Osteoporosis Prevention Counseling During Health Maintenance Examinations
A researcher approached women patients aged 18 to 65 years as they were registering for an annual health maintenance examination with a participating provider and asked each if she would be willing to answer questions about her health care after her examination. No interview content was specified at the time of the request. After her appointment each woman who agreed to take part in the study completed a 5-minute interview about any discussion she had with her provider about calcium intake and osteoporosis risk factors and prevention. The following questions were part of the protocol: “Did your provider talk to you about osteoporosis today?” and “Did he/she talk to you about your calcium intake?” Each woman provided demographic information, her personal history of osteoporosis, smoking status, menopause status, exercise history, and any estrogen prescriptions Table 1. Each woman received $5 after completing the interview. If a woman was not able to complete the interview immediately after her appointment, she was called at home that evening or the following day. Our goal was to interview 5 to 10 women per provider.
Descriptive statistics were compiled to provide an overall summary of the data as well as a summary by provider and clinic. Pearson correlation coefficients were calculated to test the degree of hypothesized association between patient age and provider-patient discussion of either calcium intake or osteoporosis prevention. The chi-square test for independence was used to assess whether physician sex was associated with an increase in frequency of discussion. We used a logistic regression model to test the hypotheses that these prevention discussions about calcium intake or osteoporosis prevention occurred more often when a woman or midlevel provider was seen or if the patient was older, while controlling for other health factors (osteoporosis, race, and menopausal status).
Results
A total of 449 women were interviewed at the 8 clinics, an average of 7.5 per provider. The consent rate for patients approached for an interview was 90.4%. The average patient age was 40 years, with a range of 18 to 65 years. Three hundred and eighty-five (91%) of the women were white and only 24 (3%) said they had osteoporosis. Forty-six percent of the women interviewed reported discussing osteoporosis with their providers, and 54% reported discussing calcium intake during the visit. Overall, 61% reported a discussion of either calcium intake or osteoporosis. Two of the 8 clinics had significantly higher rates of either osteoporosis or calcium discussions (89% and 92%, respectively), while the discussion rate for the other 6 clinics was approximately 50%.
The providers included 37 faculty physicians, 15 second-year family practice resident physicians, and 8 nurse practitioners and physician assistants. The mean age of the providers was 42 years (mean=46 years for men and 38 years for women). The group was evenly split between men and women. Sixty-two percent of the providers were faculty, 25% residents, and 13% nurse practitioners or physician assistants.
Table 2 shows the significant increase in provider-patient discussion about osteoporosis and calcium intake as patient age increases. Regardless of provider sex, women of all ages reported discussions of calcium supplementation more often than discussion of osteoporosis risk only. Younger women reported conversations with their providers about osteoporosis approximately one third of the time during a health maintenance visit. This increased to 50% for women in their 40s and to more than 60% for women in their 50s and 60s. Almost half of the younger women reported discussing the importance of calcium intake, while women older than 60 years reported discussions of calcium in more than 60% of the interviews.
The logistic regression model presented in Table 3 shows the odds of the hypothesized variables having an influence on the outcome of a woman having a discussion of either calcium or osteoporosis with her provider. It shows that patient age is significant, with women younger than 40 years reporting these discussions half as often as the total patient group. Women in their 40s continued to be less likely to have prevention discussions, while women in their 60s were significantly more likely than those aged 40 to 60 years to have talked with their providers about topics important for osteoporosis prevention. The model also shows that ethnicity, smoking status, amount of exercise, menopause status, and patient history of osteoporosis were not related to occurrence of these discussions. Provider sex was significant, however, with women much more likely to discuss either calcium intake or osteoporosis prevention than men (P=.004). Men discussed these topics in only 24% of visits with women younger than 40 years, increasing to more than 40% when their patients reached their 40s, 53% for women in their 50s, and 62% of women in their 60s. A separate logistics regression model showed that provider dietary calcium intake and calcium supplements were not associated with differences in counseling rates. Provider personal experience with osteoporosis showed a borderline significant association with lower rates of counseling (P=.04).
