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Treatment and Prevention Practices in Postmenopausal Women After Bone Mineral

Density Screening at a Community-Based Osteoporosis Project
Christine I. Rohr, DO
John M. Clements, MPA
Arup Sarkar, MD

Objective: To determine the use of treatment and prevention screening in the populations most at risk.1–8
practices in postmenopausal women who have received the Osteoporosis screening in the older female population
results of an osteoporosis screening. through community centers, living facilities, and health fairs
Methods: Telephone survey to follow-up with women who is an effective tool in identifying low BMD in women at high
underwent dual-energy x-ray absorptiometry scanning at a risk for osteoporosis and osteopenia.9 To gain the maximum
community-wide osteoporosis screening project. Participants advantage from such screening programs, patients must be
categorized by their scan results as having normal bone min- made aware of the importance of following up a diagnosis of
eral density or low bone mineral density were asked about their low BMD with their primary care physicians to determine
osteoporosis treatment and prevention practices since receiving the best treatment and prevention options. In addition, the
their scan results. primary care physician should initiate a treatment plan
Results: Two hundred nineteen women were interviewed. involving appropriate recommendations for lifestyle modifi-
Calcium supplement use increased significantly in both groups cation and/or pharmacologic intervention.
(P=.002). There was no significant difference in the number of Previous studies have been at odds as to whether a diag-
women using alendronate sodium, calcitonin, and selective nosis of low BMD is an effective incentive for patients to follow
estrogen receptor modulators before and after screening. Both up with their primary care physicians for treatment guide-
groups reported increases in exercise levels and dairy intake, lines. In a review of studies examining clinical practices in
but the difference was not statistically significant. osteoporosis treatment, Siris et al10 reported that physicians in
Conclusions: Our results indicate that the use of over-the- general are not evaluating patients with fractures for osteo-
counter calcium supplements increases after osteoporosis porosis, nor are they prescribing calcium, vitamin D, or phar-
screening. However, the use of treatments that require a physi- macologic therapy to reduce future risk of fracture. The authors
cian prescription does not increase after screening regardless further reported that only 5% to 39% of patients with frac-
of the patient’s bone mineral density status. tures received appropriate screening and treatment for osteo-
porosis despite clinical guidelines supporting the use of
J Am Osteopath Assoc. 2006;106:396–401 therapy.10 Noncompliance with recommendations after den-
sitometry can make widespread screening ineffective and inef-
ficient.10 We hypothesize that a large number of women who
T he availability and declining cost of reliable bone mineral
density (BMD) tests, such as dual-energy x-ray absorp-
tiometry (DEXA), has enhanced the ability of primary care
have received a diagnosis of either osteoporosis or osteopenia
do not receive the follow-up care or guidance needed to pre-
physicians to screen for and diagnose osteoporosis and vent fractures.
osteopenia. Promising medical treatments for patients with The purpose of our study was to determine what, if any,
low BMD provide further incentive to carry out BMD action was taken by patients after being screened for osteo-

From the Departments of Medical Education (Rohr, Clements); Research We undertook a telephone-based follow-up survey of post-
(Clements); and Family Medicine (Sarkar), Synergy Medical Education Alliance,
Saginaw, Mich. menopausal women who had participated in a large com-
This study was presented as a poster presentation at the American Public munity-based osteoporosis screening project that was con-
Health Association’s 131st Annual Meeting in San Francisco, Calif, on November ducted by our group.9 Subjects were from the general public
19, 2003.
Address correspondence to John M. Clements, MPA, Director of Research and self-referred when the screening was made available at
and Educational Programs, Synergy Medical Education Alliance, 1000 local senior centers, living facilities, and health fairs. The orig-
Houghton Ave, Saginaw, MI 48602-5303. inal study was conducted to increase access to BMD testing in
the elderly population. Bone mineral density testing and coun-

396 • JAOA • Vol 106 • No 7 • July 2006 Rohr et al • Original Contribution


seling on osteoporosis and osteopenia were provided to 635 no significant difference in the number of women using alen-
female residents of senior facilities from January through dronate, calcitonin, and selective estrogen receptor modulators
December 1999. Screening was conducted using DEXA. before and after screening. With regard to exercise and dairy
Patients were assessed for risk, screened for BMD, and referred intake, though we did not have baseline data for comparison,
for follow-up care. In addition to diagnostic assessment, as noted, 30 (39%) women reported an increase in exercise, and
patients received lifestyle counseling, recommendations for 12 (15.5%) reported an increase in dairy intake since the
calcium intake, and recommendations for follow-up with their screening (Figure 1).
primary care physicians for treatment or prevention practices.
Between August and November 2001, we conducted a Women With Low Bone Mineral Density
follow-up study of the community-based screening project, As in the group with normal BMD, there was a significant
approved by the institutional review board of Synergy Med- increase in the use of calcium supplements in women with low
ical Education Alliance (Saginaw, Mich). We contacted subjects BMD (64 [45.4%] vs 111 [78.5%]; P=.001). The decrease in HRT
by telephone to obtain current information on their progress use in this group was statistically significant (30 [21%] vs 9
since the screening. The present study focused on the post- [6.3%]; P=.003). There was no significant difference in the
menopausal women who were found to have either normal or number of women using alendronate, calcitonin, and selective
low BMD based on the following t score classifications of low estrogen receptor modulators before and after screening.
BMD from the World Health Organization11: Finally, 44 (31%) women in this group reported an increase in
 normal BMD: ⭓1 exercise, and 33 (23%) reported an increase in dairy intake
 osteopenia: ⬍⫺1 to ⬎ ⫺2.5 (Figure 2).
 osteoporosis: ⭐ ⫺2.5
We categorized the women into two groups according to their Results for Entire Cohort
screening results: normal BMD and low BMD (ostopenia or Overall, there was a statistically significant increase in the use
osteoporosis). Questions assessed whether the participants of calcium supplementation (92 [42.1%] before screening vs 156
had engaged in any osteoporosis treatment or prevention [71.3%] after screening; P<.001). The use of HRT decreased
practices since receiving the screening results, including use of significantly (P<.001) after screening, with just 25 (11.7%)
over-the-counter calcium supplements, physician-prescribed women using HRT compared with 52 (23.9%) before screening.
medications (alendronate sodium, calcitonin, hormone replace- In addition, women with normal BMD were significantly
ment therapy [HRT], and selective estrogen receptor modu- more likely to report HRT use than those with low BMD (17
lators), and dairy intake and exercise. We compared the data [22.7%] vs 9 [6.3%]; P<.001). There was no significant difference
from the initial screening project with the data collected during in the use of alendronate, calcitonin, and selective estrogen
the follow-up survey. (There were no baseline data on dairy receptor modulators before and after screening. Although we
intake and exercise.) Data were analyzed using a Pearson ␹2 did not have a baseline for comparison, 75 (34.4%) women
test to determine the significance of differences in nominal reported an increase in exercise, and 46 (21.1%) reported an
data between proportions of two groups. increase in dairy intake since the screening. There was no sig-
nificant difference in the reported increase in exercise or dietary
Results intake between the group with normal BMD and the group
A follow-up telephone survey was administered to 234 older with low BMD.
women (age range, 59-86 years; mean, 74.9 years) who par-
ticipated in the initial BMD screening program. We were able Comment
to obtain status and follow-up information for 219 of the 234 While use of HRT decreased in our cohort, the use of calcium
women. The normal BMD group comprised 77 (35.2%) supplementation increased in both groups and was signifi-
women, and the low BMD group comprised 142 (64.8%) cant for the entire cohort. During screening, nonprescription
women. calcium supplementation was recommended to all women
and emphasized to those at high risk. In addition, women
Women With Normal Bone Mineral Density with low BMD were referred to their primary care physicians
In the group with normal BMD, there was a statistically sig- for follow-up to begin prescription therapy; whether they took
nificant increase in calcium supplement use (P=.002), from 28 this step and whether they received guidance and/or pre-
(37%) taking calcium supplements before the screening to 47 scriptions for therapy was not studied. There were no signif-
(61.6%) taking them after the screening. The use of HRT icant increases in the use of any therapy that needed a pre-
decreased, but the decrease was not significant (24 [30.7%] scription. Based on these results, it appears that the immediate
before screening vs 17 [22.7%] after screening; P=.07). There was recommendation of nonprescription therapy is more effective

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* *

Figure 1. Women with normal bone mineral density (n=77). Patient compliance with recommended osteoporosis treat-
ment and preventive therapies. HRT indicates hormone replacement therapy; SERMs, selective estrogen receptor mod-
ulators. The asterisk [*] indicates that there were no baseline values for exercise and dairy intake.

in increasing compliance with treatment and prevention. A understood the protective nature of HRT, whether they were
question for additional studies is whether patients would be concerned about side effects of HRT, whether the level of
more likely to use prescription therapy if prescriptions were information that physicians provide to patients regarding the
given as soon as screening results were obtained. If other pre- importance of therapy is adequate, and whether patients felt
vention or treatment strategies were as readily available to continued HRT use was necessary as they aged.
the public without a physician prescription or physician over- There was no statistically significant increase in the use of
sight, we probably would have seen increases in their use as prescription therapy, probably because the physicians partic-
well. ipating in the screening project relied on participants to make
Participants reported a statistically significant decrease appointments with their primary care physicians for follow-
in HRT use after receiving the results of their BMD scan even up. Either the patients did not take this step or their physicians
though HRT as prevention or treatment for low BMD has did not adequately prescribe treatment.
been shown to reduce bone loss and increase BMD in the There may be several reasons why patients do not engage
spine and hip, thereby reducing the risk of hip and spinal in treatment or prevention practices after receiving their
fractures in postmenopausal women.12–14 It is important to screening results. We did not investigate the financial status
note that this study took place prior to changing guidelines on of our patients, but it may be possible that some individuals
HRT use, so it is unlikely that the decrease was a response to were not financially able to bear the costs of following up with
new guidelines recommending the discontinuation of HRT.15 physicians or paying for prescriptions. It may be possible that
Although we did not explore the reasons for discontinuing patients were not motivated to follow-up because they did
HRT, there are several areas for further study that could pro- not understand the results of the screening or the importance
vide explanations for the decrease in HRT use that we of therapy. This issue could be resolved by providing more
observed. These areas include determining whether subjects extensive patient education on osteoporosis. Finally, physi-

398 • JAOA • Vol 106 • No 7 • July 2006 Rohr et al • Original Contribution



* *


Figure 2. Women with low bone mineral density (n=142). Patient compliance with recommended osteoporosis treat-
ment and preventive therapies. HRT indicates hormone replacement therapy; SERMs, selective estrogen receptor mod-
ulators. The asterisk [*] indicates that there were no baseline values for exercise and dairy intake.

cians may not attend to cases of osteoporosis properly, an found that 40% of women with low BMD were not using HRT
often underdiagnosed and undertreated disease.10,16,17 at an 8-month follow-up as recommended by their physicians.
The issue of compliance is one that needs to be addressed The current controversy and recommendations on the use of
both in physician practice and in patient behavior. Andrade et HRT may make HRT a less likely treatment for osteoporosis.
al16 undertook a study to document the rate of patient treatment Ryan et al19 conclude that screening should not be widely rec-
following fracture and subsequent diagnosis of osteoporosis. ommended until improved compliance with recommenda-
They reported that of 3492 women older than 60 years with a tions is demonstrated.
fragility fracture, only 24% received treatment for osteoporosis Studies have also shown that screening increases com-
in the year following the fracture. In addition, they found that pliance. Torgenson et al20 studied the effect of an osteoporosis
increasing age was significantly associated with a decrease in screening program on HRT use. They found that screening for
the recommendation and use of therapy.16 Another study low BMD in a sample of perimenopausal women significantly
identifying treatment practices in patients with acute hip frac- increased their use of HRT. Papaioannou et al21 examined
ture reported that only 3.5% of patients were treated for osteo- decisions made by women at risk for osteoporosis-related
porosis.17 fractures who were educated about HRT and who were also
Hsieh et al18 found that few women take measures to counseled about their BMD screening results. Their findings
prevent osteoporosis despite believing that it is a serious con- indicate that a combination of education on HRT and BMD is
dition. Ryan et al19 studied compliance with recommenda- significantly associated with an increase in the use of HRT
tions to use HRT in postmenopausal women following and other osteoporosis preventive medications. Hsieh et al18
screening for osteoporosis. Their results indicate that screening found that women who were actively worrying about devel-
leads to an immediate increase in HRT use among women oping osteoporosis were more likely to be engaged in pre-
who are at high risk for osteoporosis. However, they also ventive behavior. Fitt et al22 found that effective communica-

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80 Before Screening

After Screening







HRT Calcium Alendronate Calcitonin SERMs Exercise* Dairy*


Figure 3. Entire study population (N=219). Patient compliance with recommended osteoporosis treatment and pre-
ventive therapies. HRT indicates hormone replacement therapy; SERMs, selective estrogen receptor modulators. The
asterisk [*] indicates that there were no baseline values for exercise and dairy intake.

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