Osteoporosis—a disease in which bones lose density and become more fragile and susceptible to fracture—is one of the leading causes of death and disability among older adults, leading to decreased quality of life, loss of mobility and chronic pain.

It affects men and women of all races—but postmenopausal women are at highest risk. Among the 11 million people affected by osteoporosis in the United States, over two-thirds are postmenopausal women.

Despite being a treatable disease, it remains underdiagnosed and undertreated in the US general population, with significant disparities in care between non-White and White women—and Black women experiencing the most disparities.

Studies have shown that non-White women are less likely to be screened for osteoporosis, to be prescribed pharmacotherapy or to receive treatment post-fracture. And while non-White women fracture at lower rates than White women, they experience higher rates of disability and death when a fracture occurs.

A team of researchers led by Karina N. Ruiz-Esteves, MD, Jimmitti Teysir, MD (co-first authors) and Sherri-Ann Burnett-Bowie, MD, MPH, from the Endocrine Division and Department of Medicine at Massachusetts General Hospital took a closer look at these disparities and outlined a plan for addressing them in a recent review in the journal Maturitas.

Screening and Reimbursement

Both the United States Preventative Services Task Force (USPSTF) and the Bone Health and Osteoporosis Foundation recommends screening of all women 65 years and older and postmenopausal women 65 and younger with known risk factors.

To minimize financial barriers to screening, Medicare reimburses routine bone mineral density screening tests—x-rays that measure the amount of minerals in your bones—every two years.

Despite the clarity of these recommendations, past research has identified significant differences in screening rates for osteoporosis in Black women 65 and older, even after adjusting for insurance and access to medical care.

For example, an assessment of claims-based data from 1.6M women nationwide found that Black women were least likely to undergo screening for osteoporosis compared with women of other racial/ethnic backgrounds across the three age brackets assessed (50-64, 65-79, and 80+).

These differences persisted even after adjusting for socioeconomic status, insurance type, co-occurring medical disorders, healthcare utilization and geographic area.

More research is needed to uncover all of the factors driving these disparities, the authors write.

Provider factors may include medical decision-making (regarding patient life expectancy vs. perceived risk), communication barriers, implicit or explicit bias or lack of knowledge regarding screening reimbursements, the researchers say. Patient-level factors could include medical mistrust, a lack of treatment adherence, and individual preferences and beliefs.

Digging Deeper Into Risk Factors

For women under the age of 65, the current guidelines introduce uncertainty into decision making process by reserving screening for patients at increased risk of osteoporotic fracture.

However, most of the widely accepted risk factors are based on a reference population of White women, which may not capture all the factors that contribute to risk in other racial and ethnic groups.

For example, the current diagnostic standard for osteoporosis is a bone density test that is 2.5 times below the mean value of a reference population of young healthy individuals. In most cases, this reference population is primarily young White women.

Since bone density can vary by race—and a variety of other factors beyond bone density also contribute to fracture risk—it is possible that some at-risk non-White patients are not being identified by bone density scans alone.

To account for risk factors beyond bone density, the Fracture Risk Assessment Tool (FRAX) was developed in the early 2000s. FRAX incorporates 12 different risk factors (age, sex, weight, height, femoral neck bone mineral density, past fragility fracture, family and smoking history and more) to assess a patient’s 10-year risk of a major osteoporotic fracture.

However, much of the data used to develop FRAX was also based on primarily White patient populations. Race correction factors (to account for the lower overall rates of fracture in non-White populations) were added to FRAX after the fact, but these corrections may not be working effectively given the ongoing disparities in care, the researchers say.

FRAX also does not account for other diseases that can impact fracture risk such as type 2 diabetes and chronic kidney disease, which are more prevalent in non-White populations. 

Moving Forward

According to the team, fixing the problem will require a multi-pronged approach that includes increasing awareness about screening recommendations and reimbursement, collecting more data about fracture risk in diverse populations and reassessing the race-based corrections built into current screening tools to ensure they accurate capture risk.

Burnett-Bowie and Elaine Yu, MD, MSSC, from the Endocrine Division at Mass General are also working with a task force with the American Society for Bone and Mineral Research to study if the use of race and ethnicity-based corrections in FRAX is justified. (Yu is a co-author of the Maturitas study).

“Part of the legacy of 2020 for all scientists and health care providers is to reconsider why we do what we do,” Burnett-Bowie says. “Once we’ve started doing something on a regular basis, we tend to assume that’s the right thing to do without challenging the rationale for what we are doing.”

“The osteoporosis model is a little different, because there are definitely lower rates of fracture in Black patients,” she adds. “The challenge is that while they fracture less often, Black patients are more likely to die with fracture. That’s an outcome that needs to be avoided as well.”

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