Clinical studies
Adherence with osteoporosis practice guidelines: A multilevel analysis of patient, physician, and practice setting characteristics

https://doi.org/10.1016/j.amjmed.2004.06.040Get rights and content

Purpose

The diagnosis and treatment of patients at risk of fragility fractures is uncommon. We examined the patient, physician, and practice characteristics associated with adherence to local osteoporosis guidelines.

Methods

Data were obtained from electronic medical records from one academic medical center. Local guidelines suggest screening and consideration of treatment for at-risk patients, including women aged ≥65 years, women aged 50 to 64 years who smoke cigarettes, persons who used more than 5 mg of oral prednisone for >3 months, and those with a history of a fracture after age 45 years. Clinical notes, medication lists, and radiology records were reviewed to determine whether patients had undergone bone mineral density testing or received any medications for osteoporosis. Possible correlates of guideline adherence, including patient, physician, and practice site characteristics, were assessed in mixed multivariable models.

Results

We identified 6311 at-risk patients seen by 160 doctors at 10 primary care sites during 2001 to 2002. Of these patients, 45% (n = 2820) had a prior bone mineral density test and 30% (n = 1922) had received a medication for osteoporosis; 54% (n = 3401) had one or the other. After adjusting for patient case mix, 17% to 71% of patients had been managed according to local guidelines and had undergone at least bone mineral density testing or received a medication. Patient variables that significantly lowered the probability of guideline adherence included age >74 years (odds ratio [OR] = 0.49; 95% confidence interval [CI]: 0.43 to 0.55), age <55 years (OR = 0.34; 95% CI: 0.28 to 0.42), male sex (OR = 0.17; 95% CI: 0.12 to 0.23), black race (OR = 0.40; 95% CI: 0.34 to 0.47), and having more than one comorbid condition (OR = 0.79; 95% CI: 0.69 to 0.89). Patients seen by male physicians were less likely to have care that was adherent with guidelines (OR = 0.70; 95% CI: 0.55 to 0.89).

Conclusion

Rates of adherence with local osteoporosis guidelines for patients at risk of fragility fractures vary by patient, physician, and practice site characteristic.

Section snippets

Study samples

This study included all 10 primary care practices affiliated with one large academic medical center; half are hospital based and the others are community based. Each practice is linked through a centralized electronic medical record, and each physician is affiliated with one of the 10 practices. All physicians are trained in internal medicine; some have additional subspecialty training but practice as primary care physicians. Residents in internal medicine at several different sites were

Results

A total of 6311 patients met one of the four inclusion criteria; some met more than one criterion (Table 1). The mean (± SD) age of patients was 69 ± 13 years. Most patients were female and there was a wide racial distribution. The average number of comorbid conditions was one, and 60% of patients were taking at least one medicine. There were some differences among the patients meeting different at-risk criterion; subjects in the oral glucocorticoid user group were the youngest and those in the

Discussion

We examined the associations between patient, physician, and practice site characteristics and adherence to local osteoporosis guidelines in a large group of patients at risk of osteoporosis who were seen by primary care doctors affiliated with one academic medical center. Several patient characteristics were associated with undergoing bone mineral density testing or receiving a medication for osteoporosis (or both), and included age, sex, race, and comorbid conditions. Physician sex was also a

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Supported in part by grant HS11046 from the Agency for Healthcare Research and Quality. Dr. Solomon is also supported by grants AR48616 and AR48264 from the National Institutes of Health, and by the Arthritis Foundation.

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