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RESEARCH AND PRACTICE |
The authors are with the School of Public Health & Health Sciences, University of Massachusetts at Amherst.
Correspondence: Requests for reprints should be sent to Stephen H. Gehlbach, MD, MPH, University of Massachusetts at Amherst, School of Public Health & Health Sciences, Amherst, MA 01003 (e-mail: gehlbach{at}schoolph.umass.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This study explored the recognition and treatment of osteoporosis and vertebral fracture among older women by primary care physicians.
Methods. Data from the National Ambulatory Medical Care Survey from 1993 to 1997 were examined for evidence of diagnosis and treatment of osteoporosis or vertebral fracture during visits by White women 60 years and older to primary care physicians.
Results. Fewer than 2% of the women received diagnoses of osteoporosis or vertebral fracture, although expected prevalence is 20% to 30%. Appropriate drug treatment, including antiresorptive agents and calcium and vitamin D, was offered to only 36% of the diagnosed patients.
Conclusions. Few cases of osteoporosis or vertebral fracture in older women are being diagnosed and treated by primary care physicians.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Recent advances in medical treatment, including several bisphosphonates, a selective estrogen receptor modulator, and nasal calcitonin spray, can reduce the risk of fracture.6,11–17 Estrogen replacement and calcium supplementation have been confirmed as effective strategies for reducing bone loss.18–22
Despite the availability and efficacy of these agents, however, recognition and appropriate treatment of osteoporosis by clinicians appear less than ideal. Only 5% of the women who had osteoporosis diagnosed by bone mineral density determinations were told by a physician that they had "osteoporosis . . . thin or brittle bones."1 Of the older women hospitalized at a regional medical center who had radiographically demonstrated vertebral fractures, only 17% had these noted in medical records, and only 30% of those identified had appropriate treatment recorded.23
This study examined recognition and treatment of osteoporosis by a national sample of primary care physicians who treat older women and determined the rate of prescribing appropriate medications for osteoporosis.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We selected a subsample of all visits by White women 60 years and older to primary care physicians (family physicians, general practitioners, internists, obstetricians, and gynecologists). Diagnostic categories used to indicate recognition of osteoporosis included osteoporosis (ICD-9-CM code 733.0) and vertebral fractures (ICD-9-CM codes 805.2, 805.4, 805.8, 733.13, and 737.10). Vertebral fractures were included because they are common manifestations of osteoporosis and predict future fractures.5–8
Three categories of drugs were selected as appropriate prescribing responses to the diagnosis of osteoporosis or vertebral fracture: (1) calcium and vitamin D supplements, (2) estrogen replacement, and (3) calcium metabolism regulators, specifically bisphosphonates and calcitonin.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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). There were no differences by physician specialty. Recognition increased somewhat for older patients: 3.1% for women 80 years and older, 1.5% for women aged 70 to 79 years, and 0.9% for women aged 60 to 69 years (Table 2). In 1997, the year with the highest recognition, 4.3% of those aged 80 years were identified compared with 1.8% of those aged 60 to 69 years.
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). Among subcategories of drugs, the most notable increase was for bisphosphonates and calcitonin; 0% were prescribed in 1993 compared with 27% of the cases in 1997. Estrogen replacement therapy and calcium and vitamin D supplement ordering did not change dramatically. Hormone replacement was prescribed for about 20% of the diagnosed women, a rate that compares with 7% to 9% for women who were not recognized as having osteoporosis. Use of calcium and vitamin D supplements ranged from 13% to 21%. Bisphosphonate and calcitonin prescribing was higher for women 70 years and older than for women aged 60 to 69 years (about 20% and 4%, respectively), whereas estrogen replacement prescriptions decreased with age (Table 2). Only 13% of the diagnosed women 80 years and older were receiving estrogen compared with about 22% in the younger age groups. Surveys in community populations suggest that the prevalence of osteoporosis or vertebral fracture is much higher than these data indicate. Melton et al.2 estimated the prevalence of vertebral deformity among Rochester, Minn, women 50 years and older as 25%. Davies et al.3 found that 27% of 661 Nebraska women older than 60 years had vertebral fractures. Kado et al.4 reported that 20% of 9575 women 65 years and older had radiographic evidence of vertebral fracture. Data from the National Health and Nutrition Examination Survey III indicated that 30% of the postmenopausal women had bone mineral density levels meeting the World Health Organization's criteria for osteoporosis.1
On the basis of these reports, it is reasonable to assume that 20% to 30% of White women older than 60 years have osteoporosis or vertebral fracture. Prevalence would be at least this high among women visiting primary care offices. Physicians are, thus, identifying fewer than 10% of the women who have osteoporosis or vertebral fracture. Recognition improves little in older patients, even though advancing age is a potent risk factor for osteoporosis.2,3 Rates are only 1% in the younger age category and 3% for octogenarians.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Recognition and treatment of osteoporosis by primary care physicians appear low for several reasons. The National Ambulatory Medical Care Survey data report form accommodates only 3 diagnoses and 6 medications, so it may be insufficient to gather all physician recognition or treatment. Osteoporosis may not rank among the 3 most important medical problems for older individuals or may not be considered relevant to the particular, sampled visit. Although there are more opportunities to record medications, physicians may not consider nonprescription supplements, such as calcium and vitamin D. Newer prescription drugs, such as bisphosphonates, should be recorded, however.
Clinical factors also may contribute to low recognition. Osteoporosis is an asymptomatic disease that is difficult to diagnose in the absence of fracture. Even when fractures are present, they often do not produce symptoms or precipitate visits to physician offices. Unless obvious spinal deformity is evident as a result of multiple fractures, radiographic examination is necessary to make the diagnosis. Low bone mineral density is the best indicator of osteoporosis, but the test may be costly and not easily accessible. At the time our data were collected, expert groups were not recommending bone mineral density screening.25
Attempts to identify risk profiles that assist clinicians in selecting patients for referral to bone mineral density screening have been disappointing. Lydick et al.26 developed a clinical risk score that showed reasonable predictive value in identifying patients with low bone density, but subsequent validation studies found that the model had poor specificity and did little to reduce referrals for the examinations.27,28
Even when osteoporosis is recognized, physicians do not always respond by ordering treatment to reduce the risk of future fractures. Slightly more than one third of the women given diagnoses were prescribed an appropriate medication. Prescribing rates did increase from 20% to 55% over the study interval, however. This increase was largely a result of the prescribing of bisphosphonates and corresponded to the Food and Drug Administration approval of alendronate in 1995. Recorded prescribing of calcium and vitamin D supplements and estrogen was consistently low at about 20% of diagnosed patients. Hormone replacement was prescribed for approximately 20% of the osteoporotic women, a figure consistent with the report by Cummings29 that 14% of the women in the Study of Osteoporotic Fractures were taking estrogen at the time they were enrolled. Calcium and vitamin D supplementation was about half the rate found by the Study of Osteoporotic Fractures Group29 but, as suggested earlier, may have been underreported in the National Ambulatory Medical Care Surveys.
Since our study data were collected, the National Osteoporosis Foundation, in collaboration with several specialty colleges, issued a report30 and recommendations suggesting bone mineral density testing for all women older than 65 years and for younger postmenopausal women at additional risk for osteoporosis who are willing to accept treatment.10 With greater agreement among expert groups on the need for identification and treatment, the low rates of recognition and treatment we found may improve. Because the condition is responsible for more than 400 000 hospital admissions and 2.5 million physician visits in the United States each year, which cost the health system $13.8 billion,10 this should be considered a public health priority.
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Acknowledgments |
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Footnotes |
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Accepted for publication December 30, 2000.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Melton LJ III, Lane AW, Cooper C, Eastell R, O'Fallon WM, Riggs BL. Prevalence and incidence of vertebral deformities. Osteoporos Int. 1993;3:113–119.[Medline]
3. Davies KM, Stegman MR, Heaney RP, Recker RR. Prevalence and severity of vertebral fracture: the Saunders County Bone Quality Study. Osteoporos Int. 1996;6:160–165.[Medline]
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Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR. Vertebral fractures and mortality in older women: study of Osteoporotic Fractures Research Group. Arch Intern Med. 1999;159:1215–1220.
5. Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med. 1991;114:919–923.
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Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA. 1999;282:637–645.
7. Black DM, Arden NK, Palermo L, et al., for the Study of Osteoporotic Fractures Research Group. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. J Bone Miner Res. 1999;14:821–828.[Medline]
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10. Physician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 1999.
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Liberman UA, Weiss SR, Broll J, et al. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med. 1995;333:1437–1443.
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Delmas PD, Bjarnason NH, Mitlak BH, et al. Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women. N Engl J Med. 1997;337:1641–1647.
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Felson DT, Zhang Y, Hannan MT, Kiel DP, Wilson PW, Anderson JJ. The effect of postmenopausal estrogen therapy on bone density in elderly women. N Engl J Med. 1993;329:1141–1146.
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Cauley JA, Seeley DG, Ensrud K, Ettinger B, Black D, Cummings SR. Estrogen replacement therapy and fractures in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1995;122:9–16.
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Effects of hormone therapy on bone mineral density: results from the Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial. JAMA. 1996;276:1389–1396.
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Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med. 1997;337:670–676.
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25. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams & Wilkins; 1996.
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27. Von Muhlen D, Visby Lunde A, Barrett-Connor E, Bettencourt R. Evaluation of the simple calculated osteoporosis risk estimation (score) in older Caucasian women: the Rancho Bernado Study. Osteoporos Int. 1999;10:79–84.[Medline]
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