UROLOGIC NURSING November-December 2019 Volume 39 Number.docx

UROLOGIC NURSING / November-December 2019 / Volume
39 / Number 6 293
Rikka Burroughs, DNP, BA, ARNP, AGPCNP-C, CUNP, is a
Nurse Practitioner, Physicians’
Clinic of Iowa, Cedar Rapids, IA and University of Iowa
College of Nursing, Iowa City, IA.
Bone Health Assessment in Men
On Androgen Deprivation Therapy
For Prostate Cancer: A Nurse
Practitioner-Led Quality
Improvement Protocol
Rikka Burroughs
P
rostate cancer is the most
common solid organ
cancer and is the second
leading cause of cancer
mortality for men in the United
States (American Cancer Society
[ACS], 2018; American Uro -
logical Association [AUA],
2018). An d rogen dep rivation
therapy (ADT) is a common ther-
apy for locally advanced prostate
cancer, and is the mainstay of
treatment for metastatic and bio-
chemically recurrent prostate
cancer (Loblaw et al., 2007;

National Comprehensive Cancer
Network [NCCN], 2017). Al -
though an effective treatment for
prostate cancer, ADT causes
accelerated loss of bone mass,
leading to increased risk for frac-
ture (Chahin, Gualamhusein,
Breunis, & Alibhai, 2016; Damji,
Bies, Alibhai, & Jones, 2015).
Approximately 1 in 2 men
(44.8%) diagnosed with prostate
cancer and on Medicare will
receive ADT, many for 2 years or
longer (Gilbert, Kuo, & Shahinian,
2011; Meng et al., 2002); the actu-
al incidence of prostate cancer in
the full U.S. population of men is
unknown. ADT can cause mor-
bidities that are often inadequate-
ly addressed (NCCN, 2017). Two
such sequelae are osteopenia and
secondary osteoporosis (Chahin
et al., 2016; NCCN, 2017).
Substantial bone loss can occur
within the first 6 months of ADT
therapy (Datta & Schwartz, 2012).
In fact, 1 in 10 men treated with
ADT will sustain a new fracture
within 24 months of treatment
initiation (Datta & Schwartz,
2012). About 6 in 10 men diag-
nosed with prostate cancer are
over age 65 years, and when
screened, as many as half of these

men are noted to have low bone
mass prior to initiation of ADT
(ACS, 2018; Panju et al., 2009).
Therefore, ADT treatment places
them at even further risk of frac-
ture (Panju et al., 2009).
Significance of the Problem
Osteoporosis-related frac-
tures are associated with in -
creased morbidity and mortality
(Walsh & Eastell, 2013). Low bone
© 2019 Society of Urologic Nurses and Associates
Burroughs, R. (2019). Bone health assessment in men on
androgen deprivation
therapy for prostate cancer: A nurse practitioner-led quality
improvement
protocol. Urologic Nursing, 39(6), 293-301
doi:10.7257/1053816X.2019. -
39.6.293
Androgen deprivation therapy (ADT) causes bone loss. Despite
this, there is sub-
stantial variability in clinical practice related to bone health
prevention and treat-
ment for men with prostate cancer receiving ADT. This quality
improvement proj-
ect facilitated consistency in providing evidence-based care for
bone health in
men with prostate cancer on ADT at a private urology clinic.
Key Words: Bone health, osteoporosis, Plan-Do-Study-Act,

men’s health,
bone density, nurse practitioner utilization.
SERIES/RESEARCH
Instructions for
CNE Contact Hours
UNJ 1914
Continuing nursing education (CNE)
contact hours can be earned for
completing the learning activity
associated with this article. Instructions
are available at suna.org/library
Deadline for submission:
December 31, 2021
1.3 contact hour(s)
294 UROLOGIC NURSING / November-December 2019 /
Volume 39 / Number 6
mass and fracture can cause
increased anxiety and depres-
sion, decreased self-esteem, de -
creased socialization, increased
isolation, strained relationships
with social support persons,
increased pain, overall higher
health care costs, decreased sur-
vival, and decreased quality of
life for patients and their care-

givers (Chahin et al., 2016; Damji
et al., 2015; National Osteo -
porosis Foundation [NOF], 2019;
Turner et al., 2016a).
Men are often under-diag-
nosed, under-educated, and
under-treated for low bone mass
(Chahin et al., 2016; Shahinian,
Kuo, Freeman, & Goodwin,
2005). Men receiving ADT have a
50% increased risk of fracture;
however, men receiving ADT are
not routinely screened and treat-
ed for osteopenia or osteoporosis
(Chahin et. al, 2016; Damji et al.,
2015; Shahinian et al., 2005).
Bone health practices not con-
forming to current guidelines for
men on ADT are observed across
the spectrum of care from pri-
mary care to urology and radia-
tion and medical oncology
(Alibhai et al., 2006; Al-Shamsi
et al., 2012; Tanvetyanon, 2005).
The NCCN (2017) guideline
for prostate cancer recommends
use of supplemental calcium and
vitamin D for all men on ADT.
The NCCN (2017) also recom-
mends obtaining a baseline dual-
energy X-ray absorptiometry
(DXA) to measure bone mineral
density (BMD) in men with

increased risk for fracture prior
to or within 90 days of initiation
of ADT. DXA is a radiologic test
that quantifies BMD, a determin-
ing factor of bone strength
(Lewiecki et al., 2016). The
NCCN (2017) also recommends
additional treatment if DXA
shows high fracture risk using a
fracture risk tool, such as the
Fracture Risk Assessment Tool
(FRAX). FRAX is completed by
the health care provider and
assesses select risk factors, such
as glucocorticoid and smoking
history, personal and familial
fracture history, alcohol use, and
height and weight (Kanis et al.,
2011; University of Sheffield,
n.d.). FRAX determines a 10-year
probability of fracture of the hip
or other major fracture, such as
wrist, shoulder, or spine that is
responsive to treatment (Kanis et
al., 2011; University of Sheffield,
n.d.).
Despite NCCN guideline rec-
ommendations, there is substan-
tial variability in provider prac-
tice, knowledge, prevention, and
treatment of low bone density for
men on ADT (Al-Shamsi et al.,
2012; Damji et al., 2015; NCCN,
2017; Panju, et al., 2009; Pradhan

et al., 2012; Tanvetyanon, 2004).
Risks of fracture within this pop-
ulation, coupled with co-mor-
bidities and lifestyle choices, fur-
ther place this population at risk
(Chahin et al., 2016). Damji and
colleagues (2015) found that only
about 32% of the 83 urologists
and 73 radiation oncologists they
surveyed tested BMD routinely
(≥ 80% of patients) prior to start-
ing ADT. Low self-reported com-
petency levels regarding calcium
SERIES
Research Summary
Introduction
Androgen deprivation therapy (ADT) is a common ther-
apy for locally advanced prostate cancer, as well as for bio-
chemically recurrent and metastatic prostate cancer. An
effective treatment for men with prostate cancer, ADT can
cause morbidities which are often not fully or adequately
addressed in urology.
Purpose
The purpose of this quality improvement (QI) project
was to facilitate consistency in providing evidence-based
care related to bone health screening, education, and treat-
ment for men with prostate cancer on ADT by decreasing
barriers to assessment and creating a pathway from urolo-
gists to the nurse practitioner who also specializes in bone
health and prostate cancer.

Methods
An office-based protocol for an internal referral process
was developed to facilitate transition from urologist to nurse
practitioner in a urology clinic. The protocol included the
referral order, lab order, and appropriate time interval, and
was implemented upon the initiation of ADT. A survey
assessed urologist knowledge and perceived treatment bar-
riers prior to and after education and implementation of the
protocol.
Results
The number of patients seen by the nurse practitioner
within 90 days of ADT treatment initiation increased from
36% (Q4 2017) to 53% (Q4 2018) (p > 0.05). The proportion
of patients who completed the lab set after implementation
of the referral process increased from 16% (Q4 2017) to
73% (Q4 2018) (p < 0.01). The urologist survey demonstrat-
ed an increase in urologist perception of the importance of
bone health assessment, overall knowledge of bone health
for men on ADT, and a reduction in barriers to bone health
care.
Conclusion
Implementation of a protocolized internal referral
process facilitated consistency in providing timely, evidence-
based care related to bone health for men with prostate can-
cer on ADT. This QI project enhanced urologist knowledge
of bone health in men on ADT and reduced barriers to bone
health care.
Level of Evidence: V-B
Source: Johns Hopkins Hospital/Johns Hopkins University,
2016.

39 / Number 6 295
(64%) and vitamin D supplemen-
tation (62%), providing educa-
tion regarding healthy bone
behaviors (40.5%), and managing
osteopenia and osteoporosis
(41.2%) among survey partici-
pants were also found (Damji et
al., 2015). Furthermore, less than
20% of survey participants
received at least some type of
specialized training and educa-
tion regarding bone health risk
and measurement (Damji et al.,
2015).
Reasons for low rates of bone
health screening include pro -
viders’ lack of understanding of
bone health, poor clarity of
guidelines, and insufficient
knowledge of potential conse-
quences of low bone density
(Damji et al., 2015). Jain, Bilori,
Gupta, Spanos, and Singh (2016)
identified additional reasons for
low screening rates, including
low priority for providers to
screen for low bone density and
that the electronic medical
record (EMR) lacks reminders to

support clinical decision-mak-
ing. Pradhan and colleagues
(2012) noted the unavailability of
the DXA scan within the practice
area as a contributing factor for
lack of screening. Provider time
constraints, discomfort with pa -
tient counseling regarding low
bone density, and risk of overbur-
dening the patient with informa-
tion are other reasons cited for
not following the guidelines (Jain
et al., 2016; Turner et al., 2016b).
Literature Review
A literature search was con-
ducted to examine the evidence
on improving bone health prac-
tice in the care of men treated
with ADT for prostate cancer.
PubMed and the Cumulative
Index to Nursing and Allied
Health Literature (CINAHL) data-
bases were reviewed. Key search
terms included implementation,
protocol, osteoporosis, prostate
cancer, nurse practitioner, health
care costs, and fracture (Pub -
Med); and prostatic neoplasms,
androgen deprivation, urologic
nursing, urology, osteoporosis,
calcium, and vitamin D
(CINAHL). Inclusion criteria

included vitamin D and calcium
supplementation in men with
low bone mass, men treated with
ADT for prostate cancer, and
provider knowledge of treatment
guidelines for men with low
bone mass. Exclusion criteria
included articles specific to
women and children, comple-
mentary and alternative medi-
cine and non-FDA approved sup-
plements, and articles focused
specifically on skeletal-related
events in metastatic prostate can-
cer.
Only English language arti-
cles from peer-reviewed journals
limited to the last 5 years were
considered because NCCN guide-
lines for men on ADT changed
significantly within that time
frame. Articles with data from
outside the United States were
accepted due to the paucity of
information available on similar
projects. Ultimately, the total
number of relevant articles using
these search strategies was 29.
All 29 articles were then
reviewed.
Adherence to guidelines and
patient outcomes can improve by
implementation of a screening
protocol (Hall, Shrader, &

Ragucci, 2009; Turner et al.,
2016b). Hall and colleagues
(2009) conducted a pharmacist-
led osteoporosis clinic in a fami-
ly medicine practice. A protocol
was designed based upon evi-
dence-based practice guidelines
that included patient education,
screening, prevention, and treat-
ment of osteoporosis (Hall et al.,
2009). Turner and colleagues
(2016b) established a nurse prac-
titioner-led bone health clinic for
men with prostate cancer. A care
pathway was developed that
included a referral from the
oncologist to the nurse practi-
tioner who orders labs and imag-
ing, refers to maxillofacial sur-
geons for dental evaluation, and
provides education and counsel-
ing to patients and their families
(Turner et al., 2016b). Bone
health management is then coor-
dinated with the prostate cancer
follow-up visit (Turner et al.,
2016b). Turner and colleagues
(2016b) also attempted to main-
tain the patient’s optimal quality
of life and prevent or delay skele-
tal-related events. Both studies
ameliorated the gap in provider
and patient knowledge and lack
of guideline adherence as related
to low bone health, while de -

creasing the workload of the
physician provider.
Purpose
The purpose of this quality
improvement (QI) project was to
facilitate consistency in provid-
ing evidence-based care related
to bone health screening, educa-
tion, and treatment for men with
prostate cancer on ADT. Spec -
ifically, this project aimed to
enhance urologist knowledge of
bone health in men on ADT, cre-
ate a protocol for bone health
referral, increase timely referrals
from the urologist to the nurse
practitioner (who also special-
ized in bone health), and obtain
appropriate lab studies prior to
the referral to prevent treatment
delays.
Method
The Institutional Review
Board at the University of Iowa
deemed this project as not
human subject research.
Setting
This QI project was imple-

mented in a private, physician-
owned urology clinic in Iowa
that specializes in disorders of
the genitourinary system, includ-
ing prostate cancer. There were 6
physicians and 1 nurse practi-
tioner in the clinic, all of whom
treated patients with prostate
cancer at varying stages of the
disease. Prior to the start of this
project, no established evidence-
based protocols were in place for
SERIES
bone health monitoring and
treatment in patients on ADT,
such as calcium and vitamin D
supplementation, baseline DXA
scans, patient education regard-
ing bone health, or bone strength-
ening medications.
QI Methodology
T h e P l a n - D o - S t u d y - A c t
(PDSA) method for quality
improvement was chosen for this
project (Langley, 1996). The
model is relevant because it uses
a systematic, data-guided me -

thod to process improvement. It
also reduces waste and efforts.
Interventions
The interventions focused on
three objectives: 1) increase time-
ly referrals (within 90 days of
ADT initiation) to the nurse prac-
titioner through an internal refer-
ral process, 2) increase the rate of
completion of an appropriate lab
set (i.e., prostate-specific antigen
[PSA], total testosterone, calci-
um, and vitamin D) prior to the
visit with the nurse practitioner
by implementing electronic
standing orders, and 3) improve
the urologists’ knowledge of
bone health management inter-
ventions to decrease barriers to
these interventions.
Performance Improvement
Process
An internal referral process
was created within the urology
clinic to facilitate the transition of
care from the urologist to the
nurse practitioner, who also spe-
cialized in bone health (see Figure
1). Group and one-on-one educa-
tion and training sessions were
provided by the nurse prac -

titioner/project leader to the 6
urologists, 6 nurses, 1 medical
assistant, and 9 office staff regard-
ing bone health. This included the
importance of obtaining the
appropriate lab set and referring
the patient to the nurse practition-
er within 90 days of initiation of
ADT. Written materials were also
provided. Although the RNs, MA,
and office staff had no active role
in this project, they were made
aware of the protocol and why it
was important to allow them to
address questions from patients.
The project protocol was de signed
solely to facilitate referral from
MD to the nurse practitioner.
An electronic order set for
MDs was created, which includ-
ed a referral to the nurse practi-
tioner in the appropriate time
interval and necessary labs. The
scheduled appointment with the
nurse practitioner coincided
with the next ADT injection. Due
to technological issues within a
new EMR, the order set did not
work properly through the
entirety of the project. Therefore,
laminated reminder cards were
placed at each work station with
the protocol information.

An electronic survey guided
by the current literature was
developed to assess urologists’
knowledge of bone health and
perceived treatment barriers.
Identified barriers included cost
of assessment tests and treat-
ments, unclear benefit to bone
health assessment and treatment,
patient’s lack of insurance, urolo-
gist time constraints, urologist
lack of knowledge of bone health,
and clarity of the guidelines. The
survey was administered prior to
education and implementation of
SERIES
Figure 1.
Flow Chart for Patients Referred for Bone Health
Patient started on ADT
Patient referred to NP
First appointment
with NP
• Referral to NP with 90 days of initiation of ADT
• Order PSA, total testosterone, calcium, and vitamin D
• Discuss rationale for ADT treatment

• Discuss potential side effects of ADT
• Discuss risks and obtain consent for bone health
treatment
• Rx calcium and vitamin D supplements, if needed
• Baseline serum total testosterone, calcium, and
vitamin D, if not already completed
• Assess patient understanding
• Provide patient literature
• Provide NP contact information
• Order additional labs or imaging as needed
Notes: ADT = androgen deprivation therapy, NP = nurse
practitioner, PSA = prostate-specific antigen.
39 / Number 6 297
the order set, and after comple-
tion of the QI project.
Data were manually extract-
ed from the EMR by the nurse
practitioner. Because a new and
different EMR was introduced
between the pre-implementation
and post-implementation time
frames, data were collected from
two unique and separate EMR
systems. Data collected from the
EMRs were identical and includ-
ed new referrals, date of first
ADT injection, date seen by the

nurse practitioner, if the patient
was seen within 90 days of ADT
initiation or beyond, labs ob -
tained prior to the first appoint-
ment with the nurse practitioner,
if the patient was a repeat refer-
ral, and from whom they were
referred.
Analysis
It was not possible to collect
data on the number of patients
with prostate cancer on ADT
who were not referred to the
nurse practitioner; thus the num-
ber of patients seen by the nurse
practitioner within 90 days of
initial ADT treatment was used
as a proxy.
Statistical analyses were con-
ducted to compare the propor-
tions of patients referred and
completion of the lab set ordered
before and after the interven-
tions. Using Fisher’s exact test
and 95% confidence intervals, a
plausible range of values was
determined. Confidence inter-
vals are a substitute for applying
interventions to the entire popu-
lation of all urologists who treat-
ed patients on ADT. The differ-
ence among the entire popula-
tion then would plausibly fall

within this range.
Fisher’s exact test is appro-
priate for smaller counts. While
the Fisher’s exact test does not
calculate variability, other meth-
ods were used to measure the
variability. The uncertainty of the
sample proportions was quanti-
fied by using 95% confidence
intervals.
Due to the small sample size
of urologists (n = 6), no formal
test on the differences in survey
responses was conducted. In -
ferential methods could not be
completed; therefore, no calcula-
tion of the variability in respons-
es was done.
Results
Prior to the project concep-
tion, 28 patients were referred for
bone health to the nurse practi-
tioner between October 1 and
December 31 (Q4) in 2016. All
patients referred during this time
were new to the nurse practition-
er. One (3.5%) was referred with-
in 90 days of ADT initiation, and
none (0%) had the appropriate
lab set completed.

In Q4 of 2017 prior to project
implementation, a total of 69
patients were referred for bone
health, of which 25 (36.2%) were
new to the nurse practitioner. Of
these 25 new patients, 9 (36%)
were referred within 90 days of
starting ADT and (16%) had the
lab set completed.
In Q4 of 2018, after project
implementation, a total of 76
were referred for bone health. Of
these, 15 (19.7%) were new to
the nurse practitioner. Of these
new patients, 8 (53.3%) were
referred within 90 days of start-
ing ADT, with 11 (73.3%) having
the labs completed. The other 7
(46.7%) new patients started
ADT more than 90 days prior,
and all (100%) had the appropri-
ate lab set completed. Of note, all
SERIES
Figure 2.
Proportion of Complete vs. Incomplete Lab Sets
among New Patient by Year
1.00
0.75
0.50

0.25
0.00
P
e
rc
e
n
t
Proportion of ‘Yes’: 4/25
Oct-Dec 2017 Oct-Dec 2018
Year
Complete Labs
Yes No
Note: ADT = androgen deprivation therapy.
patients referred in 2017 were re-
referred (if not deceased) for fol-
low up in 2018.

There was a significant
increase in the number of
referred patients who completed
the lab set after the referral
process was implemented. The
percentage increased from 16%
in Q4 2017 to 73% in Q4 2018
(95% confidence interval, 2.459,
92.936, p < 0.01) (see Figure 2).
While not statistically signif-
icant, the percentage of patients
seen by the nurse practitioner
within 90 days of initial treat-
ment increased from 36% (Q4
2017) to 53% (Q4 2018) (95%
confidence interval, 0.458, 9.073,
p > 0.05) (see Figure 3).
The urologist survey was
administered prior to education
and project implementation, and
again after project completion.
Results demonstrated an increase
in urologists’ perception of the
importance of bone health
assessment in men on ADT and
overall knowledge of bone
health. A better understanding of
the NCCN guidelines and modifi-
able risk factors associated with
low bone mass was observed.
Responses also indicated a
decrease in barriers to bone
health evaluation and referral to
the nurse practitioner, including

ease of referral and minimal time
constraints. The survey revealed
a concern for insurance coverage
and cost of treatment remained.
A distribution of pre- and post-
intervention survey responses is
displayed in Figure 4.
Discussion
The QI project facilitated
consistency in providing evi-
dence-based care related to bone
health screening, education, and
treatment for men with prostate
cancer on ADT at the urology
clinic. Specifically, this project
enhanced the urologists’ knowl-
edge of bone health in men on
ADT, created a pathway for bone
health referral, increased timely
referrals to the nurse practitioner
who specializes in bone health,
and increased the number of
patients who had the appropriate
lab set completed prior to being
seen by the nurse practitioner for
bone health.
Prior to the project QI proto-
col, there was no standardized
method of assessing patients for
bone health within this urology
clinic. Therefore, improvements

in lab set completion, patient
referrals, urologist-perceived im -
p o r t ance of bone health, and
reduction in barriers to assess-
ment and treatment may be
attributable to interventions of
this project.
Implementation of the proto-
col did not increase the burden
on urologists, nurses, or office
staff. The electronic order set
required development by the
Information Technology (IT)
department; however, the elec-
tronic order set was not function-
al for the first six weeks of the
project. This order set proved to
be a non-vital component of the
protocol because urologists still
improved their referrals and lab
orders by using laminated cards.
Resources and costs associat-
ed with this QI project were min-
imal, including IT costs to devel-
op the order set. The overall costs
of the project included printing
costs for the educational materi-
als and laminating costs for the
reminder cards. The nurse practi-
tioner served as project leader
and performed all educational
duties for staff, nurses, and urol-
ogists outside of designated

patient care time. The urology
clinic incurred the cost of staff,
nurse, and physician wages dur-
ing the education and implemen-
tation of the project.
SERIES
Figure 3.
Proportion of New Patients Seen within 90 Days
of
1.00
0.75
0.50
0.25
0.00
P
e
rc
e
n
t
Oct-Dec 2017 Oct-Dec 2018

Year
Complete Labs
Yes No
Note: ADT = androgen deprivation therapy.
39 / Number 6 299
SERIES
F
ig
u
re
4
.
In
t
h
e
p
a
s
t

3
m
o
n
th
s
,
h
o
w
o
ft
e
n
d
id
y
o
u
f
in
d
t
h
e

f
o
llo
w
in
g
a
b
a
rr
ie
r
to
s
c
re
e
n
in
g
a
n
d
t

re
a
ti
n
g
lo
w
b
o
n
e
m
in
e
ra
l
d
e
n
s
it
y
/o
s

te
o
p
o
ro
s
is
i
n
m
e
n
o
n
A
D
T
?
P
re
P
o
st
1

7
%
1
7
%
1
7
%
8
3
%
6
7
%
0
%
P
re
P
o
st
0
%

0
%
0
%
0
%
1
0
0
%
1
0
0
%
P
re
P
o
st
8
3
%
3

3
%
1
7
%
0
%
0
%
6
7
%
P
re
P
o
st
3
3
%
1
7
%

3
3
%
0
%
3
3
%
8
3
%
P
re
P
o
st
1
7
%
0
%
3
3
%

1
7
%
5
0
%
8
3
%
P
re
P
o
st
1
7
%
3
3
%
3
3
%

0
%
5
0
%
6
7
%
1
0
0
1
0
0
5
0
5
0
0
P
e
rc
e
n
ta

g
e
R
e
s
p
o
n
s
e
A
lw
a
ys
O
ft
e
n
S
o
m
e
tim
e
s

R
a
re
ly
N
e
ve
r
In
co
n
ve
n
ie
n
ce
o
f
o
rd
e
ri
n
g
a

d
d
iti
o
n
a
l l
a
b
s/
te
st
s
R
e
fe
rr
in
g
t
o
N
P
f
o
r

sc
re
e
n
in
g
,
e
d
u
ca
tio
n
,
a
n
d
t
re
a
tm
e
n
t
o
f

lo
w
b
o
n
e
m
a
ss
T
im
e
r
e
q
u
ir
e
d
t
o
s
cr
e
e
n
,
e

d
u
ca
te
,
a
n
d
t
re
a
t
m
e
n
o
n
A
D
T
f
o
r
lo
w
b
o

n
e
m
a
ss
U
n
ce
rt
a
in
ty
h
o
w
t
o
in
te
rp
re
t
re
su
lts
o

f
te
st
s
o
rd
e
re
d
U
n
ce
rt
a
in
ty
o
f
b
e
n
e
fit
s
o
f

sc
re
e
n
in
g
a
n
d
t
re
a
tin
g
f
o
r
lo
w
b
o
n
e
m
a
ss

in
m
e
n
o
n
A
D
T
U
n
ce
rt
a
in
ty
r
e
g
a
rd
in
g
t
h
e

a
d
m
in
is
tr
a
tio
n
,
d
o
si
n
g
,
m
o
n
ito
ri
n
g
,
e
tc

.,
o
f
m
e
d
ic
a
tio
n
s
fo
r
lo
w
b
o
n
e
m
a
ss
N
o
te
s

:
A
D
T
=
a
n
d
ro
g
e
n
d
e
p
ri
va
tio
n
t
h
e
ra
p
y,
N
P

=
n
u
rs
e
p
ra
ct
iti
o
n
e
r.
There were no measured rev-
enue increases by implementa-
tion of the protocol. However,
revenue was likely generated by
the increase in services provided
by implementation of the proto-
col. Anecdotally, the coding
auditors reported billing codes
for patients seen by the nurse
practitioner increased during Q4
2018 due to the augmented level
of complexity and/or time spent

with the patient.
No observed opportunity
costs were associated with this
project. However, there could
have been an unintentional
decrease in patient referrals to
the nurse practitioner for other
urology conditions. For instance,
urologists were aware of the new
protocol, and therefore, may not
have sent other non-ADT urology
patients as normally would be
referred due to concern for over-
burden after establishing the new
pattern for ADT management.
The urology nurse practitioner in
this clinic was salaried with
RVU-based bonuses semi-annu-
ally. Patient appointment times
were scheduled as 40 minutes,
similar to new patients, as com-
pared to 20 minutes for other
established patients. Patients
were scheduled in either two 20-
minute recheck appointment
slots or a new patient slot.
Therefore, the nurse practitioner
frequently saw fewer new
patients than was templated in
the schedule. This urology clinic
has dedicated urology coders
who review each encounter for
each provider; therefore, their
workload did not increase.

Strengths of this QI project
include universal acceptance
and support by urologists of the
clinic. A group consensus on the
importance of bone health, as
well as who would assess and
treat these patients, was essential
for success. Consistency in bone
health practice was lacking in
urologic and oncologic practices
within this clinic. This QI proto-
col addressed many of the most
common causes of nonadherence
to guideline recommendations
by decreasing barriers to assess-
ment and treatment, improving
knowledge of bone health and
clarity of the guidelines, and
reducing time constraints.
An unexpected finding was
that urologists started referring
all patients on ADT for greater
than 12 months regardless of
when they received their first
ADT injection. Although this
was outside of the original proj-
ect objectives, it followed the
NCCN (2017) guidelines for bone
health in men on ADT.
Limitations
The greatest limitation of this
QI project was the inability of the

EMR systems to mine data elec-
tronically. This prevented analy-
sis of the proportion of patients
who were referred versus those
who were not referred. The
change to a new EMR late in proj-
ect development also created
limitations, including failure of a
functional order set throughout
the entirety of the project.
Another challenge was inherent
in one objective; patient referrals
were determined by incidence of
advancing prostate cancer that
required ADT, not by physician
knowledge or decrease in barri-
ers. Those started on ADT could
not be controlled nor predicted.
A final limitation is the sample
size of urologists surveyed.
Conclusions
Creation and implementa-
tion of a streamlined referral pro-
tocol improved collaboration
between the nurse practitioner
and urologists. It improved ad -
herence to the NCCN guidelines
by establishing a protocol for evi-
dence-based assessment of bone
loss in all patients. The protocol
led to earlier treatment for bone
loss in select patients and poten-

tially decreased adverse effects of
ADT. Lastly, urologists reported a
decrease in barriers to bone
health assessment and treatment.
The sustainability of the
bone health assessment protocol
was demonstrated by the request
of urologists to continue with the
referral process, but with some
changes. Therefore, a new proto-
col was developed, which will
continue to include the nurse
practitioner’s evaluation of new
patients starting on ADT, but also
any patients on ADT greater than
12 months who have not yet had
bone health evaluation.
The bone health assessment
protocol could feasibly be adapt-
ed to other urology clinics in a
wide variety of institutions that
care for men with prostate cancer
on ADT. Such institutions
include private physician or hos-
pital-owned clinics, public and
private teaching hospitals and
clinics, multispecialty institu-
tions, and rural outreach hospi-
tals across geographic areas. The
bone health champion could be a
single or group of nurse practi-
tioners that are trained in bone
health assessment and manage-
ment. Ideally, the champion

would also be proficient in
prostate cancer management.
The protocol could then be seam-
lessly incorporated into the
prostate cancer clinic and elimi-
nate extra visits for the patient.
Urologist knowledge of bone
loss related to ADT increased
after implementation of educa-
tion and the referral process.
Bone health can be added into a
prostate cancer treatment algo-
SERIES
Creation and implementation of a streamlined
referral protocol improved collaboration
between the nurse practitioner and urologists.
39 / Number 6 301
rithm with little financial cost to
the clinic. This program allowed
the nurse practitioner to serve as
the bone health champion in the
urology clinic and did not
increase the workload to urolo-
gists.
References
Alibhai, S.M., Rahman, S., Warde, P.R.,

Jewett, M.A., Jaffer, T., & Cheung,
A.M. (2006). Prevention and man-
agement of osteoporosis in men
receiving androgen deprivation ther-
apy: A survey of urologists and radi-
ation oncologists. Urology, 68(1),
126-131. doi:10.1016/j.urology.2006.
01.054
Al-Shamsi, H.O., Lau, A.N., Malik, K.,
Alamri, A., Ioannidis, G., Corbett, T.,
… Papaioannou, A. (2012). The cur-
rent practice of screening, preven-
tion, and treatment of androgen-
deprivation-therapy induced osteo-
porosis in patients with prostate
cancer. Journal of Oncology, 2012,
958596. doi:10.1155/2012/958596
American Cancer Society (ACS). (2018).
Key statistics for prostate cancer:
How common is prostate cancer?
Retrieved from https://www.canc-
er.org/cancer/prostate-cancer/about/
key-statistics.html
American Urological Association (AUA).
(2018). Castration-resistant prostate
cancer. Retrieved from https://
www.auanet.org/guidelines/castra-
tion-resistant-prostate-cancer-(2013-
amended-2015)
Chahin, R., Gulamhusein, H., Breunis, H.,
& Alibhai, S.M. (2016). Quality of

care provided to prostate cancer (PC)
patients for prevention and treat-
ment of osteoporosis induced by
androgen deprivation therapy
(ADT). Sup port Care Cancer, 24(11),
4713-4720. doi:10.1007/s00520-016-
3320-1
Damji, A.N., Bies, K., Alibhai, S.M., &
Jones, J.M. (2015). Bone health man-
agement in men undergoing ADT:
Examining enablers and barriers to
care. Osteoporosis International,
26(3), 951-959. doi:10.1007/s00198-
014-2997-6
Datta, M., & Schwartz, G.G. (2012).
Calcium and vitamin D supplemen-
tation during androgen deprivation
therapy for prostate cancer: A criti-
cal review. Oncologist, 17(9), 1171-
1179. doi:10.1634/theoncologist.20
12- 0 051
Gilbert, S.M., Kuo, Y.F., & Shahinian, V.B.
(2011). Prevalent and incident use of
androgen deprivation therapy am -
ong men with prostate cancer in the
United States. Urologic Oncology,
29(6), 647-653. doi:10.1016/j.urol
onc.2009.09.004
Hall, L.N., Shrader, S.P., & Ragucci, K.R.
(2009). Evaluation of compliance
with osteoporosis treatment guide-

lines after initiation of a pharmacist-
run osteoporosis service at a family
medicine clinic. Annals of Pharma -
cotherapy, 43(11), 1781-1786. doi:
10.1345/aph.1M366
Jain, S., Bilori, B., Gupta, A., Spanos, P., &
Singh, M. (2016). Are men at high
risk for osteoporosis underscreened?
A quality improvement project.
Permanente Journal, 20(1), 60-64.
doi:10.7812/TPP/14-190
Johns Hopkins Hospital/Johns Hopkins
University. (2016). Johns Hopkins
Nursing Evidence-Based Practice
Model – Appendix C: Evidence level
and quality guide. Retrieved from
https://www.hopkinsmedicine.org/e
v i d e n c e - b a s e d - p r a c t i c e / _ d o c s /
a p p e n d i x _ c _ e v i d e n c e _ l e v e l _
quality_guide.pdf
Kanis, J.A., Hans, D., Cooper, C., Baim, S.,
Bilezikian, J.P., Binkley, N., …
McCloskey, E.V. (2011). Inter -
pretation and use of FRAX in clini-
cal practice. Osteoporosis Inter -
national, 22(9), 2395-2411. doi:10.
1007/s00198-011-1713-z
Langley, G.L. (1996). The improvement
guide: A practical approach to
enhancing organizational perform-
ance. San Francisco, CA: Jossey-
Bass Publishers.

Lewiecki, E.M., Binkley, N., Morgan, S.L.,
Shuhart, C.R., Camargos, B.M.,
Carey, J.J., … Leslie, W.D. (2016).
Best practices for dual-energy X-ray
absorptiometry measurement and
reporting: International Society for
Clinical Densitometry guidance.
Journal of Clinical Densitometry,
19(2), 127-140. doi:10.1016/j.jocd.
2016.03.003
Loblaw, D.A., Virgo, K.S., Nam, R.,
Somerfield, M.R., Ben-Josef, E.,
Mendelson, D.S., … Scher, H.I.
(2007). Initial hormonal manage-
ment of androgen-sensitive metasta-
tic, recurrent, or progressive prostate
cancer: 2006 update of an American
Society of Clinical Oncology prac-
tice guideline. Journal of Clinical
Oncology, 25(12), 1596-1605. doi:10.
1200/jco.2006.10.1949
Meng, M.V., Grossfeld, G.D., Sadetsky, N.,
Mehta, S.S., Lubeck, D.P., & Carroll,
P.R. (2002). Contemporary patterns
of androgen deprivation therapy use
for newly diagnosed prostate cancer.
Urology, 60(3, Suppl. 1), 7-11.
doi:10.1016/S0090-4295(02)01560-1
National Comprehensive Cancer Network
(NCCN). (2017). Prostate cancer ver-
sion 2.2017. NCCN clinical practice
guidelines in oncology. Retrieved

from https://www.nccn.org/profes
sionals/physician_gls/pdf/prostate.
pdf
National Osteoporosis Foundation (NOF).
(2019). Overall health. Retrieved
from https://www.nof.org/patients/
treatment/overall-health/
Panju, A.H., Breunis, H., Cheung, A.M.,
Leach, M., Fleshner, N., Warde, P., …
Alibhai, S.M. (2009). Management of
decreased bone mineral density in
men starting androgen-deprivation
therapy for prostate cancer. British
Journal of Urology International,
103(6), 753-757. doi:10.1111/j.1464-
410X.2008.08156.x
Pradhan, M.R., Mandhani, A., Chipde,
S.S., Srivastava, A., Singh, M., &
Kapoor, R. (2012). Bone densitomet-
ric assessment and management of
fracture risk in Indian men of
prostate cancer on androgen depri-
vation therapy: Does practice pat-
tern match the guidelines? Indian
Journal of Urology, 28(4), 399-404.
doi:10.4103/0970-1591.105750
Shahinian, V.B., Kuo, Y.F., Freeman, J.L.,
& Goodwin, J.S. (2005). Risk of frac-
ture after androgen deprivation for
prostate cancer. New England
Journal of Medicine, 352(2), 154-
164. doi:10.1056/NEJMoa041943

Tanvetyanon, T. (2005). Physician prac-
tices of bone density testing and
drug prescribing to prevent or treat
osteoporosis during androgen depri-
vation therapy. Cancer, 103(2), 237-
241.
Turner, B., Ali, S., Drudge-Coates, L., Pati,
J., Nargund, V., & Wells, P. (2016a).
Skeletal health part 1: Overview of
bone health and management in the
cancer setting. Urologic Nursing,
36(1), 17-21, 26. doi:10.7257/1053-
816X.2016.36.1.17
Turner, B., Ali, S., Drudge-Coates, L., Pati,
J., Nargund, V., & Wells, P. (2016b).
Skeletal health part 2: Development
of a nurse practitioner bone support
clinic for urologic patients. Urologic
Nursing, 36(1), 22-26. doi:10.7257/
1053-816X.2016.36.1.22
University of Sheffield. (n.d.) FRAX®
Fracture Risk Assessment Tool.
Retrieved from https://www.shef
f i e l d . a c . u k / F R A X / t o o l . a s p x ?
country=23
Walsh, J.S., & Eastell, R. (2013).
Osteoporosis in men. Nature Review
Endocrinology, 9(11), 637-645. doi:10.
1038/nrendo.2013.171
SERIES

Copyright of Urologic Nursing is the property of Society of
Urologic Nurses & Associates,
Inc. and its content may not be copied or emailed to multiple
sites or posted to a listserv
without the copyright holder's express written permission.
However, users may print,
download, or email articles for individual use.

UROLOGIC NURSING November-December 2019 Volume 39 Number.docx

Recommended

Recommended

More Related Content

Similar to UROLOGIC NURSING November-December 2019 Volume 39 Number.docx

Similar to UROLOGIC NURSING November-December 2019 Volume 39 Number.docx (20)

More from jessiehampson

More from jessiehampson (20)

Recently uploaded

Recently uploaded (20)

UROLOGIC NURSING November-December 2019 Volume 39 Number.docx