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Byline: D. H. Solomon (1), M. T. Connelly (2), C. J. Rosen (3), B. Dawson-Hughes (4), D. P. Kiel (5), S. L. Greenspan (6), E. S. Leib (7), M. Holick (8), A. H. Miguel (9), J. S. Finkelstein (10) Keywords: Bone mineral densitometry Primary care Osteoporosis Abstract: Large population-based surveys have shown that approximately 30% of people over age 65 years have osteoporosis and that 17% of the population over 65 years will sustain a fracture during their lifetime. Many people with osteoporosis are never being evaluated even though effective treatments are available. We examined why primary care physicians order few bone mineral density scans. We conducted a cross-sectional survey of primary care physicians practicing in any of the six New England states. Target physician specialties included internal medicine, general practitioners/family physicians, and obstetrician-gynecologists who had a facsimile number listed with the American Medical Association. Demographics, practice characteristics, use of bone densitometry, and attitudes regarding osteoporosis, bone densitometry and health maintenance were assessed by questionnaire. Twelve percent (n=494) of the physicians responded to the questionnaire. Respondents were similar to non-respondents with respect to years of practice, training and geographical state, though they were more likely to be female (pa$?0.05). Respondents had a mean age of 51 years, and 51% were trained in internal medicine, 25% in general practice/family practice and 24% in obstetrics-gynecology. The mean number of self-reported bone densitometry referrals per month was 10+-11, and 25% of respondents reported that they referred fewer than 4 patients per month. In adjusted logistic models, factors significantly associated with referring fewer than 4 patients per month were: training in internal medicine (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.0--3.9) or general practice/family practice (OR 2.6, 95% CI 1.3--5.2) versus obstetrics-gynecology practicing in an urban setting (OR 2.5, 95% CI 1.3--4.9) or rural/small town setting (OR 2.2, 95% CI 1.2--4.1) versus a suburban setting spending less than 50% of professional time in patient care (OR 4.0, 95% CI 1.7--9.5) seeing the lowest proportion of postmenopausal women (OR 2.5., 95% CI 1.2--5.3) the belief that calcium and vitamin D are adequate to treat osteoporosis (OR 2.1, 95% CI 1.0--4.5) and the belief that osteoporosis treatment should not be based on bone density results (OR 3.2, 95% CI 1.7--6.1). Potentially modifiable physician beliefs and a number of practice characteristics are associated with low referral rates for bone densitometry. Educational strategies aimed at improving the use of bone density testing should consider these factors. Author Affiliation: (1) Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 221 Longwood Avenue, Suite 341, Boston, MA 02115, USA (2) Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, Massachusetts, USA (3) , Maine Osteoporosis Center, Bangor, Maine, USA (4) USDA Nutrition Center, Tufts University, Boston, Massachusetts, USA (5) , Hebrew Rehabilitation Center for Aged Research and Training Institute and Harvard Medical School Division on Aging, Boston, Massachusetts, USA (6) Division of Endocrinology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA (7) Division of Rheumatology, University of Vermont, Vermont, USA (8) Division of Endocrinology, Boston University Medical Center, Boston, Massachusetts, USA (9) , Procter &amp Gamble Pharmaceuticals, USA (10) Endocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA Article History: Received Date: 22/03/2002 Accepted Date: 03/09/2002 Article note: Electronic Publication

Byline: S. L. Greenspan (1), S. Cheng (2), P. D. Miller (3), E. S. Orwoll (5) Keywords: Key words:Bone mineral density -- Calcaneus -- Fracture -- Osteoporosis -- Ultrasound Abstract: The aim of this study was to establish a normative database, assess precision, and evaluate the ability to identify women with low bone mass and to discriminate women with fracture from those without for a highly portable, scanning calcaneal ultrasonometer: the QUS-2. Fourteen hundred and one Caucasian women were recruited for the study. Among them were 794 healthy women 25--84 years of age evenly distributed per 10-year period to establish a normative database. Of these, 171 aged 25--34 years were defined as the young normal group for the purpose of T-score determination. Precision was assessed within 1 day (short-term) and over a 16-week period (long-term) in 79 women aged 25--84 years. Five hundred twenty-eight women ranging from 50 to 84 years of age with or without prevalent fractures of the spine, hip or forearm were measured to compare the QUS-2 with bone mineral density (BMD) of the hip and spine. Mean calcaneal broadband ultrasound attenuation (BUA) was constant in healthy women from 25 to 54 years of age and decreased with increasing age thereafter. Short-term precision, with and without repositioning of the heel, and long-term precision yielded comparable results (BUA SDs of 2.1--2.4 dB/MHz, coefficients of variations (CVs) of 2.5--2.9%). Calcaneal BUA was significantly correlated with BMD of the total hip (TH), femoral neck (FN) and lumbar spine (LS) in 698 women (r= 0.6--0.7, all p&lt 0.0001). A similar relationship was observed for LS BMD compared with either TH or FN BMD (r= 0.7, p&lt 0.0001). Prevalence of osteoporosis in our population (WHO criteria) was 20%, 17%, 21%, and 24% for BUA, BMD of the TH, FN and LS, respectively. Age-adjusted values for a 1 SD reduction in calcaneal BUA and TH and FN BMD predicted prevalent fractures of the spine, forearm, and hip with significant (p&lt 0.05) odds ratios of 2.3, 2.0 and 2.1, respectively. Areas under the receiver operating characteristic curves for age-adjusted bone mass values predicting prevalent fracture were 0.62 for BUA, 0.59 for TH BMD, 0.60 for FN BMD, and 0.57 for LS BMD all statistically equivalent. We conclude that the QUS-2 calcaneal ultrasonometer exhibits reproducible clinical performance that is similar to BMD of the spine and hip in identifying women with low bone mass and discriminating women with fracture from those without. Author Affiliation: (1) Divisions of Endocrinology and Metabolism, and Geriatric Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA, US (2) Department of Health Sciences, University of Jyvaskyla, Jyvaskyla, Finland, FI (3) Department of Medicine, University of Colorado Health Sciences Center, US (4) Colorado Center for Bone Research, Lakewood, CO, USA, US (5) Department of Medicine, Oregon Health Sciences University, Portland, OR, USA, US (6) Portland VA Medical Center, Portland, OR, USA, US Article note: Received: 19 July 2000 / Accepted: 6 December 2000