PROPOSAL OF RATIONAL SCREENING FOR OSTEOPOROSIS IN THE PRIMARY CARE SETTING
Background. Early identification of postmenopausal women with osteoporosis by means of bone mineral density (BMD) measurement is a prerequisite for reducing the incidence of osteoporotic fractures. Primary care physicians have a leading role in referring such patients, however, given the cost of the BMD measurement, efficient screening criteria remain to be determined. Currently available criteria (e. g., SCORE, ORAI) are very broad with low specificity. Objective of our study is to assess simple decision rules that could enhance identifying patients with high risk of fracture while concurrently minimizing number of unnecessary measurements.
Methods. In the study, 357 primary care physicians (GPs and gynecologists) referred their patients to BMD measurements based on the following decision rules: women (i) should be postmenopausal for at least 5 years, (ii) should have body mass index (BMI) less than 26 kg/m2, and (iii) should have never been diagnosed with osteoporosis. BMD of lumbar spine and/ or hip was measured by dual-energy x-ray absorptiometry (DXA) in 5 centers using Hologic (Hologic Corp., Bedford, MA) or Lunar (Lunar Corp., Madison, WI) densitometers. Results of BMD measurements were expressed in terms of the T-score and were forwarded to the primary care physicians.
Results. 2339 postmenopausal women participated in the study; by the end of the study, 327 physicians (92%) reported results on 2196 women (94%). 1332 women of 2196 (61%) were identified as osteoporotic, 637 (29%) as osteopenic, and 227 (10%) had normal BMD. Approximately 30% of patients with osteoporosis suffered from previous low-trauma fracture. Among all women, the prevalence of osteoporosis was 34% for ages less than 55 years, 50% for ages 55–59 years, and 69% for ages above 60 years. The number of DXA measurements needed to detect one osteoporotic patient among women older than 60 years and with BMI < 24.5 kg/m2 was 1.32.
Conclusions. Results of our study suggest that three simple decision rules provide efficient guidance for BMD measurement referrals. Moreover, these decision rules proved to be efficient in the primary care setting. Since a vast majority of women enrolled in the program (90%) had either osteopenia or osteoporosis, it can be expected that these decision rules primarily apply to identification of patients who are at relatively high risk of fracture. These rules should be thus recognized as the initial judicious tool for identifying patients with osteoporosis in the primary care setting, which should be later supplemented by other broader criteria.
Kanis JA, Gluer CC. An update on diagnosis and assessment of osteoporosis with densitometry. Osteoporos Int 2000; 11: 192–202.
Meunier PJ, Delmas PD, Eastell R et al. Diagnosis and management of osteoporosis in postmenopausal women: Clinical guidelines. Clin Therap 1999; 21: 1025–44.
National Osteoporosis Foundation. Physicians’ guide to prevention and treatment of osteoporosis. Belle Mead, NJ: Excerpta Medica Inc.; 1999: 1–1.
Kanis JA, Delmas P, Burckhardt P, Cooper C, Togerson D. The European Foundation for Osteoporosis and Bone Disease, for guidelines for diagnosis and management of osteoporosis. Osteoporos Int 1997; 7: 390–406.
Cadarette SM, Jaglal SB, Murray TM, McIsaac WJ, Jospeh L, Brown JP. Evaluation of decision rules for referring women for bone densitometry by dual-energy X-ray absorptiometry. JAMA 2001; 286: 57–63.
Lydick E, Cook K, Turpin J, Melton M, Stine R, Byrnes C. Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care 1998; 4: 37–48.
Cadarette SM, Jaglal SB, Kreiger N, McIsaac WJ, Darlington GA, Tu JV. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ 2000; 162: 1289–94.
Van der Voort DJ, Brandon S, Dinant GJ, van Wersch WJ. Screening for osteoporosis using easily obtainable biometrical data: Diagnostic accuracy of measured, self-reported and recalled BMI, and related costs of bone mineral density measurements. Osteoporos Int 2000; 11: 233–9.
Koh LKH, Ben Sedrine W, Torralba TP et al. A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int 2001; 12: 699–705.
World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report Series 843. Geneva: WHO, 1994: 1–1.
Kanis JA, Torgerson D, Cooper C. Comparison of the European and USA practice guidelines for osteoporosis. Trends Endocrinol Metab 2000; 11: 28–32.
Black DM, Cummings SR, Karpf DB et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 348: 1535–41.
Van der Voort DJM, Geusens PP, Dinant GJ. Risk factors for osteoporosis related to their outcome: Fractures. Osteoporos Int 2001; 12: 630–8.
Hren R. Merjenje mineralne kostne gostote – klinična raziskava. 9. slovensko srečanje o uporabi fizike. Ljubljana: Društvo matematikov, fizikov in astronomov Slovenije, 2001: 1–1.
The Author transfers to the Publisher (Zdravniški vestnik/Slovenian Medical Journal) all economic copyrights following form Article 22 of the Slovene Copyright and Related Rights Act (ZASP), including the right of reproduction, the right of distribution, the rental right, the right of public performance, the right of public transmission, the right of public communication by means of phonograms and videograms, the right of public presentation, the right of broadcasting, the right of rebroadcasting, the right of secondary broadcasting, the right of communication to the public, the right of transformation, the right of audiovisual adaptation and all other rights of the author according to ZASP.
The aforementioned rights are transferred non-exclusively, for an unlimited number of editions, for the term of the statutory
The Author can make use of his work himself or transfer subjective rights to others only after 3 months from date of first publishing in the journal Zdravniški vestnik/Slovenian Medical Journal.
The Publisher (Zdravniški vestnik/Slovenian Medical Journal) has the right to transfer the rights, acquired parties without explicit consent of the Author.
The Author consents that the Article be published under the Creative Commons BY-NC 4.0 (attribution-non-commercial) or comparable licence.