Test (questionnaire) on the risk of developing osteoporosis: Medical blog of an emergency doctor. Approaches to the prevention and treatment of osteoporosis Drug treatment and prevention of osteoporosis

30.06.2020 -

The event takes place as part of a month dedicated to the regional holiday - Pensioner's Day. For the third year in a row, it has been organized by the exhibition company SoyuzPromExpo. The project is supported by the Yekaterinburg City Administration, City Center medical prevention, Ekaterinburg Employment Center, Ural Branch Pension Fund Russia, Russian Post.

The goal of the project is to improve the quality of life of middle-aged and older people living in Yekaterinburg and the Sverdlovsk region, to promote the sale of goods and services for them. One of the main values of the event is that visitors have the opportunity to communicate with government officials, household and social services, specialists in the field of medicine, psychology, tourism, financial and legal services.

Over the course of three days, about one hundred participants of the exhibition-fair will present their stands to visitors, where they will be able to look, try on, buy the things they like, and take part in various master classes.

On each of the three days, exhibition guests will undergo free medical diagnostics (measure blood pressure, cholesterol and blood sugar levels, determine body mass index) and receive consultations with doctors.

Visitors will listen to lectures by leading city specialists on the prevention and treatment of osteoporosis, strokes, senile dementia, and will also receive useful information about proper nutrition.

You can learn about employment opportunities at the stand of the Yekaterinburg Employment Center. Specialists from the Ural branch of the Pension Fund of the Russian Federation will talk about the new pension formula. Every day at the exhibition-fair there will be a drawing of prizes among visitors.

The accompanying program of the exhibition includes more than 30 events, including a beauty contest for people over 50 years old “The Most Charming and Attractive”, a workshop on the topic of social fraud and Beauty Day.

Deputy Head of the Yekaterinburg City Administration for Social Policy Mikhail Matveev:

The age over 50 is traditionally called elegant. According to statistics, life expectancy is increasing, and there are more and more people of elegant age. And they want to lead an active lifestyle and feel like full-fledged members of society. They can receive support at such exhibitions. The administration of the city of Yekaterinburg has a positive attitude towards the exhibition “The Third Age”, which has been organized by the SoyuzPromExpo company for the third year in a row. Because people need help, they need communication, a place where they can come and get answers to various questions - which are within the competence of the Employment Center, the Pension Fund, medical and sanatorium-resort institutions. The exhibition is needed by people of mature age, here they can get a lot useful information, which they then use in their active life.

Text prepared by Elena Porunova

Keywords

OSTEOPOROSIS / OSTEOPOROSIS / QUALITY OF MEDICAL CARE/ QUALITY OF MEDICAL CARE / DIAGNOSTICS / DIAGNOSTICS

Annotation scientific article on clinical medicine, author of the scientific work - Dreval A.V., Marchenkova L.A., Grigorieva E.A.

Using a questionnaire survey of residents of the Moscow Region (MO) over the age of 55 years with a confirmed diagnosis of postmenopausal osteoporosis (OP), we studied the procedure for establishing the diagnosis of postmenopausal OP in the Moscow Region, the main range of specialists involved in the diagnosis of postmenopausal OP, and the diagnostic methods they use. The results of the survey of patients showed that 57.4% of them first consulted an endocrinologist for AP, 19.7% to an orthopedic traumatologist, 13.1% to a rheumatologist, and 4.9% to a neurologist. Endocrinologists referred patients for bone densitometry in 79% of cases, and they also diagnosed postmenopausal AP in 70% of cases. Only a small part of orthopedic traumatologists and rheumatologists in the Moscow Region are involved in diagnosing postmenopausal AP as part of their main activities; therapists and doctors practically do not do this general practice and gynecologists. Although the majority of patients had to see only two (38% of respondents), three (30%) or one doctor (28%) to confirm the diagnosis of AP, in most cases it took up to 1 year from the time of the first visit to a specialist to the diagnosis of AP ( 39%). In a small proportion of patients, the diagnosis of AP was based on examination by only one method: in 12% of cases, only X-ray densitometry was used, in 4%, ultrasonometry, and in 2%, radiography of skeletal bones. Of the remaining patients who underwent more than one study to verify the diagnosis of AP, the majority underwent X-ray densitometry (77%) and biochemical analysis blood (77%), 67% x-ray of the spine, 16% blood test for markers of bone metabolism and ultrasonometry. Bone densitometry is carried out mainly in medical institutions (health care institutions) in Moscow (73%) or in MONIKI named after. M.F. Vladimirsky (17%), which is due to the lack of bone densitometers in regional medical institutions of the Moscow Region.

The estimation of the quality of diagnostics of post-menstrual osteoporosis in the Moscow region from the results of a questionnaire study

The present questionnaire study including female residents of the Moscow region (MR) above the age of 55 years with the confirmed diagnosis of post-menopausal osteoporosis (OP) was designed to obtain an insight into the procedure employed to diagnose post-menopausal OP, categories of specialists involved in diagnostics of this condition, and the methods they use for the purpose. The results of the study indicate that 57.4% of the patients with OP in the first place applied for advice in connection with this disease to an endocrinologist, 19.7% to an orthopedist-traumatologist, 13.% to a rheumatologist, and 4.9% to a neurologist The endocrinologists referred such patients for bone densitometry and made the diagnosis of post-menopausal osteoporosis in 79% and 70% of the cases respectively. Only a small fraction of orthopedists-traumatologists and rheumatologists practicing in the Moscow region are engaged in diagnostics of post-menopausal osteoporosis as a part of their major activities. At the same time, therapists, gynecologists, and general practitioners do not practically encounter the patients complaining of post-menopausal OP. 38%, 30% and 28% of the respondents reported to have applied to two, three, and one physicians respectively to have the diagnosis of this condition confirmed. However, in the majority of the cases the period from the first visit to a specialist until the establishment of the definitive diagnosis was as long as 1 year (39%). The diagnosis of OP in a small number of the patients was made with the use of a single method, e.g. X-ray densitometry (12%), ultrasonometry (4%), and X-radiography of the skeletal bones (2%). The remaining patients were examined by more than one method; most of them had the primary diagnosis verified by means of X-ray densitometry (77%), blood biochemical analysis (77%), X-radiography of the spinal column (67%), and either by the detection of the serum bone turnover markers or ultrasonometry (16%). The majority of densitometric procedures were performed based at the Moscow Therapeutic and Prophylactic Department and M.F. Vladimirsky Moscow Regional Research Clinical Institute (73% and 17% respectively) for the lack of densitometers in the local medical facilities of the Moscow region.

Text of scientific work on the topic “Assessing the quality of diagnosis of postmenstrual osteoporosis in the Moscow region according to a questionnaire survey of patients”

Evaluation of the quality of diagnosis of postmenopausal osteoporosis in the Moscow region according to a questionnaire survey of patients

Prof. A.V. DREVAL, Ph.D. L.A. MARCHENKOVA, E.A. GRIGORIEV*

The estimation of the quality of diagnostics of post-menopausal osteoporosis in the Moscow region from the results of a questionnaire study

A.V. DREVAL, L.A. MARCHENKOVA, E.A. GRIGORIEVA

State Institution Moscow Regional Research Clinical Institute named after. M.F. Vladimirsky; Moscow Regional Center for Osteoporosis

Using a questionnaire survey of residents of the Moscow Region (MO) over the age of 55 years with a confirmed diagnosis of postmenopausal osteoporosis (OP), we studied the procedure for establishing the diagnosis of postmenopausal OP in the Moscow Region, the main range of specialists involved in the diagnosis of postmenopausal OP, and the diagnostic methods they use. The results of the survey of patients showed that 57.4% of them consulted an endocrinologist for the first time regarding AP, 19.7% - to an orthopedic traumatologist, 13.1% - to a rheumatologist and 4.9% - to a neurologist. Endocrinologists referred patients for bone densitometry in 79% of cases, and they also diagnosed postmenopausal AP in 70% of cases. Only a small part of orthopedic traumatologists and rheumatologists in the Moscow Region are involved in diagnosing postmenopausal AP as part of their main activities; therapists, general practitioners and gynecologists practically do not do this. Although the majority of patients had to see only two (38% of respondents), three (30%) or one doctor (28%) to confirm the diagnosis of AP, in most cases it took up to 1 year from the time of the first visit to a specialist to the diagnosis of AP ( 39%). In a small proportion of patients, the diagnosis of AP was based on examination by only one method: in 12% of cases, only X-ray densitometry was used, in 4% - ultrasonometry, and in 2% - radiography of skeletal bones. Of the remaining patients who underwent more than one study to verify the diagnosis of AP, the majority underwent X-ray densitometry (77%) and a biochemical blood test (77%), 67% - spinal radiography, 16% - a blood test for markers of bone metabolism and ultrasonometry. Bone densitometry is carried out mainly in medical institutions (health care institutions) in Moscow (73%) or in MONIKI named after. M.F. Vladimirsky (17%), which is due to the lack of bone densitometers in regional medical institutions of the Moscow Region.

Key words: osteoporosis, quality of medical care, diagnosis.

The present questionnaire study including female residents of the Moscow region (MR) above the age of 55 years with the confirmed diagnosis of post-menopausal osteoporosis (OP) was designed to obtain an insight into the procedure employed to diagnose post-menopausal OP, categories of specialists involved in diagnostics of this condition, and the methods they use for the purpose. The results of the study indicate that 57.4% of the patients with OP in the first place applied for advice in connection with this disease to an endocrinologist, 19.7% to an orthopedist-traumatologist, 13.% to a rheumatologist, and 4.9% to a neurologist The endocrinologists referred such patients for bone densitometry and made the diagnosis of post-menopausal osteoporosis in 79% and 70% of the cases respectively. Only a small fraction of orthopedists-traumatologists and rheumatologists practicing in the Moscow region are engaged in diagnostics of post-menopausal osteoporosis as a part of their major activities. At the same time, therapists, gynecologists, and general practitioners do not practically encounter the patients complaining of post-menopausal OP. 38%, 30% and 28% of the respondents reported to have applied to two, three, and one physicians respectively to have the diagnosis of this condition confirmed. However, in the majority of the cases the period from the first visit to a specialist until the establishment of the definitive diagnosis was as long as 1 year (39%). The diagnosis of OP in a small number of the patients was made with the use of a single method, e.g. X-ray densitometry (12%), ultrasonometry (4%), and X-radiography of the skeletal bones (2%). The remaining patients were examined by more than one method; most of them had the primary diagnosis verified by means of X-ray densitometry (77%), blood biochemical analysis (77%), X-radiography of the spinal column (67%), and either by the detection of the serum bone turnover markers or ultrasonometry (16%). The majority of densitometric procedures were performed based at the Moscow Therapeutic and Prophylactic Department and M.F. Vladimir-sky Moscow Regional Research Clinical Institute (73% and 17% respectively) for the lack of densitometers in the local medical facilities of the Moscow region.

Key words: osteoporosis, the quality of medical care, diagnostics.

Osteoporosis (OP) is one of the most important modern problems healthcare due to the high prevalence and severity of its complications - low-energy fractures proximal part hips, vertebrae and forearms. In Russia, AP is detected on average in 30.5-33.1% of women and in 22.8-24.1% of men over 50 years of age, which

is more than 10 million people. Thus, in our country, approximately every third woman and fifth man age group OP suffer.

AP leads to huge social and economic losses in all countries of the world. In Europe, for example, the number of disabilities as a result

*e-mail: [email protected]

complications of AP are greater than with cancer (with the exception of lung cancer), and are comparable to those with rheumatoid arthritis, bronchial asthma And arterial hypertension. In Europe, 179,000 men and 611,000 women experience proximal fractures each year femur against the background of AP, and the cost of associated therapy is estimated at 25 billion euros. The duration of hospitalization for women over 45 years of age suffering from postmenopausal AP in European countries is significantly higher than for diabetes mellitus, myocardial infarction and breast cancer.

Despite this, the OP is still not recognized in Russia socially significant disease, medical specialties within which it is recommended to deal with this problem have not been identified (except for rheumatologists and general practitioners), the network of OP offices is poorly developed, there is a lack of equipment for assessing the level of bone mineral density (BMD), etc. As a result, there is no screening and early densitometric diagnosis of AP in risk groups, and in the vast majority of patients with AP, most of whom are postmenopausal women, the diagnosis is established only at the stage of complications.

The purpose of the study is to study, based on a questionnaire survey of patients, the existing procedure and duration of diagnosis of postmenopausal AP in the Moscow region (MO), to assess the main range of specialists involved in the diagnosis of postmenopausal AP and the diagnostic methods they use in order to outline possible ways to improve medical care relevant patients.

Material and methods

The work was carried out in Moscow regional center EP on the basis of the Department of Therapeutic Endocrinology of the State University MONIKI named after. M.F. Vladimirsky. The study group was formed from residents of the Moscow Region over the age of 55 years, postmenopausal for 5 years or more with a confirmed diagnosis of postmenopausal AP according to X-ray densitometry (T-criterion<-2,5 в позвоночнике и/или проксимальном отделе бедра). В 43% обращений диагноз ОП был установлен после проведения рентгеновской абсорбциометрии в МОНИКИ им. М.Ф. Владимирского, в 30% случаев - в лечебно-профилактических учреждениях (ЛПУ) МО, 27% женщин, проживающих в различных регионах МО, в связи с отсутствием рентгеновских денситометров в ЛПУ МО были направлены специалистами в ЛПУ Москвы для проведения обследования и верификации диагноза.

The study did not include patients suffering from secondary forms of AP and severe co-

accompanying somatic or psychiatric pathology, the presence of which could affect the results of the survey.

Women who met the inclusion criteria were asked to answer a questionnaire on the quality of diagnosis of postmenopausal AP, developed at the State Institution MONIKI named after. M.F. Vladimirsky. The questionnaire consisted of 19 items, 9 of which had suggested answer options - “yes”, “no”, “I don’t know” or ready-made answers, and 10 - required respondents to fill out freely.

Survey questions:

1. In what year were you first diagnosed with AP?

2. What associations does the word “OP” evoke for you?

3. Have you heard about AP before this diagnosis was made to you?

4. Before the diagnosis of AP, did any of the doctors tell you that you were at high risk of developing AP?

5. Are you now interested in information about the OP’s problem? What sources of information do you trust most?

6. Are there classes (schools) on the prevention of AP in your area?

7. Do you think it is important to prevent bone fractures in yourself?

8. Which specialist did you first contact about AP or which specialist first recommended that you be examined about AP?

9. How long did it take from the first visit to the doctor until the diagnosis of AP was confirmed?

10. How many specialists did you have to consult to confirm the diagnosis of AP?

11. What specialty doctor diagnosed AP?

12. In which institution was the diagnosis of AP made?

13. What examinations were performed on you to confirm the diagnosis of AP?

14. Have you ever undergone a densitometric examination? What specialty did the doctor refer you to? How much did you pay for the research?

The questionnaire was provided to women in printed form and filled out by them with their own hands without the participation of researchers; instructions for completion were given in the questionnaire. All study participants gave their written consent to use the data obtained for scientific work.

Questionnaires that were more than 50% complete were included in the statistical analysis. As a result, the study group included 362 women from 17 districts and urban units of the Moscow Region, whose average age was 65 years (59; 70 years), the duration of the postmenopausal period was 16 years (10 years; 21.5 years), the duration of the disease with postmenopausal AP from the moment of diagnosis verification 5 years (2 years; 9 years).

Statistical processing of the obtained data was carried out in the Microsoft Statistica 6.0 program using nonparametric statistical methods. The average values of all indicators are presented as medians and quartiles (25%;75%). To compare the significance of differences in dependent samples, adjusted for multiple comparisons, the Wilcoxon test was used; the values of ^ were considered statistically significant.<0,05.

Results

To verify the diagnosis of AP, respondents had to receive consultation from 1 to 5 specialists (on average 2 (1;3) specialists). Although the majority of patients consulted only two (38% of respondents), three (30%) or one doctor (28%) to confirm the diagnosis, from the time of the first visit to the doctor until the diagnosis of AP was made, in most cases it took up to 1 year (39% ) (Fig. 1). In only 4% of cases, the diagnosis of AP was established within 1 week, in 29% - within 1 month, and in 28% of women, from the moment of the first visit to the doctor until the diagnosis was verified, it took from 1 to 8 years (Fig. 2).

More than half of the patients first consulted an endocrinologist (57.4%) regarding symptoms of AP, and much less often - an orthopedist-traumatologist (19.7%), a rheumatologist (13.1%) and a neurologist (4.9%). It is endocrinologists who are most often the first to recommend

Rice. 1. The number of specialists whom patients had to consult to verify the diagnosis of postmenopausal AP.

less from from

weeks weeks months to to month of year

Patients were advised to undergo bone densitometry (in 79% of cases), less often this was done by orthopedists-traumatologists (2%), neurologists (2%) and doctors of other specialties (17%) (Fig. 3).

As a result, in the vast majority of cases, the diagnosis of AP was made by an endocrinologist (70%) and, with a much lower frequency, by an orthopedic traumatologist (13%), a neurologist (6%), a rheumatologist (4%) and other specialists, in particular radiologists (8% ).

In a small proportion of patients, the diagnosis of AP was based on examination using only one method: in 12% of cases, doctors from the Moscow Region used only X-ray densitometry to verify the diagnosis of AP, in 4% - ultrasonometry, and in 2% - radiography of skeletal bones (Fig. 4). Of the remaining patients who underwent more than one study to verify the diagnosis of AP, 77% were recommended x-ray densitometry, the same number of patients - a biochemical blood test, 67% of patients - spinal radiography, with the same frequency (16% of cases) - blood test for markers of bone metabolism and ultrasonometry.

Most of the women surveyed (73%) had bone densitometry performed in Moscow medical institutions, 17% - in MONIKI named after. M.F. Vladimirsky and 10% - in health care facilities of the Moscow Region. Considering that at the time of the survey there was not a single X-ray densitometer in the district health care facilities of the Moscow Region, these examinations were obviously carried out on mobile X-ray densitometers for studying the bones of the forearm, temporarily installed in the districts as part of screening programs. Only for 30% of patients the study was carried out free of charge - at the expense of compulsory medical insurance on the basis of MONIKI named after. M.F. Vladimirsky (17%) or locally as part of screening examinations (13%); 38% of patients paid less than 500 rubles for bone mineral density testing, 19% - from 500 to 1000

Endocrinologist Orthopedist-traumatologist Neurologist

Doctors of other specialties

Rice. 2. The time it took from the first visit to the doctor to the diagnosis of postmenopausal AP.

Rice. 3. The doctor who first referred the patient for a densitometry study.

X-ray of the spine

Biochemical blood test

Biochemical markers of bone metabolism

X-ray bone densitometry

Bone ultrasonomegria

□ % of the number of responses ] 16.0% □ % of the number of respondents

■% of respondents who indicated only this answer

Rice. 4. Examinations that were performed on patients to confirm the diagnosis of postmenopausal AP.

rub. and 13% - more than 1000 rubles. The average cost of X-ray densitometry for patients was 700 rubles. (400; 1100 rubles).

Discussion

The duration of diagnosis (up to 1 year, in most cases) can be explained by the fact that patients needed to receive consultations from up to 5 specialists before the correct diagnosis was established, and the study verifying the diagnosis of AP is carried out in a limited number of diagnostic and treatment institutions - for residents Moscow Region free of charge at MONIKI (the only X-ray densitometer at the Moscow Region at the time of the study for studying the axial skeleton) and for a fee at medical facilities in Moscow.

Currently, there are 167 X-ray densitometers operating throughout the Russian Federation, 86 (52%) of them are in medical facilities in Moscow. Thus, the equipment in Moscow is 8.6 devices per 1 million population, and in the country - 0.6 per 1 million population

The Moscow Region currently has only 3 stationary X-ray densitometers and, if we take European standards as a standard (11 devices per 1 million), then this is extremely insufficient to ensure high-quality, timely diagnosis of AP in a region with a population of more than 7 million people. In the USA, the equipment with bone densitometers is 40 devices per 1 million people. However, it should be emphasized that densitometric examination of postmenopausal women is justified from an economic point of view only when the issue of prescribing treatment for AP cannot be decided unambiguously based on an initial assessment of risk factors for fractures

For example, using a special Internet program FRAX (http://www.shef.ac.uk/FRAX/). In this case, bone densitometry of the spine

and hips should only be used to confirm the diagnosis of AP in patients with an average (uncertain) risk of fractures (in most countries this is 10-20% of the absolute 10-year risk of all fractures). Unfortunately, FRAX has not yet become widespread in our country, where the risk of fractures in patients is either calculated very approximately using simple questionnaires, or is not calculated at all and therefore bone densitometry is unjustifiably often used, which entails unreasonable material expenses for patients and the state .

Delayed diagnosis of AP may also be due to the fact that there is no mandatory follow-up of persons with AP or persons who have suffered a pathological fracture due to AP, and also the principles of interdisciplinary interaction and continuity of primary care physicians and specialists in the treatment of patients with bone pathology have not been developed; Doctors in clinics generally do not have experience in the clinical use of densitometry methods and are not familiar with the specifics of biochemical blood parameters, the choice of treatment regimens and the prevention of AP. A previously conducted analysis in Russia of the provision of outpatient care to patients with AP showed that even doctors who attended thematic improvement seminars on the problem of AP do not always take responsibility for deciding on the tactics of managing patients with AP.

Ignoring or underestimating the problem of OP is typical not only for Russia, but also for many other countries. A study by the Worldwide AP Foundation, conducted in 11 countries, showed that doctors do not warn women of menopausal age about the risk of developing AP. The majority of patients who have already experienced low-energy fractures are not referred for diagnostic studies to verify the diagnosis of AP, and 80% of patients with a high risk of subsequent

For fractures with minimal trauma, antiresorptive therapy is not prescribed. The combination of these factors leads to the fact that diagnosis and treatment of the disease begins after the occurrence of complications of AP - fractures of various locations.

The results of the study showed that in the Moscow Region, endocrinologists are mainly involved in the management of patients with postmenopausal AP. Most patients turn to them, they recommend a specific examination and ultimately verify the diagnosis. Only a small part of orthopedic traumatologists and rheumatologists in the Moscow Region engage in OP as part of their main activities. It should be noted that radiologists, who, according to the data obtained, diagnosed AP in 8% of cases, can only describe radiographs and give an opinion on the presence of pathological changes and compression fractures, after which a mandatory consultation with a clinician is necessary. It is possible that such a high percentage of diagnosis of AP by radiologists is due to the fact that the data were obtained from a survey of patients with AP who do not have a medical education, who probably do not see the difference between the verified diagnosis and the radiologist’s conclusion.

Similar data were obtained as a result of a survey of doctors from the Moscow Region, conducted in 2006-2008: 89.3% of endocrinologists, 85.7% of rheumatologists, 60% of neurologists are involved in the management of patients with AP as part of their main activities, and primary care doctors are practically not involved. At the same time, it is the endocrinologist in the Moscow Region who is the main specialist whose consultation doctors recommend to patients to verify the diagnosis of AP and prescribe therapy; endocrinologists also provide the largest flow of patients for densitometric examination. In Europe and the USA, general practitioners and family doctors identify people with risk factors for AP, refer them to specialists for specific examinations, and monitor patients receiving anti-osteoporotic therapy. In Russia, there is now also a tendency to expand the scope of activity of therapists and family doctors in this direction; in particular, it is recommended to implement long-term treatment of AP, but at the same time, diagnosis and choice of treatment regimen is carried out by “narrow” specialists - rheumatologists, endocrinologists and others (order of the Ministry of Health and Social Development of the Russian Federation of May 4, 2010 No. 315n: “by local therapists, general practitioners (family doctors) treat patients suffering from primary AP (postmenopausal and senile), receiving therapy on the recommendation of a specialist doctor).”

It is noteworthy that in the Moscow Region, the management of patients with an established diagnosis of postmenopausal AP and receiving antiresorptive therapy is practically not carried out by therapists, general practitioners and family doctors, which, taking into account the recommendations of the Ministry of Health and Social Development of the Russian Federation, requires correction. In particular, it is planned to continue to conduct cycles/training schools for primary care physicians on the diagnosis and treatment of AP on the basis of the Department of Endocrinology of the Faculty of Internal Medicine of MONIKI.

As the results of this study show, verification of the diagnosis of AP using dual-energy X-ray densitometry is carried out mainly in Moscow (in medical institutions or in MONIKI), which is due to the lack of bone densitometers in regional medical institutions of the Moscow Region. Thus, optimization of early diagnosis of postmenopausal AP is impossible without the widespread implementation of screening programs to identify groups at high risk of fractures, provision of accessible densitometric examination of postmenopausal women with risk factors for fractures, and advanced training in AP for general practitioners and family doctors. These measures will make an important contribution to the healthcare economy of the Moscow Region (by reducing the costs of treatment and rehabilitation of patients with osteoporotic fractures) and will increase the quality and life expectancy of patients with postmenopausal AP.

Conclusion

According to a survey of patients with postmenopausal AP in the Moscow Region, 57.4% of them turn to an endocrinologist for the first time about AP, and much less often to an orthopedic traumatologist (19.7%), a rheumatologist (13.1%) and a neurologist ( 4.9%). It is endocrinologists in the Moscow Region who most often refer patients for bone densitometry (in 79%) and ultimately establish a diagnosis of postmenopausal AP (in 70%). Although the majority of patients had to contact only two (38% of respondents), three (30%) or one (28%) doctors to confirm the diagnosis of AP, from the time of the first visit to a specialist until the diagnosis of AP is established, in most cases it takes up to 1 year ( 39%). In the provision of medical care to patients with AP, it is necessary to increase the role of primary care doctors, who are currently practically not involved in the management of patients with AP in the Moscow Region. To improve quality and minimize the time from the first visit to a doctor to the diagnosis of postmenopausal AP, it is necessary to conduct cycles/schools of training for primary care physicians in the diagnosis and treatment of AP. Verification of the diagnosis of AP using dual-energy X-ray densitometry is carried out mainly in medical institutions in Moscow

(73%) or at MONIKI named after. M.F. Vladimirsky (17%), which is due to the lack of bone densitometers in regional medical institutions of the Moscow Region. The Moscow Region currently has only 3 stationary X-ray densitometers, and if we take European standards as a standard (11 devices per 1 million population), this is extremely insufficient to ensure high-quality, timely diagnosis of AP in a region with a population of more than 7 million.

Concept and design of the study: A.V. Dre-val, L.A. Marchenkova.

Collection and processing of material: E.A. Grigorieva.

Statistical data processing: E.A. Grigorieva.

Text writing: E.A. Grigorieva, L.A. Marchenkova.

Editing: A.V. Dreval, L.A. Marchen-kova.

LITERATURE

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Osteoporosis (OP) is a systemic skeletal disease from the group of metabolic osteopathies, which is characterized by a decrease in bone strength and an increased risk of fractures. Bone strength reflects the integration of two main characteristics: bone mineral density and bone quality (architecture, turnover, damage accumulation, mineralization).

As numerous epidemiological studies have shown, there is not a single race, nation, ethnic group or country in which AP does not occur: it is detected in 75 million people living in the United States, European countries and Japan combined. One in three menopausal women and more than half of those aged 75-80 years suffer from AP. The incidence of AP increases with age, so the increase in life expectancy in recent decades in developed countries and, accordingly, the increase in the number of older people, especially women, leads to an increase in the incidence of AP, making it one of the most important health problems worldwide.

The social significance of osteoporosis is determined by its consequences - fractures of the vertebrae and bones of the peripheral skeleton, causing a significant increase in morbidity, increased disability and mortality among the elderly, which, accordingly, results in large material costs in the field of healthcare. Among the urban population of Russia, 24% of women and 13% of men aged 50 years and older have at least one clinically significant fracture. The annual incidence of proximal femur fractures among the population aged 50 years and older in Russia averages 105.9 per 100 thousand population of the same age; the frequency of fractures of the distal forearm is 426.2/100 thousand population. Single studies of the prevalence of vertebral fractures have shown that this figure ranges from 7.2 to 12% in men, and from 7 to 16% in women.

The most severe medical and social consequences of AP are caused by fractures of the proximal femur. Thus, mortality during the first year after a fracture in various cities of Russia ranged from 30.8 to 35.1%, with 78% of survivors a year later and 65.5% after two years still needing constant care.

These data indicate the importance of carrying out preventive measures in order to reduce the incidence of AP, its timely diagnosis and prescribing therapy to prevent the occurrence of fractures.

Numerous studies have convincingly demonstrated that bone mass is the main determinant of the mechanical properties of bone tissue and determines up to 75% of its strength, so bone densitometry - a measurement of bone mineral density (BMD) - can serve as a predictor of fracture. The risk of developing a fracture increases with age, and the high incidence of fractures in older people is mainly due to low BMD. In 1994, a group of WHO experts formulated diagnostic criteria for osteoporosis, based on quantitative assessment of BMD in various areas of the skeleton. According to these criteria, osteoporosis is defined as a decrease in BMD of 2.5 standard deviations or more from the average BMD for a young adult.

During a densitometric examination of persons aged 50 years and older in Russia in accordance with WHO criteria, AP was detected in 30.5-33.1% of women and in 22.8-24.1% of men, thus, when recalculated for the population country (145,167 thousand people, according to the 2002 census), about 10 million Russians suffer from osteoporosis.

There is no specific early diagnosis for osteoporosis other than existing fractures. However, mass osteodensitometry is impossible due to limited access to this study, as well as economic infeasibility. For these reasons, knowledge and consideration of risk factors when diagnosing and organizing the prevention of osteoporosis are of particular importance.

Currently, proven risk factors include: gender, age, body weight, heredity, history of fractures, hypogonadism, taking glucocorticoids, low physical activity, smoking, insufficient calcium intake, vitamin D deficiency, alcohol abuse. Thus, women have a higher risk of developing AP, which is associated with hormonal status, as well as smaller bone size and overall lower bone mass. In addition, women lose bone mass faster and in greater amounts due to menopause and longer life expectancy: bone loss in women is 0.86-1.21% at different sites of the skeleton, while in men only 0 .04-0.90%. A decrease in BMD begins at 45-50 years of age, but a significant increase in the risk of osteoporosis has been identified from 65 years of age. Therefore, age 65 years or older should be considered a predictor of bone fractures. It should be noted that even such a factor as low BMD correlates with age. For example, a 55-year-old person with low BMD has a significantly higher risk of developing osteoporosis than a 75-year-old person with the same BMD.

Weight loss or low body mass index (BMI) are indicators of low BMD (low BMI is considered< 20 кг/м 2 , или вес тела менее 57 кг) . Имеет значение и потеря массы тела более чем на 10% от веса в возрасте старше 25 лет .

People with a family history of osteoporosis have lower BMD. This is thought to be due to low peak bone mass running in families. Moreover, the family history includes not only the diagnosis of osteoporosis itself, but also the presence of kyphosis and fracture with minimal trauma in first-degree relatives after the age of 50 years. The presence of previous fractures associated with minimal trauma is associated with the risk of fractures in both postmenopausal women and men over the age of 65 years. People with a fracture of any location have a 2.2 times higher risk of a subsequent fracture than people without a previous fracture.

At the same time, the number and location of fractures have prognostic significance. Thus, previous vertebral fractures increase the risk of subsequent fractures by more than 4 times, and are also predictors of fractures in other locations, including the femoral neck.

Risk factors for osteoporosis include deficiency of sex hormones in both women and men. For example, women with early (before age 45) menopause have a higher risk of developing osteoporosis than women with late menopause.

Low physical activity is a risk factor for osteoporosis. Lack of constant physical activity can lead to bone loss.

Smoking is a significant risk factor for the development of osteoporosis. BMD in smokers is 1.5-2 times lower than in non-smokers. Women who smoke are significantly more at risk of hip fractures than non-smokers.

Among the factors influencing the formation of the human skeleton, an important place is occupied by good nutrition with sufficient intake of calcium and vitamin D. It has been proven that a sufficient amount of calcium from food reduces the risk of fractures. According to other sources, there was a significant connection between milk consumption and higher BMD in premenopausal women aged 45-49 years. Research into the relationship between calcium intake and bone health has shown that calcium slows age-related bone loss and may reduce the risk of bone fractures. A positive effect on the condition of bone tissue is exerted by both additional calcium intake from food and drug support with calcium preparations.

Vitamin D is necessary to ensure calcium absorption and metabolic processes in bone tissue. With age, there is a decrease in the level of vitamin D in the blood serum, progression of renal failure, a decrease in time spent in the sun and a decrease in the skin's ability to produce vitamin D, which leads to secondary hyperparathyroidism, which, in turn, entails an increase in bone metabolism and development osteoporosis. Other significant risk factors for osteoporosis and related fractures include alcohol abuse (alcoholism). Currently, there are isolated studies confirming the negative effect of alcohol on bone tissue formation even when consuming low doses of alcohol (up to 30 ml of strong drinks per day), which is apparently associated with impaired absorption of calcium and vitamin D. In addition, with Alcohol abuse increases the tendency to fall, which means the risk of bone fractures increases.

We must not forget that a number of diseases and conditions, as well as taking certain medications, can also cause osteoporosis. Secondary osteoporosis can be divided into two broad groups: osteoporosis due to an underlying disease, such as rheumatoid arthritis, and osteoporosis resulting from treatment (iatrogenic). Thus, systemic use of glucocorticoids for more than 3 months is one of the key risk factors for osteoporosis.

It should be emphasized that the combination of several risk factors for osteoporosis and fractures has a cumulative effect: as their number increases, the risk increases. For example, if a patient has low BMD and a history of fractures associated with minimal trauma, or the patient is over 65 years of age and has low BMD, then the risk of osteoporotic fractures is significantly increased and appropriate therapy should be given first priority to this patient. The presence of several risk factors in one patient should be taken into account when determining the priority for osteodensitometry.

The International Osteoporosis Society has proposed a screening questionnaire, the completion of which allows you to identify individuals who have an increased risk of developing osteoporosis. This questionnaire (Fig.) is filled out by the patient independently. Analysis of risk factors is considered as the initial link in the diagnosis of AP. Preventive treatment should be started in postmenopausal women who have 2 or more risk factors for osteoporosis.

Prevention of bone loss requires two approaches: healthy lifestyle promotion and pharmacological intervention.

Initially, prevention is based on modification of risk factors. Primary prevention measures include weight correction, smoking cessation, limiting alcohol consumption, an active lifestyle and exercise, and sufficient calcium intake from food or in the form of pharmacological preparations in combination with vitamin D.

The fundamental principle of preventing and treating osteoporosis is adequate intake of calcium and vitamin D. Adequate dietary intake of calcium helps maintain adequate bone density. In addition, calcium enhances the antiresorptive effect of estrogens on bone. Low intestinal calcium absorption and decreased calcium intake with age are associated with an increased risk of fractures. Calcium absorption is similar from most foods, but is significantly reduced from foods rich in oxalic acid, with the exception of soy. To minimize side effects and improve absorption, calcium supplements should be taken during or after meals. The most common side effects that occur are flatulence and constipation. These problems are more common with carbonate and less common with citrate. With normal renal function, calcium intake in doses up to 2500 mg does not contribute to hypercalcemia and stone formation. Taking calcium supplements on an empty stomach may increase the risk of kidney stones. Research shows that calcium citrate is better absorbed than calcium carbonate. The absorption of calcium carbonate is reduced with a single dose of more than 600 mg of ionized calcium, so it must be administered in several doses. A contraindication for the use of calcium supplements is hypercalciuria (urinary calcium excretion of more than 300 mg/day), which is not controlled by thiazides. For most women, calcium and vitamin D supplements can be safely prescribed indefinitely.

Vitamin D is essential for sufficient calcium absorption and normal bone metabolism. Vitamin D synthesis is carried out under the influence of ultraviolet rays and depends on skin pigmentation, the geographic zone in which the region is located, day length, time of year, weather conditions and the area of skin not covered by clothing. Another important source of vitamin D is food. Fatty fish such as herring, mackerel, and salmon are especially rich in it. Dairy products and eggs contain small amounts of vitamin D.

Studies examining the effectiveness of combined calcium and vitamin D supplementation have shown a slower rate of bone loss and a reduction in the incidence of fractures. Thus, in elderly women living in nursing homes, taking calcium (1200 mg) and vitamin D (800 IU) for 18 months reduces the risk of hip fracture by 43% and the risk of any non-vertebral fractures by 32%, and also increases BMD in the proximal femur by 2.7%. This effect may be lost when calcium and vitamin D are discontinued. Prescribing calcium with vitamin D for three years in postmenopausal women resulted in a 27% reduction in the relative risk of hip fracture.

There is no evidence that active people under 65 years of age need vitamin D supplementation, but patients over this age should receive at least 400 IU of vitamin D per day. In cases where there is a possibility of developing vitamin D deficiency (patients who lead a sedentary lifestyle or do not leave the house) or it is laboratory confirmed, the recommended dose of vitamin D is 800 IU per day. This combination of calcium (600 mg) and vitamin D3 (400 IU) corresponds to the complex drug natecal D3 (1-2 tablets per day).

In addition, calcium and vitamin D supplements should be considered an essential component of any osteoporosis treatment regimen.

Treatment of osteoporosis is a difficult task, since it is diagnosed quite late, when there are already fractures of various locations. Therapy for OP should be long-term, since the effect may appear after a long time. The goal of treatment is to slow down and, if possible, stop bone loss, prevent bone fractures, improve the patient's condition, reduce pain, and improve quality of life.

Currently, to treat already developed AP and prevent the occurrence of new fractures, the entire arsenal of modern medications is used, used both as monotherapy and as part of combination therapy.

It should be emphasized that the main criterion for the effectiveness of a drug in the treatment of AP is a decrease in the incidence of new bone fractures during 3-5-year follow-up and an increase in BMD, determined using bone X-ray densitometers.

The general mechanisms of action of antiresorptive agents to reduce the risk of fractures are aimed at reducing bone resorption and promoting new bone formation. It is believed that increasing BMD in the spine by 8% or in the hip by 5% reduces the risk of vertebral fractures by approximately 50%, non-vertebral fractures by 35%. Some drugs do not provide a high increase in BMD, although they reduce the incidence of fractures. It is believed that antiresorbent agents that do not increase or only slightly increase BMD, however, reduce the risk of fractures by approximately 20-25%, probably due to a decrease in bone resorption.

Pathogenetic therapy for AP includes: drugs that slow down bone resorption - bisphosphonates, calcitonin, selective estrogen receptor modulators (SERMs), estrogens; medications that primarily enhance bone formation - parathyroid hormone, fluorides; agents that have a multifaceted effect on bone tissue are vitamin D and its active metabolites.

From the perspective of evidence-based medicine, when the effectiveness and tolerability of individual drugs is studied in blind, multicenter, randomized studies, the first-line drugs used for the treatment of osteoporosis are considered to be bisphosphonates, the high efficacy and satisfactory tolerability of which have been proven. The ability of bisphosphonates to suppress pathological bone resorption and stimulate bone formation determines their therapeutic effect in osteoporosis. The drug Fosamax (alendronate), which is a nitrogen-containing bisphosphonate, is registered in Russia. Alendronate at a dose of 10 mg/day showed high efficiency: increasing BMD from 5.4 to 13.7%, it significantly reduced the incidence of fractures of the spine (by 47%), hip (by 51-56%), and forearm (by 48%); In 64% of patients, the progression of vertebral deformities slowed down.

A comparative study of the effectiveness of alendronate 70 mg once a week with daily dosing of 10 mg showed that the increase in BMD was 6.8 and 7.4%, respectively, in the spine, and 4.1-4.3% in the hip. While there is already indisputable evidence of the effect of a dose of 10 mg/day on reducing the incidence of fractures, such data are not yet available for the use of 70 mg of the drug once a week. At the same time, it has been clearly shown that in terms of the effect on BMD of the spine, hip and whole body, the tolerability of alendronate at a dosage of 70 mg once a week is equivalent to taking 10 mg per day. Adverse effects - esophagitis, erosion, hemorrhage, reflux, gastritis, stomach ulcer, etc. - are less common when taking 70 mg of alendronate. Contraindications for alendronate therapy are hypersensitivity to the drug, hypocalcemia, and the presence of esophageal diseases.

Alendronate is prescribed 70 mg once a week, or 10 mg daily, in large courses, for 3-5 years, but the final duration of therapy with this drug has not yet been determined.

Salmon calcitonin (miacalcic) is another drug used to treat osteoporosis and prevent fractures and is available in 2 forms: 100 IU injection ampoules and 200 IU nasal spray vials.

Calcitonin is a polypeptide hormone consisting of 32 amino acids, produced mainly by parafollicular cells of the thyroid gland.

A long-term, randomized, placebo-controlled, 5-year multicenter trial (PROOF) and a 2-year trial (QUEST) demonstrated the effectiveness of 200 IU Miacalc (nasal spray) in reducing bone resorption and the risk of vertebral fractures in women with osteoporosis at 33-36 %, demonstrated good tolerability of the drug. There was no effect of calcitonin therapy on the risk of hip fracture. It is important to emphasize: myacalcic improves bone quality regardless of changes in BMD, which has been proven in studies conducted using magnetic resonance.

In accordance with the recommendations for intranasal use, the drug at a dose of 200 IU per day can be administered continuously for 3-5 years, taking into account its effectiveness, or in cyclic courses (2-3 months of treatment, 2-3 months break), although the effectiveness of the latter method needs further confirmation: the choice of such a treatment regimen is largely due to the high cost of the drug.

One of the significant advantages of miacalcic is its pronounced analgesic effect, especially in relation to bone pain.

The most common side effect of calcitonin nasal spray is irritation of the nasal mucosa. Minor nosebleeds are less common. In most cases, these adverse reactions are mild or moderate and do not require discontinuation of the drug. With parenteral administration of calcitonin preparations, side effects are observed more often: nausea or vomiting, hot flashes to the face and skin rash at the injection site. Serious complications when using nasal or parenteral forms of calcitonin are observed in less than 1% of patients. A comparative analysis of the results of using the injectable form of 100 IU and the nasal form of 200 IU revealed their equal effectiveness.

Hormone replacement therapy (HRT) significantly reduces the risk of fractures in postmenopausal AP. The use of HRT not only prevents bone loss in postmenopausal women, but also increases BMD in 95% of women. The increase in bone mass in the lumbar spine averages from 2 to 6% over 12 months. Interestingly, the effect of HRT was greater in women with lower baseline BMD and in those who had an additional risk factor for osteoporosis. According to a series of multicenter studies conducted in the United States, and especially the WHI (Women's Health Initiative) study, which included more than 16,600 postmenopausal women who received HRT for more than 5 years (8506 people) and were observed in the placebo group (8102 people), a reduction in risk hip fractures occurred in 34% of patients, spine fractures in 34%, and all fractures in 24% of the treatment group. However, in the group receiving HRT, there was an increased risk of coronary heart disease, stroke, breast cancer (the maximum risk was observed between 4-5 years of the study), and thromboembolism. Due to these side effects of drugs used during HRT, their long-term use for the treatment of osteoporosis is limited: the question of the prescription and duration of HRT is decided individually for each patient, depending on contraindications and the possible risk of complications. Its use is allowed to relieve menopausal symptoms.

In many countries, selective estrogen receptor modulators (SERMs) have been increasingly used for the prevention and treatment of postmenopausal AP over the past 3-5 years. The drug Evista (raloxifene) is registered in Russia; it is prescribed in 1 tablet. per day (60 mg), regardless of food intake or time of day, in combination with calcium and vitamin D supplements. Raloxifene has estrogen-like effects on bone tissue and lipid metabolism, but has an antiestrogenic effect on the endometrium and mammary epithelium. Raloxifene reduces the incidence of vertebral fractures by 34-50%, prevents loss of BMD in the hip and other parts of the skeleton, and reduces the risk of developing breast cancer without increasing the incidence of uterine cancer. According to a meta-analysis, raloxifene significantly increases BMD, compared with placebo, in all areas of the skeleton by 1.33-2.51%. However, the drug's ability to reduce the risk of hip and forearm fractures, as well as cardiovascular disease and mortality rates in women at risk requires further confirmation. The most serious side effect associated with raloxifene is venous thromboembolism. In addition, hot flashes to the face and cramps in the calf muscles may occur.

Raloxifene is contraindicated in persons with a history of venous thromboembolism, thrombophlebitis of the deep veins of the leg, women who can become pregnant, as well as those who have hypersensitivity to any component of the drug tablets. The use of raloxifene is considered undesirable in women with frequent hot flashes.

Drugs that stimulate bone formation include primarily parathyroid hormone (PTH), which in recent years has gained increasing recognition in the treatment of AP. Currently, there is evidence of a positive effect on bone of teriparatide, the N-terminal fragment (1-34) of human parathyroid hormone.

In a prospective, randomized, double-blind, placebo-controlled, multicenter study of 1637 postmenopausal women with vertebral fractures who received daily subcutaneous teriparatide 20 or 40 mcg or placebo for an average of 18 months, an increase in spinal BMD of 10-14% was found. , femoral neck - by 3-5%. The risk of vertebral fractures in patients receiving 20 mcg of teriparatide was reduced by 65%, and in the group receiving 40 mcg by 69%, compared with placebo. The risk of nonvertebral fractures was reduced by 53% in the 20 mcg group and by 54% in the teriparatide 40 mcg group compared with placebo. Treatment with teriparatide reduced the risk of severe vertebral fractures by 90%.

The most common side effects were dizziness, orthostatic hypotension, and leg cramps. Nausea and headache were dose-dependent and were significantly more common in patients receiving 40 mcg of teriparatide. Taking teriparatide for 2 years has been found to be effective and safe; there is no data yet regarding further use of the drug.

Fluoride preparations - sodium fluoride (ossin) and monofluorophosphate (tridine) also enhance bone formation. Research results show that fluoride preparations increase spinal BMD by 8.1% after 2 years of treatment and by 16.1% after 4 years, compared with the control group, do not affect the risk of vertebral fractures during a two- and four-year course of treatment and increase the likelihood of non-vertebral fractures during therapy carried out for 4 years. Side effects include disorders of the gastrointestinal tract (epigastric pain and nausea), the appearance of arthralgia.

The role of active metabolites in the treatment and prevention of osteoporosis is of interest. A meta-analysis conducted in 2004 including 17 randomized studies assessing the effect of active metabolites of vitamin D on BMD and the risk of fractures in primary osteoporosis showed an almost 2-fold reduction in the risk of fractures of any localization, compared with controls. However, a reduction in risk was observed for both vertebral and non-vertebral fractures.

The effectiveness of active metabolites of vitamin D in reducing the risk of hip fracture has not been proven.

Non-drug treatment methods are an essential part of the strategy for managing a patient with osteoporosis. They include educational programs, giving up bad habits, physical exercise and other physical activity, if indicated - wearing hip protectors. Physical activity programs for osteoporosis should be structured in such a way that physical activity increases in intensity, starting with low-intensity exercise. In addition, all doctors should recommend walking to patients, which helps both improve bone tissue and improve overall health. Massage is prescribed no earlier than 3-6 months after the start of drug treatment, and is carried out carefully, by stroking and rubbing, without active force pressure, especially if the spine is damaged. Manual therapy is contraindicated. If back pain persists for a long time, it is necessary to consult an orthopedist-traumatologist for further treatment and, first of all, prescribe a corset, which patients wear for a long time, at least 1-2 years.

Thus, organizing the prevention and treatment of osteoporosis in each individual patient is a rather difficult task, the successful solution of which depends both on the doctor’s correct interpretation of the patient’s condition, and on the patient’s readiness for long-term therapy, as well as awareness of the need for material costs.

For questions regarding literature, please contact the editor.

N. V. Toroptsova, Candidate of Medical Sciences
L. I. Benevolenskaya, Doctor of Medical Sciences, Professor
Institute of Rheumatology RAMS, Moscow

Patient Survey Questionnaire

The Moscow City Compulsory Medical Insurance Fund, studying the population’s attitude to reforms in the medical care system, urges you to express your opinion by answering the questions in our questionnaire.

It's easy to fill out the form. Possible answer options are given for many questions on the survey. Choose from the proposed answers the one that matches your opinion and mark it. If none of the proposed answer options suits you, write the answer yourself.

The anonymity of your answers is guaranteed!

Thank you in advance for your cooperation!

We ask you to answer questions regarding your health

1. How do you assess your health?

1. Good => go to question 3

2. Average

2. How do you explain your health? (you can provide multiple answers)

1. Age

2. Unsatisfactory environmental and sanitary conditions of the area of residence (work)

3. Work overload

4. Lack of opportunity for regular rest

5. Poor nutrition

6. Long-term conflict situation at home

7. Long-term conflict situation at work

8. Inattention to your health, bad habits

9. Inaccessibility of quality medical care

10. Hereditary predisposition

11. Consequences of the war

12. Other (write)

3. What diseases have you visited the clinic for in the last year? (you can provide multiple answers)

1. Diseases of the heart and blood vessels (coronary artery disease, hypertension, angina pectoris, myocardial infarction, atherosclerosis, arrhythmia, tachycardia, rheumatism, heart disease, strokes, varicose veins, thrombophlebitis, etc.)

2. Diseases of the digestive system (diseases of the teeth and oral cavity, esophagus, gastritis, duodenitis, enteritis, colitis, cholecystitis, cholelithiasis, pancreatitis, hepatitis, cirrhosis of the liver, peptic ulcer, hernia, etc.)

3. Diseases of the musculoskeletal system (diseases of the joints, curvature of the spine, radiculitis, osteoporosis, osteomyelitis, osteochondrosis, spinal hernia and

4. Respiratory diseases (bronchial asthma, bronchitis, pneumonia, emphysema, pneumosclerosis, allergic and vasomotor rhinitis, nasopharyngitis, sinusitis, influenza, ARVI, etc.)

5. Endocrine diseases (diabetes, thyroid diseases, hormonal disorders, etc.)

6. Diseases of the genitourinary system (gynecological diseases, prostate adenoma, prostatitis, urolithiasis, pyelonephritis, glomerulonephritis, hematuria, cystitis, etc.)

7. Diseases of the nervous system (parkinsonism, tremor, epilepsy, multiple sclerosis, migraine, etc.)

8. Ear diseases (otitis media, auditory nerve diseases, etc.)

9. Eye diseases (cataracts, glaucoma, retinal diseases, etc.)

10. Oncological diseases

11. Skin diseases (dermatitis, psoriasis, lichen, urticaria, nail diseases, etc.)

12. Mental and behavioral disorders

13. Blood diseases and immunodeficiencies

14. Injuries, burns, frostbite, poisoning and their consequences

4. Do you suffer from chronic diseases?

2. No => go to question 10

5. Are you registered with a dispensary?

6. Do you undergo an annual medical examination?

1. Don’t have => go to question 10

2. Applying now => go to question 10

3. I have group III

4. I have group II (with the right to work)

5. I have group II (without the right to work)

6. I have group I

7. Disabled childhood

8. As a result of the reform on monetization of benefits, you chose to receive:

1. Preferential medications

2. Cash compensation => go to question 10

9. Have you had any difficulties in obtaining subsidized medications?

When writing a prescription at a clinic

When receiving medicine from a pharmacy

10. Do you use the services traditional healers, homeopaths, psychics, etc.? (you can provide multiple answers)

1. Never had to before => go to question 12

2. Contacted a homeopath

5. To different healers

6. Other services (write)

11. Did this alternative treatment help you?

3. It got worse

4. I find it difficult to answer

12. In case of illness, do you turn to the Temple for help?

1. Yes, and this is my main support.

2. Yes, but I have other forms of support.

3. No, I don’t contact you

13. How do you eat?

2. Rather bad

3. Satisfactory

4. Rather good => go to question 15

5. Ok => go to question 15

6. Undecided => go to question 15

14. What do you attribute poor nutrition to? (you can provide multiple answers)

1. With financial difficulties

2. With working mode

2. No => go to question 19

16. Does your employer provide any support in obtaining medical care?

2. No => go to question 19

3. Undecided => go to question 19

17. How does your employer support you? (you can provide multiple answers)

1. Organizes medical stations

2. The enterprise has a medical facility for employees (for example, a clinic, a medical unit)

3. Provides spa treatment

4. Provides additional health insurance(in the form of voluntary health insurance)

5. Makes payment (full or partial) for medical care

6. Other (write)

18. What type of medical services were provided to you at the expense of your employer over the past year? (you can provide multiple answers)

1. Treatment in a clinic

2. Treatment in hospital

3. Treatment in medical institution enterprises

6. Dental care

7. Vaccination

8. Other (write)

9. I did not use any medical services from my employer

Please answer questions related to your contacts with the healthcare system (excluding dental care)

19. Where do you usually get treatment? (you can provide multiple answers)

1. B district clinic at the place of registration

2. In the clinic at the place of actual residence

3. In a departmental clinic

4. In paid institutions

(1 - very poor quality, 2 - bad, 3 - satisfactory, 4 - good, 5 - very good, 6 - difficult to answer):

jViii/n	1 to face wad	Nalli
jViii/n	1 to face wad	1	2	?	4	$	a
1	IVrtTOJPGYA POLNKI "PPPSN PLATE TFOPISKN
1	1 Iiigiklshshka at the place of fact*geskpi p IIROZhINGINIA
	Vsdpmstpytptaya tschtgtkshchshka
L	1G armored institutions
$	Other institutions (specify KrJKMV)

1. Never => go to question 23

3. From 2 to 5 times

4. Over 5 times

22. For what purpose did you come to the clinic? (several options can be ticked)

1. Treatment

2. Walkthrough medical examination(medical examination)

3. Getting advice

4. Obtaining certificates, directions, prescriptions and other documents

5. Other (write)

To the therapist

2. To the surgeon

3. Neuropathologist

4. To the ophthalmologist

5. Otolaryngologist

6. To the dentist

7. Radiologist

8. Cardiologist

9. To the registry

10. To no purpose

1. Never

2. Once

3. Twice

4. Four times

5. More than four times

Total number of days sick leave(write)_

25. How long does it take you to get to the clinic where you usually get treatment?

1. Up to 10 minutes inclusive

2. From 10 to 30 minutes inclusive

3. From 30 minutes to 1 hour inclusive

4. More than 1 hour

26. Is the work schedule of doctors and clinic services convenient for you?

27. How long on average after making an appointment can you get an appointment with a specialist doctor?

1. Same day

2. The next day

3. Within 2-7 days

4. Over a week

5. I generally can’t get an appointment with the right specialist.

28. How long does it take you to wait to see a doctor?

2. From 15 to 30 minutes

3. From 30 minutes to 1 hour

4. From 1 to 2 hours

5. Over 2 hours

6. Over 3 hours

29. Do you consider the duration of a medical appointment sufficient?

3. I find it difficult to answer

30. Do you think the medical workers at the clinic have sufficient qualifications?

3. I find it difficult to answer

31. Do you think medical workers carry out preventive measures(information, health education, medical examination, vaccination, etc.)?

3. I find it difficult to answer

We ask you to answer questions regarding your relationship with medical professionals

32. What are the main emotions you experience in relation to the medical workers of the clinic?

1. Sympathy

2. Trust

3. Antipathy

4. Mistrust

5. Other (write)

6. I find it difficult to answer

33. From what sources do you mainly get medical information about diseases, methods of their treatment and medications?

1. From medical workers

2. From information announcements in the clinic

3. From friends and relatives

4. From popular science literature

5. From periodicals

6. On the radio

7. On TV

8. Via the Internet

9. Other (write)

34. Tell me, do you receive enough information about the state of your health from medical workers at the clinic?

1. Too much information

2. Yes, exactly as much as needed

3. No, I would like more

1. Complete trust and mutual understanding

2. Partial trust and understanding

3. Lack of any trust and mutual understanding

4. I find it difficult to answer

36. Do you understand what the doctor explains?

1. Yes, completely => go to question 38

2. Only partially

3. Nothing is clear

37. What makes it difficult to understand the explanations of medical workers?

1. They use too many complex, technical terms

2. They speak incomprehensibly, quickly, do not repeat or clarify anything that is not clear.

3. They don’t explain, but write illegibly

4. Other (write)

5. I find it difficult to answer

38. When conducting an examination and prescribing treatment for you, the doctor takes into account your state of health, previous diseases and operations, age, etc.?

2. When and how

39. Do you think the doctor listens to your complaints carefully?

40. How do you assess the professional qualities of your doctor? Rate the following qualities on a scale of 1 to 5

(1 - very bad, 2 - bad, 3 - satisfactory, 4 - good, 5 - very good, 6 - difficult to answer):

rowspan=2 bgcolor=white>11|i:n)n"i"ion of quality

No. n/a	Iza.t.it
No. n/a	1	2	3	4	S	6
1	Kompstsi gp that is, prof"itsiot niches
2	Spґ) і in singing professional
3	The consequences of treatment
4	And I sewed the approach
	L my i and fi.ii tsi i failure Hitvi"i t. (11 t>I"tuk.tvie nіn working Jvkviv")

41. What words do you think can most accurately describe your doctor:

1. Doctor-guardian (all decisions are made by the doctor without asking the patient’s opinion)

2. Persuading doctor (the doctor offers a choice of plan, treatment methods, medications and convinces of the need to choose one or another method)

3. A doctor who builds his relationship with the patient on mutual trust and consent (the patient’s role is passive, the doctor conveys to the patient only the information necessary in his opinion)

4. A doctor-informant who provides the patient with the necessary information and complete freedom of choice upon his request.

5. Other (write)

42. Is the doctor involved in your problems, does he empathize with you?

2. When and how

43. Do you talk to your doctor about personal topics?

44. Describe your condition, which most often occurs after visiting a doctor?

1. There is optimism, a feeling of support, understanding, trust

2. Nothing changes

3. Pessimism, dejection, and concern appear

45. How long have you been seeing your doctor?

1. Less than a year

2. From 1 to 3 years

3. From 3 to 5 years

4. More than 5 years

46. In your opinion, is there a difference in the attitude of doctors towards different groups patients (men and women, young and old, etc.)?

2. No => go to question 48

3. Difficult to answer => go to question 48

47. Which group of patients are doctors more attentive to?

1. Yes, always => go to question 50

49. Why don’t you follow your doctor’s orders?

1. I don’t trust the doctor

2. I don’t trust official medicine

3. I do not agree with the methods and medications chosen for treatment

4. I don’t like taking medications.

5. I don’t believe in the possibility of recovery.

6. There is not enough money for medicines

7. It’s not entirely clear what needs to be done

8. Because of your own laziness

9. Other (write)

10. I find it difficult to answer

50. What actions do you take if you do not agree with the doctor’s recommendations?

1. I don’t take any action, I do what I’m told

2. I explain my position to him.

3. I don’t say anything, I just don’t do them.

4. I accuse him of incompetence.

5. I turn to another specialist

6. Other (write)

51. Does it happen that a doctor does not carry out what you think are necessary diagnostic or therapeutic procedures?

1. Yes, quite often

2. Yes, sometimes

3. No, never

52. If you have any adverse reaction on the received medicinal product Who will you contact first?

1. To relatives

2. To friends or neighbors

3. See your doctor

4. To your friend’s doctor

5. Other (write)

Yes

3. I find it difficult to answer

54. Have you encountered medical errors?

1. Yes, often

2. Yes, sometimes

3. No, never

55. Do you have conflicts with medical workers?

1. Yes, all the time

1. With representatives of the clinic administration

2. With doctors

3. With nurses

4. With nurses

5. With reception staff

6. With everyone equally

57. What was the main reason for the conflict?

1. Inability to get an appointment with another doctor

2. Violation of medical ethics

3. Doctor making decisions without my consent

4. An attempt by the doctor to obtain personal material gain

5. Reluctance to prescribe a number of diagnostic and/or therapeutic procedures

6. Failure to disclose information about my health condition, disease or treatment

7. Medical error

8. Other (write)

58. What qualities of a doctor are most important to you?

1. Attentiveness and compassion for the patient

2. Communication skills

3. Qualification

6. The prestige of his specialty

7. His intelligence level

8. Other (write)

59. How do you see an ideal doctor?

1. Age_

3. Academic degree

4. Nationality

5. Religion

6. Personal qualities

7. Professional qualities

60. How do you assess the balance of rights and responsibilities between doctors and patients?

1. Patients have more rights than doctors.

2. Doctors have more rights than patients.

3. Patients and doctors have equal rights

6. I find it difficult to answer

61. Does it ever happen that you ask a doctor to prescribe you some kind of treatment or prescribe certain medications?

1. Yes, often

2. Yes, sometimes

3. No => go to question 63

4. I find it difficult to answer

62. In this case, does the doctor fulfill your wishes?

2. Yes, if the desire coincides with his opinion

3. Yes, if the desire corresponds to the data of tests and examinations

5. I find it difficult to answer

63. Do you think it is necessary to develop rules for communication between medical workers and patients?

3. I find it difficult to answer

We ask you to answer questions regarding the healthcare system as a whole

64. Have you ever had to refuse treatment due to lack of money?

(you can provide multiple answers)

1. Yes, I had to

65. Which of the following statements best suits your situation? (you can provide multiple answers)

1. Never used the services of private medical institutions

2. I can’t afford private ones. medical services

3. To pay for private medical services, I have to cut other expenses

4. I will be able to pay for private medical services without significantly reducing my (family) budget

5. Paying for private medical services is not a problem for me.

6. I find it difficult to answer

66. Do you support the development of a private (paid) healthcare system?

3. I find it difficult to answer

We ask you to answer questions related to healthcare financing

67. Which of the following statements can you agree with?

1. Medical care should be free, as before

2. Along with free help there should be paid medical services

3. Services should not be free

4. Services must be partially paid depending on financial situation patient

5. I find it difficult to answer

68. Have you ever had to pay for medical services directly out of pocket?

2. No, never

3. I find it difficult to answer

69. Approximately what amount did you have to spend on shadow payments over the last year? (Please write)

70. How much out of pocket are you willing to spend annually on health-related services (including medications)?

1. Up to 1000 rub.

2. From 1000 to 2000 rubles.

3. From 2000 to 3000 rubles.

4. From 3000 to 4000 rubles.

5. More than 4000 rub.

6. I find it difficult to answer

Questions related to health insurance

71. What type of health insurance policy do you have?

1. Mandatory

2. Voluntary

3. Mandatory and voluntary

4. I don’t have

5. I find it difficult to answer

72. Do you have enough information on health insurance?

1. Yes, enough information

2. No, there is not enough information

73. Would you like to know more? (you can provide multiple answers)

1. Yes, about compulsory health insurance

2. Yes, about voluntary health insurance

Issues related to patients' rights

74. Have you ever had problems getting medical care outside the city?

1. Did not arise

2. I was denied due to lack of insurance

3. I was denied if I had a policy

75. Have you ever had to file a complaint against the work of your attending physician or a medical institution?

2. No => go to question 79

76. What was the reason for your complaint? (you can provide multiple answers)

1. Denial of medical care

2. Poor organization of patient reception

3. Payment for a service that should be free

4. Poor quality of medical care

5. Problems with preferential drug coverage

6. Poor attitude from medical staff

7. Inadequacy of medical care or services provided (for example, insufficient level of examination)

77. Where did you apply? (you can provide multiple answers)

1. To the administration of the medical institution

2. To the Health Committee

3. To a medical insurance organization

4. To the Moscow City Compulsory Medical Insurance Fund

6. To other organizations (write)

78. Are you satisfied with the response to the complaint?

3. There was no answer

79. As a patient, do you know your rights?

2. No => go to question 81

3. Difficult to answer => go to question 81

80. How did you find out about your rights? (you can provide multiple answers)

1. From the doctors who are treating me

2. B medical organizations which I visited

3. From employees of the compulsory health insurance fund

4. From information materials of the clinic stands

5. From the media

81. Who do you think represents the patient’s rights? (you can provide multiple answers)

2. Compulsory health insurance fund

3. Institution providing medical care(clinic or hospital)

4. Health authority

6. None of the above organizations

7. Others (write)

8. I find it difficult to answer

82. Compulsory health insurance gives patients the opportunity to choose medical institution And insurance company. Have you taken advantage of this right? (you can provide multiple answers)

1. Yes, I chose (another) clinic

2. Yes, I chose (another) doctor

3. Yes, I changed my insurer

4. No, I wanted to change the medical institution, but I couldn’t.

5. No, I wanted to change doctor, but I couldn’t.

6. No, there has been no need for this until now

7. No, because I didn’t know about this right

83. How would you rate the quality of medical care provided:

1. Excellent

2. Good

3. Satisfactory

4. Bad

Improved

2. No changes occurred

3. Worsened

4. I find it difficult to answer

85. How do you assess the state of healthcare in Moscow?

1. Good

2. Satisfactory

4. I find it difficult to answer

We ask you to answer personal questions

1. Male

2. Female

87. Age

1. Up to 19 years of age inclusive

2. From 20 to 29 years old

3. From 30 to 39 years old

4. From 40 to 49 years old

5. From 50 to 59 years old

6. From 60 years and older

88. Education 1. Primary

4. Secondary special

5. Unfinished higher education

89. Social status(check only one answer, indicate your main status)

1. Student => go to question 91

2. Worker

3. Engineer, employee

4. Civil servant

5. Pensioner => go to question 91

6. Working pensioner

7. Unemployed => go to question 91

8. Housewife => go to question 91

90. What organization do you work for? (check only one answer, indicate your main place of work)

1. In a commercial organization

2. In a budget organization

91. Your marital status

1. Married

2. Single (not married)

92. Do you have children under the age of 18?

1. Yes (how much)

93. How many workers are there in your family? (indicate exact number) Write

94. What is the average monthly income of your family per person?

1. Less than 1000 rub.

2. From 1000 to 2000 rubles.

3. From 2000 to 3000 rubles.

4. From 3000 to 4000 rubles.

5. From 4000 to 5000 rubles.

6. From 5000 to 6000 rubles.

7. From 6000 to 7000 rubles.

8. From 7000 to 8000 rubles.

9. More than 8,000 rubles.

10. I find it difficult to answer

Thank you for the information you provided!

This is a test International Osteoporosis Association « Are you at risk for osteoporosis?»

Your family history

(what you can't change)

1. Did your parents have (have) a fracture due to minimal trauma (a fall from their own height or less) or were they diagnosed with osteoporosis?

2. One of your parents had (has) poor posture (such as “ widow's hump»)?

Your personal clinical data

(those risk factors that a person is born with or cannot control. But this does not mean that they do not need to be addressed. It is necessary to be aware of these factors in order to take measures to reduce bone mineral loss)

3. Are you 40 years or older?
4. As an adult, have you ever had bone fractures with minimal trauma?
5. Do you often fall? More than once a year? Do you have a fear of falling?
6. After 40 years, has your height decreased by 3 cm or more?
7. You have low body weight (BMI)< 19 кг/м 2)?
8. Have you taken glucocorticoid tablets (prednisolone, medrol) for more than 3 months without a break (prescribed for bronchial asthma, rheumatoid arthritis and other inflammatory diseases)?
9. Do you have rheumatoid arthritis?
10. Have you ever been diagnosed with hyperfunction (increased function) of the thyroid or parathyroid glands?

For women

11. Did you stop menstruating before the age of 45?
12. Have you ever stopped menstruating for 12 months or more (not due to pregnancy, menopause, or hysterectomy)?
13. Did you have your ovaries removed before age 50 and are not taking hormone replacement medications?

For men

14. Have you ever suffered from impotence, decreased libido or other symptoms caused by low level testosterone?

Lifestyle Risk Factors

15. Do you regularly drink alcohol (more than 2 drinks per day)?
16. Do you smoke or have you ever smoked?
17. Your daily physical activity is less than 30 minutes (walking, Homework etc.)?
18. Do you avoid milk or dairy products or are you allergic to them and do not take additional calcium supplements?
19. You go to fresh air less than 10 minutes (with skin exposed to sun) without supplemental vitamin D?

If you answered " Yes” to any of these questions, it does not mean you have osteoporosis. Positive answers mean that you have clinically proven risk factors which can lead to osteoporosis and fractures. Show the test results to the doctor, he will prescribe x-ray bone densitometry and, if necessary, treatment. If you have no or few risk factors, you still need to monitor for their occurrence in the future.

Notes

1. Body mass index(BMI) is calculated for both men and women based on height and weight. Weight in kg must be divided by height in meters squared (weight in kg/[height in m] 2). Reduced index - less than 18.5, normal - 18.5-24.9, increased - 25-29.9, obesity - 30 or more.

2. 1 dose of alcohol- this is 10 ml (or 8 g) of pure ethyl alcohol. Drinking alcohol in high doses increases the risk of osteoporosis and fractures. Beer 4% - 250 ml, wine 12.5% - 80 ml, vodka 40% - 25 ml.

Test (questionnaire) on the risk of developing osteoporosis: Medical blog of an emergency doctor. Approaches to the prevention and treatment of osteoporosis Drug treatment and prevention of osteoporosis

Annotation scientific article on clinical medicine, author of the scientific work - Dreval A.V., Marchenkova L.A., Grigorieva E.A.

Related topics scientific works on clinical medicine, author of the scientific work - Dreval A.V., Marchenkova L.A., Grigorieva E.A.

The estimation of the quality of diagnostics of post-menstrual osteoporosis in the Moscow region from the results of a questionnaire study

Text of scientific work on the topic “Assessing the quality of diagnosis of postmenstrual osteoporosis in the Moscow region according to a questionnaire survey of patients”

Your family history

Your personal clinical data

For women

For men

Lifestyle Risk Factors

Notes

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