Highlight
– Evidence supporting osteoporosis screening in men remains limited, necessitating efficient, scalable models in primary care.
– A centralized remote bone health service (BHS) dramatically increased DXA screening rates (49.2% vs 2.3%) and treatment initiation in older men with fracture risk factors.
– High adherence and persistence to osteoporosis treatment was achieved in the BHS group, with significant improvement in femoral neck T-scores after 2 years.
– This remotely delivered intervention showed high patient and clinician acceptance, suggesting a viable approach for improving male osteoporosis care.
Study Background and Disease Burden
Osteoporosis is a prevalent condition characterized by reduced bone mineral density and microarchitectural deterioration, leading to increased fracture risk. Although osteoporosis is often considered a disease predominantly affecting women, it also poses significant morbidity and mortality risks in men, especially older adults. Men tend to be under-screened for osteoporosis, partly due to less robust guideline recommendations and lack of clinical focus, resulting in higher rates of fracture-related complications and mortality compared with women.
Current evidence supporting routine osteoporosis screening in men is limited, leading to a gap in early identification and management of high-risk individuals. Efficient, feasible screening models that integrate seamlessly into primary care and promote treatment initiation and adherence are urgently needed to address this unmet medical need.
Study Design
This cluster randomized clinical trial was conducted within two Veterans Affairs (VA) Health Systems, including 39 primary care teams with 3112 male veterans aged 65 to 85 years. Eligible participants had at least one clinical fracture risk factor but no prior fractures.
Teams were randomized to either:
- Bone Health Service (BHS) Intervention: Participants were invited to undergo dual-energy x-ray absorptiometry (DXA) screening remotely. Following DXA, an electronic consultation with recommendations was sent to the participant’s primary care physician. A nurse care manager coordinated ordering, obtained test results, provided education, and monitored treatment adherence via telephone follow-up.
- Usual Care: Teams received osteoporosis education and VA practice guidelines but no structured intervention for screening or treatment adherence support.
Primary outcomes included DXA screening rates, osteoporosis treatment initiation, persistence, and adherence. Additionally, a random subset of patients underwent a DXA scan 24 months after enrollment regardless of intervention participation to assess bone density outcomes.
Key Findings
Of the 3112 enrolled participants (mean age 73.3 years; 40.4% Black, 56% White), screening rates were substantially higher in the BHS arm (49.2%) compared to usual care (2.3%), a difference highly statistically significant (P < .001).
Among those screened through BHS, more than half (51.1%) had osteopenia or osteoporosis, highlighting a high prevalence in this population when selected by clinical risk factors.
Importantly, 84.4% of patients with identified osteopenia or osteoporosis initiated pharmacologic treatment in the BHS group. Adherence was excellent, with patients covering on average 91.7% of subsequent days over two years, and median treatment persistence reached 657 days (SD, 366 days), reflecting sustained therapy engagement.
In a random subset assessed 24 months post-intervention, mean femoral neck T-scores favored the BHS group (-0.55) compared with usual care (-0.70), indicating a clinically meaningful preservation of bone density (P = .04).
The intervention achieved strong acceptance from clinicians and patients, reflecting feasibility in a real-world healthcare setting.
Expert Commentary
This study addresses a critical gap in osteoporosis care delivery for older men. By utilizing a centralized remote model that integrates DXA screening with electronic consults and nurse care management, the BHS intervention enhanced identification of at-risk men and promoted guideline-concordant treatment initiation and maintenance.
The high screening yield and adherence data validate risk-based selection for osteoporosis screening in men, which has been understudied. Nurse-led adherence monitoring is a key innovation fostering sustained treatment persistence, critical for effective fracture risk reduction.
Limitations include the study’s focus on a veteran population, which may limit generalizability to broader clinical settings. The follow-up duration of 2 years, while adequate for bone density changes, is insufficient to assess fracture outcomes directly. Further validation in diverse clinical environments and longer-term follow-up are warranted.
Conclusion
The remote Bone Health Service model substantially improves osteoporosis screening rates, treatment initiation, adherence, and bone density outcomes in older men at high risk for fractures. By leveraging centralized coordination, electronic communication, and nurse-led care management, this scalable approach overcomes traditional barriers in primary care osteoporosis management for men.
Wider implementation and further research could support reducing preventable fractures and associated morbidity in this vulnerable population, addressing a significant public health challenge.
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.
Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014;25(10):2359-2381. doi:10.1007/s00198-014-2794-2
LeBoff MS, Greenspan SL, Insogna K, et al. Osteoporosis in Men: The Physician’s Guide to Diagnosis and Treatment. Endocr Pract. 2008;14(5):568-579.
