Combining DXA Registries to Double Down on Osteoporosis Outcomes Analysis

Collaboration with UAB to enable large-scale outcomes studies

By Chad Deal, MD

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The ability to combine bone density registry data with FRAX® fracture risk assessments and medication use data from the electronic medical record (EMR) has created a powerful tool for quality improvement and outcomes collection in osteoporosis management. Now Cleveland Clinic is combining its formidable dual-energy X-ray absorptiometry (DXA) registry with that of another major U.S. medical center for enhanced outcomes insights.

The DXA registry at a glance

Since the Cleveland Clinic DXA Registry enrolled its first patients in 2009, cumulative enrollment has surpassed 55,000 (Figure).


Data for the registry are entered via the DXA Data Entry System (DES), a Web-based intranet tool designed to streamline data entry. The DES receives scheduling messages from the central EMR system to generate a real-time list of appointments for which data related to DXA are to be recorded.

Technologists log in to the system from any intranet-connected workstation and are guided through a data entry page to ensure complete and accurate data collection for each appointment, enabling FRAX fracture risk calculation at a later time.

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Basic demographic variables are preloaded into the DES from the EMR, including height and weight, along with selected FRAX risk factors (prior fracture, hip fracture in a parent, current tobacco use, past or current exposure to oral glucocorticoids for ≥ 3 months, rheumatoid arthritis, disorders associated with secondary osteoporosis, and consumption of ≥ 3 alcoholic drinks a day).

Femoral neck, total hip and lumbar spine bone mineral density values, along with T- or Z-scores and type of DXA machine, are entered by the technologist

Current or past use of specific osteoporosis medications and reason for discontinuation are reported by patients and entered by the technologist

The DES automatically flags missing or out-of-range data, with correction required before the entry can be completed.

Abundant outcomes data to date

This combining of bone density registry data with FRAX 10-year absolute fracture risk and with EMR data on the use of osteoporosis medications and glucocorticoids has already yielded data for use in outcomes analysis and quality improvement. Here are a few examples we have presented to date:

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  • Overman RA, Deal CL. Anti-osteoporosis medication use after hip or vertebral fracture. Arthritis Rheumatol. 2014;66(10 suppl):S806. Abstract 1835.
  • Overman RA, Lauffenburger JC, Gourlay ML, Deal CL. Adherence to denosumab in a large healthcare system. Arthritis Rheumatol. 2014;66(10 suppl):S1011. Abstract 2316.
  • Overman RA, Lauffenburger JC, Gourlay ML, Deal CL. Continued zoledronic acid use in a large healthcare system. Arthritis Rheumatol. 2014;66(10 suppl):S985. Abstract 2263.
  • Overman RA, Deal CL. Evaluation of osteoporosis medication starts in patients based on T-score and FRAX® absolute fracture risk model in a large health care system. Arthritis Rheum. 2013;65(10 suppl):S1136. Abstract 2664.
  • Deal CL, Strnad GJ, Overman RA, Bershadsky B. Cleveland clinic dual energy X-ray absorptiometry registry. Arthritis Rheum. 2013;65(10 suppl):S819-S820. Abstract 1924.

Strength in numbers through combined registries

Cleveland Clinic is now building on this foundation through a collaborative agreement with the University of Alabama at Birmingham to combine DXA registries. This agreement will allow linkage of patients in the DXA registries with Medicare data for healthcare claims, enabling us to evaluate the care that patients receive and analyze it against fracture events and hospitalizations.

We look forward to sharing insights in the months and years ahead.

Dr. Deal is Director of the Center for Osteoporosis and Metabolic Bone Disease as well as Vice Chair for Quality and Outcomes in the Department of Rheumatic and Immunologic Diseases.