Journal of General Internal Medicine

, Volume 24, Issue 8, pp 956–962 | Cite as

Population-Based Fracture Risk Assessment and Osteoporosis Treatment Disparities by Race and Gender

  • Jeffrey R. Curtis
  • Leslie A. McClure
  • Elizabeth Delzell
  • Virginia J. Howard
  • Eric Orwoll
  • Kenneth G. Saag
  • Monika Safford
  • George Howard
Original Article



Undertreatment of osteoporosis has been recognized as a common problem in selected patient subgroups. However, primary prevention has been hampered by limited risk assessment tools that can be applied to large populations.


Using clinical risk factors with a new tool from the World Health Organization (FRAX) and recommendations from the National Osteoporosis Foundation (NOF), we evaluated fracture risk and osteoporosis treatment in a US cohort.


African Americans and Caucasians recruited from 2003–7 across the US as part of a longitudinal study.




The number of persons receiving prescription osteoporosis medications was assessed by race, sex, and fracture risk. Multivariable logistic regression evaluated the association between receipt of osteoporosis medications and fracture risk after controlling for potential confounders.


Among 24,783 participants, estimated fracture risk was highest for Caucasian women. After multivariable adjustment for fracture-related risk factors, the likelihood of receipt of osteoporosis medications among African Americans was lower than among Caucasians [odds ratio (OR) = 0.44, 95% confidence interval (CI) 0.37, 0.53] and for men compared to women (OR = 0.08, 95% CI 0.06–0.10). Even for the highest risk group, Caucasian women with 10-year hip fracture risk ≥3% (n = 3,025, 39.7%), only 26% were receiving treatment.


A substantial gap exists between 2008 NOF treatment guidelines based on fracture risk and the receipt of prescription osteoporosis medications. This gap was particularly notable for African Americans and men. FRAX is likely to be useful to assess risk at a population level and identify high-risk persons in need of additional evaluation.


osteoporosis fracture African American Caucasian epidemiology FRAX bisphosphonate 



Work for this analysis was supported in part by the National Institutes of Arthritis and Musculoskeletal and Skin Diseases (AR053351) and the Arthritis Foundation. REGARDS is supported by a cooperative agreement U01 NS041588 from the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Neurological Disorders and Stroke or the National Institutes of Health. Representatives of the funding agency have been involved in the review of the manuscript, but not directly involved in the collection, management, analysis, or interpretation of the data. The authors acknowledge the participating investigators and institutions for their valuable contributions: The University of Alabama at Birmingham, Birmingham, Alabama (Study PI, Statistical and Data Coordinating Center, Survey Research Unit): George Howard DrPH, Leslie McClure PhD, Virginia Howard PhD, Libby Wagner MA, Virginia Wadley PhD, Rodney Go PhD, Monika Safford MD, Ella Temple PhD, Margaret Stewart MSPH, J. David Rhodes BSN; University of Vermont (Central Laboratory): Mary Cushman MD; Wake Forest University (ECG Reading Center): Ron Prineas MD, PhD; Alabama Neurological Institute (Stroke Validation Center, Medical Monitoring): Camilo Gomez MD, Susana Bowling MD; University of Arkansas for Medical Sciences (Survey Methodology): LeaVonne Pulley PhD; University of Cincinnati (Clinical Neuroepidemiology): Brett Kissela MD, Dawn Kleindorfer MD; Examination Management Services, Incorporated (In-Person Visits): Andra Graham; Medical University of South Carolina (Migration Analysis Center): Daniel Lackland DrPH; Indiana University School of Medicine (Neuropsychology Center): Frederick Unverzagt PhD; National Institute of Neurological Disorders and Stroke, National Institutes of Health (funding agency): Claudia Moy Ph.D.

Conflicts of Interest

JRC: Consulting: Roche, UCB, Procter & Gamble, CORRONA; speakers bureau: Procter & Gamble, Eli Lilly, Roche, Novartis; research grants: Merck, Procter & Gamble, Eli Lilly, Amgen, Novartis

KGS: Consulting: Merck, Novartis, Procter & Gamble, Amgen, Aventis, Eli Lilly; speakers bureau: Novartis; research grants: Amgen

ED: Research grants: Amgen

Others: None

EO: E.O. has received honoraria from and served as a consultant for Merck. He has received research support from Amgen, Pfizer, Novartis, Zelos Therapeutics, Imaging Therapeutics, and Solvay Pharmaceuticals. He has received research support from and served as a consultant for Ely Lilly & Co. and served as a consultant for Servier.


  1. 1.
    National Osteoporosis Foundation: Clinician’s Guide to Prevention and Treatment of Osteoporosis. 2008 [updated 2008; cited accessed April 10, 2008].Google Scholar
  2. 2.
    Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22(3):465–75.PubMedCrossRefGoogle Scholar
  3. 3.
    Jacobsen SJ, Goldberg J, Miles TP, Brody JA, Stiers W, Rimm AA. Hip fracture incidence among the old and very old: a population-based study of 745,435 cases. Am J Public Health. 1990;80:871–3.PubMedCrossRefGoogle Scholar
  4. 4.
    Kellie S, Brody J. Sex specific and Race specific Hip Fracture Rates. Am J Public Health. 1990;80(3):326–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Jacobsen S, Goldberg J, Miles T, Brody J, Stiers W, Rimm A. Race and sex differences in mortality following fracture of the hip. Am J Public Health. 1992;82(8):1147–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Mikuls TR, Saag KG, George V, Mudano AS, Banerjee S. Racial disparities in the receipt of osteoporosis related healthcare among community-dwelling older women with arthritis and previous fracture. J Rheumatol. 2005;32(5):870–5.PubMedGoogle Scholar
  7. 7.
    Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, et al. Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int. 1998;8(5):468–89.PubMedCrossRefGoogle Scholar
  8. 8.
    Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, et al. Proximal femur bone mineral levels of US adults. Osteoporos Int. 1995;5(5):389–409.PubMedCrossRefGoogle Scholar
  9. 9.
    Lewiecki EM, Watts NB, McClung MR, Petak SM, Bachrach LK, Shepherd JA, et al. Official positions of the international society for clinical densitometry. J Clin Endocrinol Metab. 2004;89(8):3651–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Curtis JR, Carbone L, Cheng H, Hayes B, Laster A, Matthews R, et al. Longitudinal trends in use of bone mass measurement among older americans, 1999–2005. J Bone Miner Res. 2008;23(7):1061–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA. 2002;288(15):1889–97.PubMedCrossRefGoogle Scholar
  12. 12.
    Melton LJ 3rd, Johnell O, Lau E, Mautalen CA, Seeman E. Osteoporosis and the global competition for health care resources. J Bone Miner Res. 2004;19(7):1055–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS, et al. An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int. 2001;12(7):519–28.PubMedCrossRefGoogle Scholar
  14. 14.
    Schneyer CR, Lopez H, Concannon M, Hochberg MC. Assessing population risk for postmenopausal osteoporosis: a new strategy using data from the Behavioral Risk Factor Surveillance System (BRFSS). J Bone Miner Res. 2008;23(1):151–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Kanis JA, for WHO Scientific Group. Assessment of Osteoporosis at the Primary Care Level. Technical Report.: World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK; 2007.Google Scholar
  16. 16.
    Dawson-Hughes B, Tosteson AN, Melton LJ 3rd, Baim S, Favus MJ, Khosla S, et al. Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int. 2008;19(4):449–58.PubMedCrossRefGoogle Scholar
  17. 17.
    Howard VJ, Cushman M, Pulley L, Gomez CR, Go RC, Prineas RJ, et al. The reasons for geographic and racial differences in stroke study: objectives and design. Neuroepidemiology. 2005;25(3):135–43.PubMedCrossRefGoogle Scholar
  18. 18.
    Chen Z, Kooperberg C, Pettinger M, Bassford T, Cauley J, LaCroix AZ, et al. Validity of self-report for fractures among a multiethnic cohort of postmenopausal women: results from the Women’s Health Initiative observational study and clinical trials. Menopause. 2004;11(3):264–74.PubMedCrossRefGoogle Scholar
  19. 19.
    Melchior L, Huba G, Brown V, Reback C. A short depression index for women. Educ Psychol Meas. 1993;53:1117–25.CrossRefGoogle Scholar
  20. 20.
    World Health Organization Fracture Risk Assessment Tool. Available from: Accessed May 31st, 2008.
  21. 21.
    Tosteson AN, Melton LJ 3rd, Dawson-Hughes B, Baim S, Favus MJ, Khosla S, et al. Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int. 2008;19(4):437–47.PubMedCrossRefGoogle Scholar
  22. 22.
    Hosmer JDW, Lemeshow S. Applied Logistic Regression: 2nd Edition. John Wiley and Sons; 2000.Google Scholar
  23. 23.
    Lemeshow S, Hosmer JDW. A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol. 1982;115:92–106.PubMedGoogle Scholar
  24. 24.
    Curtis JR, Arora T, Donaldson M, Alarcon G, Callahan L, Moreland L, Bridges L, Mikuls TR. Skeletal health among African Americans with recent onset rheumatoid arthritis. Arthritis Care and Research. In press.Google Scholar
  25. 25.
    Gourlay ML, Callahan LF, Preisser JS, Sloane PD. Osteoporosis preventive care in white and black women in community family medicine settings. South Med J. 2007;100(7):677–82.PubMedGoogle Scholar
  26. 26.
    Mudano A, Casebeer L, Patino F, Allison J, Weissman N, Kiefe C, et al. Racial disparities in osteoporosis prevention in a managed care population. South Med J. 2003;96(5):445–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Block AE, Solomon DH, Cadarette SM, Mogun H, Choudhry NK. Patient and physician predictors of post-fracture osteoporosis management. J Gen Intern Med. 2008;23(9):1447–51.PubMedCrossRefGoogle Scholar
  28. 28.
    Solomon DH, Morris C, Cheng H, Cabral D, Katz JN, Finkelstein JS, et al. Medication use patterns for osteoporosis: an assessment of guidelines, treatment rates, and quality improvement interventions. Mayo Clin Proc. 2005;80(2):194–202.PubMedCrossRefGoogle Scholar
  29. 29.
    Curtis JR, Westfall AO, Allison JJ, Becker A, Casebeer L, Freeman A, et al. Longitudinal patterns in the prevention of osteoporosis in glucocorticoid-treated patients. Arthritis Rheum. 2005;52(8):2485–94.PubMedCrossRefGoogle Scholar
  30. 30.
    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15(10):767–78.PubMedCrossRefGoogle Scholar
  31. 31.
    Hamrick I, Whetstone LM, Cummings DM. Racial disparity in treatment of osteoporosis after diagnosis. Osteoporos Int. 2006;17(11):1653–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Morris CA, Cabral D, Cheng H, Katz JN, Finkelstein JS, Avorn J, et al. Patterns of bone mineral density testing: current guidelines, testing rates, and interventions. J Gen Intern Med. 2004;19(7):783–90.PubMedCrossRefGoogle Scholar
  33. 33.
    Binkley N, Kiebzak GM, Lewiecki EM, Krueger D, Gangnon RE, Miller PD, et al. Recalculation of the NHANES database SD improves T-score agreement and reduces osteoporosis prevalence. J Bone Miner Res. 2005;20(2):195–201.PubMedCrossRefGoogle Scholar
  34. 34.
    Mikuls TR, Saag KG, Curtis J, Bridges SL Jr., Alarcon GS, Westfall AO, et al. Prevalence of osteoporosis and osteopenia among African Americans with early rheumatoid arthritis: the impact of ethnic-specific normative data. J Natl Med Assoc. 2005;97(8):1155–60.PubMedGoogle Scholar
  35. 35.
    Broussard DL, Magnus JH. Risk assessment and screening for low bone mineral density in a multi-ethnic population of women and men: does one approach fit all? Osteoporos Int. 2004;15(5):349–60.PubMedCrossRefGoogle Scholar
  36. 36.
    Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, et al. A simple tool to identify asian women at increased risk of osteoporosis. Osteoporos Int. 2001;12(8):699–705.PubMedCrossRefGoogle Scholar
  37. 37.
    Cauley JA, Lui LY, Ensrud KE, Zmuda JM, Stone KL, Hochberg MC, et al. Bone mineral density and the risk of incident nonspinal fractures in black and white women. JAMA. 2005;293(17):2102–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Looker AC, Flegal KM, Melton LJ 3rd. Impact of increased overweight on the projected prevalence of osteoporosis in older women. Osteoporos Int. 2007;18(3):307–13.PubMedCrossRefGoogle Scholar
  39. 39.
    Alamanos Y, Voulgari PV, Drosos AA. Incidence and prevalence of rheumatoid arthritis, based on the 1987 American College of Rheumatology criteria: a systematic review. Semin Arthritis Rheum. 2006;36(3):182–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2009

Authors and Affiliations

  • Jeffrey R. Curtis
    • 1
    • 6
  • Leslie A. McClure
    • 2
  • Elizabeth Delzell
    • 3
  • Virginia J. Howard
    • 3
  • Eric Orwoll
    • 4
  • Kenneth G. Saag
    • 1
    • 7
  • Monika Safford
    • 5
  • George Howard
    • 2
  1. 1.Division of Clinical Immunology and RheumatologyUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamUSA
  4. 4.Department of MedicineOregon Health Sciences UniversityPortlandUSA
  5. 5.Division of Preventive MedicineUniversity of Alabama at BirminghamBirminghamUSA
  6. 6.Center for Education and Research on Therapeutics of Musculoskeletal DisordersUniversity of Alabama at BirminghamBirminghamUSA
  7. 7.Department of Medicine and EpidemiologyUniversity of Alabama at BirminghamBirminghamUSA

Personalised recommendations