Background: Guidelines for screening and treatment for postmenopausal osteoporosis have been created for primary care physicians, and there is growing interest in helping physicians tailor their care to patients' fracture risk. Little is known, however, about current physician knowledge or practices in osteoporotic fracture prevention, or the likely impact of tailored care recommendations on physician practices.
Methods: A cross-sectional survey targeting primary care physicians was mailed to a random sample of U.S. physicians stratified to include nationally representive proportions of general practitioners, family practitioners, general internists and obstetrician-gynecologists. All physicians' surveys included a first section containing Likert-scaled items measuring osteoporosis knowledge, attitudes and screening behaviors. The secons section of the survey included four patient vignettes varied systematically by patient age, weight, and bone mineral density (g/cm2, T-score and Z-score). One-half the physician sample (intervention group)was randomly assigned to receive case-based estimates of lifetime and five-year hip fracture risk derived from the Study of Osteoporotic Fractures in addition to T-score and Z-score results for these vignettes. Control physicians received only T-score and Z-score results. Respondents in both groups were asked how they would manage these cases, which included (case 1) a seventy-year old white woman with a T-score of –2.5 of average weight without any additional risk factors, and 3 patients with T-scores of –1.01 (a 70-year old of average weight (case 2), a 70-year old with low weight (case 3), and a 50-year old of average weight (case 4)). The effect of the additional tailored fracture risk information on prescription drug recommendations was examined using the Chi square statistic.
Results: There were 287 primary care respondents, including 28% females in a cohort with a median age of 49. There was no differences between intervention physicians and control physicians in specialty, age, or gender, nor were there differences between respondents (overall response rate 52%) and nonrespondents in age or gender. In Likert-scaled survey responses (strongly disagree to strongly agree), 86% of physicians agreed (responded with agree or strongly agree) that they were familiar with osteoporosis screening or treatment guidelines. However, only 66% agreed that guidelines were clear and 18% believed that BMD tests results were confusing. While 87% of physicians agreed that all women over 65 should be screened for osteoporosis, 85% also agreed that they use risk factors to determine which older women to screen. Ninety-three percent of physicians believed that bisphosphonates were efficacious or very efficacious in fracture prevention. Thirty-two percent reported weekly bisphosphonates were either well or very well-tolerated by patients.
Intervention physicians randomized to receive fracture risk predictions were statistically no more or less likely to recommend prescription medication use for any of the four case women. There was a trend toward lesser medication recommendations among intervention physicians for the seventy-year old average-weight woman (p=.053). Treatment recommendations for intervention vs control groups were as follows: 95% vs 96% (case 1), 25% vs 36% (case 2), 44% vs 45% (case 3), and 38% vs 43% (case 4).
Conclusions: Primary care physicians randomized to receive tailored absolute fracture risk estimates for patients in clinical vignettes with a range of fracture risks were no more or less likely to recommend prescription osteoporosis medications than control physicians. Physicians reported familiarity with osteoporosis guidelines and nearly all recommended prescription treatment of a patient with BMD <-2.5. As they also reported perceptions (such as poor patient tolerability of bisphosphonates) which might impact care, the effects of tailored fracture risk estimates and other factors upon physician and patient behavior deserve further study.
Disclosure Information:
Faculty Member's Name: Joan M. Neuner, MD, MPH
I have no relationships to disclose.
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