Minimizing Disparities in Osteoporosis Care of Minorities With an Electronic Medical Record Care Plan

  • Ronald A. Navarro
  • Denise F. Greene
  • Raoul Burchette
  • Tadashi Funahashi
  • Richard Dell
Symposium: AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium



Ethnic disparities in care have been documented with a number of musculoskeletal disorders including osteoporosis. We suggest a systems approach for ensuring osteoporosis care can minimize potential ethnic disparities in care.


We evaluated variations in osteoporosis treatment by age, sex, and race/ethnicity by (1) measuring the rates of patients after a fragility fracture who had been evaluated by dual-energy xray absorptiometry and/or in whom antiosteoporosis treatment had been initiated and (2) determining the rates of osteoporosis treatment in patients who subsequently had a hip fracture.

Patients and Methods

We implemented an integrated osteoporosis prevention program in a large health plan. Continuous screening of electronic medical records identified patients who met the criteria for screening for osteoporosis, were diagnosed with osteoporosis, or sustained a fragility fracture. At-risk patients were referred to care managers and providers to complete practice guidelines to close care gaps. Race/ethnicity was self-reported. Treatment rates after fragility fracture or osteoporosis treatment failures with later hip fracture were calculated. Data for the years 2008 to 2009 were stratified by age, sex, and race/ethnicity.


Women (92.1%) were treated more often than men (75.2%) after index fragility fracture. The treatment rate after fragility fracture was similar among race/ethnic groups in either sex (women 87.4%–93.4% and men 69.3%–76.7%). Osteoporotic treatment before hip fracture was more likely in white men and women and Hispanic men than other race/ethnic and gender groups.


Racial variation in osteoporosis care after fragility fracture in race/ethnic groups in this healthcare system was low when using the electronic medical record identifying care gaps, with continued reminders to osteoporosis disease management care managers and providers until those care gaps were closed.



The authors thank Ramon Jimenez, MD, and Alberto Bolanos, MD, of the American Association of Latino Orthopaedic Surgeons for their support of our presentation at the 2010 AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium and Augusto Focil, MD, of the California Hispanic Osteoporosis Foundation for his support of this work. Of course, this work was shepherded into the 2010 Musculoskeletal Healthcare Disparities Research Symposium via the advocacy of Laura Tosi, MD, and Mary O’Connor, MD, who are role models for the next generation of orthopaedic surgeons.


  1. 1.
    Cauley JA, Wu L, Wampler NS, Barnhart JM, Allison M, Chen Z, Jackson R, Robbins J. Clinical risk factors for fractures in multi-ethnic women: the Women’s Health Initiative. J Bone Miner Res. 2007;22:1816–1826.PubMedCrossRefGoogle Scholar
  2. 2.
    Cheng H, Gary LC, Curtis JR, Saag KG, Kilgore ML, Morrisey MA, Matthews R, Smith W, Yun H, Delzell E. Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data. Osteoporos Int. 2009;20:1507–1515.PubMedCrossRefGoogle Scholar
  3. 3.
    Curtis JR, McClure LA, Delzell E, Howard VJ, Orwoll E, Saag KG, Safford M, Howard G. Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med. 2009;24:956–962.PubMedCrossRefGoogle Scholar
  4. 4.
    Dell RM, Greene D, Anderson D, Williams K. Osteoporosis disease management: what every orthopaedic surgeon should know. J Bone Joint Surg Am. 2009;91(Suppl 6):79–86.PubMedCrossRefGoogle Scholar
  5. 5.
    Dunlop DD, Manheim LM, Song J, Sohn MW, Feinglass JM, Chang HJ, Chang RW. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46:200–208.PubMedCrossRefGoogle Scholar
  6. 6.
    Emejuaiwe N, Jones AC, Ibrahim SA, Kwoh CK. Disparities in joint replacement utilization: a quality of care issue. Clin Exp Rheumatol. 2007;25:44–49.PubMedGoogle Scholar
  7. 7.
    Epstein AJ, Gray BH, Schlesinger M. Racial and ethnic differences in the use of high-volume hospitals and surgeons. Arch Surg. 2010;145:179–186.PubMedCrossRefGoogle Scholar
  8. 8.
    Institute of Medicine. Race, ethnicity, and language data: standardization for health care quality improvement. Washington, DC: National Academies Press; 2009. Available at: Accessed February 23, 2011.
  9. 9.
    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;32:870–875.PubMedGoogle Scholar
  10. 10.
    Neuner JM, Zhang X, Sparapani R, Laud PW, Nattinger AB. Racial and socioeconomic disparities in bone density testing before and after hip fracture. J Gen Intern Med. 2007;22:1239–1245.PubMedCrossRefGoogle Scholar
  11. 11.
    Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349:1350–1359.PubMedCrossRefGoogle Scholar
  12. 12.
    Wei GS, Jackson JL, Herbers JE Jr. Ethnic disparity in the treatment of women with established low bone mass. J Am Med Womens Assoc. 2003;58:173–177.PubMedGoogle Scholar
  13. 13.
    Wynia MK, Ivey SL, Hasnain-Wynia R. Collection of data on patients’ race and ethnic group by physician practices. N Engl J Med. 2010;362:846–850.PubMedCrossRefGoogle Scholar
  14. 14.
    Zingmond DS, Melton LJ 3rd, Silverman SL. Increasing hip fracture incidence in California Hispanics, 1983 to 2000. Osteoporos Int. 2004;15:603–610.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Ronald A. Navarro
    • 1
  • Denise F. Greene
    • 1
  • Raoul Burchette
    • 1
  • Tadashi Funahashi
    • 1
  • Richard Dell
    • 1
  1. 1.Department of Orthopaedic SurgerySouthern California Permanente Medical Group, Kaiser Permanente, South Bay Medical CenterHarbor CityUSA

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