Remote Bone Health Service for Osteoporosis Screening in High-Risk Men: A Cluster Randomized Clinical Trial.

Importance: Evidence supporting osteoporosis screening in men is limited. Efficient models that promote osteoporosis screening and adherence in primary care are needed. Objective: To test the impact of a centralized, remote bone health service (BHS) on screening, treatment, adherence, and bone density in older men with fracture risk factors. Design, Setting, and Participants: This cluster randomized clinical trial involved 39 primary care teams in 2 Veterans Affairs (VA) Health Systems that included 3112 male veterans aged 65 to 85 years who had at least 1 fracture risk factor but had no prior fractures. Data were analyzed from July through November 2025. Intervention: Eligible men in medical teams randomized to BHS were invited to undergo dual-energy x-ray absorptiometry (DXA) scan, followed by an electronic consult to their primary care clinician with additional recommendations. A nurse care manager entered orders, obtained test results, provided patient education, and monitored adherence over the phone. Primary care teams randomized to usual care received osteoporosis education and VA practice guidelines. Main Outcomes and Measures: DXA screening rates, osteoporosis treatment, persistence, and adherence were compared between patients in BHS and usual care. A random subset of patients in each team had a DXA 24 months after team enrollment, regardless of whether they had been screened during the intervention. Results: Of the 3112 randomized participants (mean [SD] age, 73.3 [5.3] years; 1260 [40.4%] were Black; and 1748 [56%] were White), 49.2% (830 of 1688) in the BHS group were screened vs 2.3% (33 of 1424) in the usual care group (P < .001). More than half of those screened (441 [51.1%]) had osteopenia or osteoporosis. One hundred fifty-seven patients (84.4%) in the BHS group initiated osteoporosis treatment and achieved high levels of adherence with a mean of 91.7% of subsequent days covered and a high persistence with a mean 657 (SD, 366) days over 2 years of follow-up. The mean femoral neck T-score 2 years after team initiation in a random subset favored BHS vs usual care (-0.55 vs -0.70, P = .04). Conclusions and Relevance: This cluster randomized clinical trial found that the BHS model was associated with significantly improved osteoporosis screening, treatment, and adherence compared with usual care, with high patient and clinician acceptance. Selecting men for osteoporosis screening based on clinical risk factors before a fracture has occurred has a high screening yield. This approach requires validation in other clinical settings and with longer follow-up to determine impact on fractures. Trial Registration: ClinicalTrials.gov Identifier: NCT04079868.