Osteoporosis: we are neglecting our own.

In the dawn of the twenty-first century, we claim with pride to practice evidence-based medicine, but when it comes to osteoporosis, what we practice is different from the available evidence. The evidence we have gathered about the disease, its implications and treatment, has not yet affected our practice. Osteoporosis is still largely neither diagnosed, nor treated.

This is regrettable because the outlook after diagnosing osteoporosis is so much better than that of breast cancer, for instance. Ironically, although there are more cases of osteoporosis than breast cancer, (1) our efforts to identify patients with early breast cancer by far outstrip those with osteoporosis. We have not yet been able to educate health care professionals and the lay public on the importance of diagnosing and treating osteoporosis early.

This is strange because we know so much about the epidemiology of osteoporosis: about half of Caucasian women over the age of 50 years are expected to sustain an osteoporotic fracture. (2) The morbidity and mortality associated with hip fractures is well known. Mortality is increased by about 24% in the first year; about 20% of the patients need long term institutional care and many of those who are able to resume their daily activities are handicapped by pain. (3,4) About 50% of the women who sustain an osteoporotic hip fracture are so disabled that they remain permanently incapacitated. (5) Numerous papers and editorials have been written on the physical, psychological, social, and economic implications of osteoporosis and fractures.

We know the impact of medications that are presently available on the risk of hip and other fractures. (6) Compared with the cost of medical care following a hip fracture, the dollar cost of these medications for the individual patient is not excessive. The cost in terms of pain and suffering can only be subjectively assessed. Researchers have projected the cost of treating osteoporosis compared with that of treating fractures, and concluded that it is cost-effective to screen and treat all women aged 65 years and older. (7) The cost of treating osteoporosis is also likely to decrease significantly in the very near future as the patent on alendronate expires and more medications become available.

The paper by McNearney and coworkers (8) published in this issue of the Southern Medical Journal clearly demonstrates that house staff do not rank osteoporosis as high as many other chronic diseases. The major contribution of this paper is to identify some of the factors that modulate the decision of the house staff to diagnose and treat osteoporosis.

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Major factors affecting the house staff's attitude were related to finances: availability of medications on the formulary (58%), accessibility to clinic (56%), lack of insurance (51%), and patient personal finances (51%). This is very regrettable as we are the wealthiest nation on earth, the one with the most sophisticated health care, and yet we readily acknowledge and accept that financial restraints prevent us from either diagnosing or treating a condition that affects at least half of our female population over the age of 50 years. We placidly accept that about half of these women will sustain a hip fracture and yet we are very concerned about human rights in underdeveloped countries. We are reluctant to spend a few thousand dollars to prevent our next-door neighbor from sustaining a hip fracture, and yet readily spend billions to defend human rights in far away lands. We refrain from spending a few thousand dollars at home for a high probability outcome in the near future (reducing hip fractures by about half within 2 to 3 years), but freely spend billions far away from home for a low probability outcome in the distant future (human rights and democracy in underdeveloped and developing countries). We need to do better: we need to take care of our own first.

The diagnosis of osteoporosis is relatively simple and not expensive. Prevention is cheap and treatment is not costly compared with repairing a hip fracture. The evidence is available. Let us practice what we claim to practice.

References

1. King AB, Saag KG, Burge RT, et al. Fracture reduction affects Medicare economics: impact of increased osteoporosis diagnosis and treatment. Osteop Int 2005;16:1545-1547.

2. Cummings SR, Melton LJ 3rd. Epidemiology and outcomes of osteoporotic fractures. Lancet 2002;359:1761-1767.

3. Ray NF, Chan JK, Thamer M, et al. Medical expenditures for the treatment of Osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res 1997;12:24-35.

4. Chrischilles EA, Butler CD, Davis CS, et al. A model of lifetime osteoporosis impact. Arch Intern Med 1991;151:2026-2032.

5. Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 1993;94:646-650.

6. Hamdy RC, Chesnut CH 3rd, Gass ML, et al. Review of treatment modalities for postmenopausal osteoporosis. South Med J 2005;98:1000-1014.

7. Schousboe JT, Ensrud KE, Nyman JA, Melton LJ 3rd, Kane RL. Universal bone densitometry screening combined with alendronate therapy for those diagnosed with osteoporosis is highly cost-effective for elderly women. J Am Geriatr Soc 2005;53:697-704.

8. McNearney TA, Shepherd AJ, Chhabra A, Goel N. Primary care house staff attitudes toward osteoporosis management. South Med J 2006;99:461-466.

Always do right. This will gratify some people and astonish the rest.
--Mark Twain

Ronald C. Hamdy, MD, FRCP, FACP 

Editor-in-chief