Background: Bone loss is common in patients with breast cancer and can impact treatment decisions related to endocrine therapy. Hence, bone density assessment prior to start of endocrine therapy is highly important, especially because endocrine therapy is recommended as the first line of adjuvant treatment in patients with ER+ breast cancer. However, implementing bone density assessment in a timely manner is challenging, particularly early in the care trajectory, which involves many specialties and includes many other tests and procedures. We conducted a care delivery optimization in a large health system to implement bone density testing and referral for bone health consultation prior to endocrine therapy. The optimization was conducted as part of implementing the 4R Oncology model (Right Info, Right Care, Right, Right Patient, at the Right Time), a novel approach to optimizing patient-facing care planning, team-based delivery and patient self-management. Here we describe the impact of this optimization. Methods: A cohort of 278 women with breast cancer who were in the 4R intervention (the 4R cohort) was compared to a historical control cohort of 201 women who received care pre-4R. Demographic, bone health history, and oncologic care data were abstracted from chart review and clinical databases. The prevalence of bone loss and timing of bone density consultation request was compared between the 4R and historical control cohorts. Results: The age, race/ethnicity and rate of ER+ cancer were similar between the cohorts. Patients in the 4R cohort were significantly more likely than those in the control cohort to have received a consultation for bone density screening prior to the start of endocrine therapy. They were also more likely to receive a bone density test result during their care. These findings remained significant when data were restricted to those ≥ 50 years (as a proxy for postmenopausal status) and those with ER-positive breast cancer. The rates of osteopenia and osteoporosis were similar between the cohorts: control 47%, 24%; 4R cohort: 46%, 23% respectively (data not shown). Conclusions: Care optimization using the 4R Oncology Model was associated with a significant improvement in the timing of bone density test before initiation of endocrine therapy. The 4R Oncology Model can lead to more informed decision making in adjuvant endocrine therapy for patients with breast cancer. Additional optimizations to improve the rates of bone density tests and referrals will be beneficial.

*Statistically significant compared to control, p<0.05.