With the recent reexamination of how to consider race/ethnicity in medical treatment, many practitioners may feel confused about implementing such procedures. The ENDO 2023 symposium “Addressing Racial and Ethnic Disparities in Osteoporosis Care” provided attendees with an understanding of the impact of incorporating race/ethnicity in osteoporosis care as well as suggestions for treating their own patients.

One of the most important movements in medicine today is the examination of racial and ethnic inequities in care — and how to remedy them. The Endocrine Society continued its leadership on this issue with a session at ENDO 2023 on “Addressing Racial and Ethnic Disparities in Osteoporosis Care.”

“Broadly speaking, in medicine right now there is a general reckoning on how we consider race and ethnicity in clinical algorithms,” according to session moderator Joy Y. Wu, MD, PhD, who is Chief of the Division of Endocrinology at Stanford University School of Medicine. “Educating physicians and the healthcare workforce about disparities and how to screen and treat patients from a culturally relevant perspective is important.”

A 2021 review in the Journal of Bone and Mineral Research provided some snapshots of disparities — and complexities — in osteoporosis care. The review found that as a population non-Hispanic Black adults have higher bone mineral density and a lower prevalence of osteoporosis compared with Hispanic, non-Hispanic White, and Asian adults. And yet, researchers have known for decades that Black men and women have significantly higher mortality following a hip fracture than their White counterparts. These worse outcomes could be related to the fact that Black adults are less likely to receive osteoporosis screening and treatment compared with White  adults.

Risk Assessment

The Fracture Risk Assessment Tool (FRAX) is the most widely used tool to predict fracture risk in the United States. It rates the 10-year risk of hip and major osteoporotic fractures based on age, sex, smoking and drinking status, parental and personal history of fractures, and certain medications and medical conditions as well as race and ethnicity. The U.S. FRAX calculator returns a lower fracture risk for patients identified as Black, Asian, or Hispanic, compared with White patients.  

“Broadly speaking, in medicine right now there is a general reckoning on how we consider race and ethnicity in clinical algorithms. Educating physicians and the healthcare workforce about disparities and how to screen and treat patients from a culturally relevant perspective is important.”

Joy Y. Wu, MD, PhD, chief, Division of Endocrinology, Stanford University School of Medicine, Stanford, Calif.

Diagnostic tools that include race as a variable are coming under increasing scrutiny. One of the most prominent examples of a revised diagnostic algorithm is the estimated glomerular filtration rate (eGFR) formula for kidney function. For many years, the most commonly used eGFR formula singled out Black patients with an adjustment factor that gave them a score indicating better kidney function for a given creatinine level — despite the fact that Black Americans experience kidney disease at higher levels than the White population.

Spurred on by the idea that race is a social construct, not a biological one, the American Society of Nephrology and the National Kidney Foundation combined to lead a comprehensive review of the appropriateness of this approach. Researchers went back to the original data used to calculate the formula and combined it with newer data to create a new formula to apply to all patients regardless of their race.

The Endocrine Society and others are reconsidering the use of race in FRAX, but a race-free, eGFR-like solution may not turn out to be the best approach for osteoporosis, according to Wu. “FRAX is based on large reference databases from around the world,” Wu says, with some 70 countries developing their own models. A few of these include race or ethnic adjustments.

“The hope is we could have more refined calculations for individuals” with more data, Wu says,

because the interplay of ethnicity and treatment can be complex. For example, for a given bone mineral density, American women of Asian descent have lower rates of hip fracture than their White counterparts. Yet among those being treated with bisphosphonates, Asian women have higher rates of the rare complication of atypical femur fracture. “So the risk-benefit calculation is different among population groups, and that is one area where it could be very important to know race and ethnicity,” Wu says.

She also notes that the limited number of race choices that can be input into the formula can mask great heterogeneity. “Within the ‘Asian’ category, there are more than 20 countries of origin. It is an incredibly heterogeneous range of geography, culture, diet, and socioeconomic status, so many things that impact our health outcomes,” Wu says.

As with any tools in medicine, FRAX needs to be updated periodically and the changes need to be guided by science, says Ruban Dhaliwal, MD, MPH, whose contribution to the ENDO session will focus on “Strategies to Reduce Skeletal Health Disparities.” Dhaliwal is the Endocrine Society’s health equity researcher and chairperson, as well as lead author of “Eradicating Racism: An Endocrine Society Policy Perspective,” which appeared in The Journal of Clinical Endocrinology & Metabolism in 2022.

She notes that whatever the future holds for FRAX, there are steps clinicians can take in their practices to lessen inequities. Although screening for osteoporosis has established benefits in reducing fracture risk through the implementation of lifestyle modification and pharmacological treatment, “certain subgroups of the U.S. population are screened 40% less than other groups. As gatekeepers, it is incumbent upon physicians to optimize the use of the tools available,” Dhaliwal says.

Clinicians should educate patients about screening recommendations, and enlist the capabilities of electronic health records, which have in-built abilities to provide healthcare maintenance reminders, to make sure their patients are being screened for osteoporosis.

Another effective tool that should see more widespread use is the fracture liaison service, which “has been consistently shown to improve outcomes in patients with osteoporosis-related fractures. We need a systemized application of these services to reduce inequities across healthcare institutions,” Dhaliwal says. “There is a great deal of work to be done to improve access to care and enhance the quality of service.”

Beyond Bones

On organizational and community levels, clinicians can take steps to lessen racial inequities, Dhaliwal says: “Workforce diversity in clinical and non-clinical settings is an important component of interventions aimed at reducing health disparities and advancing health equity. Clinicians can ensure their workforce matches the demographics that they serve, which can help build trust in the community. Building trust in the community can help activate and promote patient engagement. Another role that even a sole practicing clinician can take on is advocacy, to look for places to enhance access to care. Physicians are the best voice for their patients.”

“Clinicians can ensure their workforce matches the demographics that they serve, which can help build trust in the community. Building trust in the community can help activate and promote patient engagement. Another role that even a sole practicing clinician can take on is advocacy, to look for places to enhance access to care. Physicians are the best voice for their patients.”

Ruban Dhaliwal, MD, MPH, SUNY Upstate Medical University, Syracuse, N.Y.

“We need to raise public awareness about osteoporosis as an important public health burden,” Wu concludes. “It is something that can be screened for and managed. An important message is that fractures are not necessarily inevitable with aging because screening and prevention could reduce the number of fractures.”

Seaborg is a freelance writer based in Charlottesville, Va. In the January issue he wrote about the Endocrine Society’s newest Clinical Practice Guideline, “Management of Individuals with Diabetes at High Risk for Hypoglycemia.”