Osteoporotic fractures: going the wrong way

​​A couple of new articles shed some more light on prevention of osteoporotic fractures (following a recent blog on 2/5/18: http://gmodestmedblogs.blogspot.com/2018/02/prolonged-bisphosphonates-and-increased.html ). i will divide them over today and tomorrow.

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A Medicare claims analysis of hip fractures found a higher than projected incidence from 2012-2015 (see osteoporosis hip fracture trends OsteopIntnl2018 in dropbox, or doi.org/10.1007/s00198-017-4345-0 )

Details:

--hip fracture sample included 149,964 women annually from Medicare claims data from 2002-2015 in women ≥ 65 years old

--proportion of fractures by age group:

    --65-69: 5.5

    --70-74: 7.8

    --75-79: 13.8

    --80-84: 22.1

    --85-89: 25.8

    --90+: 24.9

Results:

--age-adjusted hip fracture rates, weighting to the 2014 population​, decreased linearly each year from 2002-2012 at about -1.8%/year, then plateaued at higher than projected from 2013-2015, with a sampling of age-adjusted incidence per year:

    --2002: 884

    --2003: 864

    --2008: 807

    --2011: 757

    --2013: 741

    --2014: 740

    --2015: 741

--the decline from 2002-2015 was most pronounced in the older ages, though flattened out for all from 2012-15

--the lack of continued decline from 2012-2015, based on the linear trend for the prior 11 years:

    -- there were 11,464 more hip fractures than predicted

    ​--2293 more deaths within one year of of the hip fracture, assuming a 20% 1-yr mortality rate (see below)

    --additional Medicare expense of $459 million, based on average of $40,000 per fracture

Commentary:

--there are 2 million osteoporotic fractures in the US each year, associated with 432,000 hospitalizations, 2.5 million office visits, and 180,000 nursing home admissions.

--hip fractures:

    --account for 14% of all osteoporotic fractures, but 72% of fracture-related expenses (for the 6 months after a hip fracture: cost $34,509-$54,054 per fracture treatment)

    --20-30% of patients die in the year following a hip fracture

    --50% of those who survive will never be able to ambulate without assistance

    ​--25% will require long-term care

 --the good news, previously:

    --it is pretty clear than bisphosphonates decrease osteoporotic hip fractures (eg, a meta-analysis found a 55% decrease with alendronate: see Iwamoto J. Clin Interv Aging 2008; 3(3):483)

    ​--from a sample of 20% of Medicare recipients from 1985-2005, there was initially a rise in age-adjusted hip fracture incidence (9.9% for women, 16.4% for men), then a steady decline from 1995-2005 (24.5% for women and 19.2% for men)

    --mortality from hip fractures decreased from 1986-1995 and remained unchanged from 1995-2005

    --these changes cannot be fully accounted for by the introduction of bisphosphonates in 1995

--so, why are things not continuing to improve??

    --Bone mineral density (BMD) testing rates are low: a 2017 report (see doi.org/10.1016/j.amjmed.2016.10.018​) found that overall screening rates in the Medicare Advantage and commercial enrollees were 21.1%, 26.5%, and 12.8% among women ages 50-64, 65-79, and 80+ years, but that between 2008-2014 for women aged 50-64 BMD rates decreased 31.4%, changed little for women aged 65-79, and increased 37.7% [the latter being helpful, but most of the horse had already escaped from the barn; and the overall rates of screening anyway are pretty abysmal]

    --office-based DEXA testing (dual-energy xray absorptiometry, a common form of BMD testing) has declined parallel to decreases in Medicare reimbursement (which is now below costs of doing the test)

    --decline in use of meds which reduce fracture risk: some of this decrease follows the studies showing harm with estrogen replacement (though it is clearly good for bone). part is due to safety concerns about atypical femoral fractures and osteonecrosis of the jaw, which are rare but highlighted in the media). see http://gmodestmedblogs.blogspot.com/2018/02/prolonged-bisphosphonates-and-increased.html​ for details on these unusual adverse effects

    --part may be the use of "drug holidays" after 5 years (see article tomorrow)

    --a US study found that most patients who had a hip fracture are NOT given osteoporosis prevention meds (see Kim SC. J Bone Miner Res.2016; 31(8): 1536):

        --this study addressed the question of the impact of FDA's safety-related announcements, which included osteonecrosis of the jaw in 2005, atrial fibrillation in 2007 and atypical femur fractures in 2010

        --bisphosphonate scripts decreased dramatically from 15% in 2004 to 3% in last quarter of 2013 in these women following a hip fracture (!!!) [another study of patients with commercial or Medicare supplemental health insurance found that the rate of osteoporosis prescriptions within 12 months after a hip fracture decreased from 40.2% in 2002 to 20.5% in 2011 (see DOI: 10.1002/jbmr.2301).] 

        --prior to the 2007 announcement, there was a 4% increase used in each quarter, then a 4% decrease (though no change in other osteoporosis meds).

        --after the 2010 announcement there was a further decrease of 4% each quarter, after it had stabilized

    --primary care clinicians are treating so many conditions that it is burdensome to deal with this issue (and more time-consuming clinical conditions as patients get older....). and the increase in comorbidities (eg diabetes, etc) can lead to increased use of some meds that make osteoporosis worse

so, this study raises several striking issues

--hip fractures have a quite dramatic effect on patients quality of life as well as mortality​

--the FDA alerts, which are certainly important, can easily be highlighted without a proper perspective in the media, increasing concern of harm disproportionately over benefit, and unfortunately seem to have been associated with a pretty dramatic drop in bisphosphonate use

--hip fractures are not continuing to decrease at the anticipated rate, for a variety of reasons as above, including perhaps decreased reimbursements and the effect of these FDA warnings. 

--And, the dramatic decrease in prescriptions for bisphosphonates in extremely high risk women (who have already had an osteoporotic hip fracture) is really shocking (sort of like not giving statins to those with documented CAD for fear of rhabdomyolysis)

--to me, there are real differences between concerns about using yet another diabetes drug (eg SGLT-2 inhibitors) vs a bisphophonate for osteoporosis for which there are no easy alternatives yet documented benefit over harm

--and, on the other hand, patients are not really getting optimal early osteoporosis prevention, including appropriate vitamin D assessment/treatment, calcium intake, exercise, decreasing smoking/alcohol, fall prevention.  the blog tomorrow will review some new data on vitamin D deficiency placing postmenopausal women at high future fracture risk, and ​what might be a reasonable approacht​​​​