Osteoporosis screening for men: Are family physicians following the guidelines?

Article (PDF Available)inCanadian family physician Medecin de famille canadien 54(8):1140-1141, 1141.e1-5 · September 2008with20 Reads
Source: PubMed
Abstract
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. Chart audit. The Family Medicine Centre at Hotel Dieu Hospital in Kingston, Ont. All male patients at the Family Medicine Centre older than 65 years for a total of 565 patients associated with 20 different physicians' practices. Rates of screening with bone mineral density (BMD) scans for osteoporosis, results of BMD testing, and associations between results of BMD testing and age. 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. 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.

Figures

1140
Canadian Family Physician Le Médecin de famille canadien  VOL 54: AUGUST AOÛT 2008
Research
Print short, Web long*
Osteoporosis screening for men
Are family physicians following the guidelines?
Natalie Cheng MD Michael E. Green MD MPH CCFP
ABSTRACT
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
Many family physicians remain unaware of the prev-
alence and complications of osteoporosis among
men. They are also unaware of the guidelines for
screening for osteoporosis in men.
This study shows that most male patients older than
65 years (80.9%) in these academic family prac-
tices were not being screened as recommended
by the Osteoporosis Society of Canadas 2002
Clinical Practice Guidelines for the Diagnosis and
Management of Osteoporosis in Canada.
There were large variations in screening rates among
the different practices, and even the most successful
practices achieved screening rates of only 30% to
40%.
*Full text is available in English at www.cfp.ca.
This article has been peer reviewed.
Can Fam Physician
2008;54:1140-1.e1-5
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.
Cet article a fait l’objet d’une révision par des pairs.
Can Fam Physician
2008;54:1140-1.e1-5
POINTS DE REPèRE DU RéDACTEUR
Plusieurs médecins de famille ignorent la prévalence
et les complications de l’ostéoporose chez l’homme
ainsi que les principes directeurs concernant le
dépistage de cette maladie chez l’homme.
Cette étude montre que la plupart des clients de
plus de 65 ans (80,9%) de ces établissements univer-
sitaires de médecine familiale n’avaient pas subi le
dépistage recommandé par les directives de pratique
clinique de 2002 pour le diagnostic et le traitement
de l’ostéoporose de la Société de l’ostéoporose du
Canada.
Le taux de pistage varie beaucoup d’un établis-
sement à un autre, et même les plus performants
atteignent à peine un taux de 30 à 40%.
pistage de lostéoporose chez lhomme
Les médecins de famille suivent-ils les directives?
Natalie Cheng MD Michael E. Green MD MPH CCFP
RéSUMé
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.
SULTATS Surles 565 patients étuds, 108(19,1%) avaient subiune ODM.Les taux de dépistage 
variaient de 0% à 38% dans les 20 établissements. Sur les105 patients tess (les sultats manquaient 
pour3 patients), 15(14,3%) psentaient de l’ostéoporose, 43 (41,0%) de l’ostéopénie et 47 (44,8%) des 
sultats normaux. Il n’y avait pas d’association significative entre les résultats de lODM etl’âge. Les taux 
de dépistage chez les plus de 75 ans étaient plus éles que chez les patients de 65 à 75 ans;ce taux était 
maximal dans le groupe des 85 à 89ans.
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.
Recherche
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
O
steoporosis causes  a great deal of morbidity 
and  mortality  worldwide.About1  in8  men in 
Canada have osteoporosis, compared with 1 in 
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  guidelinesfor  screening  for 
osteoporosis in men.
In the past,  diagnosis and treatment of osteoporo
-
sis  largely  focused  on  women, particularly postmeno
-
pausal women. Thereis, however, agrowing body of 
literature highlighting the prevalence and complica
-
tions of osteoporosis and the usefulness of treating it in 
men. Men suffer nearly30%ofallhipfractures,
7
19%of 
menolderthan50 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 wholive 
in thecommunity to have fractures.
10
Men aretwice as 
likely as women  to  die in  hospital after hip  fractures 
and have substantially higher 1-year mortality rates 
from hipfractures  (31%  to40%of  men vs  17%  to20% 
of women).
11-14
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
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  13579  (5.5%) were orderedfor  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  afterthey  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  largehealth  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  inCanada
21
and  the 
2006 update  from  the  Canadian  Consensus  Conference 
on  Osteoporosis
22
outline  major  and  minor  risk  factors 
for  osteoporosis. They  recommend that  all  postmeno
-
pausal  women  and  all  men  older  than  50  bescreened 
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
Research objective
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.  Thereis  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  ofBMD  screening  among  menolderthan  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. 
METhODS
The  study,  a  retrospective  cross-sectional  chart audit, 
was carried out at the Family Medicine Centre (FMC) at 
Hotel  Dieu  Hospitalin  Kingston,  Ont.  The  FMC  has20 
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 
years old.
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 software
24
for statistical analysis. 
The  project was  reviewed  and  approved  by  theHealth 
Sciences Research Ethics Board at Queen’s University in 
Kingston.
RESULTS
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 eligiblepatients, 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  younghealthy  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.
DISCUSSION
This studyshows thatmost male patients olderthan 65 
years inthese academic practices were notbeing 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 thesubstantial 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 
higherrates of BMD screening among thesepatients so 
that  they  can  be  treated  and  many  more  fractures  can 
Table 1. Bone mineral density results: N = 105.
PATIENTS NORMAL OSTEOPENIA OSTEOPOROSIS
No. of patients 47 43 15
% of patients tested
(95% condence
interval)
44.8
(35-54.8)
41.0
(31.5-51)
14.3
(8.2-22.5)
Table 2. Patients screened in each age group
PATIENTS 65-69 Y 70-74 Y 75-79 Y 80-84 Y 85 Y
No. of patients 171 140 122 78 54
No. of patients screened
29 22 28 15 14
% of patients screened
(95% condence interval)
17.0
(11.1-23.4)
15.7
(10.1-22.8)
23.0
(15.8-31.4)
19.2
(11.2-29.7)
25.9
(15-39.6)
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 
withthe risk factors that identify people who shouldbe 
assessed for osteoporosis.
The  original  World Health Organization denitions 
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  theperceived  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
Jaglalet  aldid  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  andsuccinct  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  inprevention 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 
0
10
20
30
40
50
60
70
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
No. screened
Male patients >65 y
Percentage screened
PATIENTS
PHYSICIAN
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  oldermen,  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 tendencytoward  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  andage,  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.
Limitations
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  hadBMD  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 limitedby thesizeof theprac
-
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
-
cally significant.
Conclusion
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  carephysicians  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. 
Acknowledgment
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.
Contributors
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.
Competing interests
None declared
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
mg13@queensu.ca
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    • "In contrast, our research team has previously reported undertesting among high-risk patients at a population level [4]. In Canada and the US, about 50% of women over 65 years of age and 81% of men have not had a BMD test678. In a systematic review of practice patterns in the management of osteoporosis after fragility fracture, BMD testing was performed in less than 15% of patients with recent fractures in 15 of 23 studies [6]. "
    [Show abstract] [Hide abstract] ABSTRACT: . Evidence of inappropriate bone mineral density (BMD) testing has been identified in terms of overtesting in low risk women and undertesting among patients at high risk. In light of these phenomena, the objective of this study was to understand the referral patterns for BMD testing among Ontario’s family physicians (FPs). Methods . A qualitative descriptive approach was adopted. Twenty-two FPs took part in a semi-structured interview lasting approximately 30 minutes. An inductive thematic analysis was performed on the transcribed data in order to understand the referral patterns for BMD testing. Results . We identified a lack of clarity about screening for osteoporosis with a tendency for baseline BMD testing in healthy, postmenopausal women and a lack of clarity on the appropriate age for screening for men in particular. A lack of clarity on appropriate intervals for follow-up testing was also described. Conclusions . These findings lend support to what has been documented at the population level suggesting a tendency among FPs to refer menopausal women (at low risk). Emphasis on referral of high-risk groups as well as men and further clarification and education on the appropriate intervals for follow-up testing is warranted.
    Full-text · Article · Jan 2016
    • "Our findings are consistent with other studies investigating osteoporosis disease management383940. However, they also highlight continuing gaps: specifically, 42% of at-risk patients who completed the RAQ reported never having had a BMD test, and the rate of osteoporosis investigations was significantly lower among men than women (consistent with other reports [18,41] ). Persistence of these gaps may be explained, in part, by how interventions are designed to overcome them. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems, yet gaps in management still exist. In response, we developed a multi-component osteoporosis knowledge translation (Op-KT) tool involving a patient-initiated risk assessment questionnaire (RAQ), which generates individualized best practice recommendations for physicians and customized education for patients at the point of care. The objective of this study was to evaluate the effectiveness of the Op-KT tool for appropriate disease management by physicians.Methods The Op-KT tool was evaluated using an interrupted time series design. This involved multiple assessments of the outcomes 12 months before (baseline) and 12 months after tool implementation (52 data points in total). Inclusion criteria were family physicians and their patients at risk for osteoporosis (women aged ¿50 years, men aged ¿65 years). Primary outcomes were the initiation of appropriate osteoporosis screening and treatment. Analyses included segmented linear regression modeling and analysis of variance.ResultsThe Op-KT tool was implemented in three family practices in Ontario, Canada representing 5 family physicians with 2840 age eligible patients (mean age 67 years; 76% women). Time series regression models showed an overall increase from baseline in the initiation of screening (3.4%; P¿<¿0.001), any osteoporosis medications (0.5%; P¿=¿0.006), and calcium or vitamin D (1.2%; P¿=¿0.001). Improvements were also observed at site level for all the three sites considered, but these results varied across the sites. Of 351 patients who completed the RAQ unprompted (mean age 64 years, 77% women), the mean time for completing the RAQ was 3.43 minutes, and 56% had any disease management addressed by their physician. Study limitations included the inherent susceptibility of our design compared with a randomized trial.Conclusions The multicomponent Op-KT tool significantly increased osteoporosis investigations in three family practices, and highlights its potential to facilitate patient self-management. Next steps include wider implementation and evaluation of the tool in primary care.
    Full-text · Article · Sep 2014
    • "Furthermore, these fractures can significantly impair quality of life, physical function, and social interaction and can lead to admission to long-term care91011. Although guidelines are available for osteoporosis disease management121314 , many patients are not receiving appropriate diagnostic testing or treatment1516171819 . Clinical decision support systems (CDSSs) may be one solution to closing these practice gaps because they can provide evidence at the point of care to facilitate disease management. "
    [Show abstract] [Hide abstract] ABSTRACT: ABSTRACT: Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems. Although guidelines on assessing and managing osteoporosis are available, many patients are not receiving appropriate diagnostic testing or treatment. Findings from a systematic review of osteoporosis interventions, a series of mixed-methods studies, and advice from experts in osteoporosis and human-factors engineering were used collectively to develop a multicomponent tool (targeted to family physicians and patients at risk for osteoporosis) that may support clinical decision making in osteoporosis disease management at the point of care. A three-phased approach will be used to evaluate the osteoporosis tool. In phase 1, the tool will be implemented in three family practices. It will involve ensuring optimal functioning of the tool while minimizing disruption to usual practice. In phase 2, the tool will be pilot tested in a quasi-experimental interrupted time series (ITS) design to determine if it can improve osteoporosis disease management at the point of care. Phase 3 will involve conducting a qualitative postintervention follow-up study to better understand participants' experiences and perceived utility of the tool and readiness to adopt the tool at the point of care. The osteoporosis tool has the potential to make several contributions to the development and evaluation of complex, chronic disease interventions, such as the inclusion of an implementation strategy prior to conducting an evaluation study. Anticipated benefits of the tool may be to increase awareness for patients about osteoporosis and its associated risks and provide an opportunity to discuss a management plan with their physician, which may all facilitate patient self-management.
    Full-text · Article · Jul 2011
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