The epidemiology of osteoporosis

Osteoporosis is defined as "...a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture." Compared to normal bone, osteoporotic bone shows a reduction in the number of trabeculae, thinning of the trabeculae, and loss of connectivity of the trabeculae. The overall result is deterioration of bone strength and an increase in the susceptibility to fracture. Osteoporosis is essentially a "silent" disease until a fracture occurs. When multiple fractures occur, they can cause significant deformity of the spine, leading to kyphosis, loss of vertebral height, and subsequent loss of overall height. The patient with osteoporosis experiences chronic pain and back fatigue. In addition, gastrointestinal and respiratory symptoms may occur as a consequence of the changes in the skeletal shape.

An evidence-based approach to prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID Consensus Participants

OBJECTIVE

To make recommendations for the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) in primary care practice, particularly for patients at high risk for NSAID-induced complications.

OPTIONS

The use of misoprostol to prevent gastrointestinal ulceration and other unwanted NSAIDs effects was considered. The role of cyclooxygenase-2 (COX-2) versus COX-1 inhibiting agents was also examined.

OUTCOMES

Reduction of complications associated with long-term use of NSAIDs.

EVIDENCE

Evidence was gathered in late 1995 from published research studies and reviews. Position papers were prepared by faculty and advisory board members and discussed at the Canadian NSAID Consensus Symposium in Cambridge, Ont., Jan. 26 and 27, 1996.

VALUES

Recommendations were based on randomized, placebo-controlled clinical trials (level I evidence) and case-control studies (level II evidence) involving NSAID use when such evidence was available. When the scientific literature was incomplete or inconsistent in a particular area, recommendations reflect the consensus of the participants at the symposium (level III evidence). Physicians were recruited from across Canada for their expertise in rheumatology, gastroenterology, epidemiology, gerontology, family practice, and clinical and basic scientific research.

BENEFITS, HARMS AND COSTS

Although a reduction in complications due to inappropriate NSAID use should reduce costs of additional investigations, admissions to hospital and time lost from work, definitive cost analysis studies are not yet available.

RECOMMENDATIONS

Currently, no NSAID is available that lacks potential for serious toxicity; therefore, long-term use of NSAIDs should be avoided whenever possible, particularly in high-risk patients (e.g., those who are elderly, suffer from hypertension, congestive heart failure, renal or hepatic impairment or volume depletion, take certain concomitant medications or have a history of peptic ulcer disease) (level I evidence). If NSAIDs are to be used in patients with gastric or nephrotoxic risk factors, the lowest effective dose of NSAID should be used (level III evidence); NSAIDs that are weak COX-1 inhibitors may be preferred (level II evidence). In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications (level I evidence). However, the clinical judgement of the practising clinician must always be part of any therapeutic decision.

VALIDATION

These recommendations are based on the consensus of Canadian experts in rheumatology, gastroenterology and epidemiology, and have been subjected to external peer review.

Determinants of physician confidence in the primary care management of musculoskeletal disorders

OBJECTIVE

To examine the determinants of confidence in managing musculoskeletal (MSK) disorders among primary care physicians.

METHOD

A self-administered questionnaire was mailed to a stratified (by urban/rural location) random sample of 798 Ontario primary care physicians who were members of the College of Family Physicians of Canada. Two mailings and a reminder postcard were used to increase response. As the main outcome measure, confidence was measured on a 10 point Likert-type scale.

RESULTS

The overall response rate was 68.3%. Most respondents were practising in a full time group setting; their average age was 40.3 years. Respondents were significantly more confident in performing a comprehensive cardiovascular examination than a MSK examination. Highest levels of confidence were observed for using nonsteroidal antiinflammatory drugs and managing common MSK disorders. Lower scores were reported for doing a joint injection/aspiration. Rural physicians were more confident than urban physicians in doing a joint injection/aspiration and monitoring patients who were taking disease modifying agents. Previous continuing medical education (CME) was significantly (p < 0.01) related to all confidence outcomes using multiple regression analysis. For many outcomes, men reported higher confidence scores than women after adjustment for various demographic characteristics.

CONCLUSION

CME may be the most important and modifiable variable to improve physician management of MSK disorders.

The provision of specialist rheumatology care: implications from a survey of rheumatologists in Ontario, Canada

OBJECTIVE

To describe the practice characteristics and whereabouts of rheumatologists in Ontario, Canada in order to make inferences regarding the current status of clinical rheumatology services.

METHODS

All 136 identified Ontario rheumatologists received a self-administered, mailed questionnaire.

RESULTS

The adjusted response rate was 74.2%. For respondents, there was a mean of 14.4 years in practice (1-42 years), 74.7% were male, and 91.3% were practising in urban and/or suburban locations. Only 6 were practising principally in remote northern locations. Sixty-three percent of respondents had a university faculty appointment; 40.4% geographic full time (GFT) and 22.3% clinical only. University appointed rheumatologists, and in particular those with GFT status, were more likely to have a particular clinical focus (p < 0.0001), saw fewer patients on fewer half days/week (p < 0.0001 and p = 0.0001, respectively), had longer waiting times to see a new patient (9.8 weeks for GFT versus 5.9 weeks and 7.0 weeks for clinical only and nonappointed, respectively; p = 0.009), and had greater research, teaching and administrative duties (p < or = 0.0001 for each). University appointment was not associated with the likelihood of having additional nonrheumatology clinical responsibilities.

CONCLUSION

A major proportion of rheumatologists in Ontario are university based with significant research, teaching, and administrative responsibilities, which limits their availability as consultants. These findings have implications for the future training of rheumatologists and for future studies of rheumatology manpower requirements.

Waiting times for knee-replacement surgery in the United States and Ontario

BACKGROUND

Canada, which has universal single-payer health insurance, is often criticized for waiting times for surgery that are longer than those in the United States. We compared waiting times for orthopedic consultations and knee-replacement surgery and patients' acceptance of them in the United States and in the province of Ontario, Canada.

METHODS

A stratified random sample of 1486 Medicare recipients (629 from the U.S. national sample, 428 from Indiana, and 429 from western Pennsylvania) and 516 people from Ontario who had been hospitalized for knee replacement between 1985 and 1989 were surveyed by mail in 1992. Patients were asked how long they had waited to see an orthopedic surgeon and to have surgery, the acceptability of these waiting times, and their overall satisfaction with surgery.

RESULTS

About 80 percent of the questionnaires were returned, but not all the respondents answered all the questions. The rate of response to specific questions was about 60 to 65 percent in both countries. The median waiting time for an initial orthopedic consultation was two weeks in the United States and four weeks in Ontario. The median waiting time for knee replacement after the operation had been planned was three weeks in the United States and eight weeks in Canada. In the United States, 95 percent of patients in the national sample considered their waiting time for surgery acceptable, as compared with 85.1 percent in Ontario. Overall satisfaction with surgery ("very or somewhat satisfied") was 85.3 percent for all U.S. respondents and 83.5 percent for Canadian respondents.

CONCLUSIONS

Waiting times for initial orthopedic consultation and for knee-replacement surgery were longer in Ontario than in the United States, but overall satisfaction with surgery was similar.