is approved for the treatment of postmenopausal osteoporosis in women who are at high risk for fracture for a period of no more than 2 years at a dose of 20 |g injected subq daily.
c. A repeat PA lumbar spine bone density study is recommended in 1 year to assess therapeutic efficacy if prescription therapy is initiated.
This report is actually only one page long, using standard margins and line spacing. Headings and phrases are underlined for emphasis to ensure that they are read. In future reports, the same format would be followed, which helps the physician learn where to look for the pertinent clinical information and ensures that nothing of importance is overlooked. In this particular report, the lengthiest section is the reiteration of therapeutic options for the treatment of postmenopausal osteoporosis. As noted earlier, if you know that the referring physician does not need or would not appreciate this type of reminder, it can be omitted.
If other reporting formats have been found to be useful or more appropriate for a particular practice they should certainly be used. The densitometrist is responsible for device quality control, skeletal site selection, scan frequency, precision issues, data analysis, diagnosis, fracture risk assessment, therapeutic recommendations, and assessments of therapeutic efficacy. But the success or failure of the densitometrist and the promise of the marvelous technologies that we use ultimately resides in the accuracy, clarity and completeness of the reports that we send to the physicians who have asked for our assistance in the care of their patients. It is a privilege to be asked; it is a challenge that we must not fail.
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