Racial Differences and Disparities in Osteoporosis Care

Educational Objectives

The goal of this program is to improve management of osteoporosis by addressing racial differences and disparities in care. After hearing and assimilating this program, the clinician will be better able to:

1. Cite potential pitfalls of the current definitions and clinical criteria for osteoporosis.
2. Compare risk for osteoporosis among different racial and ethnic groups.
3. Identify factors that may contribute to disparities in osteoporosis management and fracture outcomes among different racial and ethnic groups.

Summary

Introduction: recent data from the National Health and Nutrition Examination Survey (NHANES) showed significant racial and ethnic disparities in osteoporosis prevalence among adults ≥50 yr of age in the United States; prevalence is 40% in Asian adults, 21% in Hispanic adults, 17% in White adults, and 8.2% in Black adults; despite these disparities, current osteoporosis screening guidelines do not account for race or ethnicity

Dual-energy x-ray absorptiometry (DEXA): the Bone Health and Osteoporosis Foundation recommends DEXA screening for all women ≥65 yr of age and men ≥70 yr of age; the United States Preventive Services Task Force supports screening based on risk factors but finds insufficient evidence for osteoporosis screening guidelines in men; this suggests a potential sex disparity and highlights concerns about how disparities in screening and treatment could exacerbate existing health inequities; a 2017 study on DEXA screening found that odds of receiving a DEXA scan were 8% to 18% lower in non-Hispanic Black adults compared with non-Hispanic White adults; other racial and ethnic groups either had higher or similar rates of screening compared with White adults; early Medicare data show that Black patients had half the rate of DEXA screenings compared with White patients, even after fractures

Literature: Dell et al (2011) demonstrated no overall racial disparities in general osteoporosis treatment after implementing a comprehensive bone health program; however, disparities emerged in the treatment of hip fractures, with Black and Asian women receiving less treatment compared with White and Hispanic women; the study also noted significantly lower treatment rates in men, particularly Black and Asian men with hip fractures; Torchia et al (2019) found that likelihood of receiving osteoporosis medications after hip, distal radius, or proximal humerus fractures was 20% lower in Black than in White patients; no significant difference was observed between White and Hispanic patients, but some other racial and ethnic minority groups had higher medication use; similar disparities were observed when broken down by sex; recent research on Medicare data for women with postmenopausal osteoporosis (Kirk et al) found that Asian and Hispanic women had higher rates of osteoporosis treatment ≤2 yr of a fracture compared with White women; in contrast, likelihood of receiving treatment ≤2 yr after a fracture was 34% lower in non-Hispanic Black women; no significant difference was observed in treatment rates for American Indian or Alaskan Native women

Evaluating the effect of disparities on osteoporosis management: research has focused on several key areas, the prevention of fractures, post-fracture outcomes, and related disparities; the ultimate goal of osteoporosis treatment is to prevent fractures, but disparities in management can affect fracture rates and outcomes; Wright et al (2020) found that mortality rate was ≈25% higher in Black women with fractures compared with White women, with this disparity consistent across most major fracture types except for clinical vertebral fractures; economically, fractures had a more severe financial effect on Black women, often leading to a shift from Medicare to dual Medicare and Medicaid coverage; this indicates a 2- to 3-fold higher financial distress compared with White women; Black and Asian women who experienced fractures had a 13- to 17-fold increase in risk for subsequent fractures compared with 6- to 9-fold increase in White and Hispanic women

Quality of life (QoL): although no specific data are available on routinely used QoL scales, indicators such as time to surgery, 90-day readmissions, and reoperations suggest poorer outcomes for Black patients compared with White patients; Black patients also face disparities in receiving acute physical therapy post-fracture, which can negatively affect their recovery and ambulation; this lack of physical therapy contributes to a downward spiral of poor outcomes, potentially increasing mortality rates among Black women with fractures; data highlight the need for more contemporary research to better understand and address these disparities

Current osteoporosis definition: based on a T score of -2.5 that is derived from a reference population of young, healthy, non-Hispanic White women from NHANES 3 (1988-1994); given that bone mineral density has increased in US adults over time, whether this reference population should be updated is in question; additionally, whether to use race and sex-specific reference groups is debated because current comparisons often involve different demographics (eg, men vs women, Black vs White); updated, more inclusive normative data on bone health are needed to better reflect diverse populations

Fracture risk assessment (FRAX): the use of race and ethnicity in fracture risk algorithms, eg, FRAX, has been debated; FRAX requires users to select racial or ethnic categories, which influences fracture risk predictions based on fracture and mortality rates; concerns have been raised about whether incorporating race and ethnicity into these algorithms perpetuates disparities; the American Society for Bone and Mineral Research (ASBMR) recommended excluding race and ethnicity from fracture prediction models to better reflect US demographic changes; however, the FRAX group argued that race-specific models may offer more accurate predictions and prevent health disparities; the debate underscores the challenge of balancing equitable care with accurate risk assessment in diverse populations

Limitations: include exclusion of certain racial and ethnic minority groups (eg, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islanders are included in Asian group) and the oversimplification of broader categories; this can lead to disparities in fracture prediction and management; fracture rates vary within broad racial categories, eg, among different Asian or Hispanic origin groups; Native Hawaiians and Pacific Islanders may have different fracture rates compared with other Asian populations, and fractures among specific Hispanic groups vary; the current FRAX model may not fully account for these differences and could contribute to inequities; race often serves as a proxy for underlying factors, eg, socioeconomic status or access to health care, which could be the actual causes of disparities; traditional risk factors, eg, age, obesity, and medication use, also vary by race and ethnicity, indicating that FRAX may not fully incorporate these variations

Disparities in osteoporosis management and fracture outcomes: can be influenced by various factors; health conditions, eg, arthritis, depression, and hypertension, differ in prevalence among racial and ethnic minority groups and may affect treatment and outcomes; for instance, arthritis is more common in White and Black individuals, while higher rates of depression are observed in Black and Hispanic populations; these conditions could contribute to poorer post-fracture outcomes beyond racial differences alone; social determinants of health, including education levels, language spoken at home, and self-rated health, play a significant role; lower education levels and use of non-English language are more common in communities of color, potentially affecting access to and quality of osteoporosis care; incorporating these factors into management strategies could help reduce disparities and improve fracture prevention and outcomes

Readings

Dell R. Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int. 2011;22 Suppl 3:457-460. doi:10.1007/s00198-011-1712-0; Kirk JK, Spangler JG, Celestino FS. Prevalence of osteoporosis risk factors and treatment among women aged 50 years and older. Pharmacotherapy. 2000;20(4):405–9 ; Torchia MT, Munson J, Tosteson TD, et al. Patterns of opioid use in the 12 months following geriatric fragility fractures: A population-based cohort study. J Am Med Dir Assoc. 2019;20(3):298-304. doi:10.1016/j.jamda.2018.09.024; US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521–2531. doi:10.1001/jama.2018.7498; Wright NC, Chen L, Saag KG, et al. Racial disparities exist in outcomes after major fragility fractures. J Am Geriatr Soc. 2020;68(8):1803-1810. doi:10.1111/jgs.16455.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Wright has been a consultant at ArgenX. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Wright was recorded at the 21st Annual Osteoporosis: New Insights in Research, Diagnosis, and Clinical Care, held online on July 25, 2024, and presented by University of California, San Francisco. For information about upcoming CME activities from this presenter, please visit Cme.ucsf.edu. Audio Digest thanks the speakers and University of California, San Francisco, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.25 CE contact hours.

Lecture ID:

OB712002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.