So:

If 30 percent of women over 60 years of age have bone density levels meeting the World Health Organization’s criteria for the diagnosis of osteoporosis, and yet only 2 percent of such women are appropriately diagnosed and treated; if greater than 90 percent of patients after a heart attack receive the right medical therapy and only 19-22 percent of women aged 67 with hip fractures and osteoporosis get the correct therapy, why is this so?

Osteoporosis is an asymptomatic disease and can be difficult to diagnose without evidence of a fracture. Even with fracture, some produce only minor symptoms and the patient may not seek medical care for the complaint, and so miss an opportunity for early diagnosis. The best single test is the bone mineral density examination. The test may be costly for the patient, and may not be available in many locales. (It is in Augusta-Waterville.)

Expert groups have been very slow to reach consensus about diagnosis and testing for this disease because of the expense of testing, and of the medications required for treatment, even though resulting fractures account for over 400,000 hospital admissions a year, and 2.5 million physician visits in the U.S., costing $14 billion per year.

Yet, osteoporosis does not rank among the three most important medical problems for older patients, does not receive the intensity of focus of a physician’s visit that coronary disease and cancer detection hold, and frankly, has not held the media’s attention in a way that chemotherapy and statin therapy have.

This is not the fault of the practicing physician who, with managed care practices and with the exigencies of private practice — with its endless forms and paperwork — must truncate the time spent with patients and has precious few minutes left to explore preventive measures and educate patients on such seemingly mundane topics as osteoporosis prevention and treatment.

It is the responsibility of health care systems, who, when “managing” a physician’s day, and who fill that day with more and more secretarial and bookkeeping work — to the exclusion of time spent with the patient — to assist both physician and patient in this regard. Data entry, insurance forms and cumbersome, arcane electronic medical records that consume unnecessary physician’s time and serve only to add to a doctor’s frustration, waste precious minutes that could be spent talking to patients — all this must ultimately be swept from the physician’s desktop. (Someone once said: “Never have a doctor do something you can pay someone else to do.” Very wise advice.)

What can be done in the meantime? Empowering patients to seek out diagnosis and treatment has been shown NOT to work. Studies have shown that this strategy is only minimally effective in improving osteoporosis quality of care. Nor does hounding doctors give any better results, for the reasons outlined above. What does work are “automatic” referrals. Standard hospital orders for automatic osteoporosis consults, when appropriate, have shown benefit. In one study, an automatic rheumatology consultation prompted much greater rates of treatment compared with those without a consultation (98 percent vs. 2 percent).

We have a “Coumadin Clinic” locally. It has streamlined the management of patients receiving blood thinners, and nationally, studies have shown a vast improvement in the quality of care of such patients. An Osteoporosis Clinic is not such a reach. Local physicians, assisted by specialty consultants, might set up a system to guide the referral, diagnosis and treatment of those individuals at risk. Physician practices can then refer their patients there for education, for prevention, for BMD determinations, and for recommendations for therapy, all with appropriate feedback to the doctor’s office. Patients may also self-refer to such a clinic, as they presently do for mammography at MaineGeneral. Hospitalized patients would have ‘automatic’ referrals, based on guidelines set up by local physicians.

Given proper oversight, there can be no downside to this. There is a downside to hip fracture in the elderly patient with osteoporosis: 15-20 percent of such patients die within a year of the fracture.

Michael A. LaCombe is a cardiologist at MaineGeneral Medical Center. E-mail questions to: [email protected]