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Gender Disparities in Osteoporosis Screening and Management Among Older Adults



One in two women and one in four men experience an osteoporosis-related fracture in their lifetime. Related morbidity and mortality rates are higher in men versus women. Current guidelines are inconsistent in the screening recommendations for osteoporosis in men. Examination of gender disparities in the management of osteoporosis-related fractures among Medicare enrollees is currently lacking.


In this retrospective cohort study using 5% National Medicare claims data from January 1, 2012 through December 31, 2016, eligible patients who were at least 65 years of age on the date of a new fracture episode were classified into two mutually exclusive cohorts on the basis of whether they received testing and/or treatment for osteoporosis in the 6-month period after the new fracture episode. The cohorts were defined on the basis of the National Committee for Quality Assurance (NCQA) quality measure “osteoporosis management in women who had a fracture.” Patients were followed to identify the occurrence of subsequent fracture, all-cause mortality, and a composite outcome—defined as the first occurrence of either subsequent fracture or mortality. Logistic regression models were carried out to identify predictors of testing and/or treatment and time-varying survival analysis to identify the relationship between the presence of testing and/or treatment and patient outcomes.


Of the 35,774 eligible patients, only 10.2% (12.1% women and 5.7% men) received osteoporosis testing and/or treatment within 6 months after a fracture. The interaction between gender and fragility fracture was significant (P < 0.0001). Fragility fracture had greater adjusted odds of testing and/or treatment among men (adjusted odds ratio [AOR] 3.47; 95% CI 2.94–4.10) than women (AOR 1.65; 95% CI 1.53–1.79). Of patients who were eligible for the outcome assessment, 27.5% experienced a subsequent fracture, 23.2% died, and 44.3% experienced a composite outcome during follow-up. Patients who received testing and/or treatment had a significantly lower hazard of all-cause mortality (hazard ratio [HR] 0.57; 95% CI 0.50–0.65; P < 0.0001) and the composite outcome (HR 0.42; 95% CI 0.39–0.45; P < 0.0001), but no difference in the risk of subsequent fracture (HR 1.02; 95% CI 0.94–1.11; P = 0.6083). Men were found to have a significantly lower hazard of subsequent fracture (HR 0.69; 95% CI 0.64–0.73; P < 0.0001), all-cause mortality (HR 0.67; 95% CI 0.61–0.72; P < 0.0001), and the composite outcome (HR 0.69; 95% CI 0.65–0.73; P < 0.0001).


Testing and/or treatment for osteoporosis among older adults with a fracture is poor in the Medicare fee-for-service population overall and worse for men compared to women. Receiving appropriate testing and/or treatment was associated with reduced mortality and the risk of composite outcome. Improving osteoporosis testing and/or treatment and reducing health disparities are essential for managing the clinical and economic burden of osteoporosis in the USA.

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  1. Centers for Disease Control and Prevention. Percentage of adults aged 65 and over with osteoporosis or low bone mass at the femur neck or lumbar spine: United States, 2005–2010. August 2015. Accessed 12 Jan 2021.

  2. Singer A, Exuzides A, Spangler L, et al. Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States. Mayo Clin Proc. 2015;90(1):53–62.

    Article  Google Scholar 

  3. Hansen D, Bazell C, Pelizzari P, Pyenson B. Medicare cost of osteoporotic fractures. The clinical and cost burden of an important consequence of osteoporosis. August 2019. Accessed 12 Jan 2021.

  4. Lewiecki EM, Ortendahl JD, Vanderpuye-Orgle J, et al. Healthcare policy changes in osteoporosis can improve outcomes and reduce costs in the United States. JBMR Plus. 2019;3(9):e10192.

    Article  Google Scholar 

  5. National Committee for Quality Assurance. Osteoporosis testing and management in older women (OTO, OMW). Accessed 12 Jan 2021.

  6. Alswat KA. Gender disparities in osteoporosis. J Clin Med Res. 2017;9(5):382–7.

    Article  Google Scholar 

  7. Gourlay ML, Overman RA, Ensrud KE. Bone density screening and re-screening in postmenopausal women and older men. Curr Osteoporos Rep. 2015;13(6):390–8.

    Article  Google Scholar 

  8. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. JAMA. 2018;319(24):2521–31.

    Article  Google Scholar 

  9. Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE. Diagnosis and management of osteoporosis. Am Fam Physician. 2015;92(4):261–8.

    PubMed  Google Scholar 

  10. Qaseem A, Snow V, Shekelle P, et al. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;148(9):680–4.

    Article  Google Scholar 

  11. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(6):1802–22.

    CAS  Article  Google Scholar 

  12. Nayak S, Greenspan SL. Cost-effectiveness of osteoporosis screening strategies for men. J Bone Miner Res. 2016;31(6):1189–99.

    Article  Google Scholar 

  13. Cass AR, Shepherd AJ, Asirot R, Mahajan M, Nizami M. Comparison of the male osteoporosis risk estimation score (MORES) with FRAX in identifying men at risk for osteoporosis. Ann Fam Med. 2016;14(4):365–9.

    Article  Google Scholar 

  14. Centers for Medicare & Medicaid Services. Medicare program - general information. 2019. Accessed 12 Jan 2021.

  15. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45(6):613–9.

    CAS  Article  Google Scholar 

  16. Bawa HS, Weick J, Dirschl DR. Anti-osteoporotic therapy after fragility fracture lowers rate of subsequent fracture: analysis of a large population sample. J Bone Jt Surge Am. 2015;97(19):1555–62.

    Article  Google Scholar 

  17. Jennings LA, Auerbach AD, Maselli J, Pekow PS, Lindenauer PK, Lee SJ. Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc. 2010;58(4):650–7.

    Article  Google Scholar 

  18. Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH. Undertreatment of osteoporosis in men with hip fracture. Arc Intern Med. 2002;162(19):2217–22.

    Article  Google Scholar 

  19. Antonelli M, Einstadter D, Magrey M. Screening and treatment of osteoporosis after hip fracture: comparison of sex and race. J Clin Densitom. 2014;17(4):479–83.

    Article  Google Scholar 

  20. Bolland MJ, Grey AB, Gamble GD, Reid IR. Effect of osteoporosis treatment on mortality: a meta-analysis. J Clin Endocrinol Metab. 2010;95(3):1174–81.

    CAS  Article  Google Scholar 

  21. Eisman JA, Bogoch ER, Dell R, et al. Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res. 2012;27(10):2039–46.

    Article  Google Scholar 

  22. Yuksel N, Majumdar SR, Biggs C, Tsuyuki RT. Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial. Osteoporos Int. 2010;21(3):391–8.

    CAS  Article  Google Scholar 

  23. Naunton M, Peterson GM, Jones G. Pharmacist-provided quantitative heel ultrasound screening for rural women at risk of osteoporosis. Ann Pharmacother. 2006;40(1):38–44.

    Article  Google Scholar 

  24. Owens GM. Gender differences in health care expenditures, resource utilization, and quality of care. J Manag Care Pharm. 2008;14(3 Suppl A):2–6.

    Article  Google Scholar 

  25. Curtis JR, Adachi JD, Saag KG. Bridging the osteoporosis quality chasm. J Bone Miner Res. 2009;24(1):3–7.

    Article  Google Scholar 

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Funding for this study and Rapid Service Fee were provided by Radius Health, Inc., Boston, USA.


All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Authors’ contributions

Sujith Ramachandran, Setareh A. Williams, Richard J. Weiss, and Yamei Wang contributed to the study concept and design. Sujith Ramachandran contributed to the collection of the data. Sujith Ramachandran, Yiqiao Zhang, Irene Nsiah, and Kaustuv Bhattacharya contributed to the data analysis. Sujith Ramachandran, Setareh A. Williams, Richard J. Weiss, Yamei Wang, Yiqiao Zhang, and Irene Nsiah contributed to interpretation of data. Sujith Ramachandran and Yiqiao Zhang wrote the initial draft of the manuscript and all authors reviewed and provided comments. All authors approved of the final draft for submission and agree to be responsible for the content of this work.

Medical Writing/Editorial Assistance

Writing/Editorial support (Sarah Hummasti, PhD) and graphic services were provided by AOIC, LLC, and were funded by Radius Health, Inc.


Sujith Ramachandran, Yiqiao Zhang, Irene Nsiah, and Kaustuv Bhattacharya report that they or their institution has received research funding from Radius Health, Inc. in relation to this work. Sujith Ramachandran reports research funding from the National Institutes of Drug Abuse outside of this work. Setareh A. Williams, and Yamei Wang are employees and shareholders of Radius Health, Inc. Richard J. Weiss is a former employee and shareholder in Radius Health, Inc.

Compliance with Ethics Guidelines

The study was approved by the University of Mississippi’s Institutional Review Board (IRB protocol#20x-19) and the use of the data for this project was covered by a data use agreement with the centers for Medicare & Medicaid services (DUA#RSCH-2019-54123). The data used in this study are fully de-identified and HIPAA compliant, and therefore consent to participate and publish does not apply. Given the retrospective nature of the study design and the de-identified data, full review of the study procedures was conducted at the IRB, and a waiver of informed consent for participation and publication was approved. All study procedures were conducted as per the ethical principles in the Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research.

Data Availability

Data underlying this study are available from the Centers for Medicare and Medicaid Services upon request.

Prior Presentation

Gender Disparities in Osteoporosis Screening & Management Among Older Adults Presented at the AMCP Nexus 2020 Virtual Meeting, October 19–23, 2020.

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Correspondence to Sujith Ramachandran.

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Ramachandran, S., Williams, S.A., Weiss, R.J. et al. Gender Disparities in Osteoporosis Screening and Management Among Older Adults. Adv Ther 38, 3872–3887 (2021).

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  • Osteoporosis treatment
  • Osteoporosis testing
  • Gender disparities
  • Fracture