Reality of Osteoporosis in Primary Healthcare: An Observational Study in a Portuguese Local Health Unit

TL;DR

This study examines how osteoporosis is managed in Portuguese primary healthcare, finding poor use of screening tools and inconsistent treatment practices.

Contribution

The study provides real-world insights into osteoporosis screening and management practices in primary healthcare settings.

Findings

FRAX® and DXA were rarely used in screening for osteoporosis.

Only 49.2% of patients with osteoporosis had follow-up DXA scans.

Most patient-initiated bisphosphonate discontinuations lacked clinical justification.

Abstract

Introduction: Osteoporosis (OP) is a common chronic condition associated with an increasing burden of fragility fractures and healthcare costs. Risk assessment and management rely on tools such as the Fracture Risk Assessment Tool (FRAX®) and dual-energy X-ray absorptiometry (DXA), yet their application in routine primary healthcare (PHC) practice remains unclear.

Objectives: To characterize real-world OP screening and management practices in a PHC setting.

Materials and methods: A single observational study with two predefined cohorts was conducted across five family health units (FHUs). The screening cohort included individuals aged exactly 50 years, women aged exactly 65 years, and men aged exactly 70 years attending consultations at those ages. The OP cohort included patients with a confirmed diagnosis of OP established between 2013 and 2023. Data were collected from electronic medical records, anonymized, and analyzed using descriptive statistical methods (IBM® SPSS® Statistics 25.0 (IBM Corp., Armonk, NY, USA)). Ethical approval was obtained from the Ethics Committee of the Unidade Local de Saúde Entre Douro e Vouga, Santa Maria da Feira, Portugal, which oversees all participating FHUs.

Results: In the screening cohort (n=770), FRAX® was not registered in 99.6% of individuals aged 50 years. DXA was not requested in 87% of women aged 65 years and 97.2% of men aged 70 years. In the OP cohort (n=679), 49.2% of patients with a diagnosis duration of two years or more underwent follow-up DXA. Physician-advised bisphosphonate discontinuation occurred in 14.4% of cases and was considered appropriate in 61.5%, based on predefined clinical criteria. In contrast, most patient-initiated bisphosphonate discontinuations occurred without documented clinical justification. Although 16.9% of patients met criteria for referral (bisphosphonate refractoriness, osteoporotic fracture, or suspected secondary OP), 75.7% were not referred to rheumatology.

Conclusion: OP screening and management in primary healthcare showed low utilization of FRAX® and DXA, inconsistent follow-up, suboptimal long-term treatment adherence, and limited referral to rheumatology, reflecting gaps in real-world clinical practice.

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