Osteoporosis preventive care in white and black women in community family medicine settings.

Background: Osteoporosis has been studied predominantly in white postmenopausal women.

Materials and Methods: We performed a cross-sectional survey of a random sample of 400 women aged 45 years and older enrolled in a family medicine community-based research network. Participants responded to 42 items regarding osteoporosis screening and prevention during primary care visits. Odds ratios were calculated comparing black versus white women, adjusting for age, weight, fracture history, family history of osteoporosis, and practice site.

Results: Compared with black women, white women had 5.96 (95% CI 3.01, 11.79) times the adjusted odds of having a past bone density test, 2.97 (95% CI 1.57, 5.60) times the odds of discussing osteoporosis with their doctor, and 2.42 (95% CI 1.30, 4.50) times the odds of a physician recommendation to take calcium.

Conclusions: Disparities in osteoporosis preventive care were found between black and white women, after adjustment for other osteoporosis risk factors.

Key Words: disparities, health services research, osteoporosis, women's health 

**********

Although osteoporosis-related fractures are an important source of morbidity and mortality in elderly people from all ethnic backgrounds, studies of osteoporosis have been conducted predominantly in postmenopausal white women. Current guidelines for osteoporosis preventive care have been based on prospective data on white women, and recommendations for other patients are usually not specified. For example, the National Osteoporosis Foundation (NOF) Guide to Prevention and Treatment of Osteoporosis primarily addresses postmenopausal white women, not men, premenopausal women, or nonwhite women. (1) The NOF recommends that until adequate data are available, risk factors currently identified for white women should be used for others on an individual basis to determine the need for bone density testing and treatment, and all patients should follow general lifestyle recommendations for good bone health. The 2002 US Preventive Services Task Force Recommendations and Rationale Statement on Screening for Postmenopausal Osteoporosis (2) mentions that "at any given age, African-American women on average have higher bone mineral density than white women and thus are less likely to benefit from screening." However, the accompanying Evidence Summary (3) acknowledges that "no bone density studies or treatment trials include large numbers of nonwhite women, and it may be difficult to provide ethnicity-specific screening recommendations in the absence of more evidence."

Most substantive updates to osteoporosis prevention guidelines have only been available since 2000, and several studies indicate these guidelines are still underappreciated and poorly implemented in all patient groups. (4-6) The few studies examining osteoporosis-related care among ethnic groups have uniformly found lower rates of screening, prevention and treatment in nonwhite patients compared with postmenopausal white women. (7-11) More data are needed on patients from community clinics to document whether such disparities exist in primary care settings.

We conducted a cross-sectional survey of women aged 45 and older from community family medicine practices participating in a practice-based research network in the state of North Carolina to compare rates of osteoporosis preventive care in black and white women. Our primary objective was to determine whether racial disparities existed in self-reported osteoporosis-related attitudes and preventive care activities for female respondents.

Methods

Subjects

Our study population was a random sample of 400 female participants aged 45 years and older from 5 family medicine practices participating in the North Carolina Family Medicine Research Network (NC-FM-RN). This 21-clinic, practice-based, university-sponsored network is devoted to research on chronic diseases in primary care. Between 2001 and 2004, an inception cohort of over 4000 individuals from 16 practices was enrolled, and the age and racial/ethnic distribution of the cohort is similar to that of the state of North Carolina. (12) In the summer of 2004, 1934 individuals from 5 new practices were added. Informed consent to participate in a research cohort was obtained at the time participants were recruited into the NC-FM-RN. At that time, 1411 individuals confirmed their approval to be contacted for all subsequent studies, including the current study.

We surveyed individuals aged 45 years and older since this age range of participants might be considered for osteoporosis preventive care and because some of the survey questions were based on the 2004 National Osteoporosis Foundation Health Issues Survey of women aged 45 and older. (13) Because updated contact information for earlier enrolled cohort subjects was incomplete at the time of survey distribution, we only sampled the 5 practices added to the NC-FM-RN in 2004. The research protocol was reviewed and approved by the Institutional Review Board of the University of North Carolina.

Outcomes

Osteoporosis preventive care outcomes included respondent reports of the following physician activities recommended in the NOF Physician's Guide to Prevention and Treatment of Osteoporosis (1): 1) osteoporosis risk factor assessment, 2) bone density testing, 3) discussion or counseling regarding osteoporosis or fracture, calcium intake, lifestyle measures and fall prevention, 4) prescriptions for medications that might be prescribed for osteoporosis prevention or treatment including calcium, hormone therapy, bisphosphonates, selective estrogen receptor modulating agents.

Survey Instrument

The 42-item survey was written by the investigators based on a literature review and results from the 2004 NOF survey of women aged 45 and older. (13-17) Questions focused on the participant's risk factors for osteoporosis, opinions about the importance of osteoporosis preventive care, whether the participant had received such care to date, and the participant's estimation of her own risk of osteoporosis or fracture. We also requested height and weight, information on past fractures (what bone was broken, year) and medications to prevent or treat osteoporosis. The survey was written in English.

Survey Administration and Data Management

We surveyed a computer-generated random sample of 400 women aged 45 years and older previously enrolled and consented in the North Carolina Family Medicine Research Network. Surveys with stamped return envelopes were mailed to potential respondents using the most recent address in the database. Potential respondents were given a local telephone number to contact study personnel if they had questions regarding the survey or the study. Additional copies of the survey were mailed at weeks 4 and 12, with a reminder card between those mailings.

Data were double-entered into a Microsoft Access database (Microsoft Corp, Redmond, Wash) by two separate research assistants who were blinded to the main hypothesis of the study. The two data entry tables were compared for accuracy and consistency, and mismatches were corrected in the Access database. Data were recorded as missing if items were unmarked, if multiple responses were marked for a single-answer item, or if comments were written that did not match any of the response options. The database was converted to Stata and SAS data sets for statistical analysis. Unreconciled data entry problems were resolved by the principal investigator in a de-identified data set.

Statistical Analysis

Descriptive statistics were tabulated for all of the respondents. Rates of osteoporosis risk assessment, bone density testing, osteoporosis counseling and osteoporosis-related medication prescriptions were compared between the ethnic groups.

In the analysis of survey responses, we accounted for uniformity of physician and respondent behaviors using Mantel-Haenszel tests to compare white versus black women, stratified by practice site. (18) For dichotomous response items, we calculated the p-value for the Mantel-Haenszel estimate of the odds ratio comparing a yes versus no response, controlling for practice. For ordinal response items, we calculated the p-value for the Mantel-Haenszel score test for trend of odds, controlling for practice (odds ratio estimate was an approximation to the odds ratio for a one unit increase in the response item rating). For nominal response items with more than two options, we calculated the p-value for the Mantel-Haenszel General Association test, controlling for practice. To compare the frequency of bone density testing in black versus white women adjusted for age, we used rank analysis of covariance appropriate to adjust for a continuous variable. (19,20) Finally, we constructed logistic regression models to examine the relationship between indicators of osteoporosis-related care and race, adjusted for age, weight, history of fracture, family history of osteoporosis, and practice site.

Statistical analyses were performed using the Stata 8.2 software, (21) except for the Mantel-Haenszel General Association test and rank analysis of covariance, which were performed in SAS 9.1. (22) A p-value of 0.05 or less was considered significant for all statistical tests.

Results

Of the 400 surveys mailed out, 275 were completed and returned, and 15 were returned to the sender due to an expired address (12) or deceased participant, (3) resulting in an adjusted response rate of 275/385 = 71.4%. Nonrespondents (n = 110) were younger on average (mean age 59.1 yr, SD 11.0) and more likely to be African-American (44.8% African-American, 53.8% white) than respondents.

Because only five respondents were both nonwhite and nonblack, we excluded those individuals and only compared white and black women. The mean age of respondents was 63.2 years, and the black women were younger on average than white women (60.3 versus 64.5 yr, P = 0.009) [Table 1]. Black women had higher self-reported weight and body mass index than white women (weight 91.9 kg versus 74.2 kg, P < 0.001; BMI 33.8 versus 28.2, P < 0.001). Although the respondents reported a low number of fractures at osteoporotic sites (hip, spine, wrist, rib), 35.9% of the women (44.2% of white participants, 16.3% of black participants) reported a history of some type of fracture in their lifetime. Significantly more white women than black women had a past bone density test (56.8% versus 21.3%, P < 0.001).

Rates of counseling were lower for black women compared with white women for discussion of the following topics: osteoporosis or fracture (25.6% versus 52.2%, P < 0.001), intake of calcium and dairy products (43.1% versus 67.1%, P = 0.007), and whether the individual might need a bone density test (26.1% versus 52.4%, P = 004) [Table 2]. Black and white women had similar rates of counseling regarding exercise and falls. Physician prescriptions of osteoporosis-related medications were lower for black women than for white women, including calcium (32.9% versus 59.5%, P < 0.001), estrogen (26.9% versus 49.4%, P = 0.002) and bisphosphonates (7.1% versus 18.0%, P = 0.04) [Table 3].

In the multivariate analysis, we tested for interactions between race and age and between race and weight in each logistic regression model, but no significant interactions were found. After results were adjusted for age, weight, history of fracture, family history of osteoporosis, and practice site, white women had 5.96 (95% CI 3.01, 11.79) times the odds of black women of having a past bone density test, 2.97 (95% CI 1.57, 5.60) times the odds of discussing osteoporosis or fracture prevention with their doctor and 2.42 (95% CI 1.30, 4.50) times the odds of a physician recommendation to take calcium (Table 4).

Attitudes toward osteoporosis care were similar in black and white women. Half of the women considered talking with their primary care provider about osteoporosis to be "very important" (50.6% of white women, 49.3% of black women). Most women thought patient and provider should share responsibility for bringing up the topic of osteoporosis (58.2% white women, 49.3% black women), and most preferred to have this discussion at the annual physical examination (65.4% of white women, 43.2% of black women).

Discussion

We surveyed 400 women aged 45 and older from primary care practices to assess rates of osteoporosis preventive care and participants' attitudes toward this care. Black women had significantly lower rates of osteoporosis counseling, osteoporosis-related medication prescriptions and bone density testing, after adjusting for osteoporosis risk factors and practice site. This occurred despite the fact that half of women in each ethnic group considered discussing osteoporosis with their doctor to be very important.

The lower rates of osteoporosis preventive care in black women who responded to our survey could be explained in part by their lower number of osteoporosis risk factors. Black women were significantly younger and heavier, had fewer past fractures, and were less likely to have a family history of osteoporosis or fracture than white women. Some providers may have decided to provide fewer preventive care services because they perceived the fracture risk in these patients to be low. However, results from the modeling analysis indicated that white race was more strongly associated with bone density testing, discussions about osteoporosis, and calcium prescriptions than any other demographic factor. As mentioned above, patient interest level was equivalent in both ethnic groups and thus could not account for the differences in reported preventive care services.

Despite higher mean bone density and lower fracture risk for age in nonwhite women compared with white women, other factors may place the former groups at risk for bone loss and fracture. A retrospective review of urban hospital records from 185 women and men with acute fragility fractures showed that in spite of higher bone density measurements, black patients had higher rates of vitamin D deficiency, were younger and had more comorbid illnesses than white patients. (23) Also, two survey studies found that black women perceived their risk of osteoporosis to be low. (24,25) This may lead these patients to ask fewer questions and seek less care related to osteoporosis and fracture prevention.

Arguably, the low levels of preventive healthcare in nonwhite postmenopausal women may be due to lack of clear direction in current guidelines. In a structured review of current osteoporosis screening guidelines and studies of bone density testing, Morris et al (26) found that screening guidelines lacked uniformity in their development and content, which could be a barrier for physicians to implement screening for any patient. Primary care clinicians may decide not to screen nonwhite women for osteoporosis due to lack of consensus over osteoporosis diagnostic standards, unfamiliarity with unique risk factors these patients might have for low bone density, and the perception that the disorder is uncommon in these patients. Since guidelines for osteoporosis preventive care are newer and less familiar than some other screening guidelines in primary care, and since standard osteoporosis screening protocols do not exist (eg, specifying age to start screening and screening intervals), low rates of uptake in primary care settings are unsurprising. As some guideline statements have suggested, a conservative approach might be warranted until better data are available, ie, consideration of risk factors for individual nonwhite women, and modification or approximation of guidelines for postmenopausal white women.

Our study has several limitations. Due to small sample size, participation limited to North Carolina family practice patients, and lack of previous validation of our survey, results may not be generalizable to all US primary care patients. Also, self-reported data from the survey may been inaccurate. In particular, the validity of self-reports for fracture may vary by fracture site and many other factors, (27,28) and our questions could not discriminate between traumatic and nontraumatic fractures. We surveyed women as young as age 45 to include women who are entering the menopausal period. Practitioners would be less likely to offer osteoporosis preventive care to women in their 40s than to older women. However, only 30 of the 270 respondents (11.1%) were under age 50, so our results mainly reflect women aged 50 and older.

Our results showed that patient race is more strongly associated with increased osteoporosis care activities than are other risk factors. Although our study was not designed to analyze clinician decision-making, our findings likely reflect a more complex situation than mere racial and gender discrimination, eg, physicians may defer osteoporosis-related care when diseases like cardiovascular disease or diabetes pose more immediate health risks to a patient. They may also choose not to provide osteoporosis-related care due to ambiguity in current guidelines and insufficient data to support a specific osteoporosis screening protocol in any group of patients. Regardless of the reasons, our results demonstrate the need for additional research and education about high-risk nonwhite women to help primary care physicians appropriately prioritize osteoporosis preventive care with competing healthcare demands.

Acknowledgments

This work was supported by the University of North Carolina Program on Aging, UNC Program in Translational Science, Bureau of Health Professions/HRSA (Academic Administrative Units in Primary Care Grant no. D54-HP00055), the American Academy of Family Physicians Foundation (Research Stimulation Grant no. G0402PB) and the Agency for Healthcare Research and Quality (Grant no. R21 HS13521).

This research study was conducted in a practice-based research network consisting of a representative sample of family practices in North Carolina, from which a cohort of participants has been enrolled and is maintained longitudinally. The network is called the North Carolina Family Medicine Research Network (NC-FM-RN), and the cohort is called the North Carolina Health Project (NCHP) cohort. The NC-FM-RN and the NCHP are jointly sponsored by the Department of Family Medicine, the Thurston Arthritis Research Center, and the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill (UNC-CH), in collaboration with the North Carolina Academy of Family Physicians. The project codirectors are Leigh Callahan, PhD, and Philip Sloane, MD, MPH. Participating family practices have included: Biddle Point Health Center, Charlotte; Bladen Medical Associates, Elizabethtown; Black River Health Services, Atkinson and Burgaw; Blair Family Medicine, Wallace; Chatham Primary Care, Siler City; Community Family Practice, Asheville; Cornerstone Medical Center, Burlington; Crissman Family Practice, Graham; Dayspring Family Medicine, Eden; Goldsboro Family Physicians, Goldsboro; Henderson Family Health Center, Hendersonville; Lumber River Family Practice, Lumberton; Moncure Community Health Center, Moncure; North Park Medical Center, Charlotte; Orange Family Medical Center, Hillsborough (pilot site); Person Family Medical Center, Roxboro; Pittsboro Family Medicine, Pittsboro; Prospect Hill Community Health Center, Prospect Hill; Robbins Family Practice, Robbins; South Cabarrus Family Physicians, Harrisburg, Concord, Mt. Pleasant & Kannapolis; Summerfield Family Practice, Summerfield; and Village Family Medicine, Chapel Hill. Activities of the NC-FM-RN and NCHP have been supported by the Centers for Disease Control and Prevention, the Agency for HealthCare Research and Quality, the National Institutes of Health, the Department of Family Medicine at UNC-CH, and the Program on Health Outcomes at UNC-CH.

References

1. National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. 1999, updated January 2003. Available at http://www.nof.org/. Accessed September 2, 2006.

2. US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 2002;137:526-528.

3. Nelson H, Helfand M, Woolf S, et al. Screening for postmenopausal osteoporosis: a review of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002;137:529-541.

4. Solomon D, Brookhart A, Ghandi T, et al. Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics. Am J Med 2004;117:919-924.

5. Gehlbach S, Fournier M, Bigelow C. Recognition of osteoporosis by primary care physicians. Am J Public Health 2002;2:271-273.

6. Ryder K, Shorr R, Tylavsky F, et al. Correlates of use of antifracture therapy in older women with low bone mineral density. J Gen Intern Med 2006;21:636-641.

7. Mikuls T, Saag K, George V, et al. Racial disparities in the receipt of osteoporosis related healthcare among community-dwelling older women with arthritis and previous fracture. J Rheumatol 2005;32:870-875.

8. Mudano A, Casebeer L. Patino F, et al. Racial disparities in osteoporosis prevention in a managed care population. South Med J 2003;96:445-451.

9. Wei G, Jackson J, Herbers J. Ethnic disparity in the treatment of women with established low bone mass. J Am Med Womens Assoc 2003;58: 173-177.

10. Hamrick I, Steinweg KK, Cummings DM, et al. Health care disparities in postmenopausal women referred for DXA screening. Fam Med 2006;38:265-269.

11. Miller RG, Ashar BH, Cohen J, et al. Disparities in osteoporosis screening between at-risk African-American and white women. J Gen Intern Med 2005;20:847-851.

12. Sloane PD, Callahan L, Kahwati L, et al. Development of a practice-based patient cohort for primary care research. Fam Med 2006;38:50-57.

13. National Osteoporosis Foundation. Health Issues Survey: Attitudes and Actions Regarding Osteoporosis, 2004. Roper ASW, 32 pp. Available at http://www.nof.org. Accessed April 4, 2007.

14. Schrager S, Plane M, Mundt M, et al. Osteoporosis prevention counseling during health maintenance examinations. J Fam Pract 2000;49:1099-1103.

15. Papa L, Weber B. Physician characteristics associated with the use of bone densitometry. J Gen Intern Med 1997;12:781-783.

16. Grisso J, Baum C, Turner B. What do physicians in practice do to prevent osteoporosis? J Bone Miner Res 1990;5:213-219.

17. Suarez-Almazor M, Homik JE, Messina D, et al. Attitudes and beliefs of family physicians and gynecologists in relation to the prevention and treatment of osteoporosis. J Bone Miner Res 1997;12:1100-1107.

18. Landis J, Sharp T, Kuritz S, et al. Mantel-Haenszel Methods. In: Armitage P, Colton J, editors. Encyclopedia of Biostatistics. London: Wiley & Sons; 1998. p. 2378-2391.

19. Stokes M, Davis C, Koch G. Categorical data analysis using the SAS system. 2nd ed. Cary, NC: SAS Institute, Inc; 2000.

20. Preisser J, Koch G. Categorical data analysis in public health. Annu Rev Public Health 1997;18:51-82.

21. StataCorp. 2003. Stata Statistical Software: Release 8.2. College Station, TX: Stata Corporation.

22. SAS Institute Inc. 2004. SAS/STAT 9.1 User's Guide. Cary, NC: SAS Institute Inc.

23. Becker C, Crow S, Toman J, et al. Characteristics of elderly patients admitted to an urban tertiary care hospital with osteoporotic fractures: correlations with risk factors, fracture type, gender and ethnicity. Osteoporos Int, Epub 2005 Nov 8:1-7.

24. Geller S, Derman R. Knowledge, beliefs, and risk factors for osteoporosis among African-American and Hispanic women. J Natl Med Assoc 2001;93:13-21.

25. Kidambi S, Partington S, Binkley N. Low bone mass prevalence and osteoporosis risk factor assessment in African American Wisconsin women. WMJ 2005;104:59-65.

26. Morris C, Cabral D, Cheng H, et al. Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med 2004;19:783-790.

27. Chen Z, Kooperberg C, Pettinger M, et al. Validity of self-report for fractures among a multiethnic cohort of postmenopausal women: results from the Women's Health Initiative observational study and clinical trials. Menopause 2004;11:264-274.

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There is no sadder sight than a young pessimist.
--Mark Twain

Margaret L. Gourlay, MD, MPH, Leigh F. Callahan, PhD, John S. Preisser, PhD, and Philip D. Sloane, MD, MPH

From the Department of Family Medicine, Department of Medicine, and Department of Biostatistics, University of North Carolina, Chapel Hill, NC.

Reprint Requests to Dr. Margaret Gourlay, Aycock Building, Manning Drive, CB #7595, UNC-Chapel Hill, Chapel Hill, NC 27599-7595. Email: [e-mail]

Supported by the University of North Carolina Program on Aging, UNC Program in Translational Science, Bureau of Health Professions/HRSA (Academic Administrative Units in Primary Care Grant No. D54-HP00055), the American Academy of Family Physicians Foundation (Research Stimulation grant No. G0402PB), and the Agency for Healthcare Research and Quality (grant No. R21 HS13521).

Accepted December 18, 2006.

RELATED ARTICLE: Key Points

* Equivalent proportions (about half) of black and white women considered discussion of osteoporosis with their primary care providers to be "very important."

* Compared to white women, black women had significantly lower rates of bone density testing, counseling, and prescriptions for osteoporosis-related medications.

* White race was more strongly associated with bone density testing, calcium prescriptions and discussions about osteoporosis than any other osteoporosis risk factor.

Table 1. Characteristics of the survey respondents (n = 270)

                                           Race
                                   White         Black
Characteristic                     (n = 190)     (n = 80)     P value

Median age, years (range)                 62 (45-94)
Mean age, years (SD)                64.5 (12.3)  60.3 (11.0)   0.009 (a)
Mean self-reported weight, kg       74.2 (17.8)  91.9 (21.8)  <0.001 (a)
  (SD)
Mean body mass index (SD)           28.2 (6.5)   33.8 (7.5)   <0.001 (a)
History of fracture, n (%)
  Hip                                3 (1.6)      1 (1.3)      1.0 (b)
  Spine                              5 (2.6)      0            0.33 (b)
  Wrist                             11.0 (5.8)    0            0.04 (b)
  Rib                                4 (2.1)      0            0.32 (b)
  Any                               84 (44.2)    13 (16.3)    <0.001 (b)
Family history of osteoporosis or   84 (44.7)    21 (26.6)     0.006 (b)
  fracture, n (%)
History of receiving a bone        108 (56.8)    17 (21.3)    <0.001 (c)
  density test (%)

Note: the n for each characteristic varied between 266 to 270, depending
on the number of missing responses.
(a) P value for student t-test comparing means in white vs. black
groups.
(b) P value for Pearson chi-square test or 2-sided Fisher exact test
comparing the difference of two proportions, by race.
(c) P value for rank analysis of covariance, adjusted for age.

Table 2. Osteoporosis-related counseling

                                     % Respondents who have talked to
                                     primary care provider about this
                                     topic
                                     White      Black
Counseling topic                     (n = 190)  (n = 80)  P value (a)

Osteoporosis or fracture             52.2       25.6      <0.001
Intake of calcium or dairy products  67.1       43.1       0.007
Exercise to strengthen bones         50.9       49.3       0.90
Falls                                25.6       28.2       0.91
Whether patient might need a bone    52.4       26.1       0.004
  density test

Note: the n for each survey question varied, depending on the number of
missing responses. For white women, n = 168-186; black women, n = 69-78.
(a) P value for Mantel-Haenszel estimate of the odds ratio comparing yes
vs. no counseling for the two groups, controlling for practice.

Table 3. Ever use of osteoporosis-related medications

                                   Percent of ever users
                               White      Black
Medication                     (n = 190)  (n = 80)  P value

Calcium                        59.5       32.9      <0.001 (a)
Vitamin D                      37.0       27.7       0.28 (a)
Estrogen                       49.4       26.9       0.002 (a)
Estrogen/progestin             21.7        8.2       0.03 (a)
Other hormone                  16.7        6.3       0.02 (a)
Bisphosphonate (alendronate,   18.0        6.0       0.02 (b)
  risedronate or pamidronate)
Raloxifene                      4.4        1.6       0.45 (b)
Calcitonin                      6.2        1.5       0.18 (b)

Note: the n for each survey question varied, depending on the number of
missing responses. For white women, n = 150-173; black women, n = 61-70.
(a) P value for Mantel-Haenszel estimate of the odds ratio comparing yes
vs. no ever use of medication for the two groups, controlling for
practice.
(b) P value for 2-sided Fisher exact test comparing the difference of
two proportions, by race.

Table 4. Relationship between patient-related factors and osteoporosis-
related care in women aged 45 and older

                                Adjusted (a) OR (95% CI) for:
                                                    Discussed
                                                    osteoporosis or
                                                    fracture prevention
                                Bone density test   with doctor
Characteristic                  (n = 267)           (n = 261)

White race                      5.96 (3.01, 11.79)  2.97 (1.57, 5.60)
Age [greater than or equal to]  1.81 (1.01, 3.24)   0.98 (0.56, 1.73)
  65
Weight < 127 lb.                1.53 (0.63, 3.71)   1.94 (0.82, 4.56)
Personal history of fracture    1.02 (0.57, 1.80)   1.03 (0.59, 1.79)
Family history of osteoporosis  1.10 (0.97, 1.24)   1.14 (1.00, 1.30)

                                  Adjusted (a) OR (95% CI) for:
                                                      Bisphosphonate
                                Calcium prescription  prescription
Characteristic                  (n = 240)             (n = 231)

White race                      2.42 (1.30, 4.50)     2.13 (0.64, 7.05)
Age [greater than or equal to]  0.88 (0.49, 1.58)     2.54 (1.05, 6.11)
  65
Weight <127 lb.                 1.44 (0.58, 3.58)     3.46 (1.13, 10.62)
Personal history of fracture    1.60 (0.90, 2.84)     4.23 (1.83, 9.82)
Family history of osteoporosis  1.10 (0.97, 1.26)     1.06 (0.89, 1.28)

(a) OR adjusted for race, age, weight, history of fracture, family
history of osteoporosis, and practice site.