Osteoporosis and the Primary Care Physician: Time To Bone Up

The magnitude of the community health problem posed by osteoporosis has been amply documented in the medical literature and the lay press. If one believes the numbers—and there is scant reason not to-it is clear that responsibility for the diagnosis, evaluation, and management of osteoporosis must quickly shift from the specialist to the primary care physician. More than 8 million persons in the United States are currently affected by osteoporotic fractures [1], and an otherwise healthy 50-year-old white woman has a 50% cumulative lifetime risk for sustaining at least one such fracture [2]. As with all diseases that are so prevalent, greater emphasis must be placed on prevention than on intervention after the fact. The challenge has been to provide the primary care physician with appropriate diagnostic tools and meaningful preventive and therapeutic options.

The most important determinant of fracture risk is bone mineral density. Fracture risk approximately doubles for each standard deviation by which this density is less than peak adult bone mass at age 30 to 35 years [3]. Accurate, precise, noninvasive methods for measuring bone mass have been available for almost three decades. Yet, osteoporosis is still most often diagnosed only after the first fragility fracture has occurred. Most authorities regard dual-energy x-ray absorptiometry as the “gold standard” for bone mass measurement. There are fewer than 1500 dual-energy x-ray absorptiometry instruments in the United States, and many of them are clustered in major academic centers. Even at full capacity, each instrument can accommodate no more than 10 to 15 persons per day. As a relatively expensive ($75 000 to $100 000) single-use instrument with …