OBJECTIVE: Our goal was to determine how often primary care providers discussed osteoporosis prevention and calcium intake with women during their health maintenance examinations.

METHODS: A total of 449 women aged 18 to 65 years participated in exit interviews immediately following a health maintenance examination at 1 of 8 Wisconsin family practice clinics.

RESULTS: Forty-six percent of these women reported discussing osteoporosis with their providers during their visit, and 51% reported discussing calcium intake. A total of 61% reported discussing either osteoporosis or calcium intake during the visit. Some providers were able to discuss these topics with more than 90% of their patients. A logistic regression model showed that providers were less likely to discuss either of these issues with women younger than 40 years (P=.019); they were more likely to discuss them with women older than 60 years (P=.002) than with women aged 40 to 60 years; and women providers were significantly more likely to discuss either issue (P=.004).

CONCLUSIONS: Primary care providers are in a good position to counsel women of all ages about their potential for avoiding osteoporosis and to recommend prevention strategies. The United States Preventive Services Task Force recommends that all women be counseled on adequate calcium intake yearly after the age of 18 years. Provider education and institutional changes may increase the frequency of this counseling for all primary care physicians.

Osteoporosis is an important cause of age-related mortality and morbidity. More than 1.5 million Americans have osteoporosis-related fractures, costing the United States health care system more than $10 billion annually.¹ Although osteoporosis can occur in men, its incidence is higher in women. Those who are postmenopausal are at the highest risk because of the bone loss that occurs with decreasing estrogen levels. The National Osteoporosis Foundation estimates that 21% to 30% of all postmenopausal white women have osteoporosis, and an additional 54% have low bone density.² Women aged older than 50 years have a 4 in 10 chance of incurring a fracture during their remaining lifetime.³

Bone mineral density measurements can identify women with low bone mass who are at risk for a fracture. Although measurements of bone mineral density may be clinically indicated in high-risk women, current evidence does not support using them as screening modalities.⁴ Medications can slightly increase bone mass and prevent further loss, but treatment options for osteoporosis are suboptimal. Most consensus recommendations focus on prevention as the best approach.^5-7

Prevention of osteoporosis should begin in adolescence with education about risk factors, encouragement of adequate dietary calcium and Vitamin D, exercise, and other healthy behaviors; it must continue throughout a woman’s life.^8-10 Several studies have shown that calcium supplementation can increase bone density in women from adolescence to postmenopause.^9,11-15 The United States Preventive Services Task Force recommends that all women be counseled on adequate calcium intake yearly after the age of 18 years.¹¹

It is unclear how many primary care providers discuss osteoporosis and calcium intake with women at their annual health maintenance examinations. A review by the lead author¹⁶ of 263 charts of women older than 50 years found an overall documented rate of osteoporosis risk assessment of 35%. A vitamin manufacturing company telephone survey of 505 women aged 18 to 65 years found that only 34% had discussed osteoporosis and 44% had discussed calcium intake with their physicians in the past year.¹⁷ A 1991 study reviewed 243 medical records of women aged between 40 and 65 years and found documentation that although 74% of the women had 2 or more risk factors for osteoporosis, only 19% had received an osteoporosis-specific intervention (ie, calcium supplementation or counseling about osteoporosis risk or hormone replacement therapy).¹⁸ Also, the medical records of only 10% of the women in our prevalence study had a documented assessment of osteoporosis risk.

We used patient exit interviews to assess the frequency of osteoporosis prevention counseling during women’s health maintenance examinations in a primary care setting. On the basis of our literature review, we hypothesized that woman providers would discuss calcium intake and osteoporosis prevention more often than men and that discussions would be more frequent as women aged. We also hypothesized that physician assistants and nurse practitioners would discuss prevention topics more frequently than physicians.

Methods

For our report of osteoporosis prevention in primary care we used data collected in 8 Wisconsin family practice clinics at the outset of an osteoporosis intervention pilot study. Seven of the clinics were residency training sites, and the eighth was a university-affiliated private practice. All faculty physicians, physician assistants, nurse practitioners, and second-year residents in each clinic were invited to participate. Of the 67 providers invited, 90% agreed to be part of the study. Each provider completed a brief questionnaire that included demographic information such as age, sex, and job title; adequacy of own calcium intake; and personal experience with osteoporosis. Each participating provider signed a consent form agreeing to allow a study invitation to be given to women patients registering for a well-woman visit. The providers knew the general content of the interviews but not the specific questions. There was a 1- to 2-month time lag from when the providers signed the consent form to the beginning of the interviews. Data collection was completed during a period of 2 to 3 months, and providers were not told on which days it would occur. The University of Wisconsin Human Subjects Committee approved the study protocol.

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).

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.

Acknowledgments

The University of Wisconsin Department of Family Medicine Research Program provided funding for our study.

Osteoporosis Prevention Counseling During Health Maintenance Examinations