title: Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics.
abstract: OBJECTIVE
  The diagnosis and treatment of patients at risk of fragility fractures is uncommon. We examined the patient, physician, and practice characteristics associated with adherence to local osteoporosis guidelines.
  
  
  METHODS
  Data were obtained from electronic medical records from one academic medical center. Local guidelines suggest screening and consideration of treatment for at-risk patients, including women aged > or =65 years, women aged 50 to 64 years who smoke cigarettes, persons who used more than 5 mg of oral prednisone for >3 months, and those with a history of a fracture after age 45 years. Clinical notes, medication lists, and radiology records were reviewed to determine whether patients had undergone bone mineral density testing or received any medications for osteoporosis. Possible correlates of guideline adherence, including patient, physician, and practice site characteristics, were assessed in mixed multivariable models.
  
  
  RESULTS
  We identified 6311 at-risk patients seen by 160 doctors at 10 primary care sites during 2001 to 2002. Of these patients, 45% (n = 2820) had a prior bone mineral density test and 30% (n = 1922) had received a medication for osteoporosis; 54% (n = 3401) had one or the other. After adjusting for patient case mix, 17% to 71% of patients had been managed according to local guidelines and had undergone at least bone mineral density testing or received a medication. Patient variables that significantly lowered the probability of guideline adherence included age >74 years (odds ratio [OR] = 0.49; 95% confidence interval [CI]: 0.43 to 0.55), age <55 years (OR = 0.34; 95% CI: 0.28 to 0.42), male sex (OR = 0.17; 95% CI: 0.12 to 0.23), black race (OR = 0.40; 95% CI: 0.34 to 0.47), and having more than one comorbid condition (OR = 0.79; 95% CI: 0.69 to 0.89). Patients seen by male physicians were less likely to have care that was adherent with guidelines (OR = 0.70; 95% CI: 0.55 to 0.89).
  
  
  CONCLUSIONS
  Rates of adherence with local osteoporosis guidelines for patients at risk of fragility fractures vary by patient, physician, and practice site characteristic.
authors.affiliation: Division of Pharmacoepidemiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02120, USA. dhsolomon@partners.org
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Solomon
authors.forename: M Alan
authors.initials: MA
authors.lastname: Brookhart
authors.forename: Tejal K
authors.initials: TK
authors.lastname: Gandhi
authors.forename: Andrew
authors.initials: A
authors.lastname: Karson
authors.forename: Soheyla
authors.initials: S
authors.lastname: Gharib
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
authors.forename: Shimon
authors.initials: S
authors.lastname: Shaykevich
authors.forename: Andrea
authors.initials: A
authors.lastname: Licari
authors.forename: Danielle
authors.initials: D
authors.lastname: Cabral
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density; D050723:Fractures, Bone / Q000209:etiology / Q000517:prevention & control; D019983:Guideline Adherence; D006801:Humans; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D010024:Osteoporosis / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D010818:Practice Patterns, Physicians'