Osteoporosis diagnosis and treatment are commonly overlooked by primary care providers and patients, leading to significant morbidity, mortality and unnecessary health care costs. Fewer than 20% of patients receive screening or treatment for osteoporosis following fragility fractures. In addition, bone density screening of women 65 years and older is low, leading to the under-use of treatments known to reduce the risk of fragility fractures. The American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), and the American College of Rheumatology (ACR) are working to close the gap between current evidence and practices via the development of quality indicators. Obstacles to improving the screening and treatment of osteoporosis are multiple and include barriers at the level of health systems, provider care, and patient factors. In order to overcome these barriers, interventions that can be widely disseminated, cost-effective and influential at multiple levels are needed. © Copyright Clinical and Experimental Rheumatology 2007.