PROPOSAL OF RATIONAL SCREENING FOR OSTEOPOROSIS IN THE PRIMARY CARE SETTING
Abstract
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.
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References
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