American Journal of Epidemiology
Copyright © 2004 by the Johns Hopkins Bloomberg School of Public Health
All rights reserved
Vol. 160, No. 5
Printed in U.S.A.
DOI: 10.1093/aje/kwh245
Factors Associated with Treatment Initiation after Osteoporosis Screening
Renee M. Brennan1, Jean Wactawski-Wende1,2, Carlos J. Crespo1, and Jacek Dmochowski3
1
Department of Social and Preventive Medicine, University at Buffalo, Buffalo, NY.
Department of Gynecology/Obstetrics, University at Buffalo, Buffalo, NY.
3 Department of Mathematics, University of North Carolina at Charlotte, Charlotte, NC.
2
Received for publication December 9, 2003; accepted for publication March 24, 2004.
The prevalence of osteoporosis and factors associated with treatment initiation after detection of osteoporosis
were determined for previously unscreened, postmenopausal women. Dual-energy x-ray absorptiometry
screening was conducted in 1997–2000 as part of an ancillary study of the Buffalo, New York, center of the
Women’s Health Initiative Observational Study. A total of 945 women were previously unaware of their bone
density, although, for 344 (36.4%), osteoporosis was newly detected through screening (T-score ≤ –2.5). Of those
women, 250 (72.7%) discussed the results with a health care provider, and 140 (56.0%) initiated treatment after
doing so. In multivariate logistic regression analyses, factors associated with treatment initiation were T-score
(odds ratio (OR) = 0.39 per unit increase, 95% confidence interval (CI): 0.23, 0.67), routine medical care more
often than yearly (OR = 2.08, 95% CI: 1.12, 3.86), college education (OR = 2.58, 95% CI: 1.25, 5.31), family
income of ≥$50,000 (OR = 2.06, 95% CI: 1.03, 4.14), and discussing screening results with a gynecologist
(OR = 3.20, 95% CI: 1.33, 7.67). These findings suggest that many postmenopausal women are unaware of their
bone density and could benefit from screening. In this study, approximately half of the women with osteoporosis
initiated treatment after screening. Disease severity, medical care frequency, education, income, and physician
type predicted treatment initiation.
bone density; densitometry; diagnosis; drug therapy; mass screening; osteoporosis, postmenopause; risk
factors
Abbreviations: CI, confidence interval; DXA, dual-energy x-ray absorptiometry; OR, odds ratio.
Osteoporosis is characterized by low bone mass and is a
progressive, systemic disease that leads to an increase in
bone fragility and susceptibility to fracture (1). Osteoporosis
is a major public health threat in the United States; approximately 44 million persons aged 50 years or older, including
30 million women, are affected by the disease (2). The
number of persons at risk is increasing as the population
ages. While the current economic impact is substantial,
management of the disease will require increasing resources
in the near future.
Detection of osteoporosis is possible at treatable stages of
the disease, and early detection and treatment have been
shown to decrease associated morbidity and mortality (3).
Dual-energy x-ray absorptiometry (DXA) is currently
considered the “gold standard” for measuring bone mineral
density and predicting fracture risk (4). Fracture risk is also
affected by other factors, such as poor bone quality and a
propensity to fall, but bone density is the single best
predictor of fracture risk. The US Food and Drug Administration has approved several treatments for the prevention
and/or treatment of osteoporosis, including bisphosphonates
(alendronate and risedronate), calcitonin, hormone therapy
(estrogen alone or in combination with progestin), raloxifene, and teriparatide (5).
Inadequate diagnosis and treatment of osteoporosis are a
problem (6, 7). Previous studies have shown that providers
recommend and women accept drug treatment more often
when screening results show an increased risk of fracture (8–
12). These studies have focused on the outcomes of a
screening test ordered by a physician. Some degree of awareness of the disease and potential interest in treatment are
implied when a physician orders a test. The factors associ-
Correspondence to Renee M. Brennan, 65 Farber Hall, University at Buffalo, 3435 Main Street, Buffalo, NY 14214 (e-mail:
[email protected]).
475
Am J Epidemiol 2004;160:475–483
476 Brennan et al.
ated with treatment following screening in an at-risk population not specifically referred by a physician have not been
well documented.
This study’s objectives were to determine the prevalence
of osteoporosis in a previously unscreened group of postmenopausal women and, for women newly determined to
have osteoporosis at screening, to assess factors associated
with drug treatment initiation.
MATERIALS AND METHODS
The study population comprised participants enrolled in
the cross-sectional study, Risk Factors for Osteoporosis and
Oral Bone Loss in Postmenopausal Women, conducted from
1997 to 2000 as an ancillary study of the Buffalo, New York,
center of the Women’s Health Initiative Observational
Study. The Women’s Health Initiative is an ongoing clinical
trial and observational prevention study of postmenopausal
women, which is funded by the National Institutes of Health
(13). This ancillary study was designed to assess the relation
between bone density and periodontal disease. Inclusion
criteria were observational study participation and at least
six teeth in the mouth. Exclusion factors were known bone
disease (other than osteoporosis), known aortic calcification,
steroid dependency (use of steroids throughout the past 6
months or longer), and active cancer or cancer chemotherapy.
Participants completed several questionnaires that
included items on known risk factors for osteoporosis and
periodontal disease. Bone densities of the spine, hip,
forearm, and total body were measured by DXA (Hologic
QDR-4500A; Hologic, Inc., Waltham, Massachusetts), and
an oral health examination was completed. Participants were
mailed a copy of their DXA results with a summary cover
sheet, which included the World Health Organization definitions and values of T-scores for four measured sites (anteroposterior spine, lateral spine, femoral neck, and total
forearm).
The impact of this DXA screening on study participants
was assessed by using a follow-up questionnaire. Participants were asked whether they discussed the DXA results
with their health care provider, whether their provider
recommended various treatments, whether they initiated any
treatment, whether they were complying with treatment, and
whether they personally decided to make any changes not
recommended by their provider. Participants were mailed
the questionnaires at least 1 year after they participated in the
study (DXA screening) to allow ample time to discuss their
DXA findings with their health care provider. A postagepaid envelope was included to return the completed questionnaires. Questionnaires not returned from the initial
mailing were followed up with a second mailing, postcard
reminders, and telephone follow-up.
This study was approved by the Health Sciences Internal
Review Board of the University at Buffalo. Informed
consent was obtained for both the Women’s Health Initiative
study and the Osteoporosis and Oral Bone Loss Study.
Data collected from the follow-up questionnaire were
combined with existing data from participants’ records of the
Women’s Health Initiative Observational Study and the
Osteoporosis and Oral Bone Loss Study to form the analyt-
ical data set. Since this study aimed to assess the impact of
osteoporosis screening in a group of postmenopausal women
unaware of their bone density status, participants who
reported a previous diagnosis of osteoporosis, previous bone
density testing, or ever taking a bone drug other than
hormone therapy were excluded from the analyses. Descriptive statistics were computed for demographics and other
variables and for outcomes of screening and discussion of
results with a health care provider.
Univariate logistic regression models were developed to
establish factors associated with drug treatment initiation
that were further analyzed in multivariate models. Factors
assessed included age (years), T-score (lowest of the femoral
neck, lateral spine, anteroposterior spine, and total forearm
T-scores), body mass index (kilograms per meter squared),
race (American Indian/Alaskan Native, Asian/Pacific
Islander, Black/African American, Hispanic/Latino, or
White), hormone therapy use (never, former, or current),
frequency of routine medical care (yearly or less or more
often than yearly), fracture history after 40 years of age (yes
or no), family history of fracture (yes or no), smoking (ever
or never), education (high school or less, college attendance/
graduation, or graduate school attendance/graduation),
current employment (yes or no), income (<$50,000 or
≥$50,000), visit date with health care provider (1997–1998
or after 1998), gender of provider (male or female), length of
relationship with provider (years), and specialty of provider
(gynecologist or other). The “other” category for specialty of
provider included mainly primary care physicians and internists but also a small number of nurse practitioners, physician’s assistants, rheumatologists, endocrinologists, and
orthopedists. The multivariate logistic regression modeling
attempted to use all factors associated (p < 0.10) with the
outcome in univariate models. Stepwise logistic regression,
with entry criteria of p < 0.10 and removal criteria of p >
0.05, was used to establish the final multivariate predictive
model. The Statistical Package for the Social Sciences
(SPSS), version 10.0 for Windows (SPSS, Inc., Chicago, Illinois), was utilized for all analyses.
RESULTS
Of the 1,952 participants in the Women’s Health Initiative
Observational Study eligible for the Osteoporosis and Oral
Bone Loss Study, 1,468 (75.2 percent) agreed to take part.
The remainder were either unable to be contacted (n = 111;
5.7 percent) or uninterested (n = 373; 19.1 percent). The
response rate for the Osteoporosis and Oral Bone Loss Study
follow-up questionnaire was 95.4 percent (n = 1,400). Of the
respondents, 945 reported never being screened or diagnosed
with osteoporosis or taking a bone drug other than hormone
therapy prior to participation in this study. Baseline characteristics of these 945 participants are presented in table 1.
Results of the DXA screening showed that 344 (36.4
percent) women previously unaware of their bone density
status were newly determined to have osteoporosis
according to World Health Organization criteria. A total of
250 (72.7 percent) of these participants reported discussing
results with a health care provider, and 140 (56.0 percent) of
those initiated drug treatment (figure 1).
Am J Epidemiol 2004;160:475–483
Treatment Initiation after Osteoporosis Screening 477
TABLE 1. Baseline characteristics of newly screened postmenopausal women previously unaware of
their bone density status (n = 945),* Buffalo, New York, 1997–2000
No. or mean (SD†)
Age (years)
72.2 (7.5)
DXA T-score value‡
–2.1 (1.2)
Body mass index (kg/m2)
27.0 (5.1)
%
Race
American Indian/Alaskan Native
4
0.4
Asian/Pacific Islander
3
0.3
Black/African American
11
1.2
Hispanic/Latino
4
White
922
97.7
Never
326
34.5
Former
188
19.9
Current
431
45.6
Routine medical care (more often than yearly)
635
67.2
Fracture history after 40 years of age (yes)
288
30.5
Family history of fracture (yes)
347
37.2
Smoking (ever)
429
45.4
High school or less
219
23.6
College attendance/graduation
407
43.9
Graduate school attendance/graduation
302
32.5
Employment status (employed)
272
29.7
Income (≥$50,000)
320
35.8
Medical insurance (yes)
904
98.9
0.4
Hormone therapy use
Education
* Race, n = 944; fracture history after 40 years of age, n = 943; family history of fracture, n = 934; education, n = 928;
employment status, n = 915; income, n = 894; medical insurance, n = 914.
† SD, standard deviation.
‡ Lowest T-score for the four sites measured by dual-energy x-ray absorptiometry (DXA): femoral neck, lateral
spine, anteroposterior spine, and total forearm.
Table 2 presents baseline characteristics of the 250
osteoporotic women (T-score ≤ –2.5) who discussed their
DXA results with their provider. Mean age was 75.5 (standard deviation, 6.6) years, and mean T-score was –3.3 (standard deviation, 0.6). Ninety-eight percent were White, and
25.6 percent were currently using hormone therapy. Most
reported college or graduate school education, having
medical insurance, and receiving routine medical care at
least yearly.
Univariate logistic regression results are presented in table
3. Women who initiated treatment were more likely to have
a lower T-score (odds ratio (OR) per unit increase = 0.42, 95
percent confidence interval (CI): 0.26, 0.68), routine medical
care more often than yearly (OR = 2.01, 95 percent CI: 1.16,
3.50) compared with yearly or less, a college (OR = 1.79, 95
percent CI: 0.96, 3.35) or graduate school (OR = 2.16, 95
percent CI: 1.08, 4.33) education compared with a high
school education or less, a total family income of $50,000 or
more (OR = 1.80, 95 percent CI: 0.98, 3.33), and discussion
Am J Epidemiol 2004;160:475–483
of screening results with a gynecologist (OR = 2.85, 95
percent CI: 1.28, 6.30).
In multivariate logistic regression analysis (table 4),
factors independently associated with treatment initiation
were lower T-score (OR per unit increase = 0.39, 95 percent
CI: 0.23, 0.67), routine medical care more often than yearly
(OR = 2.08, 95 percent CI: 1.12, 3.86) compared with yearly
or less, a college education (OR = 2.58, 95 percent CI: 1.25,
5.31) compared with a high school education or less, a total
family income of $50,000 or more (OR = 2.06, 95 percent
CI: 1.03, 4.14), and discussion of screening results with a
gynecologist (OR = 3.20, 95 percent CI: 1.33, 7.67).
Because women who were currently receiving hormone
therapy could be considered already being treated for
osteoporosis, we repeated the analysis, including only those
women not using hormone therapy at screening (n = 258).
We found that results did not change appreciably. A total of
186 (72.1 percent) women discussed the results with their
health care provider, and 103 (55.4 percent) of those women
initiated treatment. Women not on hormone therapy who
478 Brennan et al.
remained appreciably unchanged. Because of a reduced
sample size in some instances, confidence intervals widened
and resulted in fewer factors reaching statistical significance
(data not presented).
Similarly, because some providers may have been aware
of the National Osteoporosis Foundation guidelines for treatment of osteoporosis, the logistic regression analyses were
repeated by restricting them to participants who had a Tscore of –2.0 or less. According to National Osteoporosis
Foundation guidelines, these participants should be considered for treatment (15). A total of 500 (52.9 percent) participants had T-scores of –2.0 or less, and 357 (71.4 percent) of
those women discussed the results with their provider. The
logistic regression findings for treatment initiation again did
not differ appreciably (data not presented). Finally, the analysis was repeated by restricting it to Caucasian participants
only, and our findings did not change (data not presented).
DISCUSSION
FIGURE 1. Selection of study participants and outcomes of
osteoporosis screening, Buffalo, New York, 1997–2000.
initiated treatment were significantly more likely to have a
lower T-score (OR per unit increase = 0.42, 95 percent CI:
0.23, 0.76) and routine medical care more often than yearly
(OR = 2.22, 95 percent CI: 1.08, 4.53) compared with yearly
or less (table 5). Although not statistically significant, point
estimates for higher education, greater income, and gynecologist specialty did not differ appreciably from those
presented in table 4.
For the variable DXA T-score, the lowest value for the
femoral neck, lateral spine, anteroposterior spine, and total
forearm was used. These specific T-score values were
reported on a summary cover sheet provided to each participant. Women were given a copy of the entire DXA report for
each region measured. As such, each woman and her physician had T-score values for each of the sites measured as part
of this research study. In a typical clinical setting, lateral
spine values are not measured and reported. In fact, the International Society for Clinical Densitometry does not recommend using the lateral spine to diagnose osteoporosis (14).
However, since the lateral values were reported, they were
included in the analysis. To determine the impact of lateral
values on the findings, we repeated the analysis without
using lateral spine T-scores in our definition of osteoporosis.
Restricting the analysis to the femoral neck, anteroposterior
spine, and total forearm resulted in 14 percent fewer participants being defined as having osteoporosis. Regardless, the
point estimates (odds ratios) in logistic regression analysis
Only one third of study questionnaire respondents had
ever been screened for or were determined as being
osteoporotic prior to having DXA as part of participation in
this research study, but 91 percent of the same group met
National Osteoporosis Foundation guidelines for screening
(at risk for osteoporosis). The Foundation recommends that
all women under the age of 65 years who have one or more
additional risk factors for osteoporosis (in addition to being
postmenopausal and female) and all women aged 65 years or
older, regardless of additional risk factors, should have an
osteoporosis screening test (15). Furthermore, for over one
third of our study participants who reported never being
screened previously, their bone density values met World
Health Organization criteria for a diagnosis of osteoporosis
(T-score ≤ –2.5). Although participants were volunteers
from two epidemiologic studies, the prevalence of
osteoporosis was similar to that in the Third National Health
and Nutrition Examination Survey, a nationally representative sample of the US population (16). Extrapolating our
study finding to estimate US population figures, we calculate
that 22 million Caucasian women in this age group who meet
National Osteoporosis Foundation screening guidelines may
be unscreened for osteoporosis and that about 8 million of
these women would have undiagnosed disease according to
World Health Organization criteria. These calculations are
based on a US population estimate of approximately 33
million Caucasian women in the same age range (52–90
years) as that in our study (17). These figures represent
conservative population estimates and should be interpreted
with caution since our study sample was not a representative,
population-based sample. Nevertheless, our results do
suggest that a large percentage of women at risk for fracture
are currently unaware of their status because of the absence
of screening for this condition.
Of those women determined at screening to be
osteoporotic, 27 percent did not discuss their DXA results
with a health care provider. This rate of follow-up is lower
than that determined in a previous study by Rubin and
Cummings (8), which included a very high percentage of
women who received a referral from their physician for
Am J Epidemiol 2004;160:475–483
Treatment Initiation after Osteoporosis Screening 479
TABLE 2. Baseline characteristics of postmenopausal women previously unaware of their bone density status whose T-score ≤ –2.5
at screening and who discussed their results with their health care provider (n = 250),* Buffalo, New York, 1997–2000
Total
(n = 250, 100%)
No. or
mean (SD‡)
%
Initiated treatment
(n = 140, 56.0%)
No. or
mean (SD)
%
Did not initiate treatment
(n = 107, 42.8%)†
No. or
mean (SD)
Age (years)
75.5 (6.6)
75.8 (6.4)
75.4 (6.9)
DXA T-score value§
–3.3(0.6)
–3.4 (0.6)
–3.1 (0.5)
Body mass index (kg/m2)
25.7 (4.2)
25.3 (4.2)
26.1 (4.3)
%
Race
Asian/Pacific Islander
2
0.8
2
1.4
0
0.0
Black/African American†
3
1.2
0
0.0
0
0.0
White
245
98.0
138
98.6
107
100.0
Never
114
45.6
67
47.9
47
43.9
Former
72
28.8
36
25.7
34
31.8
Current
64
25.6
37
26.4
26
24.3
Routine medical care (more often than yearly)
176
70.4
107
76.4
66
61.7
Fracture history after 40 years of age (yes)
99
39.8
62
44.3
36
34.0
Family history of fracture (yes)
95
38.3
53
38.1
41
38.7
Smoking (ever)
117
46.8
65
46.4
49
45.8
High school or less
63
25.2
28
20.1
35
32.7
College attendance/graduation
114
45.6
66
47.5
46
43.0
Graduate school attendance/graduation
72
28.8
45
32.4
26
24.3
Employment status (employed)
47
19.3
23
16.8
24
23.1
Income (≥$50,000)
62
26.5
41
31.1
20
20.0
Medical insurance (yes)
242
99.2
137
100.0
102
98.1
Visit date with provider¶ (after 1998)
172
70.2
92
66.7
79
76.0
Gender of provider (female)
84
33.6
47
33.6
35
32.7
Length of relationship with provider (no. of years)
9.9
(8.8)
9.7
(8.8)
10.3
(8.9)
Specialty of provider (gynecologist)
38
15.2
29
20.7
9
8.4
Hormone therapy use
Education
* Total: fracture history after 40 years of age, n = 249; family history of fracture, n = 248; education, n = 249; employment status, n = 244;
income, n = 234; medical insurance, n = 244; visit date with provider, n = 245; length of relationship with provider, n = 246.
† Data were missing on treatment initiation for Black/African-American participants (n = 3).
‡ SD, standard deviation.
§ Lowest T-score for the four sites measured by dual-energy x-ray absorptiometry (DXA): femoral neck, lateral spine, anteroposterior spine,
and total forearm.
¶ Health care provider/physician.
screening. This difference in follow-up is likely attributable
to the difference in study design; our study involved community-like screening without referral from a physician.
Community-based screening tests are effective only if they
influence clinical decisions, and an important consideration
should be a mechanism to ensure that women discuss
screening results with their provider.
It is an important public health finding that even within
this group of healthy, well-educated, and self-selected
women, a large percentage were previously unaware of their
bone density status and were newly diagnosed with
osteoporosis. Over half of those women determined as
having osteoporosis who consulted their health care provider
Am J Epidemiol 2004;160:475–483
after screening initiated treatment, a notable percentage initiating treatment for a disease that may not have been detected
without the study DXA screening. However, almost half of
the osteoporotic women did not initiate treatment. Decisions
regarding initiation of treatment after diagnosis are multifactorial and may be influenced by risk factors for osteoporosis
and related fracture other than low bone density. Physician
recommendation and patient acceptance of treatment are
also important in decision making and may be influenced by
the perceived effectiveness of osteoporosis drug treatments
or side effects, costs, expected uptake of treatment, or agreement with treatment recommendations.
480 Brennan et al.
TABLE 3. Univariate predictors of drug treatment initiation for postmenopausal women previously
unaware of their bone density status whose T-score ≤ –2.5 at screening and who discussed their results
with their health care provider (n = 247),* Buffalo, New York, 1997–2000
Unadjusted OR†
95% CI†
p value
Age (per year increase)
1.01
0.97, 1.05
0.637
DXA T-score value‡ (per unit increase)
0.42
0.26, 0.68
<0.001
Body mass index (kg/m2) (per unit increase)
0.96
0.90, 1.02
0.148
0.00, 6.4 × 1010
0.705
Race
White
Asian/Pacific Islander
Referent
0.003
Hormone therapy use
Never
Referent
Former
0.74
0.41, 1.35
0.330
Current
1.00
0.53, 1.87
0.996
Routine medical care (more often than yearly)
2.01
1.16, 3.50
0.013
Fracture history after 40 years of age (yes)
1.55
0.92, 2.61
0.102
Family history of fracture (yes)
0.98
0.58, 1.64
0.930
Smoking (ever)
1.03
0.62, 1.70
0.921
Education
High school or less
Referent
College attendance/graduation
1.79
0.96, 3.35
0.066
Graduate school attendance/graduation
2.16
1.08, 4.33
0.029
Employment status (employed)
0.67
0.36, 1.28
0.224
Income (≥$50,000)
1.80
0.98, 3.33
0.060
Visit date with provider§ (after 1998)
0.63
0.36, 1.12
0.117
Gender of provider (female)
1.04
0.61, 1.78
0.887
Length of relationship with provider (per year increase)
0.99
0.96, 1.02
0.584
Specialty of provider (gynecologist)
2.85
1.28, 6.30
0.010
* Fracture history after 40 years of age, n = 246; family history of fracture, n = 245; education, n = 246;
employment status, n = 241; income, n = 232; visit date with provider, n = 242; length of relationship with provider,
n = 243.
† OR, odds ratio; CI, confidence interval.
‡ Lowest T-score for the four sites measured by dual-energy x-ray absorptiometry (DXA): femoral neck, lateral
spine, anteroposterior spine, and total forearm.
§ Health care provider/physician.
A unique attribute of our study is that we evaluated associations between treatment initiation and characteristics (i.e.,
gender and specialty) of health care providers. While no
significant association was found for gender of the provider,
women were over three times as likely to initiate treatment if
they consulted a gynecologist compared with other provider
specialties. This finding suggests that gynecologists may be
more likely to discuss treatment of osteoporosis. Note that
the analysis did not account for treatment recommendations
of providers that were not initiated by the participant, which
may have resulted in underestimation of the response of all
specialties of providers to their patients’ DXA results indicating osteoporosis.
It was an interesting finding that, even within a group of
women whose T-scores were less than –2.5, women whose
scores were lower were more likely to initiate treatment.
This finding is consistent with the literature showing that
lower T-score, in general, is associated with treatment initiation (8–12). It has been estimated that fracture risk approximately doubles with each standard deviation decrement in
bone density compared with optimal mean bone density
(18). Therefore, treatment would be expected to increase
with worsening T-score and increased fracture risk.
Higher level of education and greater income were positively associated with initiation of drug treatment after bone
density screening. More-educated women are perhaps more
likely to initiate discussions with their health care provider
and to have a better understanding of the risks of low bone
density. Higher education and income may also be a proxy
measure for an increased likelihood of having medical insurance, although only 1 percent of participants in this study did
not have medical insurance. No information was available
on prescription coverage. A previous study found no association with education (8); however, that study also included
Am J Epidemiol 2004;160:475–483
Treatment Initiation after Osteoporosis Screening 481
TABLE 4. Multivariate predictors of drug treatment initiation for postmenopausal women previously
unaware of their bone density status whose T-score ≤ –2.5 at screening and who discussed their results
with their health care provider (n = 231), Buffalo, New York, 1997–2000
Adjusted OR*
95% CI†
p value
DXA T-score value‡ (per unit increase)
0.39
0.23, 0.67
0.001
Routine medical care (more than yearly)
2.08
1.12, 3.86
0.020
Education
High school or less
Referent
College attendance/graduation
2.58
1.25, 5.31
0.010
Graduate school attendance/graduation
2.13
0.95, 4.75
0.066
Income (≥$50,000)
2.06
1.03, 4.14
0.041
Specialty of provider§ (gynecologist)
3.20
1.33, 7.67
0.009
* Odds ratio (OR) adjusted for other variables in the multivariate logistic regression model.
† CI, confidence interval.
‡ Lowest T-score for the four sites measured by dual-energy x-ray absorptiometry (DXA): femoral neck, lateral
spine, anteroposterior spine, and total forearm.
§ Health care provider/physician.
an overall highly educated group of women. Our study
sample had more variation in educational level. Women who
reported seeking routine medical care more often than yearly
were twice as likely as women who reported less frequent
medical care to initiate treatment for osteoporosis. These
women are perhaps more health oriented in general and may
have more opportunity to discuss their results with their
health care provider. Women were surveyed at least 1 year
after DXA screening, and the majority reported seeking
routine medical care at least yearly. As such, most participants should have had the opportunity to discuss their results
with their provider at one of their routine visits.
The results showing that higher educational level, greater
income, and more frequent routine medical care are associated with treatment initiation indicate that the same groups
of women who are more likely to utilize the health care
system are more likely to discuss results with a health care
provider and to initiate treatment after osteoporosis
screening. Since screening in a community setting is valuable in reaching at-risk groups who may not otherwise use
the health care system, this finding supports continuing challenges in emphasizing both screening and preventive health
care for older women. However, this study included a group
of women who chose to participate in a health-oriented
research study, which may limit generalizability. Women in
the general population undergoing osteoporosis screening
may be less likely than women in our study to initiate treatment after a diagnosis of osteoporosis.
Although hormone therapy use was not found to predict
treatment initiation, women who were already receiving
TABLE 5. Multivariate predictors of drug treatment initiation for postmenopausal women previously
unaware of their bone density status whose T-score ≤ –2.5 at screening, who discussed their results with
their health care provider, and who were not receiving hormone therapy at screening (n = 174), Buffalo,
New York, 1997–2000
Adjusted OR*
95% CI†
p value
DXA T-score value‡ (per unit increase)
0.42
0.23, 0.76
0.004
Routine medical care (more than yearly)
2.22
1.08, 4.53
0.030
Education
High school or less
Referent
College attendance/graduation
2.08
0.93, 4.68
0.076
Graduate school attendance/graduation
1.77
0.72, 4.37
0.216
Income (≥$50,000)
2.00
0.88, 4.56
0.100
Specialty of provider§ (gynecologist)
2.90
0.98, 8.62
0.055
* Odds ratio (OR) adjusted for other variables in the multivariate logistic regression model.
† CI, confidence interval.
‡ Lowest T-score for the four sites measured by dual-energy x-ray absorptiometry (DXA): femoral neck, lateral
spine, anteroposterior spine, and total forearm.
§ Health care provider/physician.
Am J Epidemiol 2004;160:475–483
482 Brennan et al.
hormone therapy could be considered to be appropriately
treated for osteoporosis, which may have influenced our
findings. However, restricting analyses to women not on
hormone therapy did not appreciably change our findings.
Similarly, race was not found to be a predictor of treatment
initiation, but the number of non-White subjects was
extremely small. Restriction of analyses to only White
subjects did not change our findings. In addition, repeated
analyses excluding lateral spine T-scores when determining
osteoporotic status and changing the definition of
osteoporosis to a T-score of –2.0 or less (National
Osteoporosis Foundation treatment guidelines) did not
change our findings.
This study has a number of strengths, including its similarity to a general population screening. Previous studies
have evaluated screening outcomes for women individually
referred for screening by their physician (8, 9, 11, 12).
Women in our study did not undergo screening because of
their individual risk of osteoporosis or physician referral. A
further strength of this study was our assessment of treatment initiation at a time when several treatment options had
just been approved by the Food and Drug Administration.
Prior to 1996, treatment options for osteoporosis were
limited largely to hormone therapy. Note that data collection
was completed prior to publication of findings of adverse
effects of certain types of hormone therapy in the Women’s
Health Initiative clinical trial (19).
Although all races were included in this study, about 98
percent of participants were Caucasian, limiting the generalizability of this study to Caucasian postmenopausal women.
Another important consideration is that this analysis did not
assess decisions about managing osteoporosis other than
prescription drug treatments. Initiation of nonprescription
therapies (e.g., calcium and vitamin D) and lifestyle changes
(e.g., increased exercise and smoking cessation) were not
assessed here but are important in understanding the full
influence of screening on change. This is an area for future
research.
In conclusion, this study showed that many postmenopausal women at risk of osteoporosis remain undiagnosed
and untreated. Over one third of those screened had previously undiagnosed osteoporosis. Of those women, less than
half subsequently initiated treatment. Women who had lower
T-scores, higher educational levels, and greater income and
who visited their provider more regularly were more likely
to be treated. Additionally, women consulting a gynecologist
were more likely to initiate treatment. More effort is needed
to increase screening of appropriate persons at risk of
osteoporosis and eventual fracture. Additional education on
the importance of treatment for women whose bone density
is low to prevent fractures should be emphasized to both
women and their health care providers. Ultimately, treatment
initiation is based on an individualized decision-making
process between a woman and her health care provider.
Further understanding of the factors that influence decisions
to screen for and treat osteoporosis in appropriate persons
may be useful in developing strategies to reduce fracture in
those at risk.
ACKNOWLEDGMENTS
This work was supported in part by the following grants
and contracts: US Army grants 17-96-1-6319 and 17-02-10252; Office of Research on Women′s Health and National
Heart, Lung, and Blood Institute contract N01WH32122;
National Institute of Dental and Craniofacial Research grant
R01-DE13505; National Cancer Institute grants 1P120CA96256-01A1 and 1R03-CA103475-01; and National
Institute of Environmental Health Sciences grant R01ES11368.
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