Abstract
Introduction/Objectives:
Osteoporosis screening is well-established for women but lacks widely accepted guidelines for men, despite higher post-fracture mortality rates. This study aims to increase the proportion of men ages 50 years and older with risk factors who receive appropriate osteoporosis screening.
Methods:
We conducted an interventional cohort study examining men ages 50 years and older with risk factors seen at the study clinic between March 27, 2024, and June 1, 2024. Interventions included clinical decision support in the electronic medical record and integration of osteoporosis screening into the Medicare Annual Well Visit workflow.
Results:
The proportion of eligible men with up-to-date osteoporosis screening increased from 11.6% (38/329) to 57.7% (239/414). Among those screened, 33.5% had normal bone density, 47.7% were diagnosed with osteopenia, and 18.8% had osteoporosis.
Conclusions:
Implementing clinical decision support, workflow changes, and provider education significantly improved osteoporosis screening rates. The high prevalence of osteopenia (47.7%) and osteoporosis (18.8%) underscores the need for routine screening in high-risk men. These findings highlight the potential for targeted interventions to enhance early detection and treatment, reducing fracture risk and improving long-term outcomes.
Introduction
Osteoporosis is characterized by reduced bone mass and deterioration of skeletal microarchitecture, resulting in increased fracture risk. While osteoporosis screening is well-established for women, a significant gap remains in screening practices for men despite evidence that men over 50 years with osteoporosis face higher post-fracture mortality rates compared to women. 1 The National Institutes of Health (NIH), European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and International Osteoporosis Foundation (IOF) have recognized osteoporosis as a major public health concern.2,3
Current guidelines for osteoporosis screening in men remain inconsistent due to relative lack of evidence compared to women. The US Preventive Services Task Force (USPSTF) has not established clear recommendations for routine screening in men, contributing to underdiagnosis and undertreatment. 4 Men are often diagnosed at later disease stages, resulting in poorer outcomes. 5 The National Health and Nutrition Examination Survey (2017-2018) found that nearly 30% of men aged 50 years and older have low bone density. 6
This quality improvement project aimed to increase osteoporosis screening rates among men ages 50 years and older with known risk factors by implementing clinical decision support tools, integrating screening into routine healthcare workflows, and enhancing provider education.
Methods
In January 2024, the Healthcare Maintenance (HCM) section of the Epic electronic medical record (EMR) was updated to expand an existing osteoporosis screening alert. Previously limited to at-risk female patients, we modified the alert to include male patients aged 70 years and older, as well as males aged 50 years and older with specific high-risk factors. These factors were selected based on the 2023 Endocrine Society Clinical Practice Guideline for Osteoporosis in Men. 7 From the guideline’s recommended risk factors, we included androgen deprivation therapy for prostate cancer, hypogonadism, frailty, and primary hyperparathyroidism. Other guideline-recommended factors such as long-term corticosteroid use were not included due to inability to obtain consistent and accurate data through EMR queries. Review of billing outcomes with Centers for Medicare & Medicaid Services-affiliated payers confirmed that DEXA scans associated with these diagnostic codes were eligible for coverage. Table 1
Demographic and Clinical Characteristics by Results of Last DEXA (n = 239 a ).
Number of patients who received DEXA scans.
We developed a patient report to identify individuals under clinic care who met updated screening criteria, including patient age, date of last dual-energy X-ray absorptiometry (DEXA) scan, and qualifying high-risk factors. The pre-intervention cohort was identified in January 2024 using this patient report within the Epic EMR system, which included male patients aged 50 years and older under clinic care who met our screening criteria. Baseline DEXA scan completion status was assessed through manual chart review at baseline.
Following baseline data collection, we implemented a multifaceted intervention spanning March 27, 2024, to June 1, 2024 that included: (1) incorporating osteoporosis screening into the Medicare Annual Wellness Visit workflow; (2) activating the revised healthcare maintenance reminder within the EMR; and (3) providing provider education on updated Endocrine Society osteoporosis screening recommendations via email.
We conducted manual chart review of the patient report 2 months after intervention initiation. For patients completing DEXA scans during the study period, we reviewed scan results to determine presence of osteopenia or osteoporosis and whether patients were initiated on medical therapy. Bone mineral density results were abstracted manually from the official radiology report in Epic, using the World Health Organization T-score thresholds to define osteoporosis (≤−2.5), osteopenia (−1.0 to −2.5), and normal bone density (≥−1.0). All DEXA interpretations followed the same standardized reporting format used across WVU Medicine radiology. Each report included site-specific T-scores and an overall impression (normal, osteopenia, or osteoporosis) generated by the interpreting radiologist, which was used for classification.
Our university institutional review board (IRB) waived the need for ethics approval and patient consent for the collection, analysis, and publication of these data.
Results
A total of 414 male patients aged 50 years and older with osteoporosis risk factors were included in post-intervention analysis. The mean age was 69.0 years (SD = 10.4), and mean body mass index was 29.9 kg/m² (SD = 6.8). The cohort was predominantly White (96.1%). The most common qualifying risk factors were hypogonadism (33.1%), primary hyperparathyroidism (10.6%), androgen deprivation therapy (4.1%), and frailty (2.2%). Calcium and/or vitamin D supplementation was documented in 42.3% of patients.
Prior to intervention, 11.6% (38/329; 95% CI = 8.3%-15.5%) of eligible male patients had completed a DEXA scan. After implementation, screening rates increased to 57.7% (239/414; 95% CI = 52.7%-62.6%). A chi-square test comparing pre- and post-intervention screening rates indicated statistical significance (χ² = 167.2, P < .001).
Among 239 patients who received DEXA scans during intervention, 33.5% (80/239) had normal bone mineral density, 47.7% (114/239) had osteopenia, and 18.8% (45/239) had osteoporosis. Of those with osteoporosis, 24.4% (11/45) were prescribed pharmacologic therapy, and 68.9% (31/45) lacked corresponding diagnosis codes. Among patients with osteopenia, 45.6% (52/114) had documented diagnosis, and 13.2% (15/114) were prescribed treatment.
In the full post-intervention cohort (n = 414), 36.7% (152/414) had an osteoporosis diagnosis code, and 9.4% (39/414) were prescribed treatment. Among those receiving DEXA scans, 11.7% (28/239) were receiving osteoporosis-specific pharmacologic therapy.
Discussion/Conclusion
Our study demonstrates that implementing a multifaceted intervention significantly improved osteoporosis screening rates in high-risk men, highlighting both extent of underdiagnosis and potential for systematic approaches to address this healthcare gap.
The substantial screening rate increase from 11.6% to 57.7% demonstrates effectiveness of combining clinical decision support tools with workflow integration and provider education. This finding aligns with previous research emphasizing underdiagnosis and undertreatment of osteoporosis in men and supports recent IOF calls for more consistent, evidence-based approaches to male osteoporosis screening.3,5,6
Clinical decision support systems within EMRs represent crucial strategies for improving early detection of underdiagnosed conditions, particularly important for conditions like osteoporosis that may be perceived as low priority in men due to unclear guidelines. 8 Our risk-based clinical criteria provide foundation for future quality measures. The integration of screening alerts into routine clinical workflows helps overcome provider knowledge gaps and competing priorities that often impede consistent screening practices.
The high prevalence of abnormal bone density findings (66.5% combined osteopenia and osteoporosis) underscores clinical significance of our intervention. This finding is particularly relevant given relationships between osteoporosis risk factors and clinical frailty. Frail men with undiagnosed osteoporosis face particularly high adverse outcome risks, as osteoporosis and fragility fractures can further contribute to frailty through increased pain, decreased mobility, and progressive muscle wasting. 9
Currently, no scientifically validated or nationally endorsed quality measures for osteoporosis screening in men exist. These findings could inform bodies like the National Committee for Quality Assurance in considering osteoporosis screening in high-risk men over 50 years for inclusion in future Healthcare Effectiveness Data and Information Set or Merit-based Incentive Payment System measures.
Despite significant screening rate improvement, we identified concerning follow-up care gaps. Among patients diagnosed with osteoporosis, only 24.4% received pharmacologic therapy, and 68.9% lacked appropriate diagnosis coding. These findings highlight needs for additional interventions targeting care beyond initial screening.
Study limitations include the open cohort design with partially overlapping pre- and post-intervention populations, which precludes direct baseline comparability but reflects real-world quality improvement implementation. Our screening criteria captured only a subset of guideline-recommended risk factors due to EMR data limitations. Additionally, the single academic practice setting may limit generalizability. Future research should employ patient-level tracking, include diverse healthcare settings and explore methods to capture additional risk factors systematically.
In conclusion, implementing clinical decision support tools, workflow integration, and provider education significantly improved osteoporosis screening rates in high-risk men ages 50 years and older. The high prevalence of abnormal bone density findings validates systematic screening importance in this population. These results demonstrate potential for targeted, multifaceted interventions to enhance early detection and treatment, ultimately reducing fracture risk and improving long-term outcomes.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.