Actionable osteoporosis alerts in musculoskeletal radiology reports improve secondary fracture prevention after orthopaedic fragility fractures.

UNLABELLED: A standardized osteoporosis alert in fracture radiology reports boosted osteoporosis care from 17 to 57% in 500 patients. This low-cost, scalable intervention bridges a critical communication gap between radiologists and clinicians, substantially improving secondary fracture prevention after fragility fractures.

BACKGROUND

Fragility fractures in adults aged 50 years or older are sentinel events for osteoporosis, but post-fracture evaluation and treatment remain inconsistent. Radiology reports are a scalable point of clinical communication, yet conventional fracture reports often describe morphology without explicitly recommending secondary fracture prevention.

PURPOSE: To evaluate whether an actionable osteoporosis alert embedded in musculoskeletal radiology reports improves downstream osteoporosis care after low-energy orthopaedic fractures.

METHODS

This multicenter interrupted time-series study included 500 adults aged 50 years or older with low-energy fractures treated across three centers: one academic trauma center, one academic general hospital, and one public community hospital. The pre-alert period included 250 patients from January to December 2024; the post-alert period included 250 patients from January to December 2025. The primary cohort included hip/proximal femur, clinical vertebral compression, distal radius/forearm, and proximal humerus fractures. Pelvic/sacral insufficiency fractures were retained only as an expanded secondary cohort. Low-energy fracture status was adjudicated from emergency, orthopaedic, and radiology documentation and defined as a fall from standing height or less without malignancy, periprosthetic fracture, atypical femoral fracture, or high-energy trauma. The intervention was a standardized report impression sentence recommending osteoporosis evaluation and secondary fracture prevention. The primary outcome was osteoporosis care initiation within 90 days, defined as DXA order, specialist/FLS referral, fracture-risk assessment, or anti-osteoporosis medication initiation.

RESULTS

In the expanded 500-patient cohort, actionable report wording increased from 6.8 to 82.4%. Overall radiologist adherence in the post-alert period was 206/250 reports (82.4%), varying by center from 71.7 to 88.4% and by fracture site from 66.7 to 91.4%. Osteoporosis care initiation increased from 16.8% before implementation to 56.8% after implementation. Segmented regression of 24 monthly observations demonstrated an immediate post-intervention level increase of 40.0 percentage points (95% CI, 33.0 to 47.0; p < 0.001), with no significant pre-intervention trend, no significant seasonality, and no evidence of positive autocorrelation (Durbin-Watson, 2.85). In multivariable analysis, the post-alert period remained associated with care initiation after adjustment for age, sex, fracture site, prior fragility fracture, glucocorticoid use, center, inpatient status, and baseline osteoporosis therapy.

CONCLUSION

In this model, a structured osteoporosis alert in radiology reports was associated with substantially improved secondary fracture prevention processes. A publishable real-world study should pair the report wording intervention with explicit adherence auditing, EHR report-view tracking, time-to-action outcomes, and a fully specified interrupted time-series analysis.