Developing a bone mineral density test result letter to send to patients: a mixed-methods study

Figures & data

Figure 1 Critical topics in the DXA result letter linked to the Health Belief Model.

Abbreviations: DXA, dual-energy X-ray absorptiometry; FRAX^®, Fracture Risk Assessment Tool (World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK).

Figure 2 Three versions of the DXA result notification letter (A–C).

Abbreviations: DXA, dual-energy X-ray absorptiometry; FRAX^®, Fracture risk Assessment Tool.

Figure 3 Key characteristics and differences among the three versions of the DXA result letter.

Abbreviations: DXA, dual-energy X-ray absorptiometry; FRAX^®, Fracture risk Assessment Tool.

Table 1 Characteristics of participants in the study sample, % (n)

	All sites (n=142)	Site A (n=80; 56.3%)	Site B (n=62; 43.7%)	P-value
Sex, %
Female	64.1 (91)	56.3 (45)	74.2 (46)	*0.03
Age, %
50–59	35.2 (50)	28.8 (23)	43.5 (27)
60–69	38.7 (55)	41.3 (33)	35.5 (22)
70+	26.1 (37)	30.0 (24)	21.0 (13)
Education, %
High school or less	22.3 (29)	30.4 (21)	13.1 (8)	*0.002
Some college	33.9 (44)	37.7 (26)	29.5 (18)
College graduate or more	43.9 (57)	31.9 (22)	57.4 (35)
Race, %
White	76.1 (108)	92.5 (74)	54.8 (34)	*<0.001
African American	19.0 (27)	3.8 (3)	38.7 (24)
Other	4.9 (7)	3.8 (3)	6.5 (4)
Literacy, mean (SD)	3.3 (0.6)	3.4 (0.6)	3.2 (0.5)	0.28
Numeracy, mean (SD)	3.5 (1.4)	4.3 (1.2)	2.5 (0.9)	*<0.001
General health, %
Excellent	13.9 (18)	13.2 (9)	14.5 (9)	0.44
Very good	40.8 (53)	45.6 (31)	35.5 (22)
Good	36.9 (48)	33.8 (23)	40.3 (25)
Fair	7.7 (10)	7.4 (5)	8.1 (5)
Poor	0.8 (1)	0 (0)	1.6 (1)
Bone health, %
History of previous DXA	46.2 (60)	38.2 (26)	54.8 (34)	0.06
History of osteoporosis or osteopenia	24.2 (32)	18.6 (13)	30.7 (19)	0.11
Fracture history	16.2 (21)	13.2 (9)	19.4 (12)	0.35

Note:

* Indicates variables for which the sites are significantly different (P<0.05).

Abbreviations: DXA, dual-energy X-ray absorptiometry; SD, standard deviation.

Table 2 Letter reported as easiest to understand among key study subgroups

	Percent selecting as most understandable letter			No preference	# missing	P-value
	A	B	C
Total (n=130)	26.9	44.6	19.2	9.2	12	<0.01*
Sex, %					12	0.85
Female (n=85)	27.1	43.5	21.2	8.2
Male (n=45)	26.7	46.7	15.6	11.1
Education, %					21	0.76
High school or less (n=26)	34.6	34.6	23.1	7.7
Some college (n=42)	21.4	50.0	21.4	7.1
College graduate or more (n=53)	28.3	47.2	17.0	7.6
Age, %					12	0.47
50–59 (n=46)	30.4	45.7	15.2	8.7
60–69 (n=52)	30.8	42.3	21.2	5.8
70+ (n=32)	15.6	46.9	21.9	15.6
Site, %					12	0.66
Site A (n=70)	31.4	41.4	18.6	8.6
Site B (n=60)	21.7	48.3	20.0	10.0
Race, %					13	0.92
White (n=97)	28.9	42.3	19.6	9.3
African American	19.2	53.9	19.2	7.7
Other	33.3	33.3	16.7	16.7

Note:

* P-value accounting only for difference in those that had a preference in letter format.

Table 3 Preferred letter among key study subgroups

	Percent selecting as favorite letter			# missing	P-value
	A	B	C
Total (n=135)	30.4	45.2	24.4	7	<0.001*
Sex, %
Female (n=88)	30.7	45.5	23.9	7	0.98
Male (n=47)	29.8	44.7	25.5
Education, %				17	0.88
High school or less (n=26)	30.8	42.3	26.9
Some college (n=43)	30.2	44.2	25.6
College graduate or more (n=56)	28.6	48.2	23.2
Age, %				7	0.62
50–59 (n=48)	33.3	47.9	18.8
60–69 (n=54)	25.9	46.3	27.8
70+ (n=33)	33.3	39.4	27.3
Site, %				7	0.37
Site A (n=74)	35.1	40.5	24.3
Site B (n=61)	24.6	50.8	24.6
Race, %				8	0.30
White (n=102)	32.4	41.2	26.5
African American (n=26)	19.2	57.7	23.1
Other (n=6)	50	50	0

Note:

* P-value accounting only for difference in those that had a preference in letter format.

Figure 4 Respondent preference for the five critical topics presentation by letter.

Abbreviations: DXA, dual-energy X-ray absorptiometry; FRAX^®, Fracture Risk Assessment Tool.

Table 4 Frequency of participant responses on five critical topics in the letter and a typical qualitative response

Critical topic		Letter A	Letter B	Letter C
DXA	Like	23	24	32 “It is very, very direct. This is why you had the test, because sometimes we don’t know why we had the test”.
	Dislike	13	6	27 “Don’t like the wording. Letter A explained it better”.
T-score	Like	35	68 “It eases the person into what the test results are and what that means for their health condition”.	33
	Dislike	31	34 “Didn’t like the comparison to a 30-year old”.	28
Diagnosis	Like	34	42 “It explained T-score, how to read it, and what the results meant”.	29
	Dislike	18	14	20 “It doesn’t really say what osteoporosis is. Could be more definitive”.
FRAX^®	Like	73 “This part explains percentage well. Says exactly 21 out of 100 people, which is easily understood even for people who don’t understand percentages”.	57	29
	Dislike	24 “My mind stays on bone fracturing, wording is scary to some who might frighten easily”.	14	21
Recommendations	Like	76	89 “It gives you information on what you can do to improve your bone health”.	79
	Dislike	29 “You need to tell people about the calcium, diet and exercise, so they know what to talk about with the doctor”.	30	20

Abbreviations: DXA, dual-energy X-ray absorptiometry; FRAX^®, Fracture Risk Assessment Tool.

Figure 5 Final DXA result letter with annotations on how created.

Abbreviations: DXA, dual-energy X-ray absorptiometry; FRAX^®, Fracture Risk Assessment Tool.