OSTEOPOROSIS SCREENING IS UNJUSTIFIABLY: MATERIALS AND METHODS
This study was completed in the Medicine Clinic at Barnes-Jewish Hospital at the Washington University Medical Center in St. Louis, MO. Approximately 160 internal medicine residents see patients in this urban clinic, which had over 31,000 patient visits in 2000. The clinic serves primarily middle-aged and elderly adults from minority ethnic groups. In 2000, 65% of patient encounters were with adults over the age of 50, including 42% of encounters with adults over 65. Approximately 75-80% of patients seen at this clinic are African American, and 88% have Medicaid, Medicare, or both as their primary form of medical insurance.
Evaluation of Physicians Screening Practices
Initially, a retrospective chart review of252 female patients was performed. The purpose of the chart review was to determine the osteoporosis screening practices of physicians in this clinic. Screening was also reviewed as a marker of the general screening practices for middle-aged and older women in this clinic. A random selection of charts from female patients over the age of 53 who were scheduled for physician appointments between February and April 2000 was examined. Age over 53 years was selected to increase the likelihood that the women were postmenopausal. Only those women who were patients in the clinic for at least six months and had seen a physician on at least three occasions were included. Physicians’ notes and patient registration data were used to determine ethnicity. Records were reviewed for a diagnosis of osteoporosis or osteopenia and for recommendations on the use of estrogen, vitamin D, and calcium. Radiology reports from the previous two years were reviewed for evidence of bone mineral density (BMD) testing and mammography. The investigators independently reviewed charts and 50% of the charts were reviewed by two investigators for reliability and accuracy. All radiology reports were verified by one of the investigators.
Measuring Bone Density and Assessing Risk Factors for Osteoporosis
To determine the frequency of decreased bone density, subjects were recruited to be evaluated using a peripheral bone densitometer. Postmenopausal women from the clinic were invited to participate. Recruitment was primarily through flyers posted in the clinic and nurse/physician referral. Eligible participants were postmenopausal women with no history or fragility fractures. Women taking estrogen were eligible if over the age of 65. These criteria were designed to follow the recent screening recommendations of the National Osteoporosis Foundation. Approximately 2,090 women were eligible by age criteria. One-hundred-forty-seven subjects responded, and 130 subjects completed the assessment. Seventeen subjects who scheduled appointments did not appear for assessment. Two women who were not postmenopausal were excluded from the analysis.
With the assistance of a physician, the participants completed a detailed questionnaire regarding risk factors for osteoporosis. The questionnaire has been used in prior investigations to determine presence or absence of risk factors for osteoporosis. Risk factors assessed included family history of osteoporosis, tobacco use, anticonvulsant use, estrogen use, steroid use, and calcium and vitamin-D intake. The participants’ race/ethnicity is reported based on their self-identification.
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Peripheral Bone Density
All subjects had their BMD assessed using calcaneal densitometry (Lunar PIXI, GE Medical Systems, Madison, WI). Appendicular measurements have been used to screen for low axial bone density in prior studies and have had a relatively high correlation with central dual-energy x-ray absorptiometry (DEXA). The BMD T-scores generated by the peripheral densitometer are based on the correlations with central DEXA. Based on World Health Organization (WHO) criteria, subjects with BMD between 1.0 and 2.5 standard deviations below the referenced mean for young adults (multiethnic population) were osteopenic and those with BMD 2.5 standard deviations or greater below the referenced mean for young adults were osteoporotic. All subjects with abnormal bone density were referred for central bone densitometry of the hip and spine.
Summary statistics for all demographic and clinical variables were computed for all subjects and separately by ethnic group. In the subjects whose bone densities were measured, individuals were designated as normal, osteopenic, or osteoporotic based on the manufacturers reference ranges for BMD T-scores. Bivariate associations between African Americans and Caucasians were assessed using % (chi-square) analysis. Additionally, each ethnic group was divided into three age groups and four groups by body mass index (BMI). The three age groups were those 65 or younger, those between age 65 and 75, and those over 75. Subjects were grouped by BMI according to the WHO classification for obesity; BMI less than or equal to 25 is normal, between 25 and 30 is overweight, between 30 and 35 is mild obesity, and greater than 35 is moderate-to-severe obesity. Comparisons of bone densities by diagnosis between age groups and BMI groups also used % analysis. Multivariate analyses of the demographic and clinical variables were conducted using logistic regression models. cheap cialis canadian pharmacy