Breakout session participants noted a range of evidence suggesting observed differences in osteoporosis-related outcomes among minority patients and men were potentially attributable to variations in the quality of osteoporosis and fragility fracture care delivered to these populations. Decreased bone mineral density increases fracture risk across multiple racial groups [7
]; however, rates of screening and treatment for osteoporosis are lower among minorities than among whites, both within populations at risk for osteoporosis [11
] and among patients who have already sustained a fracture [20
]. Similarly, the hospital treatment of fragility fractures differs among racial groups: African American Medicare beneficiaries receive indicated operative repair for hip fracture at lower rates than comparable white patients [25
]. Finally, differences have been documented in the care delivered to male and female patients with osteoporotic fractures, with men being 30% to 60% less likely than women to be treated for osteoporosis after hospitalization for an osteoporotic fracture [32
Participants in the breakout session identified a number of factors that may contribute to shortcomings in the quality of osteoporosis care delivered to ethnic minorities and men. These factors included (1) a lack of awareness among healthcare providers and the public regarding the need for osteoporosis screening and prevention among nonwhite and male patients, (2) lack of financial and nonfinancial incentives to promote osteoporosis screening and treatment for men and women of all ethnic groups, and (3) gaps in knowledge regarding the effectiveness of differing approaches to screening and medical management of osteoporosis, particularly among nonwhite and male patients.
Bone density screening and treatment with calcium, vitamin D, and pharmacologic therapy have the potential to produce health benefits for individuals at risk for osteoporosis and those who have already sustained a fracture [12
]. Additionally, established methods for quantifying fracture risk are demonstrated to predict the likelihood of fracture among both men and women and across racial and ethnic groups [2
]. Nonetheless, the group perceived a lack of awareness or concern among medical professionals and the public regarding the underuse of appropriate osteoporosis screening and treatment. Multiple studies in the medical literature support these concerns, documenting underdiagnosis and undertreatment of osteoporosis, among both at-risk individuals without fracture [12
] and those who sustained a fragility fracture [18
]. While most of these studies have focused on white and Asian women, emerging evidence suggests shortcomings in the diagnosis and treatment of osteoporosis may be most pronounced in racial and ethnic minorities [21
] and men [32
], even within health systems with high overall rates of screening and treatment of patients at risk for fracture [24
Participants noted few incentives exist within accreditation, payment, and quality-reporting structures to promote participation by healthcare providers in the longitudinal care of osteoporosis or fragility fractures. Participants commented the lack of a formal system to evaluate the quality of osteoporosis or fragility fracture care delivered by individual physicians may limit the development of incentives for quality improvement targeted at individual providers. Low hospital reimbursement rates for fracture care were also identified as a deterrent to diagnostic testing for underlying causes of secondary osteoporosis, bone density scanning, and initiating pharmacologic treatment for fracture during hospitalization. For example, Medicare’s Physician Quality Reporting Initiative (PQRI) provides incentive payments to physicians for reporting on selected measures of quality of care; however, participants cited the relatively limited reimbursements available through this program, as well as the small number of PQRI measures focusing on osteoporosis or fracture care, as limiting the effectiveness of this program in improving the care delivered for these conditions.
Overall, participants expressed concern that the limited incentives available for osteoporosis care may reinforce existing gaps in the quality and equity of care delivered for this condition. Further, participants voiced a concern that, without clear incentives for physicians to take ownership of fracture prevention, osteoporosis and postfracture care will likely remain a secondary priority for specialists and generalists alike.
Participants identified multiple gaps in knowledge regarding osteoporosis care that may contribute to variations in care among men and minority patients. For example, minority patients and men have historically been underrepresented in trials of interventions for the prevention of fragility fractures, thereby limiting the evidence base for development of treatment guidelines that target at-risk subgroups [23
The group expressed concern regarding the limited base of clinical evidence to guide osteoporosis management and postfracture care. Groups such as the National Osteoporosis Foundation have developed consensus documents, such as the Clinician’s Guide to Prevention and Treatment of Osteoporosis [23
], but there are limited clinical trial data on which to base care strategies, particularly in regard to the evaluation of secondary causes of osteoporosis after fragility fracture. Similarly, the lack of clinical trial data focused on men and minority patients hampers the development of strategies to reduce variations in osteoporosis and postfracture care for these populations. Efforts to standardize postfracture care have produced promising results in primarily white populations [14
], but participants agreed on a need for research to define the feasibility of implementing such strategies across diverse patient populations.