Table of Contents

Few studies have directly compared osteoporosis pharmacotherapies. In an observational study, Cadarette and associates compared the rate of nonvertebral fractures within 1 year of initiating osteoporosis pharmacotherapy among 43 135 persons age 65 years or older in 2 statewide pharmaceutical benefit programs. They found no large differences in fracture risk between risedronate or raloxifene and alendronate. Fracture risk seemed to be higher with calcitonin than alendronate. However, the study could not rule out potentially important differences between some agents.

High-deductible health plans require the patient to pay a substantial proportion of the cost of some tests and treatments. Using claims data from a Massachusetts health plan, the authors measured rates of preventive care when patients changed from a conventional HMO to a high-deductible health plan. Rates of screening for cervical, breast, or colorectal cancer did not change as patients transitioned into a high-deductible health plan. However, for colorectal cancer, patients chose a fully covered test over ones subject to the deductible.

Visit-to-visit changes in the serum cholesterol level while monitoring the effects of cholesterol-lowering medication are due to random variation and to real changes over time. The authors analyzed data from a trial that compared pravastatin with placebo in patients with coronary heart disease. Most of the visit-to-visit change in serum cholesterol was due to random variation, which should not trigger dose adjustment. To increase the contribution of real long-term change, the authors propose monitoring patients receiving stable cholesterol-lowering treatment every 3 to 5 years rather than every few months or annually.

In the United States, nearly 80% of persons who abuse opioids remain untreated. Sullivan and Fiellin examine the components of office-based treatment of opioid dependence with buprenorphine–naloxone, the role of the physician providing this treatment, and the logistics of treating this multifaceted patient population. Office-based treatment of opioid dependence allows physicians to care for and treat opioid-dependent patients in a primary care setting, in part by framing a person's addictive disorder as a manageable medical condition.

Women at high risk for breast cancer need a highly sensitive screening test. This review summarizes data from 11 prospective studies that screened very high-risk women with mammography plus magnetic resonance imaging (MRI). Assuming a 2% pretest probability of breast cancer, negative findings on both mammography and MRI reduced the probability of a histologically suspicious biopsy lesion to 0.3%, and a negative mammogram alone reduced it to 1.4%. Screening very high-risk women with both MRI and mammography might rule out cancerous lesions better than mammography alone.

The American College of Physicians developed this guideline to present the available evidence for screening men for osteoporosis. Clinicians should periodically assess an older man's risk factors for osteoporosis (strong recommendation, moderate-quality evidence) and obtain dual-energy x-ray absorptiometry (DXA) for men who are at increased risk for osteoporosis and could be candidates for drug therapy(strong recommendation, moderate-quality evidence). The body of evidence about osteoporosis screening tests in men is relatively weak.

The authors reviewed the evidence about which asymptomatic men should be evaluated for modifiable risk factors for osteoporotic fracture and receive bone mineral density (BMD) testing with DXA. Risk factors include age older than 70 years, body mass index less than 20 to 25 kg/m², weight loss greater than 10%, physical inactivity, prolonged corticosteroid use, and previous osteoporotic fracture. Tests other than DXA either are too insensitive to detect osteoporosis or have insufficient data about their accuracy; therefore, DXA remains the test of choice for identifying men with low BMD.

We have little information on the efficacy of the many osteoporosis medications relative to one another because of a dearth of head-to-head randomized trials. Cadarette and colleagues addressed this gap with an observational study. They found that fracture risk was similar with alendronate, risedronate, and raloxifene and considerably lower than with calcitonin. But is this information reliable enough to help physicians decide which drug to use in specific patients? The editorialist does not think so. He proposes a better solution, one based on the principle that if the government pays for tests or treatments, it has an obligation to evaluate them relative to one another.

High-deductible health plans provide insurance coverage only after the patient has paid all expenses below a predefined cumulative outlay. They are designed to encourage prudent use of health care, but some are concerned about underuse of key services, such as cancer screening. In this issue, Wharam and colleagues report that high-deductible health plan members and traditional HMO members have similar rates of breast cancer and cervical cancer screening. However, high-deductible health plan members used cheaper and less accurate tests to screen for colorectal cancer. Cost-sharing is a blunt tool, and cancer screening may not be immune to the potential adverse effects of high-deductible health plans.

Gone are the days when my answer to the question of whether I am married was no. No longer do I lie about my personal life.

This issue provides a clinical overview of low back pain, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits.