It is estimated that an osteoporotic fracture occurs every 3 s worldwide [8]. According to the World Health Organization (WHO), the global population aged 60 years and above will reach 2.1 billion, including 426 million people aged 80 years and above, by 2050 [9]. The term “osteoporosis” (from Ancient Greek “osteon” (bone) and “porosis” (pore, petrification)) was first introduced in the beginning of the nineteenth century in France. The word was subsequently adopted in the English medical literature in the twentieth century [10]. Not surprisingly, our understanding of the disease has evolved over the past two centuries. The diagnosis of osteoporosis in men aged 50 years and above and postmenopausal women does not require performing bone mineral density (BMD) if there is a history of low trauma (fragility) fracture.

The most common mechanism of a fragility fracture is a fall from a standing height or less [11]. Fragility fractures of the hip and spine have the most profound impact on the health of the affected patients [12]. It is estimated that VCFs are the most common osteoporotic fractures among both men and women. It is suggested that up to 65–75% of VCFs may be clinically “silent” [13, 14]. In addition, many VCFs are underreported by radiologists. Li et al. reported that 66.8% of patients with VCFs on lateral chest x-ray were undiagnosed in their initial radiology reports [5]. Black et al. showed an associated fivefold risk of sustaining a subsequent fracture in women aged 65 years and older after the initial VCF [15]. Furthermore, the presence of VCFs is associated with an increase in mortality that persists beyond one year, resulting in a 5 year survival rate of 56.5% compared to the expected 69.9% [16]. It has been reported that patients with rheumatic and musculoskeletal diseases are at increased risk of osteoporosis and related fractures compared to individuals without those conditions [17, 18]. Long-term rheumatoid arthritis is now considered a risk factor for refracture in patients with known fragility fractures [19]. Fragility fractures are more common in patients with lupus who have hematologic involvement (thrombocytopenia, hemolytic anemia) [20]. In addition, gout has been found to be an independent risk factor for the development of thoracic vertebral fractures [21].

The diagnostic delay due to underreporting of VCFs is well known. However, the impact of the awareness of the osteoporotic fracture by non-radiologists in reported VCFs in hospitalized patients or those managed in the ED has not been well described. We hypothesized that VCFs found on advanced radiology reports (CT lumbar and/or thoracic spine) during a hospital stay do not receive adequate recognition. This can lead to significant delay in the diagnosis of osteoporosis with subsequent additional vertebral or non-vertebral fractures, including hip fractures.

Our study showed that less than 20% of hospitalizations in which VCFs were reported on CT resulted in consulting FLS or referring the patient to PCP for subsequent management of osteoporosis. Even among patients with recurrent hospitalizations (13 patients), the utilization of FLS/PCP was surprisingly low. In fact, only 3 patients (out of 13) had FLS consulted (or referred to PCP) during their hospitalization. Further chart review showed that 2 of those patients had 3 hospitalizations and 1 patient had 4 hospitalizations during the study period with CT thoracic and/or lumbar spine performed during each hospitalization. The lowest percentage of FLS/PCP utilization for VCFs was by the EM teams (13%). The highest involvement of FLS (or referral to PCP) was observed in patients on the orthopedic surgery teams. However, even in the latter group, the percentage was incredibly low (36.4%).

The reason for hospitalization, the presence of prior VCFs, and the number of new VCFs did not provide any statistically significant difference in utilizing FLS/PCP in affected patients. We also observed poor recognition among healthcare providers that a vertebral compression fracture is diagnostic of osteoporosis. The term “compression fracture” was used in 85% of discharge summaries of hospitalizations. However, the term “osteoporosis” was mentioned only in 28% of all hospitalizations with VCFs. Notably, when the term “osteoporosis” was used in the “assessment and plan” section of discharge summaries, there was a statistically significant difference in the utilization of FLS/PCP during those hospitalizations (p = 0.02).

In our study, we meticulously reviewed the charts of patients with reported VCFs that were hospitalized or treated only in the ED. We manually reviewed all complete radiology reports (in addition to impressions) to identify any possible non-osteoporotic compression fractures that were excluded from the study. We particularly selected the study duration to reflect the launch of FLS service in our institution (beginning of 2017) and peak of the COVID-19 pandemic and subsequent decrease of COVID-19-related hospitalizations.

Despite being a single-center study, we did not have access to all outpatient records of the affected patients either prior to or after hospitalizations. That is because some patients may have received outpatient osteoporosis management by their PCPs not affiliated with our institution and thus capturing these patients was difficult. In addition, some of the initial low utilization of FLS could be explained by poor awareness of medical providers in our institution of FLS when it was first launched in 2017. (Fig. 3). Our data clearly show a concerning trend where, despite the mention of “compression fracture” in the impression of CT reports, the overall osteoporosis care for affected patients was suboptimal. It could be partly due to the lack of recognition of compression fracture as osteoporosis in affected patients.

With the advances of machine learning in medicine as well as recognition of diagnostic and therapeutic delays resulting from human errors, we believe that implementing certain alert protocols within the electronic medical software could potentially improve care for patients with VCFs. Some of the changes could include the use of certain phrases by radiologists in their reports. For instance, they could state that “further evaluation for possible osteoporotic nature of the compression fracture is needed.” Another option would be flagging patients with VCFs by the radiology team in the electronic medical software. That can be followed by the subsequent review by the FLS team to decrease the dependence on timely recognition of compression fractures and osteoporosis awareness by primary teams during hospitalizations.