OBJECTIVE: Our goal was to determine how often primary care providers discussed osteoporosis prevention and calcium intake with women during their health maintenance examinations.
METHODS: A total of 449 women aged 18 to 65 years participated in exit interviews immediately following a health maintenance examination at 1 of 8 Wisconsin family practice clinics.
RESULTS: Forty-six percent of these women reported discussing osteoporosis with their providers during their visit, and 51% reported discussing calcium intake. A total of 61% reported discussing either osteoporosis or calcium intake during the visit. Some providers were able to discuss these topics with more than 90% of their patients. A logistic regression model showed that providers were less likely to discuss either of these issues with women younger than 40 years (P=.019); they were more likely to discuss them with women older than 60 years (P=.002) than with women aged 40 to 60 years; and women providers were significantly more likely to discuss either issue (P=.004).
CONCLUSIONS: Primary care providers are in a good position to counsel women of all ages about their potential for avoiding osteoporosis and to recommend prevention strategies. The United States Preventive Services Task Force recommends that all women be counseled on adequate calcium intake yearly after the age of 18 years. Provider education and institutional changes may increase the frequency of this counseling for all primary care physicians.
Osteoporosis is an important cause of age-related mortality and morbidity. More than 1.5 million Americans have osteoporosis-related fractures, costing the United States health care system more than $10 billion annually.1 Although osteoporosis can occur in men, its incidence is higher in women. Those who are postmenopausal are at the highest risk because of the bone loss that occurs with decreasing estrogen levels. The National Osteoporosis Foundation estimates that 21% to 30% of all postmenopausal white women have osteoporosis, and an additional 54% have low bone density.2 Women aged older than 50 years have a 4 in 10 chance of incurring a fracture during their remaining lifetime.3
Bone mineral density measurements can identify women with low bone mass who are at risk for a fracture. Although measurements of bone mineral density may be clinically indicated in high-risk women, current evidence does not support using them as screening modalities.4 Medications can slightly increase bone mass and prevent further loss, but treatment options for osteoporosis are suboptimal. Most consensus recommendations focus on prevention as the best approach.5-7
Prevention of osteoporosis should begin in adolescence with education about risk factors, encouragement of adequate dietary calcium and Vitamin D, exercise, and other healthy behaviors; it must continue throughout a woman’s life.8-10 Several studies have shown that calcium supplementation can increase bone density in women from adolescence to postmenopause.9,11-15 The United States Preventive Services Task Force recommends that all women be counseled on adequate calcium intake yearly after the age of 18 years.11
It is unclear how many primary care providers discuss osteoporosis and calcium intake with women at their annual health maintenance examinations. A review by the lead author16 of 263 charts of women older than 50 years found an overall documented rate of osteoporosis risk assessment of 35%. A vitamin manufacturing company telephone survey of 505 women aged 18 to 65 years found that only 34% had discussed osteoporosis and 44% had discussed calcium intake with their physicians in the past year.17 A 1991 study reviewed 243 medical records of women aged between 40 and 65 years and found documentation that although 74% of the women had 2 or more risk factors for osteoporosis, only 19% had received an osteoporosis-specific intervention (ie, calcium supplementation or counseling about osteoporosis risk or hormone replacement therapy).18 Also, the medical records of only 10% of the women in our prevalence study had a documented assessment of osteoporosis risk.
We used patient exit interviews to assess the frequency of osteoporosis prevention counseling during women’s health maintenance examinations in a primary care setting. On the basis of our literature review, we hypothesized that woman providers would discuss calcium intake and osteoporosis prevention more often than men and that discussions would be more frequent as women aged. We also hypothesized that physician assistants and nurse practitioners would discuss prevention topics more frequently than physicians.
Methods
For our report of osteoporosis prevention in primary care we used data collected in 8 Wisconsin family practice clinics at the outset of an osteoporosis intervention pilot study. Seven of the clinics were residency training sites, and the eighth was a university-affiliated private practice. All faculty physicians, physician assistants, nurse practitioners, and second-year residents in each clinic were invited to participate. Of the 67 providers invited, 90% agreed to be part of the study. Each provider completed a brief questionnaire that included demographic information such as age, sex, and job title; adequacy of own calcium intake; and personal experience with osteoporosis. Each participating provider signed a consent form agreeing to allow a study invitation to be given to women patients registering for a well-woman visit. The providers knew the general content of the interviews but not the specific questions. There was a 1- to 2-month time lag from when the providers signed the consent form to the beginning of the interviews. Data collection was completed during a period of 2 to 3 months, and providers were not told on which days it would occur. The University of Wisconsin Human Subjects Committee approved the study protocol.