Blue Care Network Best Practices
Emphasizing prevention is key to treating osteoporosis
Karen Walker, M.D., M.P.H., of Associates in Gynecology and Obstetrics, in Ypsilanti, is one doctor who believes the Healthcare Effectiveness Data and Information Set® measure on osteoporosis testing needs to be more stringent.
"My area of expertise is post menopausal women and my emphasis is on prevention, and making sure women stay healthy as long as possible."
Dr. Walker, who is also director of the bone density program at IHA, follows the U.S. Preventive Services Task Force guidelines that recommend screening for osteoporosis in women 65 and older and in younger women with risk of fracture. Once a person has sustained a nontraumatic fracture, she has an increased risk of a subsequent fracture at any site. For this reason, patients who have experienced an unexplained fracture should have a bone density test. If they have osteopenia or osteoporosis along with the fracture, treatment is recommended to lower the risk of further fractures, says Dr. Walker.
"By doing bone density tests on menopausal women, I pick up a lot of osteopenia, which means the patient has a lower bone density but not low enough to be categorized as osteoporosis," says Dr. Walker.
If a patient has osteopenia, Dr. Walker prescribes Vitamin D and calcium and also recommends weight-bearing exercise.
"If I tell the patient that she is already showing signs of bone thinning, then I find patients will sit up and take notice," Dr. Walker says. "The whole point of the bone density test is to prevent fractures. There are no symptoms of osteoporosis. That's why a bone density test is so helpful," she says.
To determine which patients need treatment, Dr. Walker uses the FRAX tool and adds in the bone density of the femoral neck. The FRAX tool is used by the World Health Organization to help predict a patient's risk of having a fracture related to osteopenia in the next 10 years.
"I treat anyone who has a greater than 3 percent risk of hip fracture and anyone who has a greater than 20 percent risk of major fracture in the next 10 years," says Dr. Walker. "Women with osteoporosis should also be considered for treatment."
Dr. Walker typically sees patients annually or at least every two years if their bone density and FRAX measures remain stable.
"If a patient's bone density is worsening, but the FRAX indicates it isn't yet time to treat, I tell patients they may eventually require treatment."
In the meantime, she makes sure they are taking calcium and Vitamin D. Dr. Walker also discusses lifestyle factors that increase the risk of osteoporosis. She counsels patients to stop smoking, decrease their alcohol intake, and to increase their weight-bearing exercise.
One of the biggest challenges to treating patients is their fear that certain drugs used to treat osteoporosis can cause fractures.
"Even though there are unusual fractures in the femur in a subgroup of people, when you look at the overall population the fracture risk goes down," Dr. Walker says.
Dr. Walker prescribes biphosphonates to patients with osteoporosis. Addressing some concerns about biphosphonates, Dr. Walker says, "Some patients and doctors worry that patients with a history of gastritis or ulcers can't take these medications." She says these patients can still take the medication unless their heartburn gets worse. The medications can also be given intravenously.
"Biphosphonates are poorly absorbed, so patients need to take the medication on an empty stomach and they do need to stay upright for a period of time so it doesn't increase the acidity in their esophagus," explains Dr. Walker.
Another challenge is the quality of bone density tests and readings, says Dr. Walker. Dr. Walker has special technicians who are trained in the proper placement of patients so the femurs and spine are straight. There are also guidelines on how best to read the results.
"I often redo the bone density screenings after seeing other readings," she says.
Overall, Dr. Walker says the goal is to get primary doctors to think about osteoporosis before a patient has a fracture. "Periodic bone density tests are helpful because they show whether the patient needs to be treated and what is happening with bone loss over time," she says.