Primary care house staff attitudes toward osteoporosis management.

Objective: This study assessed possible institutional and patient-related factors influencing the delivery of postmenopausal osteoporosis (PMO) care and the diagnostic priority placed on addressing PMO, relative to other common medical conditions, by primary care house staff at our institution.

Methods: A questionnaire was designed and distributed to eligible house staff at our institution.

Results: Approximately 50% (n = 52) of the house staff participated. The supervising clinic attending, patients' lack of insurance, accessibility to medical care, comorbid conditions, and university formulary were reported to influence decisions regarding osteoporosis care. Osteoporosis was ranked 6th of 7 medical issues (hypertension, coronary artery disease, diabetes, hypercholesterolemia, adult immunizations, osteoporosis, thyroid disease) to address during a comprehensive medical visit.

Conclusions: Our institution's primary care house staff reported multiple influences on decision making regarding osteoporosis care, and an overall low priority to address this issue. Based on PMO's associated morbidity and mortality, primary care training programs are challenged to put resources toward optimizing house staff delivery of osteoporosis care.

Key Words: osteoporosis, house staff, residency, training, socioeconomic

**********

Postmenopausal osteoporosis (PMO) is a widespread condition, often underdiagnosed and undertreated in clinical practice. (1-4) This is a major public health concern, since by age 50, a woman's lifetime risk of any osteoporotic fracture is 50%, and her risk of a hip fracture alone is equivalent to the combined risk of developing breast, uterine, or ovarian cancer. (5-6) Yet, more women are screened yearly for breast cancer than for osteoporosis. (7-9) In 2000, only 1.75 of the over 20 million women aged 65 and over received a Medicare-reimbursed bone mineral density (BMD) test, yet at least 5.65 million women aged 65 and over received mammograms. (7-9)

These rates of PMO assessment are suboptimal considering the degree of morbidity and mortality associated with osteoporosis. With increased public demand for quality medical care, public and professional organizations have refocused their efforts on teaching and evaluation of clinical skills, especially at the residency level. Evaluating the residents at our institution from two different primary care clinics, we determined that they assessed PMO very infrequently, in both at-risk females and relative to other common medical conditions such as hypertension, diabetes mellitus and hyperlipidemia. (10,11)

The purpose of this study was to determine factors that might have influenced the house staff's approach to PMO utilizing a two-part questionnaire. (12) Specifically, we queried the house staff about the impact of both patient and institutional socioeconomic and medical factors on clinical decision making. We also assessed the diagnostic priority the house staff placed on PMO relative to other common medical conditions.

Methods

Study Design

The study was performed in accordance with our institution's Institutional Review Board's guidelines and approval. The study was comprised of two parts. Briefly, the first part assessed house staff delivery of medical care both pre- and posteducational interventions. The second part of the study consisted of a postassessment questionnaire delivered to the house staff after the first part of the study was complete.

Part I

Ongoing chart reviews were performed evaluating all female patients aged 45 years or older during their new patient visit or first comprehensive visit to the UTMB Internal Medicine (IM) or Family Medicine (FM) house staff clinics, respectively, in Galveston, Texas. These patients were from 30 Texas counties within an approximate 400 mile radius serviced by the university, which serves as a charity or indigent care hospital for the state. Most patients (80%) lived within 100 miles of the university clinics and lacked medical insurance.

For the first four months of the study, house staff remained blinded to the study. They were assessed for their screening and diagnostic practices via review of their clinic notes for an initial or comprehensive patient visit. House staff were then given two comprehensive lectures regarding osteoporosis. They also received instruction on using the Osteoporosis Risk Assessment Instrument (ORAI) (13,14) and an ORAI reference pocket card (see Appendix). They were told we would be assessing their delivery of osteoporosis care to patients for the next four months. During that time, an ORAI sheet was placed on the front of all eligible female patient charts as a reminder to the house staff to determine if the patient was a candidate for osteoporosis screening. Continued chart reviews assessed for any differences in diagnostic approaches to osteoporosis based on the lectures and the ORAI reminders. The results of this portion of the study will be published separately.

Part II

Questionnaire Design

We developed a two-part questionnaire with a total of 30 questions and a ranking table. It was designed to assess the impact of both patient and institutional socioeconomic and medical factors on house staff clinical decision-making in regards to PMO. It also assessed the diagnostic priority placed on osteoporosis by the house staff relative to other common medical conditions. Some of the questions were redundant to confirm the consistency of answers reflecting house staff opinions. The questionnaire required approximately 10 minutes to complete.

Part 1 of the questionnaire assessed the positive or negative influences of the patient's financial status, access to healthcare, comorbid medical conditions and/or hospital pharmacy formulary on the house staff's decisions to order diagnostic tests, eg, a bone mineral density (BMD) test, or to treat at-risk female patients for PMO. There were 15 questions, including questions on postgraduate year (PGY) training level, the number of patients seen in an average month and number of minutes spent with each patient in a typical visit. The remaining Part 1 questions (Table 1) were answered using the following scale to indicate the frequency of positive or negative influences: 1 = Always, 2 = Most of the time, 3 = Sometimes, 4 = Infrequently, and 5 = Never.

Part 2 addressed the importance house staff placed on diagnosing and treating PMO and its diagnostic priority relative to several common medical problems at the initial or comprehensive clinical visit. In the first section, the house staff were asked if they considered each of the following conditions important to diagnose and treat: hypertension, diabetes mellitus, osteoporosis and hypercholesterolemia. In separate questions requiring a 'Yes' or 'No' answer, the respondents were asked if these same four medical conditions should be addressed on the initial or comprehensive patient visit. In the second section, respondents were then asked to rank hypertension, diabetes mellitus, osteoporosis, hypercholesterolemia, coronary artery disease, thyroid disease and adult immunizations, eg, pneumococcal or influenza, in order of diagnostic and treatment priorities when conducting an initial or comprehensive patient visit. In total, there were 15 questions in the first section of Part 2 and a ranking diagram table for diagnostic priorities in the second section of Part 2 (Tables 2 and 3).

House Staff Selection for the Questionnaire

Two of our researchers attended several daily noon conferences over a 3-month period for internal medicine (IM) house staff and asked those with primary care clinic responsibilities to fill out the questionnaire. For family medicine house staff, one researcher attended a daily family medicine (FM) conference over a 1-month period of time. The internal medicine house staff were approached in early June, before the senior residents left the program, whereas the family medicine residents were initially approached with the poststudy questionnaire in August, one month after most senior residents had left the program.

Every qualified resident who was asked to fill out the questionnaire agreed to participate. The questionnaires were completed and submitted anonymously, with only the respondent's gender and postgraduate year as potential identifiers. Submission was recorded to avoid duplication of house staff response. The internal medicine responders (n = 35) represented 50% of the IM house staff with primary care responsibilities. The family medicine responders (n = 22) represented 60% of the FM house staff with primary care responsibilities.

Analysis of Data

Scores for the descriptive categories are described per convention: <0.2 = Poor, 0.2 to 0.4 = Fair, 0.41 to 0.60 = Acceptable, 0.61 to 0.80 = Good and > 0.80 = Excellent. (15) For Part 1 of the survey, we reported the percentage of house staff respondents with a "1," "2," or "3" answer (Table 1). For Part 2, first section, we assessed the percentage of respondents that answered "Yes" to the importance of addressing each medical condition. For Part 2, second section, overall rankings of the diagnostic priority of medical conditions were determined by an average rank determined from a weighted score of the number of respondents for each possible priority rank for each condition. (16) Ranking was also determined by the total percentage of house staff that ranked a particular condition first or second priority to be addressed at the initial or comprehensive visit. For all results, percentages are presented rounded to the nearest whole number.

Results

Approximately half of the IM and FM house staff with outpatient primary care clinics filled out the questionnaire. For participating IM and FM house staff, respectively, 49% and 77% were in their first two years of residency. The discrepancy in postgraduate years (PGY) between the two programs was attributed to the timing of the distribution of the poststudy questionnaire, as per Methods. The combined average for both IM and FM respondents in their first or second year was 62%. Females reflected 36% and 37% of the IM and FM participants, respectively.

The average number of clinic patients seen per month was reported as 25 for the IM house staff and 96 for the FM house staff. The number reported did not distinguish between patients seen for a follow-up visit versus an initial or comprehensive visit. Clinic scheduling templates allowed 1 hour for the initial visit in Internal Medicine and 30 minutes for the comprehensive visit in the Family Medicine clinic. The average number of minutes that were spent on a clinic patient during a typical visit was reported as 26 minutes by the IM house staff and 17 minutes by the FM house staff. Fifty-seven percent of the IM and FM house staff responded that they were able to spend between 15 to 25 minutes with a patient during a typical clinic visit. Only 28% of residents responded that they were able to spend 30 minutes with a patient on a typical clinic visit. The time reported for a typical clinic visit did not distinguish between the time spent for a follow-up visit versus an initial or comprehensive visit.

Table 1 reflects the patient and institutional factors that influenced the house staff's decision-making to diagnose and treat osteoporosis. The percentage of house staff responding to the various questions with a score of 1 to 3, reflecting acceptable to excellent correlation, (15) is detailed. Table 2 records the house staff responses regarding the importance of assessing osteoporosis and of addressing it on the first or comprehensive clinic visit. These results are compared against the actual percentage of patients that had risk factors for osteoporosis addressed or a BMD ordered as documented by chart review. House staff responses to the poststudy questionnaire are demonstrated in the second column. The last column demonstrates results obtained from the patients' medical chart reviews after the clinic visit, as described in Methods, to provide a comparison between actual practice versus perceived importance of addressing the disease state. The largest clinical care gap identified from house staff responses regarding the importance of a disease and its treatment and the medical chart review documenting actual clinical care was for osteoporosis. (10,11)

Table 3 demonstrates the assigned rank of diagnostic priorities for common medical conditions that are often addressed during an initial or comprehensive medical visit. In overall priority score, osteoporosis ranked sixth of the seven items, coming in only slightly higher than thyroid screening. Osteoporosis was the least likely disease state to be ranked as the first or second priority to be addressed at the initial or comprehensive visit, with only 7% of house staff respondents supporting a 1st or 2nd priority ranking.

At the time of the poststudy questionnaire, alendronate, risedronate, calcitonin, raloxifene and estrogen [+ or -] progesterone were US Food and Drug Administration (FDA) approved medications available by prescription to the general population for prevention and/or treatment of PMO. To compensate for costs associated with offering prescription medications to an indigent population, the university outpatient pharmacy formulary 1) limited physician prescribing of certain medications, and 2) relied on Public Health Service pricing, special reimbursement programs from pharmaceutical companies and patient copays tiered by patient ability to pay and medication cost. As a result, for PMO, the IM and FM house staff could only independently prescribe oral estrogen [+ or -] progesterone and oral calcium supplements for their patients reliant on the university outpatient pharmacy. The house staff also could prescribe raloxifene or alendronate but only with a requisite signature or cosignature of the General Medicine clinics' Medical Director or specialty faculty in Rheumatology, Endocrinology or Obstetrics-Gynecology.

Discussion

Our study questionnaire results demonstrated that socioeconomic and comorbid medical factors often influenced house staff decision-making at 2 primary care university-based clinics. Considering house staff assessment of osteoporosis occurred so infrequently, the supervising physician, as the greatest reported influencing factor for house staff, had a significant role in the house staff's failure to address PMO in their patients during an initial or first comprehensive patient visit. Although the practice patterns, general knowledge and attitudes of the supervising clinic physicians regarding osteoporosis were not addressed in our study, a previous study has reported the importance of direct attending faculty input in effective residency education. (17)

Other important factors affecting clinical decision-making reported by at least 50% of the house staff included the patient's financial status and university-based available treatment options. At the time of the study, only estrogen and hormone therapy and supplemental calcium, tiered for the patient's ability to pay, were available in the university pharmacy for osteoporosis prevention and treatment. Additional medications approved by the FDA for PMO prevention and treatment were also available, but only at a nominal discount from the retail price, restricted to selected faculty. Thus, not only were these medications difficult for the patients to afford, but the house staff could not easily offer them to the patients either. With limited treatment options, house staff may have viewed osteoporosis as a disease they could impact minimally, so neglected to diagnose and treat it. This conclusion is supported by the low diagnostic priority placed on osteoporosis by the house staff for the first visit both by survey and chart review results, despite over half of the surveyed house staff (54%) reporting that PMO was important to diagnose and treat at the first or comprehensive visit.

In marked contrast to osteoporosis, hypertension, diabetes mellitus and hypercholesterolemia are all diseases which had many more therapeutic options available on the university formulary at the time of this study. In parallel, per the chart reviews, screening and treatment for hypertension, diabetes mellitus and hypercholesterolemia occurred with higher frequency. These diseases also were given higher diagnostic priority rankings by the house staff.

House staff clinical decision-making can be influenced by limited access to medications as dictated by formulary, to the point of impairing the training experience. (18,19) Alternatively, broader access to medications has been shown to positively impact learning and patient care. Surveys have reported that community physicians learn best from medical sample availability and personal experience using the drug. (20) An additional study reports that with the availability of bisphosphonates and raloxifene, physician visits as well as the percentage of visits where treatment was prescribed for osteoporosis increased dramatically. (21) The increasing commonality of formulary restrictions reflects medical prioritization or rationing that occurs as a part of every university and community practice. Not only are hospital formularies becoming increasingly more limited, but managed care organizations consider the use of pharmacy formularies as a major strategy to curtail costs. The university hospital formulary has been a necessary development to ensure and maximize the availability of medications to patients treated by the university, especially indigent or underinsured patients.

An argument can be made that university hospital formularies or formularies associated with physician training programs be supported and expanded to make more classes of medications available and therefore improve the educative experience for the physician in training. Despite the economic strains, in 2003 the university pharmacy formulary committee did approve the addition of bisphosphonates to the tiered medications, so that monthly prescriptions for bisphosphonates could be available at minimal cost to qualified patients. Prescription cosigning privileges for bisphosphonates were also expanded to include most supervising clinic faculty in the IM clinic, although not to the FM clinic. The inclusion of bisphosphonates on the hospital formulary and expansion of cosignature authorization would be expected to increase the IM house staff diagnosis and treatment regarding PMO.

Notwithstanding formulary issues, assigning relative priorities to address osteoporosis against patients' other comorbid medical conditions is likely to be an involved thought process for house staff faced with a primarily indigent population. Although the house staff reported that the patients' medical conditions had little influence on their decision-making, the house staff might decide to rank hypertension over osteoporosis on the initial visit based on the minimal expense and ease of testing and treating hypertension relative to osteoporosis. First year costs associated with a hip fracture have been estimated at $36,864. (22) Cost-effectiveness studies become crucial to help demonstrate the potential savings realized by treating osteoporosis (8) compared with other diseases, and to guide decision-making. House staff may also consider the risk of complications and natural disease course differently for untreated hypertension compared with osteoporosis. A gap between physician knowledge and treatment practices has been described previously. (23)

Our study suggests that house staff decision-making to assess and treat osteoporosis in at-risk females is indeed complex, including limitations generated by both institutional and patient socioeconomic factors. Evaluating house staff attitudes toward diagnosis and treatment of a common chronic disease such as osteoporosis is important, as it may allow for targeted program development to help implement an osteoporosis screening program as part of their routine standard of care. Primary care providers' attitudes toward diabetes were important in their perceptions that hypertension, angina, arthritis, and hyperlipidemia were easier to treat than diabetes. (24) The house staff and faculty, as part of improving their delivery of osteoporosis care, also need to consider educating patients on available interventions, both pharmacologic and nonpharmacologic, for osteoporosis at the initial or comprehensive visit, irrespective of the socioeconomic, medical or institutional limitations.

Summary

In our descriptive study, house staff reported a low priority to address PMO at the initial or comprehensive visit. Multiple potential contributing factors were identified by our survey, including the supervising clinic physician and university formulary restrictions. Modifying various institutional and socioeconomic factors driving limited decision-making and treatment plans of physicians-in-training might allow residency training programs to better train house staff to evaluate for PMO.

Acknowledgments

The authors wish to thank Dr. Daniel Freeman and Ms. Sharon Little from the Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, for their guidance and expertise in designing the questionnaire and interpretation of the data. The authors are also indebted to Kimberly Sergeant, MS MSIS, RPh, Director of Pharmacy Services, University of Texas Medical Branch. The authors also thank Ms. Pat Gazzoli for her excellent secretarial assistance.

Appendix

[GRAPHIC OMITTED]

References

1. Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment (NORA). JAMA 2001;286:2815-2822.

2. Gehlbach SH, Fournier M, Bigelow C. Recognition of osteoporosis by primary care physicians. Am J Public Health 2002;92:271-273.

3. Siris ES, Weiss TW, Barlas S, et al. Underuse of osteoporosis treatment in postmenopausal women at high risk for low trauma fracture. J Bone Miner Res 2003;18(Suppl 2):S380.

4. U.S. Department of Health and Human Services [home page on the Internet]: Bone health and osteoporosis: a report of the Surgeon General. Washington, DC, October 14, 2004. (Accessed February 10, 2005, at www.surgeongeneral.gov/library/bonehealth)

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

6. National Osteoporosis Foundation: America's bone health: the state of osteoporosis and low bone mass in our nation. Washington, DC, 2002.

7. American Cancer Society: Breast cancer facts and figures 2001-2002. Atlanta, GA, 2002.

8. King AB, Saag KG, Burge RT, et al. Fracture reduction affects Medicare economics (FRAME): impact of increased osteoporosis diagnosis and treatment. Osteoporosis Int 2005;16:1545-1557.

9. Centers for Medicare and Medicaid Services [home page on the Internet]: Non-HMO women age 65+ with mammography services paid by Medicare, 1999-2001. Washington, DC. (Accessed February 10, 2005 at www.cms.hhs.gov/preventiveservices/lb31.pdf)

10. Chhabra A, McNearney T, Shepherd A, et al. Primary care resident evaluations for chronic health conditions: a failure to assess for osteoporosis. J Bone Miner Res 2002;17(Suppl):S204-S264.

11. Chhabra A, McNearney T, Shepherd A, et al. Low priority of diagnostic screening of osteoporosis by primary care residents. Arthritis Rheum 2002;46(Suppl):S97.

12. McNearney T, Shepherd A, Chhabra A, et al. Diagnosis and treatment of postmenopausal osteoporosis: factors influencing house staff decision-making in primary care clinics. Arthritis Rheum 2003;48(Suppl):S634.

13. Cadarette S, Jaglal SB, Krieger N, et al. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ 2000;162:1289-1294.

14. Cadarette SM, Jaglal SB, Murray TM, et al. Evaluation of decision rules for referring women for bone densitometry by dual energy x-ray absorptiometry. JAMA 2001;286:57-63.

15. Fleiss JL. Categories. Statistical methods and proportions. New York, John Wiley, 2nd Ed, 1981, p218.

16. The Math Forum at Drexel: Dr. Math [home page on the Internet]: Analyzing survey results. Philadelphia, PA, May 4, 2000. (Accessed February 10, 2005 at http://mathforum.org/library/drmath/view/52189.html)

17. Mareiness DP. Decreasing GME training stress to foster residents' professionalism. Acad Med 2004;79:825-831.

18. Orces CH, Casas C, Lee S, Garci-Cavazos R, et al. Determinants of osteoporosis prevention in low income Mexican-American women. South Med J 2003;96:458-464.

19. McLean AJ. Drug rationing in a teaching hospital. BMJ 1994;309:54.

20. Schumock GT, Walton SM, Park HY, et al. Factors that influence prescribing decisions. Ann Pharmacother 2004;38:557-562.

21. Stafford RS, Drieling RL, Hersh AL. National trends in osteoporosis visits and osteoporosis treatment, 1988-2003. Arch Intern Med 2004;164:1525-1530.

22. Grima DT, Burge RT, Becker DL, et al. Short-term cost-effectiveness of bisphosphonate therapies for postmenopausal osteoporotic women at high risk of fracture. P & T 2002;27:448-455.

23. Pazirandeh M. Does patient partnership in continuing medical education (CME) improve the outcome in osteoporosis management? J Contin Educ Health Prof 2002;22:142-151.

24. Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care 1998;21:1387-1388.

Terry A. McNearney, MD, Angela J. Shepherd, MD, Ajoy Chhabra, MD, and Niti Goel, MD

Departments of Internal Medicine, Neuroscience and Cell Biology, Microbiology and Immunology and Family Medicine, University of Texas Medical Branch, Galveston, TX and Procter and Gamble Pharmaceuticals, Inc, Mason, OH. This study was supported by an educational grant from The Alliance for Better Bone Health (Procter & Gamble Pharmaceuticals and Sanofi-Aventis) (NG, TAM).

Reprint requests to Dr. Niti Goel, 4525 Caduceus Place, Galveston, Texas 77551. Email: [e-mail]

TAM contributed to study design and was responsible for data acquisition and interpretation, writing and final approval of the manuscript. AJS contributed to data acquisition and interpretation, critical review and final approval of the manuscript. AC contributed to data acquisition, critical review and final approval of the manuscript. NG was responsible for study design, and contributed to data interpretation, writing, critical revision and final approval of the manuscript.

Niti Goel is an employee and shareholder of Procter & Gamble Pharmaceuticals, Inc., which has risedronate sodium (Actonel), an available FDA-approved medication for osteoporosis. Procter & Gamble was not otherwise involved in the conduct of this study, or writing or review of this article.

Accepted February 14, 2006.

RELATED ARTICLE: Key Points

* Multiple institutional and patient-related factors were reported to influence house staff decision-making regarding the delivery of osteoporosis care to their patients.

* Addressing postmenopausal osteoporosis at the initial or comprehensive visit relative to 6 other common medical conditions was given a low priority by primary care house staff.

* Based on the morbidity and mortality associated with postmenopausal osteoporosis, various institutional and socioeconomic factors should be modified to optimize decision making and treatment plans of physicians-in-training.

Table 1. Socioeconomic factors influencing assessment of postmenopausal
osteoporosis

                                                       Response
                                                       sometimes (3) to
                                                       always (1) (a)
Questions asked                                        (%)

How often did your sign out attending/resident         70
  influence your decision to diagnose and/or treat
  osteoporosis?
How often did treatment options (ie, choice of         58
  medicine on formulary) influence your decision to
  diagnose and/or treat osteoporosis?
How often did patient accessibility to the clinic      56
  (hours of travel, or transportation problems) or to
  other medical care (eg, county PCP) negatively
  influence your diagnostic care (eg, could patient
  come back for test)?
How often did a patient's having insurance             54
  positively impact your decision to order a bone
  densitometry?
How often was your decision to order a bone            51
  densitometry negatively influenced by the patient's
  financial status?
How often did a patient's lack of insurance (b)        51
  negatively impact your decision to order a bone
  densitometry?
How often did a patient's having insurance             49
  positively impact your decision to treat
  osteoporosis?
How often was your decision to treat a patient for     45
  osteoporosis negatively influenced by the patient's
  financial status?
How often did patient's accessibility to the clinic    40
  (hours of travel or transportation problems) or to
  other medical care (eg, county PCP) negatively
  influence your treatment decision?
How often did a patient's lack of insurance            36
  negatively impact your decision to treat
  osteoporosis?
How often did the patient's medical condition          36
  negatively affect your decision to diagnose and/or
  treat osteoporosis?

(a) Percentage of house staff who answered 1 to 3 on the scoring of Part
1. This reflects the answers Always (>80%), Most of the time (>60 to
80%), or Sometimes (40 to 60%).
(b) Lack of insurance: No private insurance, no Medicare, no Medicaid.
PCP, primary care physician.

Table 2. House staff responses vs actual screening of common medical
conditions

                                                         % screened
Questions regarding the diagnosis and           %        on initial
treatment of medical conditions                 yes (a)  visit (b,c)

Do you feel that hypertension is an important   100      95
    disease to diagnose and treat?
  Should it be addressed on the initial visit?   95
Do you feel that diabetes is an important       100      48
    disease to diagnose and treat?
  Should it be addressed on the initial visit?   98
Do you feel that hypercholesterolemia is an      96      46
    important disease to diagnose and treat?
  Should it be addressed on the initial visit?   77
Do you feel that osteoporosis is an important    98       7
    disease to diagnose and treat?
  Should it be addressed on the initial visit?   54

(a) The percentage of house staff who reported "yes" to the question.
(b) Actual percentage of patients screened for osteoporosis or who had a
bone mineral density ordered on their initial or comprehensive visit
based on medical chart reviews of those visits.
(c) Initial visit: refers to either the initial or comprehensive clinic
visit.

Table 3. Rank prioritization by house staff of common medical conditions

                         Overall   1st or 2nd
                         priority  priority rank
Disease                  rank (a)  (%) (b)

Hypertension             1         2 (69)
Coronary artery disease  2         3 (57)
Diabetes mellitus        3         1 (77)
Hypercholesterolemia     4         5 (9) (c)
Adult immunizations      5         4 (12)
Osteoporosis             6         7 (7)
Thyroid disease          7         5 (9) (c)

(a) Overall Priority Rank: The weighted average rank score
(b) First or second priority rank (%): The cumulative percentage
assigned to that disease state as the first or second priority by the
house staff for the initial or comprehensive visit.
(c) Hypercholesterolemia tied with thyroid disease for 5th as most
important to address.