Bone Health ECHO (Extension for Community Healthcare Outcomes) is an online virtual community of practice established in 2015 at University of New Mexico Health Sciences Center in Albuquerque, New Mexico, USA1,2. A typical weekly session, now averaging more than 100 participants, consists of a short didactic presentation on a topic of interest, followed by discussion, then case presentations with more discussions. It is highly interactive, with all participants encouraged to make comments, so that “all teach and all learn.” This is the prototype for collaborative case-based technology-enabled learning in the field of osteoporosis and other metabolic bone diseases. The mission is to expand global capacity to deliver best practice skeletal healthcare. A total of 18 programs have now been started, 10 in the USA and 8 in other countries, with more expected to follow. Each program is different, depending on the interests of the organizers and the needs of the participants, each in the appropriate time zone and in the right language, with all adhering to the ECHO model of learning. Case presentations often present diagnostic and treatment dilemmas that are not well addressed in current clinical practice guidelines, requiring innovative thinking based on the best available medical evidence. Case discussions are not consultations; rather, they serve identify clinical issues used to develop “teaching points” that may be relevant to many patients under the care of participants. In this way, Bone Health ECHO serves as “force multiplier.” We describe here a recent patient case that was reported and discussed on Bone Health ECHO.

A 78-year-old married woman has stage 5 chronic kidney disease (CKD) secondary to long-term use of non-steroidal anti-inflammatory drugs (ibuprofen). Except for having chronic fatigue, she is tolerating her CKD remarkably well and never been on dialysis. Other medical complaints included chronic back pain, generalized joint pain, depression, and difficulty sleeping. She was referred by her nephrologist for skeletal health management because of fractures and an abnormal bone density test. She described having a fracture of the left wrist from a fall at age 65 years, fracture of the right hand from another fall at age 65 years, and a stress fracture of the left foot at age 77 years. Dual-energy X-ray absorptiometry prior to her initial visit showed a lowest relevant T-score of -2.6 at the left femoral neck. Fracture risk calculated with the FRAX tool was high: 35% 10-year probability of major osteoporotic fracture and 21% 10-year probability of hip fracture, with input of femoral neck bone mineral density and prior fractures. She has never received medication to reduce fracture risk. Other health concerns included osteoarthritis, hypothyroidism, hypertension, hyperlipidemia, and sleep apnea. She worried about falling and used a cane at times to help with ambulation. She listed current renal- and bone-related medications as calcitriol 0.5 mcg per day (for suppression of parathyroid hormone [PTH]), calcium acetate 667 mg, 6 per day (total of 1014 mg elemental calcium per day, for phosphate binding), and vitamin D3 1000 IU per day; other medications included mirabegron 25 mg per day for overactive bladder, duloxetine 60 mg per day for depression, levothyroxine 0.15 mg per day for hypothyroidism, gabapentin 100 mg per day for chronic pain, simvastatin 40 mg per day for hypercholesterolemia, vitamin B12 1000 mcg per day, and vitamin C 500 mg per day.

At her initial evaluation, she was alert, oriented, and generally well-informed about her medical problems. Blood pressure was 120/80, weight 233 pounds, height 63 inches, and body mass index 41.3 kg/m2. Historical height loss was 1.5 inches. Strength and balance were poor, with slow rising from the chair, inability to maintain a one-leg stand, and slightly unstable gait.

She was diagnosed with CKD-Mineral and Bone Disorder (CKD-MBD)/severe osteoporosis, a diagnostic classification that has recently been proposed3, and high fall risk. Laboratory tests and spine X-rays were ordered, with results shown in the Table. She was referred for physical therapy for interventions to reduce fall risk. Her clinical information and results of her evaluation were presented at a Bone Health ECHO online meeting. A clinical question was asked, with all participants encouraged to engage in the discussion that followed.