Skip to main content
SpringerLink
Log in

Physician Differences in Managing Postmenopausal Osteoporosis

Results from the POSSIBLE US™ Treatment Registry Study

  • Original Research Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Background: Osteoporosis is a disease that often goes undetected until a fracture occurs. Previous reports indicate that disease diagnosis and care of patients with osteoporosis may vary within the medical community.

Objective: Using data from the POSSIBLE US™ registry (October 2004–December 2009), we evaluated patterns of care for a group of primary care (i.e. first-contact) physicians who frequently prescribe osteoporosis medications to determine whether variations existed in the characteristics of their postmenopausal patients; physician approaches to diagnosis; treatment choices and monitoring; and patient-reported medication use.

Methods: POSSIBLE US™ was a large prospective registry of postmenopausal women receiving osteoporosis treatment. We analysed data from 42 family practice physicians (FPPs), 50 internal medicine specialists (IMs) [internists, physicians], 41 gynaecologists (GYNs) and the 4917 patients they enrolled in the POSSIBLE US™ registry between October 2004 and January 2007. Women who had been postmenopausal for at least 1 year and who were newly initiating osteoporosis therapy, switching or augmenting therapy or continuing on a stable therapy regimen were investigated. Therapies included bisphosphonates, full-length or peptide derivative of parathyroid hormone, calcitonin, oral or transdermal postmenopausal estrogen, selective estrogen receptor modulators (SERMs), calcium and/or vitamin D supplements (alone or in combination with other therapies), or any combination of these agents. Data on physician characteristics were collected on an initial qualification questionnaire. Physicians reported data for enrolled patients at study entry and were also asked to provide relevant data obtained at clinic visits throughout the follow-up period. Patient-reported data were collected using questionnaires mailed out semi-annually throughout the follow-up period. Patient-reported and physician-reported data were assessed using ANOVA models and chi-squared (χ2) or Cochran-Mantel-Haenszel tests to evaluate differences across physician types. Multivariate logistic regression models examined the odds of patients having an osteoporosis diagnosis, being prescribed specific agents and receiving an additional dual energy x-ray absorptiometry (DXA) scan after the initial diagnostic scan. Cox proportional hazards regression models were used to determine whether the risk of patient-reported treatment discontinuation during 12 months of follow-up differed by physician characteristics.

Results: Although low-bone density diagnoses were not required, physicians reported DXA as the method of diagnosis in 84% of patients. The majority of patients were prescribed bisphosphonates (55%); the next most frequently prescribed treatment was calcium/vitamin D only (19%). Women treated by GYNs were younger; had fewer co-morbidities, higher T-scores and fewer prior fractures; were 30% less likely to carry a diagnosis of osteoporosis; and were more likely to be treated with SERMs or hormone replacement therapy (HRT) than women treated by IMs or FPPs. Patients cared for by physicians with >30 years of experience were 20% less likely to carry a diagnosis of osteoporosis, had greater odds of receiving either HRT or calcium/vitamin D only and had a higher risk of treatment discontinuation. Overall, there was less laboratory testing to assess secondary causes of osteoporosis in this cohort than might have been expected, given the high incidence of secondary osteoporosis generally in women of similar age.

Conclusions: This study documents potentially important variations in osteoporosis care, even among physicians who frequently prescribe osteoporosis medications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Table I
Table II
Table III
Table IV
Table V
Table VI
Table VII
Table VIII

Similar content being viewed by others

References

  1. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007 Mar; 22(3): 465–75

    Article  PubMed  Google Scholar 

  2. Huot L, Couris CM, Tainturier V, et al. Trends in HRT and anti-osteoporosis medication prescribing in a European population after the WHI study. Osteoporos Int 2008 Jul; 19(7): 1047–54

    Article  PubMed  CAS  Google Scholar 

  3. National Osteoporosis Foundation (NOF). Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: NOF, 2010

    Google Scholar 

  4. Cranney A, Lam M, Ruhland L, et al. A multifaceted intervention to improve treatment of osteoporosis in post-menopausal women with wrist fractures: a cluster randomized trial. Osteoporos Int 2008 Dec; 19(12): 1733–40

    Article  PubMed  CAS  Google Scholar 

  5. Majumdar SR, Johnson JA, McAlister FA, et al. Multi-faceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. CMAJ 2008 Feb 26; 178(5): 569–75

    Article  PubMed  Google Scholar 

  6. Bliuc D, Eisman JA, Center JR. A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures. Osteoporos Int 2006; 17(9): 1309–17

    Article  PubMed  CAS  Google Scholar 

  7. Solomon DH, Polinski JM, Stedman M, et al. Improving care of patients at-risk for osteoporosis: a randomized controlled trial. J Gen Intern Med 2007 Mar; 22(3): 362–7

    Article  PubMed  Google Scholar 

  8. Feldstein A, Elmer PJ, Smith DH, et al. Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. J Am Geriatr Soc 2006 Mar; 54(3): 450–7

    Article  PubMed  Google Scholar 

  9. Centers for Medicare & Medicaid Services. Your Medicare benefits. Baltimore (MD): Centers for Medicare & Medicaid Services, 2010 [online]. Available from URL: http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf [Accessed 2010 Oct 28]

    Google Scholar 

  10. Giammattei F, Giammattei J, Howland V. Physician follow-up care for osteoporosis after fragility fractures. Phys Sportsmed 2009 Dec; 37(4): 62–7

    Article  PubMed  Google Scholar 

  11. Khan SA, de Geus C, Holroyd B, et al. Osteoporosis follow-up after wrist fractures following minor trauma. Arch Intern Med 2001 May 28; 161(10): 1309–12

    Article  PubMed  CAS  Google Scholar 

  12. Simonelli C, Killeen K, Mehle S, et al. Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons. Mayo Clin Proc 2002 Apr; 77(4): 334–8

    Article  PubMed  Google Scholar 

  13. Block AE, Solomon DH, Cadarette SM, et al. Patient and physician predictors of post-fracture osteoporosis management. J Gen Intern Med 2008 Sep; 23(9): 1447–51

    Article  PubMed  Google Scholar 

  14. Solomon DH, Brookhart MA, Gandhi TK, et al. Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics. Am J Med 2004 Dec 15; 117(12): 919–24

    Article  PubMed  Google Scholar 

  15. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005 Feb 15; 142(4): 260–73

    PubMed  Google Scholar 

  16. Smith MD, Ross W, Ahern MJ. Missing a therapeutic window of opportunity: an audit of patients attending a tertiary teaching hospital with potentially osteoporotic hip and wrist fractures. J Rheumatol 2001 Nov; 28(11): 2504–8

    PubMed  CAS  Google Scholar 

  17. Tosteson AN, Grove MR, Hammond CS, et al. Early discontinuation of treatment for osteoporosis. Am J Med 2003 Aug 15; 115(3): 209–16

    Article  PubMed  Google Scholar 

  18. Miller NH. Compliance with treatment regimens in chronic asymptomatic diseases. Am J Med 1997 Feb 17; 102(2A): 43–9

    Article  PubMed  CAS  Google Scholar 

  19. Rossini M, Bianchi G, Di Munno O, et al. Determinants of adherence to osteoporosis treatment in clinical practice. Osteoporos Int 2006; 17(6): 914–21

    Article  PubMed  CAS  Google Scholar 

  20. Barrett-Connor E, Ensrud K, Tosteson AN, et al. Design of the POSSIBLE US™ study: postmenopausal women’s compliance and persistence with osteoporosis medications. Osteoporos Int 2009 Mar; 20(3): 463–72

    Article  PubMed  CAS  Google Scholar 

  21. Stafford RS, Drieling RL, Hersh AL. National trends in osteoporosis visits and osteoporosis treatment, 1988–2003. Arch Intern Med 2004 Jul 26; 164(14): 1525–30

    Article  PubMed  Google Scholar 

  22. Wehren LE. The role of the primary care physician in diagnosis and management of osteoporosis. Int J Fertil Womens Med 2002 May-Jun; 47(3): 116–22

    PubMed  Google Scholar 

  23. Tosteson AN, Do TP, Wade SW, et al. Persistence and switching patterns among women with varied osteoporosis medication histories: 12-month results from POSSIBLE US. Osteoporos Int 2010 Oct; 21(10): 1769–80

    Article  PubMed  CAS  Google Scholar 

  24. Hochberg Y. A sharper Bonferroni procedure for multiple tests of significance. Biometrika 1988 Dec; 75(4): 800–2

    Article  Google Scholar 

  25. Cadarette SM, Katz JN, Brookhart MA, et al. Trends in drug prescribing for osteoporosis after hip fracture, 1995–2004. J Rheumatol 2008 Feb; 35(2): 319–26

    PubMed  Google Scholar 

  26. Lee E, Maneno MK, Wutoh AK, et al. Long-term effect of the Women’s Health Initiative study on antiosteoporosis medication prescribing. J Womens Health (Larchmt) 2010 May; 19(5): 847–54

    Article  Google Scholar 

  27. Weiss TW, Siris ES, Barrett-Connor E, et al. Osteoporosis practice patterns in 2006 among primary care physicians participating in the NORA study. Osteoporos Int 2007 Nov; 18(11): 1473–80

    Article  PubMed  CAS  Google Scholar 

  28. Fletcher SW, Colditz GA. Failure of estrogen plus progestin therapy for prevention. JAMA 2002 Jul 17; 288(3): 366–8

    Article  PubMed  Google Scholar 

  29. Rossouw JE. Effect of postmenopausal hormone therapy on cardiovascular risk. J Hypertens Suppl 2002 May; 20(2): S62–5

    PubMed  CAS  Google Scholar 

  30. Cortet B, Blotman F, Debiais F, et al. Management of osteoporosis and associated quality of life in post menopausal women. BMC Musculoskelet Disord 2011 Jan; 12: 7

    Article  PubMed  Google Scholar 

  31. Tang BM, Eslick GD, Nowson C, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007 Aug 25; 370(9588): 657–66

    Article  PubMed  CAS  Google Scholar 

  32. Cranney A, Horsley T, O’Donnell S, et al. Effectiveness and safety of vitamin D in relation to bone health. Evid Rep Technol Assess (Full Rep) 2007 Aug; (158): 1–235

    Google Scholar 

  33. National Osteoporosis Foundation (NOF). Clinician’s guide to prevention and treatment of osteoporosis. Washington, DC: NOF, 2008

    Google Scholar 

  34. Painter SE, Kleerekoper M, Camacho PM. Secondary osteoporosis: a review of the recent evidence. Endocr Pract 2006 Jul-Aug; 12(4): 436–45

    PubMed  Google Scholar 

  35. Ioannidis G, Papaioannou A, Thabane L, et al. Family physicians’ personal and practice characteristics that are associated with improved utilization of bone mineral density testing and osteoporosis medication prescribing. Popul Health Manag 2009 Jun; 12(3): 131–8

    Article  PubMed  Google Scholar 

  36. Mudano A, Allison J, Hill J, et al. Variations in glucocorticoid induced osteoporosis prevention in a managed care cohort. J Rheumatol 2001 Jun; 28(6): 1298–305

    PubMed  CAS  Google Scholar 

  37. Solomon DH, Katz JN, Jacobs JP, et al. Management of glucocorticoid-induced osteoporosis in patients with rheumatoid arthritis: rates and predictors of care in an academic rheumatology practice. Arthritis Rheum 2002 Dec; 46(12): 3136–42

    Article  PubMed  Google Scholar 

  38. Kothawala P, Badamgarav E, Ryu S, et al. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc 2007 Dec; 82(12): 1493–501

    Article  PubMed  Google Scholar 

  39. Reginster JY, Rabenda V, Neuprez A. Adherence, patient preference and dosing frequency: understanding the relationship. Bone 2006 Apr; 38 (4 Suppl. 1): S2–6

    Article  PubMed  CAS  Google Scholar 

  40. Segal E, Tamir A, Ish-Shalom S. Compliance of osteoporotic patients with different treatment regimens. Isr Med Assoc J 2003 Dec; 5(12): 859–62

    PubMed  Google Scholar 

  41. Siris ES, Harris ST, Rosen CJ, et al. Adherence to bisphosphonate therapy and fracture rates in osteoporotic women: relationship to vertebral and nonvertebral fractures from 2 US claims databases. Mayo Clin Proc 2006 Aug; 81(8): 1013–22

    Article  PubMed  Google Scholar 

  42. Turbi C, Herrero-Beaumont G, Acebes JC, et al. Compliance and satisfaction with raloxifene versus alendronate for the treatment of postmenopausal osteoporosis in clinical practice: an open-label, prospective, nonrandomized, observational study. Clin Ther 2004 Feb; 26(2): 245–56

    Article  PubMed  CAS  Google Scholar 

  43. Payer J, Killinger Z, Sulková I, et al. Preferences of patients receiving bisphosphonates: how to influence the therapeutic adherence. Biomed Pharmacother 2008 Feb; 62(2): 122–4

    Article  PubMed  CAS  Google Scholar 

  44. Burgener M, Arnold M, Katz JN, et al. Older adults’ knowledge and beliefs about osteoporosis: results of semistructured interviews used for the development of educational materials. J Rheumatol 2005 Apr; 32(4): 673–7

    PubMed  Google Scholar 

  45. Pickney CS, Arnason JA. Correlation between patient recall of bone densitometry results and subsequent treatment adherence. Osteoporos Int 2005 Sep; 16(9): 1156–60

    Article  PubMed  Google Scholar 

  46. Ettinger B, Pressman A, Schein J. Clinic visits and hospital admissions for care of acid-related upper gastrointestinal disorders in women using alendronate for osteoporosis. Am J Manag Care 1998 Oct; 4(10): 1377–82

    PubMed  CAS  Google Scholar 

  47. Hamilton B, McCoy K, Taggart H. Tolerability and compliance with risedronate in clinical practice. Osteoporos Int 2003 May; 14(3): 259–62

    PubMed  CAS  Google Scholar 

  48. Kendler D, Kung AW, Fuleihan Gel-H, et al. Patients with osteoporosis prefer once weekly to once daily dosing with alendronate. Maturitas 2004 Jul 15; 48(3): 243–51

    Article  PubMed  CAS  Google Scholar 

  49. Recker RR, Gallagher R, MacCosbe PE. Effect of dosing frequency on bisphosphonate medication adherence in a large longitudinal cohort of women. Mayo Clin Proc 2005 Jul; 80(7): 856–61

    Article  PubMed  Google Scholar 

  50. Simon JA, Lewiecki EM, Smith ME, et al. Patient preference for once-weekly alendronate 70 mg versus once-daily alendronate 10 mg: a multicenter, randomized, open-label, crossover study. Clin Ther 2002 Nov; 24(11): 1871–86

    Article  PubMed  CAS  Google Scholar 

  51. Weiss M, Vered I, Foldes AJ, et al. Treatment preference and tolerability with alendronate once weekly over a 3-month period: an Israeli multi-center study. Aging Clin Exp Res 2005 Apr; 17(2): 143–9

    PubMed  CAS  Google Scholar 

  52. Pressman A, Forsyth B, Ettinger B, et al. Initiation of osteoporosis treatment after bone mineral density testing. Osteoporos Int 2001; 12(5): 337–42

    Article  PubMed  CAS  Google Scholar 

  53. Cole RP, Palushock S, Haboubi A. Osteoporosis management: physicians’ recommendations and womens’ compliance following osteoporosis testing. Women Health 1999; 29(1): 101–15

    Article  PubMed  CAS  Google Scholar 

  54. Rubin SM, Cummings SR. Results of bone densitometry affect women’s decisions about taking measures to prevent fractures. Ann Intern Med 1992 Jun 15; 116 (12 Pt 1): 990–5

    PubMed  CAS  Google Scholar 

Download references

Acknowledgements

POSSIBLE US™ was sponsored by Amgen Inc., Thousand Oaks, CA, USA. As a member of the POSSIBLE US™ Steering Committee, Barbara Lukert has received honoraria from Amgen Inc. Mary Anthony is employed by Amgen Inc. and Guozhi Gao was employed by Amgen Inc. at the time this study was conducted. Sacha Satram-Hoang and Sally Wade are consultants to Amgen Inc. Robert Downs has served on the POSSIBLE US™ Steering Committee, acted as a consultant to and received grants from Amgen Inc.

The authors would like to acknowledge the other members of the POSSIBLE US™ Steering Committee: Elizabeth Barrett-Connor, Ted Ganiats, Marc Hochberg, Robert Recker, Robert Rubin and Anna Tosteson. The authors would also like to acknowledge the REGISTRAT, Inc. staff who assisted the implementation of the POSSIBLE US™ study with funding provided by Amgen Inc. The authors are grateful to Aalok Nadkar and Michael Damiata, whose programming and data analysis assistance was funded by Amgen Inc. Finally, the authors would like to thank Sue Hudson and Yeshi Mikyas, whose services were funded by Amgen Inc., for their editing and assistance with the submission of the manuscript.

Author information

Authors and Affiliations

  1. Division of Endocrinology, Metabolism and Genetics, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA

    Barbara Lukert

  2. Amgen Inc., Thousand Oaks, CA, USA

    Sacha Satram-Hoang, Mary Anthony & Guozhi Gao

  3. Wade Outcomes Research and Consulting, Salt Lake City, UT, USA

    Sally Wade

  4. Division of Endocrinology and Metabolism, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA

    Robert Downs

Authors
  1. Barbara Lukert
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sacha Satram-Hoang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sally Wade
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mary Anthony
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Guozhi Gao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Robert Downs
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Barbara Lukert.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lukert, B., Satram-Hoang, S., Wade, S. et al. Physician Differences in Managing Postmenopausal Osteoporosis. Drugs Aging 28, 713–727 (2011). https://doi.org/10.2165/11595190-000000000-00000

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/11595190-000000000-00000

Keywords

Search

Navigation