This study shows that most male patients older than 65 years in these academic practices were not being screened as recommended by the Osteoporosis Society of Canada’s 2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada.21
The prevalence of osteoporosis found in this study was 14.3%, which is close to the Canadian Multicentre Osteoporosis Study’s estimate of 1 in 8 men.2
Considering the substantial prevalence of osteoporosis in older men and the high rates of morbidity and mortality related to osteoporotic fractures in this population, physicians should try to achieve higher rates of BMD screening among these patients so that they can be treated and many more fractures can be prevented. Family physicians need to become familiar with the risk factors that identify people who should be assessed for osteoporosis.
The original World Health Organization definitions for osteoporosis were developed for postmenopausal women.25
There is still debate over the reference group to be used to derive T-scores for men; however, it is generally agreed that men with T-scores lower than −2.5 are at substantially increased risk of osteoporotic fractures and should be treated.17,21
The World Health Organization is currently developing a method of estimating a 10-year absolute risk of fracture based on BMD, age, sex, and other risk factors gleaned from several large databases.
It is possible that some physicians are aware of the risk factors that indicate screening for osteoporosis but are deliberately choosing not to screen or perceive barriers to implementing fracture-prevention strategies. McKercher et al conducted a study on management of osteoporosis in long-term care patients and found that commonly cited barriers to screening and treatment included the perceived cost of investigations and treatment, the unknown benefit of treatment, and concerns about prescribing medications to elderly patients (eg, side effects and polypharmacy).26
Jaglal et al did a survey of family practitioners and found similar barriers, along with the findings that limited time and competing demands during appointments hampered physicians’ ability to provide preventive care, that there was a perception that some patients were not keen on health promotion because they were preoccupied with existing illnesses, and that physicians had difficulty keeping up with current literature.6
Some of these barriers might be overcome with research, educating physicians and patients, using physician reminders, and developing clear and succinct evidence-based clinical practice guidelines. Access to medications is improving, as demonstrated by the fact that the Ontario Drug Benefit Plan formulary has recently (as of July 12, 2007) eliminated the requirement of a failed trial of etidronate before providing coverage for other bisphosphonates with better proven clinical benefit in prevention of fractures, such as alendronate and risedronate.
On the other hand, there are situations in which screening is not indicated despite risk factors. The 2002 guidelines discuss the fact that treating patients for osteoporosis might not be indicated if there is an unfavourable risk-benefit ratio, and that screening should be done only if it will affect management.21
For example, patients who are receiving palliative care or who have relatively short life expectancies would be unlikely to benefit from treatment of osteoporosis (which can take months to years for effect). Further investigation would be beneficial for clarifying the existence of barriers to screening and treatment, as well as how often BMD testing is deliberately not done for sound clinical reasons. There also needs to be more research on why treatment response is different for women than for men.
This study showed a trend toward increased rates of screening in older men, but this trend was not statistically significant, likely owing to the small numbers of participants in each subgroup. This trend might have reflected a greater tendency toward screening because of advanced age or a higher prevalence of other risk factors for osteoporosis with age. A larger sample size would be needed to determine the nature of this relationship and whether there is actually a lower rate of screening among men older than 90.
No statistically significant relationship was found between BMD results and age, which was unexpected given the well-established increase in risk of osteoporosis with age. Because only 19% of the study population received screening, however, the sample size was not adequate to establish any relationship. This patient population likely had other risk factors aside from age that prompted screening and that would confound an age-related analysis of BMD results. A larger study would be required to determine accurately the influence of various risk factors on BMD and rates of screening.
This study took place in an academic centre where individual practices are relatively small compared with community practices and residents provide a large proportion of care under the supervision of preceptors. We do not know to what extent these results can be extrapolated to family practices in communities.
Some patients might have had BMD testing outside Kingston. Results of this testing would not have been included in this analysis, and this would have led to an underestimation of screening rates.
The sample size was limited by the size of the practices. This limited the power to analyze differences between subgroups of patients (by age, for example). A larger study would be required to know whether trends in screening rates were statistically and clinically significant.
Despite the fact that this study was carried out at a single academic centre, there were large variations in screening rates among practices. Even the most successful practices achieved screening rates of only 30% to 40%. Primary care physicians need to increase their awareness of the prevalence of osteoporosis in men, of the seriousness of its consequences, and of the indications for screening and treatment. Future studies of barriers to screening and treatment, particularly of male patients, and specific research on the benefits of treating men with osteoporosis would help guide family physicians in the management of osteoporosis.