Editorials

Osteoporosis Management: Out of Subspecialty Practice and into Primary Care

Am Fam Physician. 2004 Oct 1;70(7):1219-1220.

A 60-year-old, small-framed woman with good general health but a strong family history of osteoporosis presents for her well-woman examination. Because she meets screening criteria for osteoporosis,1 her family physician orders a bone density test. Her T-scores are −2.8 at the lumbar spine and −1.5 at the femoral neck. Osteoporosis is diagnosed, and the patient begins treatment with a bisphosphonate and calcium/vitamin D supplements. Two years later, the patient’s lumbar-spine bone density is stable, but her femoral-neck T-score has declined by 1.5 percent. She has not had a fracture. The patient asks if the change in her femoral-neck T-score represents a treatment failure and whether this finding warrants referral to a subspecialist.

We can ask the same question about this patient that we ask about any patient with chronic disease: Who should take responsibility for her care? A recent editorial in the Archives of Internal Medicine2 promotes shared responsibility by primary care physicians and subspecialists for osteoporosis management. A strategy in which primary care physicians take the lead in managing this common disorder is optimal because we are the only ones who can implement preventive measures on a population level. Osteoporosis screening and routine management does not require subspecialist input. For example, in the case of the patient described above, the T-score decrease was relatively small. The density at the femoral neck was still within the osteopenia range, and the lumbar spine bone density was stable. She had not incurred a fracture while taking a bisphosphonate. Her score change did not represent a treatment failure, and she did not require referral to a specialty clinic.

In 2002, nearly 22 million women in the United States had osteopenia (bone mineral density below normal but above the level for a diagnosis of osteoporosis). More than 8 million U.S. women 50 years and older currently have osteoporosis, and the number of affected women is expected to exceed 14 million by the year 2020.3 Women with osteoporosis are at increased risk for death or disability from fractures of the hip, spine, or wrist. Osteoporotic fractures could cost as much as $20 billion per year in the United States, with hip fractures accounting for over one third of total expenditures.4 Only primary care physicians can reach patients early enough to screen for and treat osteoporosis before fracture is imminent.

As summarized by Zizic in this issue of American Family Physician,5 well-designed randomized controlled trials have demonstrated the efficacy of risedronate (Actonel) and alendronate (Fosamax) in decreasing vertebral and nonvertebral (including hip) fractures in women with osteoporosis and a history of fracture at baseline. Alendronate also has been shown to decrease fracture incidence in women with osteoporosis but no previous fracture.6

Despite the availability of evidence-based screening guidelines and effective treatment agents,1 implementation of preventive and therapeutic measures is disturbingly low, even in patients who already have incurred fractures.7,8 Whose fault is the poor implementation? A recent survey9 found that more than 80 percent of family physicians wanted to be better informed about bone density testing and osteoporosis treatment. However, many of these physicians felt that available guidelines were out of date or otherwise not useful. A recent review indicated lack of guideline uniformity, low screening rates, and low intervention rates.10

Most osteoporosis research and guideline development still are conducted by subspecialists who are unfamiliar with the unique practice demands and needs of family physicians. It is clear that family physicians need to be involved in all phases of the process—from research to guideline formation and implementation—to ensure the construction and implementation of clinical aids that are tailored to our specialty and practice environments. Tools for screening, diagnosing, treating, and monitoring patients are available. We no longer can wait for someone else to take charge.

The Author

MARGARET GOURLAY, M.D., M.P.H., is assistant professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill, where she is conducting research on osteoporosis screening and fracture prevention. Dr. Gourlay graduated from Rush Medical College, Chicago, and completed a family medicine residency at the University of California, San Diego, Medical Center. She was an editing fellow for American Family Physician and currently is a contributing editor for AFP.

Address correspondence to Margaret Gourlay, M.D., M.P.H., Department of Family Medicine, William Aycock Bldg., Manning Dr., CB # 7595, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599-7595 (e-mail: margaret_gourlay@med.unc.edu). Reprints are not available from the author.

REFERENCES

1. U.S. Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med. 2002;137:526–8.

2. Mazanec D. Osteoporosis screening: time to take responsibility. Arch Intern Med. 2004;164:1047–8.

3. National Osteoporosis Foundation. America’s bone health: the state of osteoporosis and low bone mass in our nation. Washington, D.C.: The Foundation, 2002.

4. Cummings SR, Melton LJ 3d. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359:1761–7.

5. Zizic TM. Pharmacologic prevention of osteoporotic fractures. Am Fam Physician. 2004;70:1293–1300.

6. Cranney A, Wells G, Willan A, Griffith L, Zytaruk N, Robinson V, et al. Meta-analyses of therapies for postmenopausal osteoporosis. II. Meta-analysis of alendronate for the treatment of postmenopausal women. Endocr Rev. 2002;23:508–16.

7. Feldstein A, Elmer PJ, Orwell E, Herson M, Hillier T. Bone mineral density measurement and treatment for osteoporosis in older individuals with fractures: a gap in evidence-based practice guideline implementation. Arch Intern Med. 2003;163:2165–72.

8. Neuner JM, Zimmer JK, Hamel MB. Diagnosis and treatment of osteoporosis in patients with vertebral compression fractures. J Am Geriatr Soc. 2003;51:483–91.

9. Jaglal SR, McIsaac WJ, Hawker G, Carroll J, Jaakkimainen L, Cadarette SM, et al. Information needs in the management of osteoporosis in family practice: an illustration of the failure of the current guideline implementation process. Osteoporos Int. 2003;14:672–6.

10. Morris CA, Cabral D, Cheng H, Katz JN, Finkelstein JS, Avorn J, et al. Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med. 2004;19:783–90.


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