Screening for Osteoporosis in Men Aged 70 Years and Older in a Primary Care Setting in the United States

478826JMHXXX10.1177/1557988313478826 American Journal of Men s HealthLim et al. Article Screening for Osteoporosis in Men Aged 70 Years and Older in a Primary Care Setting in the United States American Journal of Men s Health 7(4) 350 354 The Author(s) 2013 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: 10.1177/1557988313478826 jmh.sagepub.com Sian Yik Lim, MD 1, Joon Hee Lim, MD 1, Dan Nguyen, BA 1, Rie Okamura, BA 1, Hoda Mojazi Amiri, MD 1, Michael Calmes, MD, MBA 1, and Kenneth Nugent, MD 1 Abstract Osteoporosis in men is an underrecognized and undertreated condition. Despite the National Osteoporosis Foundation recommending osteoporosis screening in men aged 70 years and older since 2008, screening rates in the United States remain undefined. In our study, we analyzed dual-energy X-ray absorptiometry (DXA) screening rates in a primary care setting. Overall, screening rates were low (11.3%). Although there was an increase with age in both the 10-year osteoporotic and 10-year hip fracture probabilities, no association was found between increased age and bone mineral density testing using DXA. Only 23.2% of patients were prescribed bone protective treatments. The performance of DXA screening strongly predicted prescription of bone protective treatment. Increased age raised the likelihood of bone protective treatment prescriptions; however, smokers were less likely to be prescribed these medications. As the population in the United States ages, an increased awareness of this major public health problem is warranted. Keywords osteoporosis, dual-energy X-ray absorptiometry, older men Osteoporosis in men is an underrecognized and undertreated condition. The National Health and Nutrition Examination Survey (2005-2006) data reported that 2% (800,000) of men aged 50 years and older have osteoporosis, and 30% (11.8 million) have osteopenia (Looker, Melton, Harris, Borrud, & Shepherd, 2010). By 2020, the number of patients with osteoporosis will increase to 3.3 million (Lim, Hoeksema, & Sherin, 2009). In 2005, the treatment of osteoporotic fractures cost 17 billion dollars in the United States, with men accounting for 25% of this cost. The cost is expected to increase in the near future as the population in the United States ages (Burge et al., 2007). Osteoporotic fractures in men are associated with higher mortality and morbidity as compared with women (Bliuc et al., 2009). Therefore, osteoporosis in men is a public health problem that requires immediate attention. The National Osteoporosis Foundation (NOF) guidelines published in 2008 recommended osteoporosis screening in men aged 70 years and older (NOF, 2008). Although the U.S. Preventive Services Task Force (2011) concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for osteoporosis in men, screening in men aged 70 years and older is supported by other organizations, such as the American College of Preventive Medicine (Lim et al., 2009), the Endocrine Society (Watts et al., 2012), and the International Society of Clinical Densitometry (Lewiecki et al., 2004). The American College of Physicians recommends that physicians perform individualized assessment of risk factors for osteoporosis in older men periodically, with age 70 years and older being one of the factors that increase the risk of osteoporosis (Qaseem et al., 2008). Since publication of guidelines by the NOF in 2008, the screening rates in men aged 70 years and older in the United States remain undefined. In our study, we analyzed the screening rates for osteoporosis in men aged 70 years and older at a university-based primary care setting in the United States. Materials and Methods We performed a retrospective chart review of patients seen at Texas Tech University Health Sciences Center Internal Medicine Clinic between January 1, 2011, and 1 Texas Tech University Health Sciences Center, Lubbock, TX, USA Corresponding Author: Sian Yik Lim, Texas Tech University Health Sciences Center, Internal Medicine, 3601 4th Street, Lubbock, TX 79430, USA. Email: sian.yik.lim@ttuhsc.edu

Lim et al. 351 January 1, 2012. A registry of male patients aged 70 years and older seen during that period was generated from electronic medical records. These records were screened by researchers for exclusion criteria. We excluded patients who were one time hospital discharge followups, one time preoperative evaluation visits, and patients not seen two or more times over a 3-year period (April 1, 2009, to April 1, 2012). We tried to include only patients who considered our clinic as their primary care provider. Electronic medical records of patients included in the study were reviewed for demographic data, clinical information, dual-energy X-ray absorptiometry (DXA) status, and prescriptions for bone protective treatments (defined as calcium supplements, vitamin D supplements, biphosphonates, teriparatide, calcitonin, and testosterone supplements). Data were collected using standardized data collection forms. The 10-year osteoporotic and hip fracture probabilities of individual patients were calculated using the World Health Organization Fracture Risk Assessment Tool. Analysis of the effect of increasing age on bone mineral density (BMD) testing was performed using chi-square test for trend with patients divided into age groups of 70 to 74, 75 to 79, 80 to 84, 85 to 89, 90 to 94, and 95 to 99 years. Pearson s correlation was used to analyze correlation of age with 10-year osteoporotic and hip fracture probabilities. To analyze the predictors for bone protective treatments, Pearson chi-square tests were used initially to calculate individual odds ratios (ORs) for each predictor. Factors that had a p value of less than.25 were selected to be further analyzed using multivariate logistic regression analysis. This study was approved by institutional review board at Texas Tech University Health Sciences Center. Results Three hundred and forty-one male patients aged 70 years and older were seen in the clinic during the study period; 310 patients were included in the study. Table 1 shows the baseline characteristics in our study population. Thirty-five patients (11.3%, 95% confidence interval [CI] = 7.8-13.8) received osteoporosis screening using DXA scans. Among those screened, BMD testing indicated that 8 patients (22.9%) were osteoporotic, 22 patients (62.9%) had low bone mass, and 5 patients (14.3%) had normal BMD. Table 2 shows the proportion of patients in each age group that received screening for osteoporosis using DXA scans. In the 70 to 74 years age group, 9.9% were screened. The proportion of patients screened with DXA scans decreased in the 75 to 79 years age group (8.2%), but then increased in the 80 to 84 years (16.7%) and 85 to 89 years age groups (18.9%). No patient aged 90 years and older was screened. No significant Table 1. Baseline Characteristics for Study Population. Median age, years (range) 76 (70-98) Race, n (%) Whites 189 (61) Hispanics 73 (23.5) African American 22 (7.1) Asian 2 (0.6) Other 24 (7.7) Mean body mass index, kg/m 2 (range) 27.7 (15-46) Marital status, n (%) Married 197 (63.5) Single/divorced/separated/other 113 (36.5) Number of comorbid conditions, n (%) 0 to 3 37 (11.9) 4 to 5 76 (24.5) 6 or more than 6 197 (63.5) Number of medications taken, n (%) 0 to 3 20 (7) 4 to 6 42 (14) 7 or more than 7 248 (80) Other comorbid conditions, n (%) Smoker 31 (10) Rheumatoid arthritis 7 (2.3) History of fracture 20 (6.5) Prolonged glucocorticoid use 9 (2.9) association was found between increasing age and BMD testing (p =.299). Results from the assessment of baseline 10-year osteoporotic fracture and 10-year hip fracture risk in our study population are shown in Table 3. The medians of the 10-year osteoporotic and hip fracture probabilities in the 70 to 74 years age group were 5.6% (range = 2.0% to 14.0%) and 1.4% (range = 0.2% to 5.3%). The medians of the 10-year osteoporotic and hip fracture probabilities peaked in the 90 to 94 years age group at 9.4% (range = 5.7% to 10.0%) and 6.1% (range = 3.0% to 7.9%), respectively. Age was positively correlated with the 10-year hip fracture probability (r =.68, p <.0001) and the 10-year osteoporotic fracture probability (r =.53, p <.0001). Seventy-two patients were prescribed bone protective treatments. This represented 23.2% of the study population. Most patients were taking calcium (14.2%) and vitamin D supplements (21.0%); 3% of the patients were taking biphosphonates. The OR for age was 1.09 (95% CI = 1.05-1.15) for each 1-year increase in age, and analysis of individual risk factors is shown in Table 4. Binary logistic regression demonstrated that BMD screening with DXA for osteoporosis was a strong predictor of receiving bone protective treatment (OR = 6.2; 95% CI = 2.8-13.6). Other predictors for bone protective treatment include increasing age, but smokers were less likely to receive prescriptions of bone protective treatments (Table 5).

352 American Journal of Men s Health 7(4) Table 2. Patients Screened for Osteoporosis Using DXA. Age group 70-74 75-79 80-84 85-89 90-94 95-99 Number of patients 131 85 48 37 7 2 Number of patients screened 13 7 8 7 0 0 Percentage of patients screened 9.9 8.2 16.7 18.9 0 0 95% confidence interval 4.8-15.0 2.4-13.0 6.2-27.3 6.3-31.5 0 0 Note. DXA = dual-energy X-ray absorptiometry. Table 3. Baseline Risk in Study Population Based on Calculation of the World Health Organization Fracture Risk Assessment Tool Score. Age group Discussion Median 10-year osteoporotic fracture risk (range) Median 10-year hip fracture risk (range) 70-74 5.6 (2.0-14.0) 1.4 (0.2-5.3) 75-79 6.9 (2.7-17.9) 2.5 (0.7-11.0) 80-84 8.9 (4.0-18.0) 4.3 (0.8-12.0) 85-89 9.1 (3.5-17.0) 5.0 (1.6-11.0) 90-94 9.4 (5.7-10.0) 6.1 (3.0-7.9) 95-99 8.5 (6.9-10.0) 6.1 (4.0-8.1) Osteoporosis in men is an underrecognized and undertreated condition. Although well recognized in women, there is a lack of awareness among medical professionals and the public that osteoporosis also affects older men (Rao, Budhwar, & Ashfaque, 2010). Several studies have shown that osteoporosis screening rates in older men are low. A study in Canada showed that screening rates for osteoporosis in older men was 19.1% (Cheng & Green, 2008). Osteoporosis in men is undertreated as compared with women (Beaupre, Majumdar, Dieleman, Au, & Morrish, 2012; Shibli-Rahhal, Vaughan-Sarrazin, Richardson, & Cram, 2011). However, since the publication of the NOF guidelines in 2008 recommending DXA screening in men aged 70 years and older, there are little data regarding screening rates of older men in the United States. In our study, screening rates for osteoporosis using DXA scans in men aged 70 years and older were low at 11.3%. The screening rates at our center are comparable with the rates in Canada (Cheng & Green, 2008) and with a recent study performed in the United States (Alswat & Adler, 2012) in which screening rates in men were 19.1% and 18.4%, respectively. Only 23.2% of patients aged 70 years and older were prescribed bone protective treatments in our study. Our study reinforces the fact that osteoporosis in men remains underrecognized and undertreated. In our study population, the baseline 10-year osteoporotic fracture and hip fracture risk increased with age. This is expected since both men and women have an exponential rise in fracture incidence as they age, although in men the increase occurs 10 years later than in women (van Staa, Dennison, Leufkens, & Cooper, 2001). Although there was a general trend that showed an increase in the proportion of patients screened from the 70 to 74 years age group to the 85 to 89 years age group, this trend was not statistically significant. No patient aged 90 years and older was screened. The fact that there was no association between increasing age and screening rates could be attributed to the small sample size in our study, and larger studies are needed to clarify this. In extremes of age, individualized decisions by physicians taking into account the patient s life expectancy and personal values may be more useful than age-based screening recommendations to avoid unnecessary DXA scans in older men. The performance of DXA scans was a strong predictor for prescription of bone protective treatments. Increasing age was also associated with increased bone protective treatment rates, but smokers were less likely to be prescribed bone protective treatment in our study. The observation that smokers are less likely to receive preventive health care has been demonstrated in several studies on the utilization of cancer screening services (Lagerlund, Sparen, Thurfjell, Ekbom, & Lambe, 2000). Our study suggests that this may occur in noncancer prevention efforts also, and smokers may represent an important target group for improvement of preventive health care programs. Several barriers are noted in osteoporosis screening in men aged 70 years and older in the United States. Because osteoporosis has been traditionally considered a women s health issue, awareness of its importance among the public and physicians remains low (Adler, 2006). Furthermore, Medicare coverage in the United States regarding DXA scans in men is limited to patients on prolonged glucocorticoids, patients with hyperparathyroidism or osteoporosis, and those with vertebral abnormalities on X-ray (Centers for Medicare & Medicaid Services, 2012). Although there are studies

Lim et al. 353 Table 4. Unadjusted Odds Ratio of Factors Affecting Bone Protective Prescription. Factor OR (95% CI) p Non-Caucasian 1.0 Caucasian 1.3 (0.7-2.2).393 Age 1.09 (1.05-1.15) Glucocorticoid use 0.4 (0.1-3.3).398 Rheumatoid arthritis 0.5 (0.1-4.6).558 History of fracture 2.9 (1.2-7.4).022 Antiandrogen use 3.3 (0.2-54.0).396 Smoker 0.1 (0.01-0.7).023 Osteoporosis screening with DXA 6.6 (3.1-13.8) <.0001 COPD 0.9 (0.4-2.2).880 CKD stage 4-5 2.3 (0.6-8.3).213 GERD 0.7 (0.4-1.3).223 Dysphagia 2.0 (0.5-8.6).342 Alcohol consumption, less than two drinks per day 1.3 (0.3-4.8).745 Note. OR = odds ratio; CI = confidence interval; DXA = dual-energy X-ray absorptiometry; COPD = chronic obstructive pulmonary disease; CKD = chronic kidney disease; GERD = gastroesophageal reflux disease. Factors with p value less than.25 were selected and analyzed using multivariate logistic regression analysis. Table 5. Logistic Regression-Predictors of Bone Protective Treatment Prescriptions. Factors OR (95% CI) Osteoporosis screening with DXA 6.1 (2.8-13.4) Increasing age 1.08 (1.03-1.13) Smokers 0.08 (0.009-0.7) History of fracture 2.5 (1.0-8.7) GERD 0.5 (0.4-1.5) CKD stage 4-5 4.0 (0.9-17.8) Note. OR = odds ratio; CI = confidence interval; DXA = dual-energy X-ray absorptiometry; GERD = gastroesophageal reflux disease; CKD = chronic kidney disease. noting the cost effectiveness of screening in older men (Schousboe et al., 2007), data in men need confirmation, clarity, and validity to convince payers, including Medicare, that at some determined age screening of men has to be funded if effective treatment is to be offered. Our study has several limitations. This study was performed at a single academic center. Therefore, practice patterns may not be generalizable to other practice settings. Our study had a relatively small sample size, which may have limited the power to detect the association between increased age and screening rates. Also, small sample size could have decreased the robustness of inferences from logistic regression analysis in our study. Another limitation is that data collection was only performed retrospectively via electric medical records at our institution. Therefore, important information, such as DXA performed at outside institutions and over-the-counter use of calcium and vitamin D supplements, may have been missed. Conclusions Osteoporosis screening rates and bone protective treatments prescriptions remain low in men aged 70 years and older. Osteoporosis in men remains underrecognized and undertreated. More research is needed to address specific issues in men, such as the cost-effectiveness of osteoporosis screening and treating older men. Increased awareness about this public health problem among the public and primary care physicians is important to protect musculoskeletal health in men in the United States as the population ages. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References Adler, R. A. (2006). The need for increasing awareness of osteoporosis in men. Clinical Cornerstone, 8(Suppl. 3), S7-S13. Alswat, K., & Adler, S. M. (2012). Gender differences in osteoporosis screening: Retrospective analysis. Archives of Osteoporosis. Advance online publication. doi:10.1007/ s11657-012-0113-0 Beaupre, L. A., Majumdar, S. R., Dieleman, S., Au, A., & Morrish, D. W. (2012). Diagnosis and treatment of osteoporosis before and after admission to long-term care institutions. Osteoporosis International, 23, 573-580. doi:10.1007/ s00198-011-1582-5

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