Recommendations for Screening for Osteoporosis

Peter L. Salgo, MD: What percentage of patients get diagnosed after becoming symptomatic? And let’s say, for the sake of the argument, symptomatic is a fracture.

Thomas P. Olenginski, MD, FACP, CCD: I’ll tell you what we do at our institution, and anybody that does FLS [fracture liaison service] care does the same. We did this because it wasn’t being done. So between 2008 and now, we’ve looked at 4 separate analyses. We want to be 100%, so we see someone in the hospital and we invite them to come back. Surprisingly, we only see 1 of every 2 patients. We only see 50%, because patients choose to go back to their primary care doctor, or they choose that because of a distance from us.

We treat 75% to 80% of the patients who do not have a contraindication post-fracture. That’s good, but what else have we learned? Even under our care, we lose them to follow-up. The typical blueprint in the medical record is maybe a preauthorization, they’re discussing cost, and it’s gone. Or you just say, “Canceled,” or “No show.” So the focus for post-fracture care and secondary fracture prevention is because it’s not being done. It’s not because no one necessarily wants to do it, it just tends to get lost in the…. We talked about comorbidities. Patients are going back and they have 3 or 4 other problems. The bone problem tends to get lost and we don’t get this done.

Andrea J. Singer, MD, FACP, CCD: Nationally, on a good day at best, you’re talking about 30% to 40% of people following a fracture getting diagnosed or treated. And it depends on what plan you look at, whether it’s an HMO [health maintenance organization] or not. But that’s probably on the high side.

Peter L. Salgo, MD: That’s crazy. That’s just crazy.

Andrea J. Singer, MD, FACP, CCD: Of course it is, absolutely.

Peter L. Salgo, MD: At what age would you test everybody?

Claire Gill: Well, our guidelines say to test every woman over the age of 65.

Peter L. Salgo, MD: OK. What about family history? Does that impact it?

Claire Gill: It does.

Peter L. Salgo, MD: How so?

Claire Gill: Well, doctors can tell you the specifics on how a family history would be….

Thomas P. Olenginski, MD, FACP, CCD: The big thing is a parent who had a hip fracture before the age of 80. But if I know that there are other fractures, or if I know in that family a parent’s being treated for osteoporosis, and if there are other risks—let’s say type 2 diabetes, someone smokes, someone has rheumatoid arthritis—that adds to the risk. And essentially to get the discussion in front of the patient, between the doctor and the patient, you need some data and you need something…. Again, a bone density test coupled with all of that is the best way to make that initial decision. And if everything is really good, that’s not the patient for whom we’re going to be doing a DEXA [dual energy x-ray absorptiometry scan] on every 2 years. It’s only the patient at risk, where we’re close to intervening with medicine or we’re intervening and we’re using that to determine their response to treatment.

Peter L. Salgo, MD: You mentioned something that I want to follow up on, because we did mention blood tests. What blood tests?

Andrea J. Singer, MD, FACP, CCD: Well, for somebody who has had a fracture, somebody who is at risk or for whom you diagnosed osteoporosis, there are certain basic blood tests that should be done. They’re not diagnostic tests. They’re part of a secondary evaluation to make sure that there is not something else going on that could be treated. There are things like a complete blood count, a comprehensive metabolic panel that includes looking for disorders of calcium metabolism. We consider kidney function and liver function. We look at a 24-hour urine calcium, and a vitamin D level. There are bone turnover markers, which indicate, they’re an indirect measure of either bone breakdown, bone resorption, or bone formation. Sometimes those can be helpful, because they’re sort of an independent indicator or risk factor in addition to bone density. But if you think it’s difficult to get bone density tests paid for, bone turnover markers are a whole other aspect.

Peter L. Salgo, MD: I sit at this table a lot. This is a conversation that comes up over and over and over again. The third-party payers always say, “There’s only so much money, and I can’t spend our money on this.” We had somebody challenge someone and say, “It’s not your money. It’s the patient’s money.” They still didn’t get it, I don’t think. But for a disease this prevalent, with this much morbidity and comorbidity, it seems really sad that we’re not getting this paid for the way it should be. After all, your disease is the most important disease.

Andrea J. Singer, MD, FACP, CCD: I think that for those of us who see patients and see the consequences, what you just said is absolutely true. It is sad to take somebody who is at a time in their life where they want to enjoy things and all of a sudden can’t pick up their grandkids, can’t get in the car and drive, can’t be out on the golf course, can’t travel, can’t do the things that give life meaning. We’ve done a number of surveys with our online population through the National Osteoporosis Foundation. What patients and caregivers worry the most about: It’s not dying. Nobody wants to die. But what they worry the most about is losing independence and losing mobility. We should be doing something to try to prevent that.