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Missed Opportunities for Prevention of Osteoporotic Fracture
Teresa C. Gallagher, PhD;
Olga Geling, PhD;
Florence Comite, MD
Arch Intern Med. 2002;162:450-456.
ABSTRACT
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Background Osteoporotic fracture is a growing public health problem burden to society.
Despite the importance of physician practices in preventing it, relatively
little is known about the osteoporosis-related practices of US physicians.
Methods A total of 1500 female members of a Connecticut independent practice
association model health plan (aged 40-69 years) were surveyed to identify
women's receipt of osteoporosis-related services (eg, prevention counseling,
bone mineral density [BMD] testing, and communication about treatment options).
These findings were compared with recommendations of the US Preventive Services
Task Force and the National Osteoporosis Foundation. We received 1007 completed
questionnaires, for a response rate of 69%.
Results Only 49% of the sample reported that a health care provider ever discussed
osteoporosis with them. In multivariate analyses, women with multiple risk
factors were not more likely than other women to have been counseled about
osteoporosis and its prevention, although those with an osteopenia/osteoporosis
diagnosis were. In contrast to National Osteoporosis Foundation recommendations,
only a small minority of high-risk women (12%-34%) had their BMD tested. Although
most women with an osteopenia/osteoporosis diagnosis reported receiving information
on estrogen replacement therapy, calcium, and weight-bearing exercise, fewer
reported receiving information on pharmaceutical alternatives to estrogen
(33%) and vitamin D (20%).
Conclusions The main trigger to physician counseling of women about osteoporosis
and its prevention is an osteopenia/osteoporosis diagnosis. Women with multiple
risk factors for osteoporosis are not being identified for preventive counseling
interventions or BMD testing.
INTRODUCTION
OSTEOPOROSIS IS a growing public health problem resulting in an enormous
burden to society. Unless comprehensive programs of prevention and treatment
are initiated, the direct medical costs for osteoporotic fractures alone are
expected to more than double (from an estimated annual $14 billion in 19951) during the next 50 years.2-3
Osteoporotic fractures also have significant social costs (chronic pain, disability,
increased dependence on others, need for nursing home care, deformity, and
death), and it is estimated that more than 243 000 older US adults have
an osteoporosis-related disability (unpublished data, 2001).
Greater utilization of available interventions to prevent, diagnose,
and treat osteoporosis can dramatically reduce the rate of osteoporotic fracture
and subsequent sequelae. Several associations, including the US Preventive
Services Task Force (USPSTF) and the National Osteoporosis Foundation (NOF),
have published evidence-based recommendations for physician practices with
regard to the prevention, detection, and treatment of osteoporosis in women.4-5 However, relatively little is known
about physician practices in reference to these recommendations. We surveyed
a large sample of female members of a managed care network to identify women's
receipt of osteoporosis-related services and compared the results with recommendations
of the USPSTF and the NOF. Because this study was conducted a year before
publication of the NOF recommendations in 1999, this study should not be viewed
as an assessment of the impact of these recommendations on clinical practice.
Instead, it provides a benchmark of physicians' osteoporosis-related practices
before dissemination of the NOF recommendations.
Osteoporosis-related services examined here include physician-patient
discussion of osteoporosis and preventive measures, receipt of bone mineral
density (BMD) testing, and physician-patient communication about treatment
options (among women with osteopenia/osteoporosis only). The NOF recommends
that physicians counsel all women on the risk factors for osteoporosis. Both
the USPSTF and the NOF recommend that physicians counsel all women about universal
preventive measures related to fracture risk (eg, take in adequate amounts
of calcium and vitamin D, perform regular weight-bearing exercise, avoid tobacco
smoking, and keep alcohol intake moderate), and the USPSTF recommends that
all perimenopausal and postmenopausal women be counseled about estrogen replacement
therapy (ERT) for osteoporosis prevention. The NOF identifies high-risk groups
that should be referred for testing: all women 65 years or older, regardless
of additional risk factors; all postmenopausal women younger than 65 years
who have 1 or more additional risk factors for osteoporosis (besides menopause);
postmenopausal women who present with fractures; women who are considering
therapy for osteoporosis (if BMD testing would facilitate the decision); and
women who have undergone hormone replacement therapy for prolonged periods.
The NOF recommends that postmenopausal women with low BMD or established osteoporosis
be offered a pharmaceutical therapy (estrogen, alendronate, calcitonin, and
raloxifene were Food and Drug Administration approved at the time of the study),
and that all patients being considered for drug treatment of osteoporosis
also be counseled on the importance of calcium, vitamin D, and exercise as
part of any pharmacologic treatment program.
SUBJECTS AND METHODS
Data are from a self-administered mail survey of a randomly selected
sample of 1500 female members (aged 40-69 years) of a Connecticut managed
care network in early 1998. Members of this independent practice association
model health plan are required to select a primary care physician from a list
of participating physicians at the time of enrollment; are encouraged but
not required to rely on their primary care physician to coordinate their care;
and do not need a referral from their primary provider to see a specialist.
Participants in the plan's Medicaid and Medicare risk plans were excluded.
The initial survey mailing was followed with a postcard reminder to the entire
sample, and 2 follow-up mailings to nonrespondents. Thirty-one questionnaires
were undeliverable or could not be completed owing to respondent illness or
lack of English proficiency. One thousand seven completed questionnaires were
received, for an effective response rate of 69% (1007/[1500 - 31]);
1004 surveys arrived in time to be entered into the database.
OSTEOPOROSIS PREVENTION COUNSELING
We identified the percentage of women reporting that a health professional
ever talked with them about osteoporosis and selected preventive measures.
Each respondent was asked whether a doctor or other health professional ever
talked with her about "osteoporosis or brittle bones," calcium in her diet,
weight-bearing exercise, "hormone replacement therapy to prevent or treat
osteoporosis," or ever advised her to quit smoking (smokers only).
We report also the prevalence of osteoporosis discussions by women's
stage of menopause. Stage of menopause was coded as premenopause, perimenopause,
or postmenopause (surgical or nonsurgical), and was determined on the basis
of survey questions on length of time since last menstrual period, recent
change in cycle regularity, and hysterectomy. (Gallagher et al6
provide more detail on study measures.)
Using multivariate analysis, we determined whether women with selected
osteoporosis risk factors5 were more likely
to have discussed osteoporosis and (in separate analyses) specific preventive
measures with their physicians. Risk factors as measured in this survey include
early menopause (menopause before age 45 or bilateral ovariectomy); low body
mass index (BMI) (<21 kg/m2, calculated using self-reported
height and weight); current cigarette smoking status; personal history of
fracture (ever fractured wrist, spine, or hip); family history of fracture
(wrist, spine, or hip fracture in parent, sibling, or grandparent); and long-term
use of corticosteroids (self-report of having used steroid medicines at least
1 month of the year for at least 5 years). All measures were based on survey
questions. Diagnosed osteopenia/osteoporosis was measured by affirmative response
to a question asking whether bones were "below normal density" on BMD testing
or, "Have you ever been told by a doctor that you had osteoporosis or brittle
bones?"
Other variables included in the multiviarate analyses predicting osteoporosis-related
discussions were demographic characteristics of women (age, education, household
income), menopause-related characteristics (stage/type of menopause, menopausal
symptoms, medical consult for menopausal symptoms), self-perceived health
status, and provider characteristics. Respondents were asked to indicate whether
they had "any of these symptoms related to menopause" (hot flashes, difficulty
sleeping, bladder problems, poor memory, vaginal dryness, irritability/mood
swings), and to rate the severity of their experience with each symptom on
an 8-point scale, ranging from "never" to "severe." A total symptom score
was created by summing the score on these 6 items (Cronbach  = .79),
and symptom experience was categorized as none or slight (0-6), mild (7-13),
moderate (14-20), or severe (21+). Medical consult for menopausal symptoms
was measured by a question asking whether the respondent ever telephoned or
visited a doctor or other health care provider for any of the above symptoms.
Measures of provider characteristics included sex and specialty of a woman's
primary care physician and the pattern of physician(s) that a woman used for
regular care (family practitioner or internist and no obstetrician/gynecologist
[ob/gyn]; ob/gyn but no family practitioner/internist; family practitioner
or internist and ob/gyn).
We considered all of the above measures for entry into the regression
models predicting discussion of osteoporosis and (in separate models) individual
preventive measures. The stepwise method was used to progressively enter variables
into the models, and the fits of the resulting nested models were compared
using likelihood ratio tests. For clinical risk factors such as smoking and
low BMI, we tested separately models that included the individual risk factors
and models that included multiple risk factors. In examining the effects of
potentially correlated factors (eg, osteoporosis risk factors and diagnosed
osteopenia/osteoporosis), we also tried fitting models that included these
factors separately. The resulting nonnested models were compared using the
Akaike Information Criterion. The models discussed are the most parsimonious
models chosen, using the above procedures.
BMD TESTING
We identified the percentage of women in the entire sample and the percentage
of high-risk women (as outlined in the NOF recommendations) reporting BMD
testing. Respondents were provided a description of BMD testing and asked
whether they ever had a BMD test. High-risk women were identified through
survey questions. We did not have a measure of "postmenopausal women who present
with fracture" and approximated this with "postmenopausal women with a lifetime
fracture history." "Women who are considering therapy for osteoporosis" was
measured with a question asking whether respondent had ever considered taking
hormone replacement therapy "to treat or prevent bone thinning, bone loss,
or osteoporosis." Use of hormone replacement therapy for prolonged periods
was measured by self-report of hormone replacement therapy use for 5 or more
years.
DISCUSSION OF TREATMENT OPTIONS
We identified the percentage of women with self-reported osteopenia
(low BMD on BMD testing) or osteoporosis ("Have you ever been told by a doctor
that you had osteoporosis or brittle bones?") who reported receiving information
about recommended treatment options. Respondents were asked whether a doctor
or other health professional ever talked with them about "medicines or supplements
to prevent or treat osteoporosis or brittle bones," and if so to indicate
which of the following (ERT, raloxifene, alendronate, calcitonin, calcium
supplements, vitamin D supplements) were discussed.
RESULTS
SAMPLE CHARACTERISTICS
Most respondents were white and non-Hispanic with a fairly high household
income (Table 1). Almost half
were in their forties, 36% in their fifties, and 15% in their sixties. Most
(58%) viewed themselves as in excellent or very good health, and very few
(8%) as in fair or poor health. Almost one third (28%) had a family history
of fracture, and 8% a personal history of fracture. Only 8% of the sample
reported osteopenia (low BMD on BMD testing) or physician diagnosis of osteoporosis.
Almost all had a primary care provider, and 26% saw a female primary care
provider. Fifty-nine percent utilized both a family practitioner or internist
and an ob/gyn for their regular care.
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Table 1. Sample Characteristics of 1004 Survey Respondents
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RECEIPT OF OSTEOPOROSIS-RELATED SERVICES
The rate of receipt of osteoporosis-related practices reported by women
in this sample varied according to the type of intervention, with very low
BMD testing rates, "middling" rates of counseling about osteoporosis and its
prevention, and high rates of communication about treatment options among
those with osteopenia/osteoporosis (Table
2). Only 49% of women in the sample reported that a health care
provider ever discussed osteoporosis with them. The overall BMD testing rate
in the sample was quite low (9%), and only somewhat higher (12%-34%) in the
high-risk groups. Most women with osteopenia or osteoporosis reported receiving
information about various treatment options (ERT, calcium, weight-bearing
exercise), but fewer reported communication about pharmaceutical alternatives
to ERT (33%) or vitamin D (20%). Only 2% reported receiving information about
the full range of treatment options.
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Table 2. Percentage of 1004 Women Reporting Receipt of Osteoporosis-Related
Services
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OSTEOPOROSIS-PREVENTION COUNSELING
As outlined in Table 3,
the percentage of women reporting having ever discussed osteoporosis with
a health care provider was very low among premenopausal women (28%) and increased
with each stage of menopause, but was still less than universal (63%) among
postmenopausal women. Discussion of specific preventive measures was also
lowest among premenopausal women (21%-44%, with the exception of a high rate
for smoking-cessation counseling among smokers), somewhat higher among perimenopausal
women, and still less than universal among postmenopausal women (57%-63%).
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Table 3. Percentage of Women Reporting Osteoporosis Discussions, by
Stage of Menopause
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In multivariate analyses predicting an osteoporosis discussion with
a health care professional (Table 4),
women with single or multiple risk factors for osteoporosis were not more
likely to have ever discussed osteoporosis with a health care provider, although
those with osteopenia or osteoporosis were (odds ratio, 27.4; 95% confidence
interval, 6.46-116.55). Also more likely to report an osteoporosis discussion
were women who were white, in their 50s, postmenopausal, in very good to excellent
health, or who consulted a health care provider regarding menopausal symptoms.
Respondent education, menopausal symptoms, and provider characteristics were
not related to the likelihood of an osteoporosis discussion.
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Table 4. Relationship Between Women's Characteristics and Discussion
of Osteoporosis With a Health Care Professional
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In multivariate analyses (not shown) separately predicting discussions
of specific preventive measures (dietary calcium, weight-bearing exercise,
ERT to prevent osteoporosis), results were very similar to those predicting
a general osteoporosis discussion. In general, women with an osteopenia/osteoporosis
diagnosis were more likely to report having discussed each of these measures
with a health professional (odds ratio range, 2.15-5.04), while those with
single or multiple risk factors were not.
COMMENT
The rate of osteoporosis discussions found here (49%) represents a striking
improvement since 1991, when only 25% of women aged 45 to 75 years reported
having ever discussed osteoporosis with a physician.7
Counseling rates were high among postmenopausal women, suggesting particular
awareness of the importance of osteoporosis prevention in the postmenopausal
period. These findings are consistent with other studies indicating that women
are most likely to be targeted for osteoporosis interventions in the postmenopausal
period or from age 50 years onward.8-10
However, counseling of premenopausal and perimenopausal women about
osteoporosis and its prevention could be dramatically increased: only 28%
and 43% of these groups, respectively, reported an osteoporosis discussion.
A significant portion of the age-related decrease in bone mass in women occurs
before menopause,11-12 and many
premenopausal and perimenopausal women may have low bone mass. Preventive
measures such as ensuring adequate intake of calcium and vitamin D may help
to maintain bone that has been acquired and counteract the process of age-related
bone loss that occurs before menopause.13
It is surprising that only 8% of this sample report having been identified
as having osteopenia or osteoporosis, possibly warranting intervention. Based
on the epidemiology of osteopenia/osteoporosis, one would expect to see a
much higher rate, as the combined prevalence of osteopenia and osteoporosis
among non-Hispanic white women 50 years and older is estimated at 50% to 68%.14 The low rate of diagnosed osteopenia/osteoporosis
observed here is especially notable because the sample is a relatively advantaged
one with generally excellent access to medical care. Most women in the sample
utilized 2 physicians for regular care (a family practitioner or internist
plus an ob/gyn); their managed care plan imposed few constraints on access
to specialty care; and the sample members lived in a geographic area anchored
by a prestigious academic medical center with a plethora of well-trained physicians
and modern health services. However, the low rate of diagnosed osteopenia/osteoporosis
observed here is consistent with the low rate of BMD testing in this sample
(9%) and other research samples indicating very low rates of BMD testing and
diagnosis of osteopenia/osteoporosis in women.15-20
The lack of targeting of women with multiple osteoporosis risk factors
for prevention counseling and the low BMD testing rates in this sample indicate
that high-risk women are not being identified early enough in the disease
to benefit from preventive measures. Other research also indicates that women
with multiple risk factors do not perceive themselves as being at risk for
osteoporosis, are not more likely than those at lower risk to worry about
osteoporosis, and are not more likely to utilize preventive measures.21-25
An osteopenia or osteoporosis diagnosis, according to our findings and those
of other studies, seems to be the cue to osteoporosis interventions; women
are most likely to discuss osteoporosis with a health care professional and
implement preventive measures after an osteoporosis diagnosis, and are most
likely to receive osteoporosis medications after a fracture.22, 24-25
Interestingly, women seeing a female primary care physician and those
utilizing an ob/gyn in addition to an internist or family practitioner for
their regular care were not more likely to report having been counseled about
osteoporosis and its prevention. This contrasts with a long line of research
indicating that women seeing female providers (if internists) or ob/gyns,
and those seeing 2 providers for regular care (family practitioner or internist
plus ob/gyn) are more likely to receive female-specific clinical preventive
services.26-31
Only a handful of studies have specifically explored practice variations in
osteoporosis care: female providers are more likely to refer women for BMD
testing,15 and gynecologists are more likely
to treat for osteoporosis,32-33
particularly with ERT.33
Many of the gaps in osteoporosis-related practices identified here seem
to be in areas where the clinical interventions, scientific knowledge, or
practice recommendations are very new. For example, low counseling rates of
women before menopause about osteoporosis prevention may be related to the
relatively weak state of scientific evidence on the efficacy of preventive
measures early in the life cycle. Low BMD testing rates among high-risk women
may be related to the relative newness of BMD testing as a diagnostic technology
and the recency of published detailed clinical recommendations outlining who
should be tested. The low rates of communication reported among women with
osteopenia/osteoporosis about pharmaceutical alternatives to ERT and about
vitamin D may be related to the very recent introduction of some of these
medications (raloxifene having been approved only several months before this
study was implemented) and the newness of scientific evidence on the efficacy
of vitamin D in reducing the risk of osteoporotic fracture.
Greater diffusion of BMD testing and osteoporosis practice guidelines,
including dissemination of available scientific evidence on the efficacy of
current osteoporosis interventions (including universal preventive measures)
may help to address the gaps in practice identified here. New clinical interventions
may also help to increase the diagnosis and treatment rates of osteoporosis,
including the availability of convenient methods to measure BMD and expansion
of the repertoire of pharmacologic treatment options well beyond ERT. The
cost of central (axial) skeleton bone densitometry devices is decreasing,
which should increase their utilization, and newer, less expensive devices
that measure peripheral bone density are becoming available. Since the time
of this study, several other bisphosphonates have been approved for osteoporosis
treatment, and anabolic agents that stimulate new bone formation34
will become available.
However, there may be significant barriers to osteoporosis prevention
counseling, diagnosis, and treatment that may not quickly self-resolve. A
national survey of primary care physicians would provide us with useful information
on current osteoporosis-related practices in a large, representative sample
of physicians and allow us to identify variations in practice by organizational
and provider characteristics. This can be followed with surveys and focus
groups to identify the barriers to more proactive osteoporosis-related practices.
General barriers might include attitudes that osteoporosis is of lower priority
than other medical conditions or insufficient knowledge of osteoporosis and
the appropriate use of available interventions (ie, "when to treat?"). Barriers
to osteoporosis prevention counseling may include competing demands on physician
time, lack of reimbursement to physicians for this activity, and questions
about the efficacy of preventive measures. Barriers to greater utilization
of BMD testing may include limited reimbursement of such by managed care and
insurance companies, organizational policies that restrict the use of BMD
testing, or controversy over the cost-effectiveness of osteoporosis diagnosis
and intervention strategies that rely heavily on BMD testing. Potential barriers
to greater use of osteoporosis-related pharmaceutical agents might include
policies and practices of managed care organizations designed to limit the
prescribing of these medications, limited reimbursement by insurance policies,
and patient compliance.
Physician lack of awareness or acceptance of current osteoporosis practice
recommendations might also be a barrier to more widespread implementation
of recommended practices. It is important to identify physicians' awareness,
acceptance, and use of osteoporosis practice recommendations to determine
the efficacy of these recommendations in changing current practices. More
health services research on the effectiveness and cost-effectiveness of recommended
practices should also help guide future practices. At present, all of the
necessary data are not available, and some guidelines rely heavily on the
opinion of experts. This research will become even more important in guiding
practices as the number of available osteoporosis clinical interventions multiplies.
POTENTIAL STUDY LIMITATIONS
We used women's self-reports to measure the delivery of osteoporosis
clinical services. Women may not always "register" the delivery of information
on health conditions by their physician or recall this information in a health
survey, so we may have underestimated the delivery of services. Our sample
was limited to women with employment-based health insurance, and so low-income
and older women are underrepresented. However, our estimates are similar to
those obtained in a recent national survey, where 61% of women 45 years or
older reported having discussed osteoporosis with their physician.35 In support of generalizability, the study was conducted
in an independent practice association model managed care organization, and
the study participants received care from an almost open-ended list of providers
throughout the state of Connecticut. Using physician-patient communication
about osteoporosis as an indicator of women's awareness of osteoporosis and
preventive measures may underestimate such awareness because much of this
information is being disseminated through the popular media, particularly
in female-specific media such as women's magazines.
CONCLUSIONS
There is room for improvement in current osteoporosis-related practices
to more closely approximate those recommended by current practice guidelines.
This may require a change from viewing osteoporosis as an illness that begins
at the point of fractures to one that should be actively assessed and treated
before fractures occur. Much work remains to be done to address the growing
and preventable burden of osteoporotic fracture in society.
AUTHOR INFORMATION
Accepted for publication July 2, 2001.
This study was supported in part by a grant from the University of Illinois
Research Board, Champaign (Dr Gallagher), and an unrestricted educational
grant from Eli Lilly & Co, Indianapolis, Ind (Dr Comite). M.D. Health
Plan, North Haven, Conn, provided material support.
This study was presented in part at the World Congress on Osteoporosis,
Chicago, Ill, June 16, 2000.
Corresponding author and reprints: Florence Comite, MD, Yale University
School of Medicine, 40 Temple St, Suite 7H, New Haven, CT 06510.
From the Departments of Community Health (Dr Gallagher) and Statistics
(Dr Geling), University of Illinois at Urbana-Champaign, and Yale University
School of Medicine, New Haven, Conn (Dr Comite).
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