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Osteoporosis Management: Physicians'Recommendations and Womens' Compliance FollowingOsteoporosis TestingRobert P. Cole PhD a , Sharon Palushock MD b & Ayad Haboubi PhD aa Allied Services Rehabilitation Hospitalb Lackawanna Medical Group , 201 Smallcombe Drive, Scranton, PA, 18411Published online: 21 Oct 2008.

To cite this article: Robert P. Cole PhD , Sharon Palushock MD & Ayad Haboubi PhD (1999) Osteoporosis Management:Physicians' Recommendations and Womens' Compliance Following Osteoporosis Testing, Women & Health, 29:1, 101-115, DOI:10.1300/J013v29n01_08

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Osteoporosis Management:Physicians’ Recommendationsand Womens’ Compliance

Following Osteoporosis Testing

Robert P. Cole, PhDSharon Palushock, MDAyad Haboubi, PhD

ABSTRACT. Physicians use several pharmaceutical agents (e.g., hor-mone replacement therapy [HRT], calcitonin, bisphosphonates, calcium,and vitamin D) to manage osteoporosis. However, relatively little re-search has examined how physicians employ these agents in osteoporosismanagement. Additionally, researchers have not examined compliancewith these treatments following the measurement of bone mass. Using amail survey, we examined physicians’ recommendation of, and women’scompliance with, osteoporosis treatment modalities (stratified by fracturerisk at the femoral neck and age) following bone mass measurement. Wefound that physicians recommended non-HRT treatment more often thanHRT treatment to women with an increased risk of fracture, andwomen’s acceptance of recommended treatments was relatively highfollowing the measurement of bone mass. [Article copies available for a feefrom The Haworth Document Delivery Service: 1-800-342-9678. E-mailaddress: getinfo@haworthpressinc.com]

KEYWORDS. Osteoporosis, compliance, bone mineral density, frac-ture risk, treatment

Robert P. Cole is Head of Clinical Outcomes Analysis at Allied Services Rehabi-litation Hospital. Sharon Palushock is a physician practicing internal medicine withthe Lackawanna Medical Group, 201 Smallcombe Drive, Scranton, PA 18411. AyadHaboubi is Director of Rehabilitation Technology at Allied Services RehabilitationHospital. Support for this research was provided by the Allied Services Foundation.

Address correspondence to: Robert P. Cole, Allied Services Rehabilitation Hospi-tal, 475 Morgan Highway, Scranton, PA 18501-1103.

Women & Health, Vol. 29(1) 1999E 1999 by The Haworth Press, Inc. All rights reserved. 101

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Current estimates suggest that as many as 40% of women in the UnitedStates will suffer a fracture of the wrist, hip, or spine due to osteoporosis(Riggs & Melton, 1995). Osteoporotic fractures frequently lead to negativefunctional outcomes (e.g., disability, loss of independence, institutionaliza-tion; Marottoli, Berkman, & Cooney, 1992; Office of Technological Assess-ment, Congress of the United States, 1994) and significant health care expen-ditures (Ray, Chan, Thamer, & Melton, 1997).The primary goal of osteoporosis management is the prevention of osteo-

porotic fracture. However, the strategies used to prevent osteoporotic fracturemay differ according to the amount of bone loss a woman has sustained. Forrecently postmenopausal women, physicians employ treatments to preventosteoporotic bone loss. By forestalling osteoporotic bone loss, women canavoid exposure to increased fracture risk. Preventative treatments primarilyinclude lifestyle changes (e.g., diet, smoking cessation) and may also includethe use of drug therapy. Traditionally, hormone replacement therapy (HRT)has been the hallmark of pharmaceutical osteoporosis prevention. HRT re-duces the rate of bone loss in postmenopausal women (Stevenson, Cust, &Gangar, 1990). In addition to HRT, other agents such as bisphosphonates(Harris et al., 1993), calcium (Riis, Thomsen, & Christiansen, 1987), calcito-nin (Overgaard, 1994), and vitamin D (Riggs & Melton, 1992) have beenshown to reduce the rate of bone loss in postmenopausal women.For women with existing osteoporosis, treatments are designed to main-

tain or increase the current level of bone strength in order to avoid osteopo-rotic fracture. Treatment for existing osteoporosis typically involves theaggressive use of drug therapy, and adjuvant lifestyle changes (Wasnich,Ross, Heilbrun, & Vogel, 1985). HRT, calcitonin, bisphosphonates, calciumand vitamin D have been shown to prevent further bone loss and/or decreasethe relative risk of fracture in osteoporotic women (e.g., Civtelli et al., 1988;Kanis et al., 1992; Lufkin et al., 1992; Nordin, Horsman, Crilly, Marshall, &Simpson, 1980; Nordin, Horsman, & Marshall, 1979; Orimo, Shiraki, Haya-shi, & Nakamura, 1987; Overgaard, Hansen, Jensen, & Christiansen, 1992;Sorensen et al., 1977; Tucci et al., 1996).Because several treatment modalities are effective in the management of

osteoporosis, it is interesting to ask which of the available alternatives dopracticing physicians recommend most frequently following an evaluation ofskeletal strength. This information is of interest because researchers havedevoted little effort toward ascertaining how practicing physicians are em-ploying available pharmaceutical agents in the management of osteoporosis.Such information may also prove useful in informing women with an in-creased risk of fracture about how the medical community is managing theconditions of similar patients.The effects of pharmaceutical treatment modalities on bone mass and

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fracture risk are potentially important determinants of the overall effective-ness of osteoporosis treatments. However, another important factor that mayinfluence the effectiveness of osteoporosis treatment is a woman’s accep-tance of that treatment. Relatively little research has focused on women’scompliance with non-HRT osteoporosis treatment modalities. Given the ef-fectiveness of non-HRT treatments in clinical research, and the mildness ofpotential side effects associated with non-HRT treatments (Chesnut, 1995),one might expect that acceptance of such treatments would be relatively high.Because physicians use non-HRT in the management of osteoporosis, it isimportant to document compliance with these treatments.Unlike compliance with non-HRT treatment modalities, researchers have

examined compliance with HRT. Those studies have generally found com-pliance with HRT to be low (Jones, Francis, & Nordin, 1982; Ravnikar, 1987;but see Wallace et al., 1990). Poor compliance is likely due, at least in part, towomen’s knowledge of research that has shown unopposed estrogen treat-ment can increase a woman’s risk for endometrial cancer (Ziel & Finkle,1975). Despite this slightly increased risk, and despite the non-skeletal bene-fits associated with HRT treatment (Agarwal & Judd, 1995), many womenare reluctant to use HRT as a long-term preventive measure. It is interesting,however, that many previous studies of compliance with HRT have examinedthe issue in women who were not known to be at an increased risk forfracture. Rubin and Cummings (1992) have suggested that informing womenwith low bone mass that they are at a greater risk for fracture may increasethe likelihood of those women adopting methods of avoiding fracture. Yet,compliance following osteoporosis testing, regardless of treatment modality,is not well documented. Therefore, it is of interest to examine compliancewith HRT and non-HRT treatments following osteoporosis testing, especiallyin those women with an increased risk of fracture.In the current study, we examined patterns of physicians’ recommenda-

tions of medication use, and women’s compliance with recommended medi-cation use following bone mineral density (BMD) measurement. BMD is ameasure of bone strength that is strongly correlated with the risk of osteopo-rotic fracture (Wasnich, Ross, Heilbrun, & Vogel, 1990). By obtaining mea-surements of a patient’s BMD, a physician can assess the degree of bone lossexperienced by a particular patient, and in turn estimate the patient’s likeli-hood of future fracture. To assess the information concerning physicians’recommendations and women’s compliance, we used a brief, multiple-choice/short-answer survey. We distributed the survey to all women who hadreceived osteoporosis testing (i.e., BMD measurement) at our facility in theprevious year. The survey asked each woman if her physician had recom-mended any medication following the review of her osteoporosis test (and if

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so, what specific medication did her physician recommend), and if she hadthen adopted that recommendation.

METHOD

Participants

This study examined data provided by 222 Caucasian women, between theages of 23 and 83 years (M = 63.2 years, SD = 11.9 years). All femaleoutpatients referred to the Allied Services Rehabilitation Hospital Women’sHealth Center (Scranton, PA) for osteoporosis testing during the period ofMay 1996 to December 1996, were invited to participate in the study (n =422). Primary physicians referred all subjects to the Women’s Health Centeras outpatients. Physicians referred the participants for testing to rule outosteoporosis because patients had presented risk factors for osteoporosis.This testing was each patient’s first BMDmeasurement at our facility. A totalof 84 physicians referred the patients who participated in the study. Only asmall portion of the sample (e.g., 9 patients) referred for testing had a historyof osteoporotic compression fracture. The majority of the BMD tests reportedherein were paid for by the patient’s medical insurance. Only 4 of the 222patients who contributed data self-paid for BMD testing.We recruited participants by mailing a brief survey directly to the potential

participant’s home. The decision to participate was reflected by the return ofthe survey to the investigators. We inferred informed consent through thereturn of a signed survey. The rate of participation was 52.6%. We did notemploy any follow-up methods to influence the rate of participation. TheAllied Services Rehabilitation Hospital Institutional Review Board approvedthe content of the survey and this research project.

Osteoporosis Testing Follow-Up Survey

We designed a short, multiple-choice/short-answer instrument to assess aphysician’s response to his or her patient’s bone scan (as reported by thepatient), and to assess the patient’s short-term compliance with the recom-mendation of her physician. Specifically, items on the survey probed: (1) wheth-er a woman’s physician had recommended any changes in medication usefollowing a bone scan; (2) what medications (if any) the woman’s physicianhad recommended (short answer); and (3) whether the patient had accepted aphysician-recommended medication. Women whose physician recommendeda medication provided the name of the medication. These individual medica-tions were later classified into the following categories: Alendronate, Calcito-nin, Calcium, HRT, Vitamin D, and Other.

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BMD Measurement

We obtained measurements of BMD through a review of each participant’sbone scan results. We used the QDR 4500 Fan Beam Bone Densitometer(Hologic, Inc., Waltham MA) to measure BMD. The QDR 4500 uses dualx-ray absorptiometry (DXA) to measure BMD. DXA is a widely used meth-od of BMD estimation because of its accuracy, precision, and low radiationdose (World Health Organization, 1994). BMD is determined by dividingbone mineral (calcium) content (measured in g) by the area of the regionscanned (measured in cm2). Thus, BMD is expressed in g/cm2. The output ofa QDR 4500 bone scan can produce information on numerous skeletal sites.However, we report only three areas: the femoral neck of the hip, the ultradistal region of the wrist, and the L1-L4 region of the lumbar spine becausethese areas show the highest incidence of fracture (Melton et al., 1997).Following the bone scan of each patient, results were communicated to the

referring physician. The data consisted of BMD, T-Scores, and T-Percent-ages. A T-Score is a standard score that is computed using the raw BMD ofeach patient, and the mean and standard deviation from a population ofsubjects who exhibit peak (or maximal) bone density at a particular skeletalsite. T-Scores, therefore, informed the physician how many standard devi-ations from the mean of peak bone density a given patient’s measurementslay. T-Scores were also expressed as T-Percentages. T-Percentages informedthe physician what percentage of the peak bone density a particular patientpossessed.

Data Collection

We sent the follow-up surveys to all potential participants in January 1997.Postage-paid envelopes were provided for the return of the survey materials.Data collection continued for six weeks following the mailing of the surveys.Therefore, the surveys assessed physicians’ and women’s behavior in theshort-term (i.e., 1 to 9 months following osteoporosis testing). All informa-tion concerning physicians’ recommendations and women’s compliance wasobtained from the completed surveys. All other information, including demo-graphics and BMD measurements were obtained from the patient’s medicalrecords following receipt of the completed surveys (inferred consent).

Statistical Analysis

A series of one-way analyses of variance (ANOVA) was used to determinewhether the sample of respondents differed from the sample of non-respond-ents on variables that might bias a physician’s recommendation of medication

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use. We compared respondents and non-respondents by age and by BMD atthe femoral neck, the ultra distal region of the wrist, and the lumbar spine(L1-L4 total). These analyses and all subsequent statistical tests were evaluat-ed using an < .05.In order to determine whether physicians’ recommendations and patient

compliance were related to BMD, it was necessary to examine fracture risk ata particular skeletal site. Although, we could arbitrarily choose a skeletal siteto stratify fracture risk, we used a logistic regression analysis to determinewhether the T-Score of the femoral neck, ultra distal wrist, or lumbar spinewas most closely related to a physician’s decision to recommend medication.In this analysis the dependent variable was a woman’s report of her physicianeither recommending or not recommending some medication followingBMD measurement. For this analysis, a recommendation of medication fol-lowing the bone scan was dummy coded as 1, while no recommendationfollowing the scan was dummy coded as 0. The independent variables used inthe model were femoral neck T-Score, ultra distal T-Score, and lumbar spineT-Score. We assumed no a priori difference in the likelihood of a physicianrecommending medication versus not recommending medication. We elimi-nated cases with incomplete data (i.e., those cases without data from all threeof the aforementioned skeletal sites) from this, and any further, analysis. Twowomen met this criterion.Upon selection of the stratification site, we used categories of fracture

risk as defined by the World Health Organization (WHO) to examine physi-cians’ recommendations and women’s compliance with those recommenda-tions (expressed as frequencies and percentages). The WHO classifieswomen according to the aforementioned T-Scores generated from BMDmeasurement. The WHO considers T-Scores greater than 1.00 normal(i.e., fracture risk is normal). The WHO considers T-Scores between 1.00and 2.50 indicative of osteopenia or low bone mass. T-Scores less than2.50 indicate osteoporosis. The WHO estimates that for each standard

deviation decrease in BMD (e.g., each 1.00 unit decrease in T-Score value),the risk of fracture increases by 100-150% (World Health Organization,1994). Following this initial stratification, physicians’ recommendationsand women’s compliance were further analyzed by the consideration of asecond stratifying variable: Age. Patients were classified into two catego-ries based upon age: Ages 65 years and older, and ages younger than 65years. Thus, patients were classified into one of the following six categoriesbased upon T-Score and age: Osteoporosis: Age 65; Osteoporosis: Age <65; Osteopenia: Age 65; Osteopenia: Age < 65; Normal: Age 65;Normal: Age < 65.

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RESULTS

Preliminary Analyses

A series of one-way ANOVAs revealed no differences between respond-ents and non-respondents with respect to age (M of respondents = 63.18years, SD = 11.90;M of non-respondents = 64.34 years, SD = 12.92), femoralneck BMD (M of respondents = .656 g/cm2, SD = .124; M of non-respond-ents = .645 g/cm2, SD = .141), ultra distal BMD (M of respondents = .344g/cm2, SD = .072;M of non-respondents = .339 g/cm2, SD = .076), or lumbarspine BMD (M of respondents = .878 g/cm2, SD = .304; M of non-respond-ents = .853 g/cm2, SD = .167). Therefore, any trends observed in the subse-quent analyses are likely not due to the sample of respondents being unrepre-sentative of the population of patients tested at our facility.The logistic regression analysis revealed a significant predictive relation-

ship between the linear combination of independent variables and the depen-dent variable, 2(3) = 57.33, p < .00001. In other words, we can conclude thata physician’s decision to recommend pharmaceutical treatment is related tofracture risk (as measured by a T-Score). Table 1 illustrates the parameterestimates for the independent variables used in this model. The regressioncoefficients for the predictor variables (i.e., b) inform us about the relation-ship between a predictor variable and the odds of receiving a recommenda-tion to change medication use. In this case, a positive b indicates that as thevalue of an independent variable increases, the odds of receiving a recom-mendation to change medication use also increases, while a negative b indi-cates that as the value of an independent variable increases, the odds ofreceiving a recommendation to change medication use decreases. An oddsratio estimates the change in the odds of receiving a recommendation ofmedication use given a one-unit change in the value of the independentvariable. Odds ratios greater than one signify an increase in the odds ofreceiving a recommendation for medication use, while odds ratios less thanone signify a decrease in the odds of receiving a recommendation for medica-

TABLE 1. Logistic Regression Model for Physicians’ Recommendation ofMedication Usage

Variable b Standard Error Odds Ratio t (216) p

Femoral Neck T-Score 0.74 0.25 0.47 2.98 .003

Lumbar Spine T-Score 0.34 0.19 0.71 1.79 .075

Ultra Distal T-Score 0.28 0.22 0.75 1.28 .202

Intercept 0.53

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tion use. Taken together, b and the odds ratio inform us how changes in thevalue of an independent variable effect the odds of receiving a recommenda-tion to change medication use. For example, femoral neck T-Score, with anegative b and an odds ratio less than one indicates that a one unit increase inT-Score, decreases the odds of receiving a recommendation for medicationuse (by more than 50%). For more information concerning the interpretationof logistic regression analysis see Wright (1995). Because femoral neckT-Score is the variable that impacts the likelihood of medication recommen-dation most, we used femoral neck T-Score as the skeletal site for stratifica-tion in subsequent analyses.

Physicians’ Recommendations

Overall, 178 women (80.2% of the total sample) reported that their physi-cian had recommended a change in medication use following BMDmeasure-ment. Of those who received a recommendation to change medication use inresponse to their bone scan results, 122 women (68.5% of those womenreporting recommended medication) reported a recommendation of calcium.Seventy-eight women (43.8% of those women reporting a recommendedmedication) reported a recommendation of alendronate sodium (a bisphos-phonate). Only one woman reported a recommendation of a bisphosphonateother than alendronate sodium. Forty-four women (24.7% of those womenreporting a recommended medication) reported a recommendation of vitaminD. Forty women reported a recommendation of calcitonin (22.5% of thosewomen reporting a recommended medication), and 14 women reported arecommendation of hormone replacement therapy (7.9% of those womenreporting a recommended medication). Note that not all women who reportedthat their physician recommended medication use supplied information onthe specific medication recommended.Next, we separated (stratified) participants into six categories based on

fracture risk at the femoral neck (e.g., osteoporosis, osteopenia, and normal)and age. We tabulated the frequencies of a reported physician recommenda-tion of alendronate sodium, calcium, calcitonin, HRT, and vitamin D forwomen in each category. Table 2 illustrates those frequencies.

Compliance

We tabulated the frequency of which women reported acceptance of theirphysicians’ recommendations of medication use across the six aforemen-tioned stratification categories for each of the five pharmaceutical treatmentmodalities: Alendronate sodium, calcitonin, calcium, HRT, and Vitamin D.Table 3 summarizes the uptake of physician recommended medication usefollowing osteoporosis testing.

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Cole, Palushock, and Haboubi 109

TABLE 2. Recommendations of Medication by Physicians Following BMDMeasurement

WHO FractureRisk Category No Alendronate(By Age) Recommendation Sodium Calcitonin Calcium HRT Vitamin D

Normal: 2 (50.0%) 1 (25.0%) 0 (0.0%) 1 (25.0%) 1(25.0%) 0 (0.0%)Age 65 (n = 4)

Normal: 14 (70.0%) 1 (5.0%) 0 (0.0%) 6 (30.0%) 0 (0.0%) 4 (20.0%)Age 65 (n = 20)

Osteopenia: 6 (15.0%) 16 (40.0%) 9 (22.5%) 26 (65.0%) 2 (5.0%) 11 (27.5%)Age 65 (n = 40)

Osteopenia: 15 (27.3%) 9 (16.4%) 6 (10.9%) 31 (56.4%) 4 (7.3%) 10 (18.2%)Age 65 (n = 55)

Osteoporosis: 1 (1.5%) 36 (54.5%) 20 (30.3%) 47 (71.2%) 2 (3.0%) 12 (18.2%)Age 65 (n = 66)

Osteoporosis: 3 (8.6%) 15 (42.9%) 4 (11.4%) 21 (60.0%) 6(17.1%) 7 (20.0%)Age 65 (n = 35)

Note: The frequency of each recommendation is indicated in regular type. The relative frequencyof each recommendation within a fracture risk category is provided in brackets following theaforementioned frequencies.

GENERAL DISCUSSION

In the current study, we examined the behaviors that follow BMD testingfor osteoporosis. Specifically, we observed what factors were likely to lead tophysicians recommending medications, what medications physicians mostfrequently recommended (given some risk of fracture), and women’s com-pliance with physician-recommended medications.Bone strength at the femoral neck (as measured by a T-Score) was the best

individual predictor of a physician’s behavior (specifically, recommending ornot recommending medication use following BMD measurement) in thisstudy. The results of the logistic regression analysis are consistent with theknown severity of fractures at different skeletal sites. Hip fractures are theosteoporotic fractures that most frequently require hospitalization and nurs-ing home care (Melton, 1995). Additionally, approximately 63.1% ($8.68billion) of total health care expenditures for osteoporotic fractures are associ-ated with the treatment of hip fractures (Ray, Chan, Thamer, & Melton,1997). Based upon the results of the logistic regression analysis, we chose tofurther examine physicians’ recommendations and women’s compliance withthose recommendations across levels of fracture risk at the femoral neck.

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TABLE3.Women’sReportedCompliancewithRecommendations ofMedica-tion by Physicians Following BMD Measurement

WHO FractureRisk Category Alendronate(By Age) Sodium Calcitonin Calcium HRT Vitamin D Overall

Normal: 1 (100.0%) -- (----) 1 (100.0%) 1(100.0%) -- (----) 3 (100.0%)Age 65

Normal: 1 (100.0%) -- (----) 6 (100.0%) -- (----) 3 (75.0%) 10 (90.9%)Age 65

Osteopenia: 13 (81.3%) 7 (77.8%) 20 (76.9%) 0 (0.0%) 10 (90.9%) 50 (78.1%)Age 65

Osteopenia: 5 (55.6%) 6 (100.0%) 26 (83.9%) 2 (50.0%) 10(100.0%) 49 (81.7%)Age 65

Osteoporosis: 31 (86.1%) 19 (95.0%) 40 (85.1%) 2(100.0%) 12(100.0%) 104(88.9%)Age 65

Osteoporosis: 13 (86.7%) 2 (50.0%) 19 (90.5%) 4 (66.7%) 7 (100.0%) 45 (84.9%)Age 65

OVERALL 64 (82.1%) 34 (87.2%) 112(84.8%) 9 (60.0%) 42 (95.5%)

Note: The frequency of women reporting uptake of a physician’s recommendation is indicated inregular type. The percentage of women who reported uptake of a physician’s recommendation,within a fracture risk category, is provided in brackets following the aforementioned frequencies.

As would be expected, women with increased fracture risk, regardless ofage, were more likely to receive recommendations of medication use. Addi-tionally, the frequency of physicians’ recommendations of medication usewas greater for older patients. This pattern of recommendations was evidentacross levels of fracture risk. Of interest was the pattern of medications whichphysicians recommended. It is of interest that recommendations increasedwith age. Previously, many osteoporosis treatments were aimed toward pre-vention, therefore, these preventive treatments have targeted youngerwomen. With the advent of a greater number of therapies designed to treatestablished osteoporosis, one would expect that the numbers of older womentargeted by osterporosis treatments will also increase. This expectation isevidenced by the data presented herein. When BMD measurements indicatedincreased fracture risk at the femoral neck (those classified in the osteopeniaand osteoporosis strata), physicians were more likely to recommend non-HRT treatment than HRT treatment. Unfortunately, the low frequency ofrecommended medication use for those with normal BMD makes assessmentof physicians’ recommendations of preventive medications difficult.By examining the patterns of reported physicians’ recommendations at the

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osteopenia and osteoporosis strata, we can see that calcium and alendronatesodium were the most frequently reported recommended medications, fol-lowed by calcitonin, vitamin D (all non-HRT modalities), and finally HRT.(Note that information concerning pharmaceutical treatment of osteoporosisprior to the osteoporosis testing reported herein was not assessed, hence, it isconceivable that some of the women surveyed may have been using pharma-ceutical osteoporosis treatment prior to said testing). The low relative fre-quency of HRT recommendations may be due to a number of reasons includ-ing the fact that the sample studied were addressed by primary physicians,and primary physicians have conventionally used HRT as a preventive mea-sure, rather than as a treatment option for existing osteoporosis. Additionally,compliance with HRT is low (Jones, Francis, & Nordin, 1982; Ravnikar,1987). Therefore, it is not surprising that the physicians observed recommendnon-HRT modalities more frequently to those women with increased fracturerisk. With respect to the recommendation of non-HRT modalities, physiciansrecommended calcium most frequently, followed by alendronate sodium,calcitonin, and vitamin D. This is an interesting result considering that clini-cal research has shown that each of these treatments can effectively preserveBMD and reduce fracture risk in women with established osteoporosis. Thereason for this difference in recommendations of treatment modalities cannotbe elucidated here. Nevertheless, one can postulate that the observed differ-ence in the recommendation of pharmaceutical treatment modalities mayhave arisen from some combination of the perceived effectiveness of eachoption, the comparative side effects associated with each treatment, the costsassociated with each treatment, biases related to the novelty of each treat-ment, expected uptake of the treatment, the marketing differences betweenthe commercial manufacturers of each drug, or from other undeterminedfactors.The second major aspect of the current research addressed the issue of

short-term compliance (i.e., compliance within 1 to 9 months following os-teoporosis testing) with physician-recommended treatments for osteoporosis.The available literature on compliance with osteoporosis treatment has fo-cused upon women’s acceptance of HRT (in the absence of informationconcerning fracture risk). Research examining compliance with non-HRTtreatment modalities is lacking. The current data provide documentation ofcompliance with non-HRT treatment modalities. Overall, compliance withthe non-HRT osteoporosis treatments alendronate sodium (82.1% com-pliance), calcium (84.8% compliance), calcitonin (87.2% compliance), andvitamin D (95.5% compliance), was relatively high regardless of fracture risk(as compared to previously reported compliance with HRT). Generally, com-pliance with non-HRT recommendations increased slightly as fracture riskincreased (see Table 3). One might argue that compliance reported by women

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with normal femoral neck BMD contradict the aforementioned statement,however, given the small number of women in this stratum who reportedreceiving recommendations to begin medication use it is difficult to placemuch confidence in the compliance rates of these women. Insofar as com-pliance with treatments shown to be effective in managing osteoporosis is adeterminant of the efficacy of osteoporosis management, the complianceresults reported herein are encouraging.Researchers have not extensively concentrated upon compliance follow-

ing a determination of fracture risk. Rubin and Cummings (1992) stated thatwomen informed of increased fracture risk would be more likely to acceptosteoporosis treatment than those women unaware of this risk. By examiningoverall compliance, regardless of treatment modality (illustrated in the farright column of Table 3), we see that compliance increased slightly as frac-ture risk increased (again, we discount compliance at the normal stratum).This trend in reported compliance is congruent with the suggestion of Rubinand Cummings. This result suggests that BMD measurement may play a partin determining compliance with physician-recommended medications. Al-though the current results are consistent with the suggestion of Rubin andCummings, it is important to stress that the result does not imply a cause andeffect relationship between an indication of increased fracture risk and highcompliance. Indeed, this factor could partially determine high compliance,but other variables may also play a role (e.g., marketing of non-HRT alterna-tives, knowledge of side effects, etc.).Compliance with HRT following BMDmeasurement remains unclear. The

present study sought to examine compliance with HRT and non-HRT treat-ment modalities following BMD measurement. Unfortunately, the recom-mendation of HRT, regardless of fracture risk, was infrequent. Although therelative infrequency of HRT recommendations is interesting, it neverthelessmakes interpretation of compliance with HRT difficult. Overall, 60.0% ofthose women who received recommendations of HRT reported compliance.This is consistent with previous examinations of compliance with HRT priorto BMD measurement. Previous research has indicated that short-term com-pliance with HRT is low, although published reports of compliance rangefrom 20% to 74% (Jones, Francis, & Nordin, 1982; Ravnikar, 1987; Wallaceet al., 1990). We hesitate to speculate further concerning compliance withHRT as additional research is necessary to understand compliance with thistreatment modality following BMD measurement.The current research provides an initial basis for the examination of com-

pliance with non-HRT treatments, and with osteoporosis treatment strategiesin general following BMD measurement. The data collected in the currentstudy were patient reports. Patients’ reporting of their own or their physi-cian’s behavior may not directly coincide with the actual behavior in ques-

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Cole, Palushock, and Haboubi 113

tion. Therefore, future studies of physicians’ behavior or women’s com-pliance with physician recommendations may examine the congruencebetween patient and physician reports (in the case of recommendations), orpatient reports of compliance and physical indicators of treatment uptake.Additionally, the current research examined short-term compliance with non-HRT treatment modalities following BMD measurement. Reported rates ofshort-term compliance with non-HRT treatments were high. However, likeHRT, non-HRT medications must be administered over long periods if theirmaximal skeletal benefits are to be derived. Therefore, future research mustexamine long-term compliance (e.g., compliance 3 years and more followingrecommendation of medication) in women with an increased risk of fracture.Analyses of long-term compliance would complement the current data andexisting data on short-term HRT compliance and, thus, would offer a richerperspective of how women respond to, and deal with indications of osteopo-rotic bone loss.

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