Promoting Osteoporosis Screening in Postmenopausal Women A how-to strategy for primary care clinicians LORRAINE S. WALLACE, PhD, FACSM; EDWIN S. ROGERS, PhD; AMY J. KEENUM, DO, PharmD; ARUNA R. SHAH, MD; LORI W. TURNER, PhD, RD

O

ABSTRACT: Screening is central to addressing the growing burden of osteoporosis among postmenopausal women but is not done often enough. One way clinicians can change this is to provide postmenopausal women with a comprehensive and personalized osteoporosis education—and to use it as a foundation for promoting bone densitometry testing as well as other preventive actions. The Health Belief Model, when interpreted in the context of osteoporosis, suggests that key educational aspects to review (and redirect) include the patient’s perceived susceptibility for the disease, her understanding of its potential for high morbidity, and her perceived benefits and barriers to following clinical recommendations. Screening indices are helpful in identifying women at risk for low bone mass and establishing the need for densitometry. All test results should be shared in detail with the patient, as studies show this improves compliance. (Women Health Primary Care 2003;6(8):380-391)

steoporosis is a systemic disorder characterized by microarchitectural deterioration of bone and increased susceptibility to fracture. Although osteoporosis can occur in men, it is principally a disease of women, who account for 80% of such cases and in whom osteoporosis (together with heart disease and cancer) is one of the three most common medical conditions.1-3 According to the National Osteoporosis Foundation, approximately 21% to 30% of postmenopausal white women have osteoporosis, and an additional 54% have low bone density. Osteoporosis presents an enormous and growing burden on the elderly. Osteoporotic fractures, for example, often lead not only to a significant reduction in quality of life, including loss of independence, but they also incur substantial costs to the individual and to the health care system. In this country, about $10 billion to $18 billion is spent each year on treating osteoporotic fractures.4 The total medical cost per hip frac-

ture is estimated at about $40,000 (2001 dollars).5 Because osteoporosis is typically an asymptomatic disease, screening has not always been considered a high priority. Such views have changed, however. Particularly in the past decade, screening has been recognized as an important strategy to reduce the burden of fracture-related morbidity, and identifying women at risk for osteoporotic fractures has become an important goal. Yet there is concern, and evidence supporting it, that screening and preventive interventions to address osteoporosis have not been fully employed. This article discusses two important roles of the primary care clinician in promoting— and ensuring—osteoporosis screening among postmenopausal women: ◆ First, primary care clinicians are in a good position to routinely order bone mineral density (BMD) testing for appropriate patients. Monetary costs to patients should not be a factor in this decision, as Medicare currently reimburses for bone densitometry testing at an average national rate of about $126.69 per total body scan.6 ◆ Second, primary care clinicians are also in an ideal setting to counsel women about osteoporosis risk factors and prevention strategies. Above all, as the primary health care providers to women, you have the

Drs. Wallace, Rogers, Keenum, and Shah are affiliated with the University of Tennessee Graduate School of Medicine in Knoxville. Drs. Wallace, Rogers, and Keenum hold the title of Assistant Professor of Family Medicine. Dr. Shah is a family practice resident. Dr. Turner is an Associate Professor in Health Science at the University of Arkansas in Fayetteville.

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Wallace et al: Osteoporosis Screening in Postmenopausal Women opportunity to reinforce the importance of timely osteoporosis screening and management. IDENTIFYING

WOMEN AT GREATEST

OSTEOPOROSIS RISK

The first step in screening for osteoporosis is to establish the patient’s risk for low bone density. Genetics is thought to account for 60% to 80% of peak bone mass, but other contributors should be considered as well, including behavioral and lifestyle factors, medications used, and medical history (Table 1).4,7-9 Bear in mind that attainment of peak bone mass is generally reached during the third decade of life.7 Screening indices: Recently, several brief osteoporosis risk indices have been developed to help clinicians identify women who are most at risk for low BMD.10-13 The purpose of these indices is to target patients who should undergo further testing with bone densitometry; most such tools factor in the patient’s age, weight, and estrogen use, since these variables are consistently useful in distinguishing degree of risk. Two validated indices are summarized in Table 2. Other indices can be found online; the Osteoporosis Education Web site (www.osteoed.org/tools/index .html) features the Simple Calculated Osteoporosis Risk Estimation tool, as well as the Osteoporosis Risk Assessment Instrument cited in Table 2. Patients can also be referred to www.agelessfoundation .org/osteoscreening/screening.html; at this site, visitors are asked numerous yes or no questions on osteoporosis risk factors and then provided with a score that classifies them as low-, moderate-, or highrisk. One of the benefits of using these risk indices is that patients can complete them at home or, as applicable, in the waiting area prior to their appointments. Clinical guidelines: Decisions regarding which patients to screen WOMEN’S HEALTH in Primary Care

should take into account not only risk indices but also clinical screening recommendations. The newest guidelines of the US Preventive Services Task Force recommend routine bone densitometry screening for all women 65 and older.14 Earlier screening is recommended (beginning at age 60) in women at increased risk for osteoporotic fractures. One way for primary care Table 1. Risk factors for osteoporotic fractures Genetic Family history Female sex White race Personal Age Long-term immobilization History of fractures or falls Medical Amenorrhea Anorexia nervosa Estrogen deficiency Hyperthyroidism Hypogonadism Low body weight Low bone density Behavioral and lifestyle Cigarette smoking Excessive alcohol consumption Excessive dietary protein Low dietary intake of calcium Physical inactivity Vitamin D deficiency Medications Anticonvulsants Corticosteroids

clinicians to increase rates of BMD screening is to order densitometry along with mammography—many postmenopausal women will need both of these tests and may appreciate having them scheduled on the same day. BONE DENSITOMETRY Considered the gold standard in assessing skeletal integrity, bone densitometry is used to diagnose os381

teoporosis, evaluate fracture risk, and monitor changes in bone density. Of the various types of densitometry, dual-energy x-ray absorptiometry (DXA) is accepted as the most accurate for identifying low BMD.15 The World Health Organization has established the following definitions for interpreting DXA scores; they are based on bone mass measurements in white women and are applicable to measurements at any skeletal site: ◆ Normal bone mass. The patient’s BMD is within one SD of a “young normal” adult (T-score is above –1). ◆ Low bone mass, or osteopenia. The patient’s BMD is between 1 and 2.5 SDs below that of a “young normal” adult (T-score between –1 and –2.5). ◆ Osteoporosis. The patient’s BMD is 2.5 or more SDs below that of a “young normal” adult (T-score below –2.5). Women in this group who have already experienced one or more fractures are deemed to have severe or “established” osteoporosis. These definitions should be used as a guide in developing treatment decisions for patients. For every SD decrease in bone density, the odds ratio for a fracture increases by 1.6 to 2.4 points.16 Although there are notable differences in BMD across racial and ethnic groups—in general, AfricanAmerican women and Hispanic women have higher BMD than do white women, while Asians have lower BMD—to date, prospective data on bone density and fracture risk are only available for white women.17,18 Thus, Bates et al suggest ordering densitometry testing for any patient who is 65 or older or who is at increased risk for fracture, regardless of race or ethnicity.15 SCREENING ISSUES AND CONCERNS Limited clinical focus on osteoporosis: Primary care clinicians do Vol. 6, No. 8/AUGUST 2003

Wallace et al: Osteoporosis Screening in Postmenopausal Women not have a good record in managing osteoporosis—identifying or treating it. Data from the 1993– 1997 National Ambulatory Medical Care Survey revealed that less than 2% of the 7,977 women 60 and older surveyed had received a diagnosis of osteoporosis or vertebral fracture by their primary care clinician.19 Moreover, appropriate pharmacologic treatment, includ-

teoporosis and its management. On a more positive note, but also raising concerns, Schrager and colleagues found that female medical providers at eight family practice clinics throughout Wisconsin were more likely to discuss osteoporosis with their patients than were male providers.21 Furthermore, women older than age 60 were more likely to receive osteo-

Table 2. Sample selection criteria for recommending bone mineral density testing* Osteoporosis Risk Assessment Instrument (ORAI)11,31

Study of Osteoporotic Fractures (SOFSURF)10

Selection cut point: Score ≥ 9

Selection cut point: Score > –1

Points are given for:

Points are given for:

Age: 15 points if the patient is 75 years or older 9 if age 65 – 74 6 if age 55 – 64 0 if age 45 – 54

Age: Add 0.2 points for each year older than 65 OR Subtract 0.2 points for each year younger than 65

Weight: 9 points if the patient weighs 60 kg or less 3 if 60 – 69 kg 0 if more than 70 kg

Weight: 1 point if the patient weighs less than 68 kg (or 150 lb) 2 if less than 59 kg (or 130 lb)

Estrogen use: 2 points if the patient is not currently taking estrogen

Current cigarette smoking: 1 point History of postmenopausal fracture: 1 point

* Women whose scores are above these cut points are deemed at high risk for osteoporosis and should be considered for bone density testing.

ing calcium, vitamin D, and antiresorptive agents, was offered to only 36% of those with the disease. A recent study that took place in an independent practice association found that less than half of the female members (ages 40 to 69) reported ever having a health care provider discuss osteoporosis with them.20 Importantly, those women with multiple risk factors were no more likely than the other women to have been counseled about osWOMEN’S HEALTH in Primary Care

porosis and calcium information than were women ages 40 to 60. A plethora of clinical barriers: In a cross-sectional study of US primary care clinicians, self-reported barriers to ordering bone densitometry included cost, unfamiliarity with guidelines, uncertainty with clinical applicability, presumed minimal impact on treatment decisions, and availability.22 How results are presented by the testing center also appears to 382

be a factor. Stock et al conducted a randomized trial assessing the impact of detailed versus standard BMD reports on family physicians’ decisions to order bone densitometry.23 They found that the physicians given detailed clinical results were nearly twice as likely to order densitometry as were those given the general descriptions, and that the greater detail resulted in much less confusion. These findings suggest that clinicians should be provided with comprehensive BMD test reports that explicitly highlight the patient’s individual degree of risk for osteoporosis or osteopenia. OSTEOPOROSIS

EDUCATION

AS A MEANS TO SCREENING

For postmenopausal women to make proactive, informed decisions regarding their bone health, they need to be educated about osteoporosis. To this end, it is important to provide the patient with explicit information on all aspects of the disease, including her personal risk, current prevalence rates (to put the magnitude of the problem in perspective), potential long-term consequences of incurring an osteoporotic fracture, and strategies to reduce risk and slow progression. Personalizing the discussion is essential to producing the greatest motivation for disease management and in addressing misconceptions. For example, a recent review of national newspapers and women’s magazines from 1998 to 2001 indicated that reporting of osteoporosis was minimal and discussion of risk factors was limited.24 Cross-sectional studies reinforce our concern that many postmenopausal women have limited knowledge of osteoporosis risk factors and preventive measures.25,26 Education plus densitometry the best equation: Two recent studies suggest that women who know that their BMD is low, who are educated about osteoporosis, or both Vol. 6, No. 8/AUGUST 2003

Wallace et al: Osteoporosis Screening in Postmenopausal Women Figure 1. A strategy for promoting osteoporosis screening: Application of the Health Belief Model Influencing factors A diversity of factors can affect an individual’s perceptions and thus indirectly modify health-related behavior. When promoting osteoporosis screening and prevention, be sure to frame your discussion according to the patient’s: ◆

Demographic profile (including age, race, education, marital status, and socioeconomic status)

◆

Medical history and knowledge

◆

Access to health care

◆

Social support

Perceived susceptibility Ensure that the patient has an accurate perception of her risk by reviewing: ◆

Modifiable and nonmodifiable risk factors for osteoporosis

◆

Statistics on osteoporosis appropriate to the patient’s age and race

◆

Her BMD test results, if available, highlighting whether she has normal bone density or has osteopenia or osteoporosis

Perceived benefits Clearly define the actions the patient should take, including how, where, and when

◆

Clarify the positive effects the patient can expect from following your recommendations

Perceived severity Assess the patient’s understanding of her risk by discussing potential short- and long-term consequences with respect to: Physical health (such as hip fracture and loss of mobility)

◆

Loss of independence

◆

Economic costs

◆

Identify and reduce barriers through reassurance, incentives, and assistance

Likelihood of action Perceived threat

◆

Perceived barriers

◆

Either having a BMD test or taking appropriate actions to promote bone health

Cues to action Like the influencing factors described above, certain events and experiences will affect the patient’s “readiness” to adopt osteoporosis screening and treatment recommendations. To facilitate such readiness, provide: ◆

Educational materials on osteoporosis

◆

Reminders of the potential consequences of not addressing one’s risk; personal experience with disease is a strong cue to action

BMD, bone mineral density.

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Wallace et al: Osteoporosis Screening in Postmenopausal Women are most likely to follow clinical recommendations. The first, a study of 508 postmenopausal women in a managed care setting, found that osteoporosis education combined with BMD testing was a better predictor of self-reported lifestyle changes (eg, calcium and vitamin D use) and initiation of pharmaceutical treatment than was education alone.27 The second study, by Marci et al, prospectively examined the impact of receipt of bone densitometry results on health-related behaviors in 701 postmenopausal women.28 They found that women with severely low bone mass were more likely to adopt osteoporosis-protective behaviors (in this case, taking a calcium supplement, exercising, or quitting smoking) than were women with normal BMD results. The Health Belief Model: De-

PRIMARY POINTS

veloped in the 1950s by social psychologists in the US Public Health Service, the Health Belief Model (HBM) has been one of the most commonly applied frameworks to explain and predict health behaviors.29 Its original purpose was to help understand why a free and conveniently located tuberculosis screening program was being underused. According to the HBM, individuals who possess certain beliefs are more likely to take the health-related actions necessary to avoid undesirable consequences. The HBM is based on four main concepts: ◆ Perceived susceptibility, or one’s perception of the likelihood of experiencing a condition or disease. ◆ Perceived severity, one’s perception of the impact a given condition or disease would have on one’s life.

Osteoporosis in Postmenopausal Women

Osteoporosis is a growing problem in postmenopausal women. The availability of effective interventions should enable clinicians to limit the magnitude of the burden but will require the institution of routine osteoporosis screening in appropriate patients, especially using bone densitometry.

To improve screening rates, consider ordering densitometry at the same time as mammography; many patients need both tests and may appreciate having them scheduled on the same day.

Recommendations vary regarding when to begin routine osteoporosis screening, though the rule-of-thumb is to start at age 65. The presence of multiple risk factors or being of Asian descent may warrant an earlier evaluation.

Education about osteoporosis is the cornerstone of successful management.

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Perceived benefits, one’s opinion of the effectiveness of the advised action to reduce risk. ◆ Perceived barriers, one’s opinion of the tangible and psychological costs of the advised action. Although not considered a major component of the model, perceived threat of disease is a key aspect of belief and reflects the combination of perceived susceptibility and severity. We believe the HBM could also be useful in understanding behaviors associated with postmenopausal osteoporosis (Figure 1). As this modified model suggests, a woman with osteoporosis is more likely to take action—that is, follow recommendations for bone density testing or preventive therapy—if she believes she is susceptible to osteoporosis and knows that its consequences are serious. Moreover, she must believe that the benefits of taking action outweigh the barriers and risks of doing so. To highlight the benefits of bone densitometry, you should clarify the positive effects to be expected (such as early detection of bone loss) and provide explicit information necessary to take action (including, for example, how, when, and where the procedure will be performed). To reduce the impact of potential barriers, your focus should be on correcting misinformation about BMD testing (being sure to reinforce that the procedure is painless and noninvasive), providing incentives, and offering assistance (such as detailed directions to the testing location). In essence, the HBM is an educational model and, when adapted in this manner, enables the promotion of individualized strategies for osteoporosis screening and prevention. ◆

TAKING THE NEXT STEP All patients diagnosed with osteopenia or osteoporosis should be informed of the options they have to minimize future bone loss. TreatVol. 6, No. 8/AUGUST 2003

Wallace et al: Osteoporosis Screening in Postmenopausal Women ment of osteoporosis is beyond the scope of this article. However, agents that have received FDA approval for both the prevention and treatment of osteoporosis include hormone replacement, bisphosphonates (alendronate and risedronate), and raloxifene. Calcitonin, while an important intervention, is indicated for osteoporosis treatment only.1 Regular weightbearing exercise and sufficient dietary calcium intake (1,200 mg/d) have also been shown to be helpful in maintaining bone mass.30 I REFERENCES 1.

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