Bridging the osteoporosis care divide

A seemingly minor fall in an older adult can do far more than break a bone. It can set off a cascade of hospitalizations, loss of independence, social isolation, and even premature death. As a PA in primary care throughout my career, with much of my research focused on geriatric issues, I have seen these consequences unfold time and again. The tragedy is that many fractures are preventable. A couple years ago, I had the opportunity to assist the American Academy of Physician Associates (AAPA) in examining major public health challenges relevant to our profession. Together, we studied where progress was being made, where gaps persisted, and how PAs could be part of the solution. Osteoporosis emerged as a compelling example of where practice gaps exist. Despite advances in diagnostic tools, fracture risk assessment, and effective medications, care for individuals with and at risk for osteoporosis remains inconsistent. Too many patients never get screened, too many high-risk individuals remain untreated, and too many clinicians struggle with when and how to move beyond first-line therapies. In this issue of JAAPA, the CME article titled “An update on osteoporosis management and fracture prevention strategies,” by Ashlyn Smith, MMS, PA-C, offers timely guidance on prevention, screening, and treatment, building on the updated 2025 US Preventive Services Task Force screening recommendations. For busy clinicians, it provides both a useful refresher and a practical roadmap. It is worth pausing to reflect on why this matters so much to our profession and the millions of people we serve. The needs assessment I conducted with AAPA highlighted several persistent challenges. Screening is often viewed too narrowly, confined to postmenopausal women, when in fact men, younger women with risk factors, and patients with secondary osteoporosis also deserve careful attention. Treatment inertia is common: even after a fragility fracture, many patients are never prescribed medication, or they abandon therapy prematurely out of fear of side effects. Risk prediction tools such as FRAX can help, but they may underestimate fracture risk in specific populations. Although most PAs are familiar with bisphosphonates, many described less confidence with navigating sequential therapy, anabolic agents, or drug holidays safely.1 These gaps are not hypothetical; they play out in clinics and hospitals every day. As PAs, our generalist training and distribution across every specialty position us to intervene where the system too often fails. We are also in rural and underserved communities, where fracture prevention and treatment resources can be limited. By broadening our screening lens, initiating therapy with confidence, and sticking with patients to support adherence, PAs can reduce fracture risk and preserve independence for older adults. Practical steps matter. Every fragility fracture should be treated as a sentinel event that prompts a diagnosis of osteoporosis. Simple workflows—EHR prompts, standing orders for DEXA referrals, clear follow-up schedules—can make bone health part of routine care. Patient education is critical. Many who decline treatment are motivated by anxiety or misinformation, not evidence. Taking time to explain benefits, risks, and what to expect can turn hesitation into acceptance. Collaboration is essential; partnering with endocrinologists, orthopedists, physical and occupational therapists, dietitians, and dentists creates a safety net that extends beyond any single encounter. The article in this issue provides a practical framework for these efforts. It reviews preventive strategies across the lifespan, clarifies the evolving role of risk calculators, and discusses therapeutic decision-making, from first-line bisphosphonates to anabolic agents. It reminds us that osteoporosis care is dynamic, requiring reassessment, persistence, and shared decision-making. Osteoporosis is often described as a silent disease, but the silence is ours if we fail to act. The fractures we see today reflect missed opportunities yesterday. The tools are here, the evidence is clear, and the need could not be greater. PAs can make a positive difference.