Our osteoporosis report card: 'A' for apathy, 'D' for effort, and 'F' for results.

We have failed our patients. We have the means to diagnose osteoporosis and have medications that can effectively reduce the risk of fracture, yet the majority of patients with osteoporosis, even those who have sustained a hip fracture, are neither diagnosed, nor treated. (1-4)

We know that 40 to 54% of white postmenopausal women over the age of 50 are expected to sustain an osteoporotic fracture. (5,6) We also know that the mortality and morbidity associated with these fractures are quite significant: the first year mortality after an osteoporotic hip fracture is increased by about 24% in women, (7,8) and is even higher in men. (9) About half of the women who sustain an osteoporotic hip fracture are so disabled that they are no longer able to resume their daily activities, (10) and as many as 20% will require long-term institutional care. (5)

Medications are available that can significantly reduce the risk of fractures. These were outlined in the June 2001 issue of the Southern Medical Journal. (11) In a future issue we plan to publish the proceedings of a symposium on hip fracture prevention held at the annual Southern Medical Association meeting in November 2003. (12-14) In the current issue, we are including abstracts on the diagnosis and screening of osteoporosis by Nelson B. Watts, MD, and on Peripheral Bone Densitometry by Gary M. Kiebzak, PhD, which were presented at the 7th Conference on Osteoporosis, held at Sea Island, Georgia, February 19 to 22, 2004. We are also publishing a section on low bone mineral density in premenopausal women by Michael Lewiecki, MD. In addition, we are pleased to include an article by Deborah T. Gold, PhD, introducing the self-management program, "Choices for Better Bone Health," as well as a review of glucocorticoid-induced osteoporosis by Kenneth G. Saag, MD, which includes an algorithm endorsed by the Southeast Osteoporosis Advisory Board.

We have the means to diagnose osteoporosis before a fracture occurs. Dual x-ray absorptiometry (DXA) is the gold standard for the noninvasive diagnosis of osteoporosis, and clear diagnostic guidelines are available (Fig. 1). (15) The National Osteoporosis Foundation has issued guidelines regarding the management of patients with low bone mass (Fig. 2). (16) The DXA scan is noninvasive, painless, and not associated with discomfort. The exposure to radiation is minimal, only a fraction of that of a chest x-ray. The test is relatively inexpensive, and the equipment is readily available.

Regrettably, however, osteoporosis remains underdiagnosed, even after patients have sustained hip fractures that have been surgically repaired. (1-4) This is puzzling since medical treatment has been shown to be cost-effective, and since Congress passed the Bone Mass Measurement Act in 1998, which mandates that bone mass measurements be reimbursed by Medicare if the person has any of the conditions listed in Figure 3. (17-19) Several other organizations have issued guidelines to help clinicians decide who should be scanned. (20)

Given that the diagnosis of osteoporosis can be established quite easily, and given that we have the means to significantly reduce the risk of osteoporosis-associated fractures, why are we neither diagnosing, nor treating, osteoporosis in the majority of patients?

Is it because we are too busy diagnosing and treating acute conditions? If so, how can we explain that many patients who present with a hip fracture are neither diagnosed, nor treated, for osteoporosis? Surely, the management of osteoporosis should be an integral part of the management of these patients. In the same way, patients who present with complications of hypercholesterolemia are not only treated for the complication, but are also managed for the underlying hyperlipidemia. Why is it different with osteoporosis? Is it because we are apathetic toward this disease? If this is the case, we deserve an "A" for apathy.

Or is it because most practicing clinicians are still under the misapprehension that there is little that can be done for osteoporosis and that it is an inevitable part of the aging process? If this is the case, we deserve a "D" for our effort to educate ourselves and our colleagues.

Regardless of the underlying reason, we deserve no more than an "F" for our results. We cannot be proud of them. There is no doubt that our health care system has the potential to deliver outstanding care, yet we let our patients with osteoporosis go undiagnosed, and often when the diagnosis is obvious because of a hip fracture, we ignore the underlying problem.

It would be very sad if action mandated by administrators, the legislature, or worse, as the result of a few lawsuits, forced us to change our modus operandi. There is still time to do the right thing without outside pressure. We need to do a better job diagnosing and treating patients with osteoporosis. We do not want an "A" for apathy. We have the means of getting an "A" for our effort and an "A" for our results. Let's go for it!

DXA--Diagnostic Guidelines WHO: t-scores

* Normal:                      +1.0 to -1.0
* Osteopenia:                  -1.0 to -2.5
* Osteoporosis:                -2.5 and lower
* Established Osteoporosis:  < -2.5 & fragility #

SPINE (PA), HIP, FOREARM, NOT HEEL, NOT PHALANGES

Fig. 1 DXA, dual x-ray absorptiometry; WHO, World Health Organization.

NOF Treatment Guidelines t-scores

Initiate treatment when t-score is (or lower):
  -1.5 in the presence of risk factors
  -2.0 in the absence of risk factors

CENTRAL NOT PERIPHERAL BONES

Fig. 2 NOF, National Osteoporosis Foundation, 2003.

Bone Mass Act, July 1998
Indications for Bone Mass Measurement Coverage

* Estrogen deficiency
* Treatment for osteoporosis with FDA approved medication
* Long term corticosteroid therapy
* Radiological abnormalities suggestive of osteoporosis
* Hyperparathyroidism

Federal Register 1998;63(121):34320-34328

Fig. 3

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9706-0538

References

1. Siris ES, Bilezikian JP, Rubin MR, et al. Pins and plaster aren't enough: a call for the evaluation and treatment of patients with osteoporotic fractures. J Clin Endocrinol Metab 2003;88:3482-3486.

2. Kamel HK, Duthie EH. The underuse of therapy in the secondary prevention of hip fractures. Drugs Aging 2002;19:1-10.

3. Harrington JT, Broy SB, Derosa AM, et al. Hip fracture patients are not treated for osteoporosis: a call to action. Arthritis Rheum 2002;47:651-654.

4. Kiebzak GM, Beinart GA, Perser K, et al. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med 2002;162:2217-2222.

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

6. Melton LJ, Chrischilles EA, Cooper C, et al. Perspective. How many women have osteoporosis? J Bone Miner Res 1992;7:1005-1010.

7. 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.

8. Col NF, Eckman MH, Karas RH, et al. Patient-specific decisions about hormone replacement therapy in postmenopausal women. JAMA 1997;277:1140-1147.

9. Center JR, Nguyen TV, Schneider D, et al. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 1999;353:878-882.

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

11. Slagle MA. Medication update. South Med J 2001;94:574-578.

12. Hamdy RC. South Med J In press.

13. Holick MF. South Med J In press.

14. Tanner B. South Med J In press.

15. Kanis et al. DXA-diagnostic guidelines for preclinical evaluation and clinical trials in osteoporosis. J Bone Miner Res 1994;9:1137.

16. NOF treatment guidelines. National Osteoporosis Foundation. Physicians Guide to Prevention and Treatment of Osteoporosis 2003.

17. Bone mass act, July 1998: indications for bone mass measurement coverage. Federal Register 1998;63:34320-34328.

18. Chrischilles EA, Dasbach EJ, Rubenstein LM, et al. The effect of alendronate on fracture-related healthcare utilization and costs: the fracture intervention trial. Osteoporosis Int 2001;12:654-660.

19. Iglesias CP, Torgerson DJ, Bearne A, et al. The cost utility of bisphos-phonates treatment in established osteoporosis. QJM 2002;95:305-311.

20. Leib ES, Lewiecki EM, Binkley N, et al. Official positions of the international society for clinical densitometry. South Med J 2004;97:107-110

Ronald C. Hamdy, MD, FRCP, FACP 

Editor