Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Although studied mainly in postmenopausal women, osteoporosis has been recognized as a prevalent disease in men through similar mechanisms (ie, age-related bone loss, hormonal alterations, and other conditions/risk factors associated with bone loss). The lifetime risk of an osteoporotic fracture in men over the age of 50 is between 20% and 30%.¹ Although this is less than the overall prevalence in women, men have higher rates of fracture-related mortality than women (mortality rate of 73.0 in women versus 166.5 in men per thousand person-years).²

Primary prevention of osteoporosis is largely sought through screening to identify those at the highest risk of fracture-related morbidity. While screening women for osteoporosis is standard clinical practice, there is uncertainty about the role of screening among men.³ The Bone Health and Osteoporosis Foundation, the International Society for Clinical Densitometry,⁴ and the Endocrine Society⁵ recommend screening all men over 70 years of age and younger men with risk factors for osteoporosis. In 2018, however, the United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend screening men for osteoporosis.⁶ Likely as a result of uncertainty in screening recommendations, screening rates for osteoporosis are low among men.⁷ In addition to whether or not to screen men for osteoporosis, there is also uncertainty about how to screen men when screening is determined to be warranted. Moreover, most male fragility fractures occur in those with bone mineral density (BMD)-defined osteopenia rather than osteoporosis due to the higher prevalence of osteopenia.⁸ In response, fracture risk-assessment tools, such as the FRAX^® tool, have been developed to identify those who may not have BMD-defined osteoporosis but are at high risk for fracture. Screening first by fracture risk, rather than by DXA, has been proposed as an alternate means to identify those at increased risk for fracture.⁹ It is unknown how effective such fracture risk assessment tools are among men. While men are often identified for osteoporosis screening and treatment because of a low-impact fracture, for primary prevention, it is critical to identify those at risk before clinically relevant effects of osteoporosis emerge.

The issue of screening for osteoporosis among men is particularly pertinent to the Veterans Health Administration (VHA). Veterans of both sexes are at higher risk for osteoporotic fractures,¹⁰ have more chronic medical conditions, have less bone-health knowledge, spend less time exercising, and have more falls than non-Veterans, contributing to a higher risk for bone health problems.¹¹ It is not known whether screening for osteoporosis and/or increased fracture risk in this population will reduce the future risk of osteoporotic fracture.^10,11 Thus, this report seeks to assess sensitivity/specificity of osteoporosis risk assessment tools among men, individual factors associated with increased risk of osteoporosis among male Veterans, the effectiveness of osteoporosis screening on patient-important outcomes such as screening rates and fracture rates, and system-level approaches for boosting osteoporosis screening among men.