Osteoporosis Prevention Counseling During Health Maintenance Examinations
Menopausal status was also associated with an increase in counseling rates, likely related to age. Two thirds of the menopausal women in this study were taking estrogen. Estrogen use was not associated with a change in counseling. Nurse practitioners and physician assistants were more likely to discuss osteoporosis prevention than their physician colleagues, although this difference was not statistically significant. A separate logistic regression, which added clinic site to the model, provided no additional explanation of the frequency of osteoporosis risk prevention discussion. Women at 2 of the clinics were significantly more likely to report discussions with their providers about either osteoporosis or calcium, but in those 2 clinics both patient age and provider sex remained significant.
Discussion
The 61% overall rate of osteoporosis and calcium discussions in our study is higher than rates documented in other studies.16-8 Since this is the only study to interview women immediately after a health maintenance visit, the accuracy of patient recall may be improved. Many providers discussed adequate calcium intake without specifically discussing osteoporosis, although the opposite was not true. It may be better to discuss a behavioral change than the risk of the disease without discussion of how to prevent it.
Woman providers discussed calcium and osteoporosis significantly more than men, which supports findings from a chart review study published by the lead author16 on the same topic. It has been well documented in the literature that women physicians provide more health screening, such as Papanicolaou tests and mammograms, than men.19,20 This is the first study to address osteoporosis prevention topics.
Provider personal experience with osteoporosis was associated with a lower rate of counseling about calcium intake and prevention strategies. This association was of borderline significance and deserves further study.
Women of older age groups more often reported discussion of osteoporosis during a health maintenance visit; however, age was not as well correlated with discussions of calcium intake. Although it is commendable that providers increased their attention to osteoporosis in older women, counseling young women is also essential to prevent osteoporosis. Adequate dietary calcium and risk reduction for osteoporosis through diet and exercise may provide young women with increased protection from osteoporosis before entering their menopausal years.
Two of the clinics in our study showed significantly higher rates of discussion of calcium and osteoporosis. These residency clinics were smaller than many of the more urban sites, and each had a faculty member who was very interested in women’s health. The percentage of woman providers is higher in one of these clinics, which may explain in part the increased rates of osteoporosis and calcium discussions in this particular clinic, but it cannot account for the other clinic, where only 33% of the providers were women. The high rates of osteoporosis prevention counseling in these 2 clinics imply that there are some institutional changes that can be implemented to improve rates of counseling in other clinics.
Limitations
There are several limitations to our study. We used patient reports to describe what occurred during a health maintenance examination but did not corroborate this data with chart reviews. A chart review done in some of the same clinics found a much lower recorded incidence of osteoporosis or calcium discussions,16 so patient reports may be a better measure. We did not collect information regarding length of visit. All of the providers routinely see women for annual examinations during a 30-minute time slot, although occasional variation may occur. We also did not collect information about each woman’s current calcium intake or use of hormone replacement therapy. Also, since with one exception this study was completed at academic practices, it may not reflect practices outside of an academic setting.
Conclusions
Major barriers to osteoporosis prevention include time constraints and competing issues brought to the visit by both the patient and the care provider. The limited time during health maintenance visits does not allow providers to address every prevention topic. Some providers feel osteoporosis is not as important an issue as tobacco smoking, cancer prevention, exercise, or diet. As a result, inclusion of osteoporosis in a universal primary care prevention agenda is currently controversial. However, according to the National Osteoporosis Foundation, a vast majority of postmenopausal white women have osteoporosis or low bone density, and others report 4 of every 10 women older than 50 years will fracture a bone over the course of their remaining lifetime.3 Because of this high prevalence, osteoporosis should be a priority prevention topic for women’s health providers.
Primary care providers are in a good position to counsel women about osteoporosis risk factors and prevention strategies. Provider education along with changes in the roles and responsibilities of staff to provide services may increase the frequency of this counseling. Further study should examine ways for primary care providers to consistently implement osteoporosis prevention.
