The $20 Billion Problem: Why We're Still Missing Osteoporosis After Fractures
As someone who sees the aftermath of missed opportunities daily in my bone health clinic, I need to be blunt with my colleagues: we're failing our patients after fragility fractures, and it's costing us—and them—dearly.
The Reality Check We All Need
Let me paint a picture that should make us all uncomfortable. If 80% of your post-MI patients never received statins, beta-blockers, or even a cardiology follow-up, you'd lose sleep over it. Yet that's exactly what's happening with osteoporosis care after fragility fractures.
In my practice, I routinely see patients 2-3 years post-fracture who've never had a DXA scan, never been started on treatment, and—most frustratingly—have suffered additional fractures in the interim. The numbers bear this out: fewer than 1 in 3 women and 1 in 5 men receive osteoporosis evaluation after a fragility fracture.
This isn't acceptable. And frankly, it's not defensible.
The Clinical Reality: Every Fracture Tells a Story
Here's what I wish every provider understood: a fragility fracture IS osteoporosis until proven otherwise. When a 65-year-old woman fractures her wrist falling from standing height, that's not "just a fall"—that's her skeleton announcing it can no longer handle normal mechanical stress.
The data from LeBoff and colleagues hits hard: only 24% of women and 14% of men get evaluated after hip fracture. Meanwhile, these patients face a doubled fracture risk within 1-2 years, often before we've even addressed the underlying bone disease.
In my clinic, I've seen too many patients whose "first" fracture was actually their third or fourth, simply because the earlier ones were treated as isolated orthopedic events rather than manifestations of systemic bone disease.
The $20 Billion Elephant in the Room
The financial implications are staggering—fragility fractures cost over $20 billion annually, projected to exceed $25 billion by 2025. But here's what keeps me up at night: we have the tools to dramatically reduce these costs right now.
DXA scanning: Available in most communities
Effective medications: Bisphosphonates, denosumab, anabolic agents—all proven to reduce fracture risk
Structured programs: Fracture Liaison Services with documented success
Yet osteoporosis treatment rates have actually declined over the past decade. Fear of rare side effects has created therapeutic paralysis, while preventable fractures continue to mount.
Why We Keep Missing the Mark
The problem isn't knowledge—it's ownership. And I see this pattern repeatedly:
Orthopedics fixes the fracture and moves on to the next case. Their job is done when the bone heals.
Emergency medicine stabilizes and refers. Osteoporosis isn't on their radar during an acute presentation.
Primary care is overwhelmed managing diabetes, hypertension, and preventive care. Bone health often gets deferred.
Specialists like me can't see every patient who's had a compression fracture or distal radius fracture.
The result? Patients slip through the cracks, and we see them again when they fracture their hip.
The Solution That Actually Works: Fracture Liaison Services
I've been advocating for Fracture Liaison Services (FLS) because I've seen them work. The model is straightforward: assign a dedicated coordinator—often a nurse practitioner, physician assistant, or pharmacist—to ensure every fragility fracture patient gets proper bone health evaluation.
The coordinator ensures:
Bone health assessment within 12 weeks of fracture
DXA ordering and completion
Basic metabolic workup (calcium, 25(OH)D, PTH, renal function)
Treatment initiation or specialist referral
Patient education and follow-up
McLellan's landmark study showed a 50% reduction in refracture rates with FLS implementation. Kaiser Permanente and Geisinger have replicated these outcomes at scale across their systems.
This isn't experimental medicine—it's proven preventive care that we're simply not implementing widely enough.
What Each of Us Can Do Tomorrow
Whether you're in family medicine, orthopedics, or emergency medicine, here's my challenge to you:
Recognize the signal: Every low-trauma fracture in a patient over 50 is osteoporosis until proven otherwise. Document it as such.
Order the basics: DXA scan, calcium, 25(OH)D, PTH, and basic metabolic panel. Most insurance covers post-fracture DXA without prior authorization.
Start treatment or refer: If you're comfortable with bisphosphonates, start them. If not, refer to endocrinology or rheumatology within 12 weeks.
Document clearly: Make it impossible for the next provider to miss this diagnosis. Use terms like "fragility fracture secondary to osteoporosis" in your assessment.
Think systems: Advocate for FLS infrastructure at your hospital or health system. The ROI is there—both clinically and financially.
The Bottom Line
I'm not asking you to become bone density experts overnight. I'm asking you to connect the dots between a fracture and the disease that caused it. The 72-year-old man who broke his hip isn't unlucky—he has a metabolic bone disease that will cause another fracture if left untreated.
We have effective treatments. We have proven care models. What we need is the clinical discipline to implement them consistently.
Because if we don't act, that next fracture isn't a possibility—it's a probability. And unlike the first one, we can't claim we didn't see it coming.
The author is a practicing endocrinologist specializing in metabolic bone disease. The views expressed are based on clinical experience and published evidence in osteoporosis care.
References:
LeBoff, M. S., et al. (2022). The Care Gap After a Fragility Fracture: A Call to Action. Journal of Bone and Mineral Research, 37(1), 3–7.
Singer, A., et al. (2015). Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States. Mayo Clinic Proceedings, 90(1), 53–62.
McLellan, A. R., et al. (2003). The fracture liaison service: success of a program for the secondary prevention of osteoporotic fractures. Osteoporosis International, 14(12), 1028–1034.
