台北地區家庭醫學專科醫師對停經後婦女骨質疏鬆症診斷與處置的障礙

隨著醫療衛生的進步，人類壽命延長，骨質疏鬆症與相關骨折已是世界性的重要流行病。在台灣老年婦女約20％有脊柱體壓迫性骨折，且每年髖部骨折約為8,000例，盛行狀況並不亞於美國白人的調查。骨質疏鬆症相關骨折可經由骨質疏鬆症防治而減少，家庭醫學專科醫師防治骨質疏鬆症角色合適，本研究調查家庭醫學專科醫師對骨質疏鬆症與相關骨折的知識、診斷治療態度與方式，以及於執業時現實遭遇困難調查，以提供相關學會及衛生醫療單位對骨質疏鬆症防治策略的資料。收集台北縣市家庭醫學專科醫師願意接受郵寄名單421位醫師。郵寄調查問卷後回收131份問卷，回覆率31.1％，男醫師有115名（87.8％），女醫師16名（12.2％），平均年齡為54.4±13.7歲，執業地點在醫院者30％，在診所執業者70％。研究結果為40.4％與48.1％家庭醫學專科醫師積極態度診斷與治療骨鬆症；有86.3％醫師誤判低估骨鬆髖骨骨折後一年存活者的依賴程度，60％醫師對停經婦女鈣質建議量了解有誤；41.2％醫師使用早期診斷骨質疏鬆症的儀器檢查，其中醫院與診所執業者有顯著差異（100.0％ vs. 16.3％）；90％醫師鼓勵適當運動與衛教高鈣飲食，有關抗骨吸收劑的治療方法，女性激素補充治療在醫院或診所執業之醫師使用狀況相似（54.0％ vs. 46.7％），採用雙磷酸鹽類或抑鈣素的治療，在醫院執業家庭醫師較多於診所執業者。受訪醫師於骨質疏鬆症診斷與治療時實際上所遭遇的困難，71.8％「執業處沒有診斷骨質疏鬆症的儀器」，68.7％「健保設限，無法在執業處執行診斷與治療」，約有半數醫師擔心女性激素的副作用或認為病患擔心女性激素的副作用，46.6％回答「執業處無抗骨吸收劑」，女性激素補充、雙磷酸鹽類或抑鈣素任一種。針對骨質疏鬆症的防治，應加強相關知識的再教育，建立危險評估與轉檢系統，建議全民健康保險制度將骨質疏鬆症的防治納入預防醫學健康檢查。（台灣家醫誌2004; 14: 70-80）

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並列摘要

Osteoporosis is a devastating disease that is increasing in prevalence as our population ages. In Taiwan, there are more than 13,000 hip fracture cases every year in the elderly population. Most of them are postmenopausal women who have a higher risk for osteoporosis. Prevention of osteoporosis is important to decrease osteoporosis-related fractures. Family physicians are in the ideal position to actively screen women for osteoporosis and identify high-risk women in a primary care practice. Awareness and attitudes of family physician towards prevention and treatment of osteoporosis have important implications in clinical practice. In Taiwan, this issue has been poorly investigated. This study is aimed to determine awareness, attitudes and barriers of family physician towards diagnosis and treatment of postmenopausal osteoporosis. This study collected 421 family physicians from a member list of the Taiwan Association of Family Medicine. These family physicians all practice primary care at local clinics or at hospitals in Taipei. A structured questionnaire including the physician’s basic data, awareness, attitudes, and barriers towards diagnosis and treatment of osteoporosis in postmenopausal women was mailed. 131 questionnaires were returned from family physicians (115 men, 16 women; mean age ± SD: 54.4 ± 13.7 years; 70% at clinics, 30% in hospitals), giving a response rate of 31.1%. This study found that 40.4% of family physicians diagnosed and 48.1% treated osteoporosis with an aggressive attitude; but 86.3% of physicians underestimated patients’ dependence in daily activities one year after osteoporosis-related fractures, while 60% lacked understanding of suggested calcium intake for postmenopausal women. Medical equipment was used for early diagnosis of osteoporosis by 41.2% of physicians, who are mostly physicians at a hospital. Information on proper exercise regimens and suggested intake of food with high calcium levels were provided by 90% of physicians. The use of antiresorptive agents and supplementary female hormone in the treatment of osteoporosis was similar in physicians at hospitals and clinics (54.0% vs. 46.7%), but physicians at hospitals tend to prescribe bisphosphonate or calcitonin more frequently. Among the difficulties encountered by physicians during diagnosis and treatment of osteoporosis, 71.8% resulted from the absence of equipment needed to diagnose osteoporosis, 68.7% from limitations set by the National Health Insurance system, which made it impossible to perform diagnosis and treatment at the place of practice. Education of physicians in the prevention and treatment of osteoporosis, and the establishment of risk evaluation and referral systems are important in caring for the growing population of patients with this illness. Inclusion of osteoporosis prevention and treatment topics in the preventive medicine health examinations of the National Health Insurance system is also suggested. (Taiwan J Fam Med 2004; 14: 71-80)