Beyond Bone Density: Closing the Gaps in Osteoporosis Management Across the Care Continuum

Osteoporosis is a systemic skeletal disease characterized by changes in bone density and microarchitecture resulting in increased fracture risk. While effective osteoporosis therapies exist, many patients at risk for fracture remain undiagnosed and untreated. The central challenge of osteoporosis management may be one of implementation rather than availability of therapeutic options. Management breaks down at successive, addressable points along the care continuum: how patients perceive their own risk, how clinicians identify who is at high or very-high risk, and whether risk-appropriate therapy is initiated and sustained. This review traces the evolution of osteoporosis management from early evidence of poor disease awareness and unclear risk definitions toward today's emphasis on imminent and very high fracture risk and on anabolic-first therapy, and characterizes the gaps that separate guidelines from practice, drawing on a decade of real-world evidence. We argue that real-world evidence helps make each gap visible and measurable, and that the long-term-care setting, where the highest-risk, least-treated patients live, may be the next frontier for osteoporosis management implementation. We close with a practical, deployable care-continuum model and a multi-stakeholder call to action for clinicians, health systems, and policymakers.