Highlight
A novel nurse-led centralized program targeting older men at risk for osteoporosis significantly increased screening rates and treatment adherence compared to usual care. Over two years, the intervention group demonstrated higher average femoral neck bone density, underscoring potential benefits in fracture prevention. The study supports initiation of osteoporosis screening in men aged 65 and older with at least one risk factor, paralleling practices in women.
Study Background and Disease Burden
Osteoporosis is a major public health concern predominantly recognized in women but increasingly appreciated in older men. Epidemiological data indicate that one in five men beyond age 50 will sustain an osteoporosis-related fracture during their lifetime, a condition often underdiagnosed and undertreated in men. Despite effective and inexpensive treatments, osteoporosis screening remains rare in men, with fewer than 10% screened before fracture occurrence. Notably, men suffer higher mortality rates post-fragility fractures compared to women, with hip fracture-related one-year mortality reaching 36%. Functional recovery post-fracture is often incomplete, highlighting an urgent need to improve early identification and management in this population.
Study Design
This cluster randomized clinical trial evaluated a remote Bone Health Service (BHS) intervention delivered within two Veterans Affairs health systems. The study enrolled 3112 male veterans aged 65 to 85 years, representing diverse racial backgrounds (40.4% Black and 56% White). The intervention leveraged an electronic health record case-finding tool and a nurse care manager to identify men with traditional osteoporosis risk factors—such as hyperthyroidism, rheumatoid arthritis, smoking, diabetes, and use of high-risk medications (antiepileptics, glucocorticoids, androgen deprivation therapy)—and to coordinate dual-energy x-ray absorptiometry (DXA) screening and treatment initiation. The nurse-led program included patient education, electronic consultations with osteoporosis experts, and follow-up calls at 1, 6, and 12 months to reinforce medication adherence and address barriers. Usual care comprised standard primary care without centralized case finding or proactive nurse involvement. The primary endpoint was change in femoral neck bone density over two years; secondary outcomes included screening rates, treatment initiation, medication adherence, and fracture incidence.
Key Findings
The BHS intervention dramatically increased osteoporosis screening rates compared to usual care (49.2% vs 2.3%; P < .001). The proportion of patients identified as eligible for osteoporosis treatment based on DXA and fracture risk assessment was comparable between groups (22.4% intervention vs 27.2% usual care). Importantly, 84.4% of men recommended for treatment in the BHS group initiated therapy, with a mean treatment persistence of 657 days and a mean proportion of days covered of 91.7%, substantially exceeding historic adherence rates (52%) at the studied VA facilities.
After 2 years, a randomly selected subset demonstrated higher mean femoral neck T-scores in the intervention arm (-0.55) compared to usual care (-0.70), although this difference did not meet the prespecified Bonferroni-corrected threshold for statistical significance (P = .04; corrected P-value threshold < .025). Fracture rates did not differ statistically between groups (1.8% vs 2.0%; P = .69), likely reflecting the relatively short follow-up and underpowering to detect fracture reduction.
Expert Commentary
Lead investigator Dr. Cathleen S. Colón-Emeric emphasized that a risk factor-based approach to screening is both feasible and acceptable to older men, mirroring effective screening paradigms in women. The intervention’s success in improving adherence addresses a critical barrier in osteoporosis management. Dr. Joe C. Huang highlighted the significant mortality risk men face after fragility fractures and the underutilization of effective therapies in this population, underscoring the clinical imperative for improved screening. The trial contributes valuable evidence supporting guideline refinement to recommend osteoporosis screening in men aged 65 years and older with risk factors.
Study limitations include the relatively short duration, insufficient power to demonstrate fracture reduction, and the predominately veteran population which may limit generalizability. Nonetheless, findings demonstrate biological plausibility given the observed improvements in bone density and adherence.
Conclusion
This Veterans Affairs cluster randomized trial demonstrates that a centralized nurse-led Bone Health Service improves osteoporosis screening uptake, treatment initiation, and medication adherence in older men at risk. Although fracture reduction was not statistically demonstrated, the improved bone density and high treatment adherence provide a strong rationale to incorporate systematic risk factor-based osteoporosis screening for men aged 65 and above. This approach could help mitigate the high morbidity and mortality burden associated with osteoporotic fractures in men. Future studies with longer follow-up are warranted to confirm fracture risk reduction and evaluate scalability across diverse healthcare settings.
References
Colón-Emeric C, Lee R, Lyles KW, Zullig LL, Sloane R, Pieper CF, Nelson RE, Adler RA. Remote Bone Health Service for Osteoporosis Screening in High-Risk Men: A Cluster Randomized Clinical Trial. JAMA Intern Med. 2025 Aug 25:e254150. doi:10.1001/jamainternmed.2025.4150. Epub ahead of print. PMID: 40853653; PMCID: PMC12379121.
Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis Int. 2006;17(12):1726-1733.
Razzaque MS, Siddiqui A, Kumar S. Osteoporosis in Men: An Update. Clin Cases Miner Bone Metab. 2014;11(3):181-190.
US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521-2531.
