Re: Fragility fracture and osteoporosis investigation

The authors of the paper “Fragility fracture and osteoporosis investigation” suggest family physicians in British Columbia are undertreating osteoporosis.[1] They conclude as a possible solution, “Patients with fractures might be referred for densitometry on admission to the emergency department and might also be offered information on supplements (calcium and vitamin D) and exercise for bone health.”

According to the MSP/BCMA clinical practice guidelines and patient information pamphlet, “Approximately 66% of BC women over 40 would be considered to have osteoporosis or osteopenia when their bone density results are compared to those of young adults.” The clinical practice guidelines state, “Patients with low trauma fractures may be assumed to have severe osteoporosis if other pathology has been ruled out and should be treated accordingly. Bone density measurement is not required to confirm osteoporosis in such cases, but may be useful as a baseline agent on which to measure the treatment.”

As family physicians, we are faced with a bewildering number of sometimes contradictory clinical practice guidelines. A recent statement of the Canadian Task Force on Preventive Health Care published in the Canadian Medical Association Journal suggests that all women 65 years or older should undergo repeat DEXA every 1 to 2 years regardless of the results of the initial DEXA (even if the result is normal).[2] This is in agreement with the US Preventive Services Task Force and the Osteoporosis Society of Canada.

All family physicians in British Columbia recently received a large binder containing the “Guidelines and Protocols for the Province of British Columbia” for many medical conditions. From my understanding of the literature, the BC Government recommendations regarding bone density testing[3] seem the most logical. Yet the authors of the above paper, likely unintentionally, are implying that those of us who follow the BC Guidelines are providing inadequate care.

Since we should all be recommending exercise and calcium for our older patients anyway, surely precious health care dollars would be better spent on other needs within the health care system.

—John Sehmer, MD
Vancouver

References

1. Ashe MC, Kahn KM, Guy P, et al. Fragility fracture and osteoporosis investigation. BCMJ 2004;46:506-509. Full Text 
2. Prevention of osteoporosis and osteoporotic fractures in postmenopausal women: recommendation statement from the Canadian Task Force of Preventive Health Care. CMAJ 2004;170:1665-1667. PubMed Citation Full Text 
3. Guidelines and Protocols Advisory Committee: Guidelines and Protocols for the province of British Columbia. www.healthservices.gov.bc.ca/msp/proto guides/index.html (accessed 10 January 2005).