1140 Canadian Family Physician • Le Médecin de famille canadien Vol 54: august • août 2008
Print short, Web long*
Osteoporosis screening for men
Are family physicians following the guidelines?
Natalie Cheng MD Michael E. Green MD MPH CCFP
OBJECTIVE To determine rates of screening for osteoporosis among men older than 65 years and to find out
whether family physicians are following the recommendations of the Osteoporosis Society of Canada’s 2002
Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada.
DESIGN Chart audit.
SETTING The Family Medicine Centre at Hotel Dieu Hospital in Kingston, Ont.
PARTICIPANTS All male patients at the Family Medicine Centre older than 65 years for a total of 565 patients
associated with 20 different physicians’ practices.
MAIN OUTCOME MEASURES Rates of screening with bone mineral density (BMD) scans for osteoporosis,
results of BMD testing, and associations between results of BMD testing and age.
RESULTS Of the 565 patients reviewed, 108 (19.1% of the study population) had received BMD testing. Rates
of screening ranged from 0% to 38% in the 20 practices. Among 105 patients tested (reports for 3 patients
were not retrievable), 15 (14.3%) were found to have osteoporosis, 43 (41.0%) to have osteopenia, and 47
(44.8%) to have normal BMD results. No significant association was found between BMD results and age.
Screening rates were higher among men older than 75 years than among men aged 65 to 75 and peaked
among those 85 to 89 years old.
CONCLUSION On average, only about 20% of male patients older than 65 years had been screened for
osteoporosis, so most of these men were not being screened by BMD testing as recommended in the guidelines.
Considering the relatively high rates of osteoporosis and osteopenia found in this study and the known
morbidity and mortality associated with osteoporotic fractures in this population, higher rates of BMD screening
and more widespread treatment of osteoporosis could prevent many fractures among these patients. Family
physicians need to become more aware of the risk factors indicating screening, and barriers to screening and
treatment of osteoporosis in men need to be identified and addressed.
EDITOR’S KEY POINTS
by? the? Osteoporosis? Society? of? Canada’s? 2002?
*Full text is available in English at www.cfp.ca.
Vol 54: august • août 2008 Canadian Family Physician • Le Médecin de famille canadien 1141
*Le texte intégral est accessible en anglais à?www.cfp.ca.
POINTS DE REPèRE DU RéDACTEUR
Dépistage de l’ostéoporose chez l’homme
Les médecins de famille suivent-ils les directives?
Natalie Cheng MD Michael E. Green MD MPH CCFP
OBJECTIF Déterminer le taux de dépistage de l’ostéoporose chez les hommes de plus de 65 ans et voir si les
médecins de famille suivent les directives de pratique clinique de 2002 pour le diagnostic et le traitement de
l’ostéoporose de la Société de l’ostéoporose du Canada.
TYPE D’éTUDE Revue de dossier.
CONTEXTE Le Family Medicine Center de l’Hôtel-Dieu de Kingston, Ont.
PARTICIPANTS Tous les patients mâles de plus de 65 ans du Family Medicine Center, soit un total de 565 clients
de 20 bureaux médicaux différents.
PRINCIPAUX PARAMèTRES éTUDIéS Taux de dépistage de l’ostéoporose par ostéodensimétrie (ODM),
résultats de l’ODM et association entre les résultats de l’ODM et l’âge.
RéSULTATS Sur les 565 patients étudiés, 108 (19,1%) avaient subi une ODM. Les taux de dépistage
variaient de 0% à 38% dans les 20 établissements. Sur les 105 patients testés (les résultats manquaient
pour 3 patients), 15 (14,3%) présentaient de l’ostéoporose, 43 (41,0%) de l’ostéopénie et 47 (44,8%) des
résultats normaux. Il n’y avait pas d’association significative entre les résultats de l’ODM et l’âge. Les taux
de dépistage chez les plus de 75 ans étaient plus élevés que chez les patients de 65 à 75 ans; ce taux était
maximal dans le groupe des 85 à 89 ans.
CONCLUSION En moyenne, seulement 20% des patients mâles de plus de 65 ans avaient subi un dépistage de
l’ostéoporose, la plupart n’ayant donc pas eu de dépistage par ODM tel que préconisé par les directives. Étant
donné les taux relativement élevés d’ostéoporose et d’ostéopénie observés dans cette étude, et connaissant la
morbidité et la mortalité associées aux fractures ostéoporotiques dans cette population, on croit qu’un plus fort
taux de dépistage et un traitement plus agressif de l’ostéoporose pourraient prévenir plusieurs fractures chez
ces patients. Le médecin de famille devrait mieux connaître les facteurs de risque qui incitent au dépistage; il
faudrait aussi cerner les facteurs qui nuisent au dépistage et au traitement de l’ostéoporose chez l’homme.
Résumé imprimé, texte sur le web*
1141.e1 Canadian Family Physician • Le Médecin de famille canadien Vol 54: august • août 2008
Research Osteoporosis screening for men
4 women.1,2 Goeree et al estimated that there were more
than 21 000 osteoporosis-related hip fractures in Canada
in 1993 and that the total cost of acute care for osteo-
porosis in Canada (including hospital stays, outpatient
care, and drug therapy) was higher than $1.3 billion.3 An
Ontario study estimated that by 2010, the annual num-
ber of hip fractures will be double the number in 1990.4
By 2041, researchers estimate that 25% of the popula-
tion will be older than 65 years.5 Considering these facts,
as well as the difficulty of accessing endocrinologists,
geriatricians, and internists, management of osteopo-
rosis will fall increasingly into the hands of family phy-
sicians.5 This trend is made clear by the fact that 80.1%
of bone mineral density (BMD) scans were ordered by
family physicians in 2000 while only 47.3% were ordered
by them in 1992.6 Unfortunately, many family physicians
remain unaware of the prevalence and complications
of osteoporosis and of the guidelines for screening for
osteoporosis in men.
In the past, diagnosis and treatment of osteoporo-
sis largely focused on women, particularly postmeno-
pausal women. There is, however, a growing body of
literature highlighting the prevalence and complica-
tions of osteoporosis and the usefulness of treating it in
men. Men suffer nearly 30% of all hip fractures,7 19% of
men older than 50 years have osteoporosis as defined
by BMD testing, and men older than 50 years have a 5%
to 6% lifetime risk of hip fractures and a 13% lifetime
risk of fragility fractures.8,9 Male nursing home resi-
dents are 5 to 10 times more likely than men who live
in the community to have fractures.10 Men are twice as
likely as women to die in hospital after hip fractures
and have substantially higher 1-year mortality rates
from hip fractures (31% to 40% of men vs 17% to 20%
In a case-control study in the United Kingdom, Pande
and Francis found that male patients had an 8-fold
increase in mortality after hip fractures and that mor-
tality continued to increase after 2 years of follow-up.15
A study by Kiebzak et al of 363 patients admitted for
atraumatic (low-energy) hip fractures revealed that
more than 30% of surviving male patients required the
aid of a walker or wheelchair after the fracture and that
the number of male patients participating in recreational
activities dropped by 50% after fractures.11
steoporosis causes a great deal of morbidity
and mortality worldwide. About 1 in 8 men in
Canada have osteoporosis, compared with 1 in
Unfortunately, there is little evidence of screening for
osteoporosis among men who have not had fractures.
Unlike women, who are often diagnosed with osteopo-
rosis through BMD screening, men are frequently diag-
nosed when they present with fractures.16,17 Jaglal et al
found that of the 244 515 BMD tests billed in Ontario in
1998, only 13 579 (5.5%) were ordered for men.18 Even
once they have had fractures, men are less likely than
women to be diagnosed and treated. Johnson et al con-
ducted BMD testing and implemented osteoporosis
treatment plans for 126 patients attending an orthope-
dic surgery clinic after they had suffered fractures and
found that 41% had osteopenia and 20% had osteopo-
rosis.19 Only 12.7% of patients had undergone BMD test-
ing before the study. Kiebzak et al found that only 4.5%
of men were treated for osteoporosis at discharge for
atraumatic fracture compared with 27% of women. At
the 5-year follow-up point in this study, only 27% of
male patients were receiving treatment for osteoporosis
compared with 71% of female patients.11 Feldstein et al
conducted a study of 1171 male patients older than 65
years enrolled in a large health maintenance organiza-
tion who had sustained at least 1 fracture.20 They found
that only about 7% had been treated for osteoporosis
during the 3 years following their fractures.
The 2002 Clinical Practice Guidelines for the Diagnosis
and Management of Osteoporosis in Canada21 and the
2006 update from the Canadian Consensus Conference
on Osteoporosis22 outline major and minor risk factors
for osteoporosis. They recommend that all postmeno-
pausal women and all men older than 50 be screened
for risk factors and that patients with 1 major or 2 minor
risk factors undergo BMD screening by central dual-
energy x-ray absorptiometry (grade A recommenda-
tion) with consideration for repeat BMD testing every 2
to 3 years to monitor changing risk.21 The 2006 guide-
lines emphasized that the 5 most important risk factors
are advanced age, low BMD, family history of fractures
(particularly maternal hip fractures), history of fragil-
ity fractures, and use of glucocorticoids for longer than
3 months.22 Khan et al further clarified the importance
of specific risk factors in men and found that fragility
fractures, systemic glucocorticoid use, and being older
than 65 are key risk factors for osteoporosis in men,
independent of their BMD.23
Despite the prevalence of osteoporosis in men and the
high rates of morbidity and mortality after fractures,
few men are being diagnosed or treated for osteopo-
rosis. There is no literature on the prevalence of BMD
screening among older men; however, based on the
low rates of screening and diagnosis among men who
have sustained fractures, the prevalence is expected
to be low. The purpose of this study was to determine
the rates of BMD screening among men older than 65
Dr Cheng was a resident training in Enhanced Rural
Skills at Queen’s University in Kingston, Ont, at the time
of this study. Dr Green is an Assistant Professor in the
departments of family medicine and community health
and epidemiology at Queen’s University and is a member
of the Centre for Health Services and Policy Research and
the Centre for Studies in Primary Care.
Vol 54: august • août 2008 Canadian Family Physician • Le Médecin de famille canadien 1141.e2
Osteoporosis screening for men Research
to see whether screening was being done as recom-
mended by the 2002 Clinical Practice Guidelines for the
Diagnosis and Management of Osteoporosis in Canada.
We intended to break the rates down by age group to
determine whether there was any identifiable relation-
ship between age and rates of screening or BMD results.
The study, a retrospective cross-sectional chart audit,
was carried out at the Family Medicine Centre (FMC) at
Hotel Dieu Hospital in Kingston, Ont. The FMC has 20
full- and part-time physicians organized into 8 teaching
practices (each with 2 to 3 faculty and 2 residents) who
care for a total of approximately 9000 patients. The FMC
uses an electronic health record system (CIS by P&P
Systems) that includes a complete, searchable patient
registry. All male patients enrolled at the FMC who were
born before June 1, 1940, were included in the study.
This cutoff date was chosen to allow a buffer period of 1
year for BMD testing to be done after patients turned 65
In Kingston, BMD testing is centralized at 2 sites, and
both sites agreed to participate in this study. Data were
collected on the dates and results of BMD testing for
all study patients as well as the ages of the patients at
the time of testing and the names of their family physi-
cians. One site provided a list of BMD results for patients
seen at their facility. Results from the second site were
obtained by searching their computerized hospital charts.
Results of all BMD testing conducted before June 1, 2006,
were included in the analysis. Data were entered into
Microsoft Excel spreadsheets and subsequently imported
into STATA version 7.0 software24 for statistical analysis.
The project was reviewed and approved by the Health
Sciences Research Ethics Board at Queen’s University in
There were 589 male patients at the FMC older than 65
years; 24 of these patients were subsequently found to
have died before June 1, 2006, and were thus excluded
from the study, leaving 565 patients. A total of 108
patients (19.1% of all eligible patients, 95% confidence
interval 15.9% to 22.6%) had received BMD testing before
June 1, 2006. Unfortunately, 3
BMD reports were missing
from the records, leaving us
with 105 patients with available
BMD T-scores (Table 1). The
Osteoporosis Society of Canada
uses the T-scores derived by the
World Health Organization to
define normal bone mass (-1 to +1), low bone mass (or
osteopenia) (-2.5 to -1), and osteoporosis (-4 to -2.5).21
T-scores are used to compare patients’ bone density
with the average bone density of young healthy adults
of the same sex and are based on standard deviations
above or below the mean BMD for the reference popula-
tion. No significant association was found between BMD
results and age (P = .0705).
To determine whether rates of screening were higher
among older patients, results were analyzed according
to age group (Table 2). While rates of BMD screening
increased after the age of 75 years, with a peak propor-
tion of 30% screened among those 85 to 89 years old,
the differences were not statistically significant. Only 2
of 14 patients older than 90 received BMD testing (15%).
Owing to the small number of patients, this age group
was combined with the 85 to 89 age group, giving a
combined screening proportion of 25.9%.
Results were also analyzed by physician to illustrate
differences in physicians’ rates of screening (Figure 1).
On average, 20% of male patients older than 65 years had
been screened; rates ranged from 0% to 38% (standard
deviation 12%). Screening rates were not related to the
size of the eligible patient population in each practice.
This study shows that most male patients older than 65
years in these academic practices were not being screened
as recommended by the Osteoporosis Society of Canada’s
2002 Clinical Practice Guidelines for the Diagnosis and
Management of Osteoporosis in Canada.21 The prevalence
of osteoporosis found in this study was 14.3%, which is
close to the Canadian Multicentre Osteoporosis Study’s
estimate of 1 in 8 men.2 Considering the substantial prev-
alence of osteoporosis in older men and the high rates
of morbidity and mortality related to osteoporotic frac-
tures in this population, physicians should try to achieve
higher rates of BMD screening among these patients so
that they can be treated and many more fractures can
Table 1. Bone mineral density results: N = 105.
Table 2. Patients screened in each age group
≥ 85 y
1141.e3 Canadian Family Physician • Le Médecin de famille canadien Vol 54: august • août 2008
Research Osteoporosis screening for men
be prevented. Family physicians need to become familiar
with the risk factors that identify people who should be
assessed for osteoporosis.
The original World Health Organization definitions
for osteoporosis were developed for postmenopausal
women.25 There is still debate over the reference group to
be used to derive T-scores for men; however, it is gener-
ally agreed that men with T-scores lower than -2.5 are at
substantially increased risk of osteoporotic fractures and
should be treated.17,21 The World Health Organization is
currently developing a method of estimating a 10-year
absolute risk of fracture based on BMD, age, sex, and
other risk factors gleaned from several large databases.
It is possible that some physicians are aware of the
risk factors that indicate screening for osteoporosis but
are deliberately choosing not to screen or perceive bar-
riers to implementing fracture-prevention strategies.
McKercher et al conducted a study on management of
osteoporosis in long-term care patients and found that
commonly cited barriers to screening and treatment
included the perceived cost of investigations and treat-
ment, the unknown benefit of treatment, and concerns
about prescribing medications to elderly patients (eg,
side effects and polypharmacy).26 Jaglal et al did a sur-
vey of family practitioners and found similar barriers,
along with the findings that limited time and competing
demands during appointments hampered physicians’
ability to provide preventive care, that there was a per-
ception that some patients were not keen on health pro-
motion because they were preoccupied with existing
illnesses, and that physicians had difficulty keeping up
with current literature.6 Some of these barriers might
be overcome with research, educating physicians and
patients, using physician reminders, and develop-
ing clear and succinct evidence-based clinical practice
guidelines. Access to medications is improving, as dem-
onstrated by the fact that the Ontario Drug Benefit Plan
formulary has recently (as of July 12, 2007) eliminated
the requirement of a failed trial of etidronate before pro-
viding coverage for other bisphosphonates with better
proven clinical benefit in prevention of fractures, such
as alendronate and risedronate.
On the other hand, there are situations in which
screening is not indicated despite risk factors. The 2002
guidelines discuss the fact that treating patients for
osteoporosis might not be indicated if there is an unfa-
vourable risk-benefit ratio, and that screening should be
done only if it will affect management.21 For example,
patients who are receiving palliative care or who have
relatively short life expectancies would be unlikely to
benefit from treatment of osteoporosis (which can take
months to years for effect). Further investigation would
be beneficial for clarifying the existence of barriers to
screening and treatment, as well as how often BMD
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Male patients >65 y
Figure 1. Physicians’ rates of screening male patients older than 65 years for osteoporosis
Vol 54: august • août 2008 Canadian Family Physician • Le Médecin de famille canadien 1141.e4
Osteoporosis screening for men Research
testing is deliberately not done for sound clinical rea-
sons. There also needs to be more research on why
treatment response is different for women than for men.
This study showed a trend toward increased rates of
screening in older men, but this trend was not statisti-
cally significant, likely owing to the small numbers of
participants in each subgroup. This trend might have
reflected a greater tendency toward screening because
of advanced age or a higher prevalence of other risk
factors for osteoporosis with age. A larger sample size
would be needed to determine the nature of this rela-
tionship and whether there is actually a lower rate of
screening among men older than 90.
No statistically significant relationship was found
between BMD results and age, which was unexpected
given the well-established increase in risk of osteoporo-
sis with age. Because only 19% of the study population
received screening, however, the sample size was not
adequate to establish any relationship. This patient pop-
ulation likely had other risk factors aside from age that
prompted screening and that would confound an age-
related analysis of BMD results. A larger study would be
required to determine accurately the influence of various
risk factors on BMD and rates of screening.
This study took place in an academic centre where
individual practices are relatively small compared with
community practices and residents provide a large pro-
portion of care under the supervision of preceptors. We
do not know to what extent these results can be extrap-
olated to family practices in communities.
Some patients might have had BMD testing outside
Kingston. Results of this testing would not have been
included in this analysis, and this would have led to an
underestimation of screening rates.
The sample size was limited by the size of the prac-
tices. This limited the power to analyze differences
between subgroups of patients (by age, for example).
A larger study would be required to know whether
trends in screening rates were statistically and clini-
Despite the fact that this study was carried out at a
single academic centre, there were large variations in
screening rates among practices. Even the most suc-
cessful practices achieved screening rates of only 30%
to 40%. Primary care physicians need to increase their
awareness of the prevalence of osteoporosis in men, of
the seriousness of its consequences, and of the indica-
tions for screening and treatment. Future studies of bar-
riers to screening and treatment, particularly of male
patients, and specific research on the benefits of treating
men with osteoporosis would help guide family physi-
cians in the management of osteoporosis.
We thank Kingston Imaging and the Imaging Department
at Kingston General Hospital for their assistance in acquir-
ing the bone mineral density data for this study.
The study was designed and conducted by Dr Cheng
under the supervision and guidance of Dr Green. This
manuscript was written by Dr Cheng and revised by Dr
Green with consideration of intellectual content. Both Drs
Cheng and Green approved the final version of the article.
Correspondence to: Dr Michael Green, Department
of Family Medicine, CHSPR, Abramsky Hall, 3rd Floor,
Queen’s University, 21 Arch St, Kingston, ON K7L 3N6;
telephone 613 533-6387; fax 613 533-6353; e-mail
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