Our survey of 1,268 women and men aged 60 and older revealed that individuals with several known osteoporosis risk factors are not being sufficiently targeted for osteoporosis screening. Most notably, older respondents were significantly less likely than younger respondents to report receiving screening recommendations from their physicians and no more likely than younger respondents to undergo screening. This is a notable finding given that age is the strongest individual risk factor for osteoporosis, with older individuals being at highest risk. This finding that older individuals are less likely to be targeted for osteoporosis screening concurs with the finding of a large-scale study in which researchers abstracted data from the electronic medical records of patients seen in ten primary care practices,18
and highlights an important area for osteoporosis screening improvement.
In our study, the presence of several other osteoporosis risk factors—such as oral steroid use >1 month, low-trauma fracture, loss of height, heavy alcohol consumption, smoking, or white race—either did not make physicians more likely to recommend screening or did not make individuals more likely to undergo screening, when adjusting for other osteoporosis risk factors. Several of our results are consistent with results of earlier studies. For example, our finding that individuals with a history of oral steroid use may not be receiving sufficient osteoporosis screening concurs with findings from other studies that patients taking oral steroids are underscreened.19,20
Our observation that osteoporosis screening was more likely in women than men is also consistent with earlier studies.18,21
Our finding that osteoporosis screening was no more likely in white adults than black adults, when adjusting for other osteoporosis risk factors, is different from findings of several previous studies and warrants further study.18,22
Our study suggests that physicians need to better assess older adults’ osteoporosis risk and ensure that high-risk individuals receive screening. Physicians should in particular be aware that individuals with advanced age (the most elderly), height loss, history of low-trauma fracture, and oral steroid use are at increased risk of osteoporosis. Physicians should be more vigilant about osteoporosis screening in at-risk patients in general (e.g., all women over the age of 65), but pay special attention to individuals with the risk factors listed above, as our results suggest that these individuals may be particularly underscreened. Several previous studies have demonstrated that adults who undergo osteoporosis testing are more likely to receive treatment;23–25
thus, improving screening rates in individuals at greatest risk is an important step towards improving osteoporosis outcomes. The best way of improving physician identification of individuals at increased risk of osteoporosis and referral for screening is unclear. Several potential strategies to improve physicians’ osteoporosis screening practices include financial incentives (e.g., incentive payments for physicians performing well on Medicare’s Physician Quality Reporting Initiative (PQRI) osteoporosis screening measures), physician reminders (e.g., electronic medical record system reminders), and the use of local opinion leaders. A direct patient education media campaign may also improve screening rates–if patients are educated about risk factors, at-risk individuals may ask their physicians for screening. Further studies are needed to evaluate the efficacy of various strategies to improve osteoporosis screening rates; one recent large randomized controlled trial of physician and/or patient education to improve osteoporosis testing and treatment rates failed to show any benefit of a brief education program.26
To our knowledge, our study is the largest survey of patient characteristics associated with osteoporosis screening. However, the study had several limitations. First, because the survey was based on self-report, there may have been recall bias concerning the receipt of screening or a screening recommendation; this is further suggested by our finding that more people reported prior screening than receiving a screening recommendation. The wording of our screening recommendation question may also have affected participants’ responses; individuals who had screening recommended by a non-physician health care provider may have answered “no” to this question. Moreover, individuals whose physicians’ ordered an osteoporosis screening test but did not discuss this with the patient may not have considered this a recommendation. Another limitation of our study is that the survey population consisted of individuals who lived in or near western Pennsylvania, volunteered for a research registry, and were disproportionately white, healthy, and highly educated, which may limit the generalizability of our results. However, if in this survey population individuals with several known osteoporosis risk factors were not more likely to receive a screening recommendation or screening, this may be an even larger problem in the general population of older adults. Furthermore, our choice of a 1-month cutoff for oral steroid use associated with increased risk of osteoporosis is shorter than the 3-month steroid use duration put forth in several guidelines.11,13
Although there is evidence that any oral steroid use increases osteoporosis risk,27
our choice of a 1-month cutoff was arbitrary, and we may have found different results had we chosen a longer steroid use duration. Finally, our survey did not capture all of the variables related to physician recommendation of screening or prior screening; for example, we did not assess body mass index, whether participants had a regular primary care physician, had health insurance, were physically active, or had comorbidities, which are likely related to osteoporosis screening. Our study also had several notable strengths, including a large sample size, nearly 70% response rate, inclusion of both female and male participants, and inclusion of key risk factors in recently published guidelines for osteoporosis prevention and treatment.11,13
In conclusion, we found that individuals with several osteoporosis risk factors, such as advanced age, oral steroid use >1 month, loss of height, and history of low-trauma fracture were either not more likely to receive osteoporosis screening recommendations or not more likely to undergo screening, when adjusting for other osteoporosis risk factors. Our study points to the need for physicians to better assess older adults’ osteoporosis risk, recommend screening to individuals at risk, and follow-up with screening for at-risk individuals. Improving screening rates in individuals at greatest risk for osteoporosis is an important step towards improving health outcomes.