Andrew Conkie, CEO, Red Star
A position statement published in JBMR Plus earlier this year should be required reading for anyone working in fracture prevention. Paskins et al. (2026), writing on behalf of the international REFRAME group, argue that the field’s longstanding focus on the osteoporosis “treatment gap” has been too narrow, and propose a broader concept: the “care gap.”
It sounds like a small shift in language, but the implications run deep.
What we’ve been measuring
For the past decade, the treatment gap has been the dominant metric in osteoporosis advocacy. Defined as the proportion of people who, despite being at increased risk of fracture, remain untreated, it has been estimated at around 75% across Europe. The concept has done important work: it has shaped a decade of clinical advocacy and helped build the case for Fracture Liaison Services.
But the treatment gap, by definition, measures one thing: whether an eligible patient ends up on medication. It does not capture whether that patient was identified systematically or stumbled into the pathway by chance. It does not ask whether they received a diagnosis they understood, or whether anyone discussed non-pharmacological approaches to fracture risk reduction. It does not reflect whether they were followed up at 12 months, or whether they stopped taking their medication because of side effects and were never offered an alternative.
The Paskins paper puts this plainly. The prevailing narrative, they argue, risks becoming “disease-focused and parentalistic, neglecting person-centred care.” The REFRAME group, which includes public contributors with lived experience of osteoporosis, proposes an alternative: the care gap, defined as “the gap between care offered to people with, or at increased risk of, osteoporotic fractures, and best practice, person-centred care.”
Why the reframing resonates
What struck me reading this paper was how closely the care gap framework maps to the reality that FLS teams describe when you actually sit with them.
FLS nurses talk about spending their days on administration rather than clinical care. They talk about identifying patients through manual, opportunistic processes that depend on which source documents happen to be available locally. They talk about losing patients to follow-up because there is no systematic mechanism to track them beyond the initial intervention. They talk about having no time for the kind of shared decision-making conversation that the clinical guidelines recommend.
The Paskins paper identifies determinants of the care gap across multiple levels: individual patient needs going unmet, healthcare professionals lacking confidence and training, services that are fragmented between primary and secondary care, and policy that insufficiently prioritises bone health. What ties these together is a structural observation: the system is designed around getting patients onto medication, and everything that falls outside that narrow goal (diagnosis, symptom management, holistic assessment, follow-up, equity) is left to individual initiative.
The paper is particularly strong on equity. Case finding for primary prevention is currently opportunistic, meaning it depends on whether your GP thinks about bone health, whether you have the advocacy skills to push for assessment, and whether your demographic profile matches the stereotypes clinicians carry about who gets osteoporosis. The authors note that under-served groups, including men, ethnic minorities, people living in areas of deprivation, care home residents, and people with dementia, are less likely to receive assessments or treatment. When the system relies on individual initiative rather than systematic processes, the people least equipped to advocate for themselves are the ones who miss out.
What this means for how we deliver FLS
If the care gap framework is right, and I believe it is, then closing it requires more than better prescribing rates. It requires infrastructure that makes systematic, equitable care the default rather than the exception.
That means moving from opportunistic case finding to automated, standardised identification across all fracture types. It means structured pathways that track patients through assessment, treatment decision, and review, so that follow-up happens because the system prompts it rather than because someone remembered. It means generating audit and outcome data as a by-product of clinical workflow, so that services can actually measure what they deliver and identify where patients are falling through. And it means freeing up clinical time so that FLS professionals can do what the evidence base and patients both call for: person-centred, informed, shared decision-making.
The paper’s own research recommendations call for “scalable, sustainable, and digitally optimised solutions” to close the care gap. I would add that the emphasis should be on the word “infrastructure.” Tools come and go. What FLS services need is underlying infrastructure that makes systematic care operationally possible, regardless of local staffing levels or IT configurations.
Where we go from here
The Paskins paper also recommends redefining the treatment gap more narrowly, as the proportion of patients eligible for pharmacological treatment who remain untreated. This is a helpful clarification. Medication adherence remains an important metric. But it should sit within the broader care gap framework, alongside measures of identification, assessment, follow-up, patient experience, and equity.
For those of us working in fracture prevention, the call to action is clear: the field needs to build the infrastructure to deliver the care model it already knows is right. The clinical evidence is there. The patient voice is there. The policy alignment is emerging. What has been missing is the operational backbone to make it all work at scale.