Sustainable impact of multi-dimensional quality improvement: Improving Dual-energy X-ray Absorptiometry (DXA) access.

Introduction: Dual-energy X-ray absorptiometry (DXA) is the gold standard for diagnosing osteoporosis; however, due to limited capacity it is not available to all patients with fragility fractures. A multidimensional quality improvement project, using the Plan–Do–Study–Act (PDSA) model, led to the implementation of several initiatives between 2022 and 2023. These included increasing scanning capacity, vetting repeat DXA requests, upskilling the bone health team, and strengthening partnerships with primary care. The objective of this study is to assess the sustainability of these initiatives in improving DXA access.

Methods: Monitoring DXA waiting list and new fragility fractures for the year 2021-25 against Key Performance Indicator 5 (KPI 5) of the Fracture Liaison Service Database (FLS-DB) national standard: the proportion of patients receiving a DXA scan within 90 days of fracture and DXA waiting times.

Results:

In 2021, baseline data showed that 875 fragility fracture patients were identified, with 29.2% (n=255) receiving a DXA scan within 90 days; the average DXA waiting list was 1,028 patients per month. Following expansion of the Aneurin Bevan FLS (AB-FLS), case identification increased substantially in 2022 and 2023. In 2022, 1,647 patients were identified, but only 16.8% (n=276) were scanned within 90 days, and the DXA waiting list increased to 1,541 patients per month. This trend continued in 2023, with 2,179 patients identified, 17.4% (n=379) scanned within 90 days, and the waiting list rising further to 1,980 patients per month.

Following implementation of targeted quality improvement initiatives, DXA access improved despite continued growth in fracture identification. In 2024, 2,621 patients were identified, with 21.9% (n=573) receiving a DXA scan, representing a 124% increase in scans compared with 2021, while the average DXA waiting list decreased to 849 patients per month.

The improvement was not only sustained but shown further improvement in 2025, when 2,830 patients were identified and 39.7% (n=1,123) underwent DXA scanning within 90 days, alongside a sustained reduction in the waiting list to an average of 868 patients per month.

Conclusion: The quality improvement project initiated in 2022 has delivered a sustained and measurable impact, successfully accommodating identification of higher fragility fracture cases. Our next aim is to spread and scale these initiatives to meet the national FLS standards across Wales.