Interactive PDSA workbook Pilot version

Prolia (denosumab) recall management

Fill this in as your practice works through a Plan-Do-Study-Act cycle on overdue Prolia recalls. Your answers save automatically on this computer. Come back across the three monthly cycles and pick up where you left off. Written so the practice manager or nurse lead can drive it.

AuthorDr Chris Mitchell AM, FAICD

CPD hoursUp to 9 (EA 3 + RP 3 + MO 3)

TimelineThree monthly data cycles

Last savednot yet

Before you start: how this workbook saves

Type into the dashed magenta boxes. Each one shows an example answer above it. If you are not sure what to write, say the same kind of thing about your own practice.
Your answers save by themselves as you type, on this computer, in this browser. Close the tab, come back next week, everything will still be here. Check the 'Last saved' date on the cover.
Use one computer for the whole cycle, usually the practice manager's. If someone else needs to add their part, click Save to file, email them the file, and they click Load from file on their computer. Then they save to file and send it back.
Click Save to file at the end of every session. It downloads a small file. Keep it in your practice records folder. It is your backup if this computer is cleaned, replaced or reset.
When the cycle is finished, click Print / Save as PDF and choose 'Save as PDF'. That PDF is what the GPs upload as evidence to the RACGP CPD portal, and what you keep for accreditation.

One caution: clearing the browser's history or cache can delete your saved answers. The Save to file backup protects you.

This workbook is a pilot. If something is confusing or does not work on your computer, tell us via the contact page so we can fix it.

Your progress

0 of 0 fields completed. This is a long activity. Do a section, close the tab, come back next week.

The four stages

PlanPick the problem. Decide what you will count and who does what.

DoRun the change. Hold the meetings. Record the numbers as you go.

StudyCompare the numbers across the weeks. Write down what you noticed.

ActKeep what worked. Drop what did not. Make the good changes permanent.

The shaded boxes show you what to write

Every question carries the answer from Dr Chris Mitchell's own Prolia recall cycle, run in his practice from November 2022 to January 2023. You do not need to invent anything: read the example, then write the same kind of answer about your practice. The dashed magenta boxes are yours.

The learning: where your educational hours come from

Three of the nine hours are educational activities (EA). Your team earns them by reading and discussing the denosumab evidence, then applying it during the cycle. Chris wants this background on hand in every practice that runs the cycle.

The full background sits in the Prolia guide: denosumab mechanism, indications and contraindications, the fracture risk from delayed or missed doses, monitoring, discontinuation and transition therapy, MRONJ and dental extraction timing, and patient education. Read it as a team at a practice meeting and log the time as EA.

Read the background for this cycle

Resources you can share with the team

TGA safety advisory: denosumab (Prolia) and the risk of rebound vertebral fractures on discontinuation
Annals of Internal Medicine (2020): fracture risk with delayed denosumab dosing
Therapeutic Guidelines: Bone and metabolism
RACGP Standards for general practices: recall and reminder system requirements
Your clinical software help pages on recall and reminder searches
Your PHN, for data-extraction and recall support

For the practice manager

Email the guide page to every GP and nurse before the education meeting, so the reading is done by the time everyone sits down. The hours they spend reading and discussing it count toward EA, and this workbook records the rest.

Plan

Topic, idea and plan

Topic: what is this PDSA about?

Example

Recovering overdue Prolia (denosumab) recalls and building a reliable reminder system that keeps patients inside the 6-month dosing window.

The idea you are testing

Example

Missed Prolia doses can rapidly lead to bone loss and fractures. We found that reminders were not consistently updated in the clinical system at the time of administration, and that some patients were not returning for their 6-month injection without follow-up contact. We wanted to reduce the number of patients with overdue reminders and set up a system that stops the backlog recurring.

Plan: what you will do and what you will count

Example

Three objectives, agreed with GPs and the nursing team: identify all patients with overdue Prolia reminders by database search; contact each overdue patient and manage appropriately (book the appointment, inactivate, or document refusal); establish a system to prevent recurrence, with the reminder updated at the time of administration and a reminder card given to the patient. We ran a database extract over three monthly cycles to track the trend, and tested phone contact against automated recall (Automed) to see which worked better for this patient group.

Aims: what does success look like, in numbers?

Example

Reduce the number of overdue Prolia reminders across the three monthly cycles. Establish whether phone contact or automated recall gets more patients to book and attend. Embed the reminder-at-time-of-administration protocol so the backlog does not rebuild, confirmed by a follow-up search at six months.

Meeting and data-cycle schedule

Chris's practice ran the activity as three monthly data cycles, led by the nursing team, with a planning meeting at the start. Type your dates in as each one happens. These dates become part of the CPD evidence, so keep them accurate.

Milestone	Date
Planning meeting: agree the approach with GPs and the nursing team
Initial database search: overdue Prolia reminders
Data cycle 1
Data cycle 2
Data cycle 3
Six-month follow-up search: confirm the trend holds
RACGP portal upload (GPs log their hours)

Study

Data collection

Run the overdue-reminder search at each monthly cycle and enter the totals here. Numbers only in the cycle boxes (66, not '66 patients'). The change column works itself out.

Example

The nursing team ran a database search for overdue Prolia reminders at each cycle. The initial search found 66 overdue reminders spanning the previous 12 months. Working the list against the reminder-at-administration protocol, the overdue count fell to 34 at the second cycle and 22 at the third. Of the original 66, 64 were patients who had not attended, not a system failure; the other 4 were reminders that had not been updated after a GP or nurse gave the injection.

What you are counting	Cycle 1	Cycle 2	Cycle 3	Change

What we learned

Example

Phone contact was more effective than automated recall (Automed) for getting patients to book and attend. Providing a script with the due date noted, and a reminder card given at the injection, kept patients informed. Booking the next appointment six months ahead at the time of administration did not work, patients did not reliably attend a booking made that far out. Private fee arrangements had reduced some patients' willingness to return. The reminder updated at the time of administration, applied consistently, is the core system change that prevents recurrence.

Act

What to keep and make permanent

Example

The Prolia reminder is now updated in the clinical system at the time of each administration, by the clinician who gives the injection. Patients are handed a reminder card with the next due date. Osteoporosis is added to the active health problems list for every Prolia patient. A GP Chronic Condition Management Plan and review is put in place where appropriate, so nurse monitoring can be billed under MBS item 10997. Phone contact is the preferred recall method, with automated recall as a supplement. A monthly overdue search runs so the backlog cannot rebuild, and clinical appropriateness is reviewed for patients with a history of missed doses.

CPD hours

Count the hours each GP spent. Reviewing the denosumab evidence and the practice knowledge base counts as EA. Reviewing the overdue recalls against the dosing schedule and setting recovery targets counts as RP. Tracking the overdue count across the three cycles counts as MO. The total adds up automatically. When in doubt, the GP lead decides what to claim.

Activity type	Hours	Evidence you already have
Educational activities (EA)		Practice meeting attendance, the denosumab education session
Reviewing performance (RP)		The overdue-recall audit and your review against the dosing schedule
Measuring outcomes (MO)		This completed workbook, the three cycle searches, meeting dates
Total	0	GPs submit as a GP-led activity via RACGP myCPD Home

In-house education is the easiest EA time to claim, and the easiest to forget

Reviewing the denosumab evidence in the guide as a team, at a practice meeting, is the most direct source of EA hours in this cycle. Log the time while you are there, because it is the part practices most often forget to claim.

Reflections (the GPs write these)

The RACGP asks each GP to reflect on three areas. Hand the computer to the GP lead for this bit, or collect a sentence or two from each GP at the follow-up meeting and type them in. There is no worked example here: these have to be your own.

Culturally safe practice Professional and health inequities Ethical practice

Participating doctors

One per line. This is for your records so nobody has to reconstruct it at portal-upload time.