Decreasing use of osteoporosis meds after hip fracture

​The decline in the prescription of osteoporosis medications after a patient has had a hip fracture has been an increasing, contrary to both recommendations and (i think) common sense (see osteop hip fracture and later meds jama2018 in dropbox, or doi:10.1001/jamanetworkopen.2018.0826 ).

Details:
-- data from Truven MarketScan commercial claims, from employer-sponsored health insurance plans for employees and their dependents, as well as Medicare-eligible retirees with employer-sponsored Medicare supplemental plans, from 2004-2015
-- 97,169 patients >50 yo, not on anti-osteoporosis meds who had a hip fracture; median age 80, 66% women.
-- assessed initial dispensing of osteoporosis medication within 180 days of hip fracture hospitalization (those already on osteoporosis treatment in the prior 6 months were excluded)
-- those with hip fracture who were given osteoporosis medications were matched with 10 patients with hip fracture who were not given the meds
-- primary endpoint was time to developing a non-vertebral osteoporotic fracture (including humerus, radius, ulna, hip, or pelvis)
--  4 potential variables (“instrumental variables”) were assessed:
    -- calendar year of cohort entry, to account for secular trends in treatment
    -- specialist access (rheumatologists or endocrinologist), which could affect the options for treatments that the patients received
    -- geographical variation, to make sure that differences in treatment were not related to typical regional preferences, as has been shown for osteoporosis treatments
    -- hospital preference, since the patient choice of the site of care might influence the treatment prescribed
-- medical comorbidities and other factors were also controlled: osteoporosis diagnosis, osteoporotic fractures, orders of bone mineral density testing, Parkinson’s, Alzheimer’s/other dementias, obesity, diabetes, rheumatoid arthritis, history of falls, syncope, gait abnormalities, and medications potentially associated with bone metabolism or fall risk (e.g., anticonvulsants, benzodiazepines, SSRIs, beta blockers, PPIs, opioids, steroids)
    -- healthcare use factors were also included: number of physician visits, acute care hospitalizations, number of different medications, and number of emergency department visits.
    -- All of these potential confounding variables were measured in a 6 month period immediately preceding cohort entry date

Results:
-- 6743 patients (6.9%) initiated treatment for osteoporosis
    -- in 2004: 9.8% (9.0%-10.6%)
    -- in 2015: 3.3% (2.9%-.8%)
-- there was a continuous decline in prescriptions over this time-period, with notable decreases from 2009-2010 and from 2014-2015
-- of the 4 instrumental variables, the hospital preference one had a stronger association with treatment over the other 3.
-- After a mean follow-up time of 1.3 years:
    -- 1940 total non-vertebral fractures occurred, hip and pelvis being the most frequent and accounting for 80% of events
        -- the incidence of fracture among those on osteoporosis medications was 5.34/100K person-years (4.63-6.13) vs 6.50/100K person-years (6.21- 6.82) in those not on medications (18% fewer)
-- though there were some differences perhaps associated with frailty between those initiating therapy and not (e.g. Alzheimer’s disease and higher age), these differences were not substantial.

Commentary:
-- after an initial osteoporotic fracture, 15-25% of patients have a 2^nd fracture within 10 years.
-- this study corroborates a Medicare database also finding a dramatic decrease in the prescription for bisphosphonates after a hip fracture. http://gmodestmedblogs.blogspot.com/2018/02/osteoporotic-fractures-going-wrong-way.html reviews that study, making the following points:
    -- lack of use of anti-osteoporosis medications was associated with 11,464 more hip fractures than predicted
    -- bone mineral density testing has decreased in women aged 50-64 by 31.4% between 2008 and 2014, which to some extent mirrors the decreasing Medicare reimbursement for this test
    -- there may be lingering concerns about the FDA’s safety announcements about medication-related osteonecrosis of the jaw in 2005, atrial fibrillation in 2007, and atypical femoral fractures 2010. The osteonecrosis of the jaw and atypical femoral fractures are pretty rare. And, a larger meta-analysis did not confirm the report of a higher rate of atrial fibrillation in those on alendronate, the most commonly-prescribed bisphosphonate (see doi: 10.1007/s00198-011-1546-9).
-- a 2016 meta-analysis of 4 studies with 3088 patients suggested a statistically significant 40% lower risk of subsequent fractures in those sustaining a hip fracture and 34% decreased mortality (see doi: 10.12669/pjms.322.9435 )
-- The goal of the study was to assess whether there might have been unmeasured confounders, finding that the site the patient received care added significantly to predicting whether the patient received osteoporosis meds
-- There are several limitations of the above study, including the fact that the sample included those in this commercial database (e.g. these patients were somewhat younger and had relatively fewer comorbid conditions as compared with fee-for-service Medicare cohorts) and the follow-up was pretty short.
-- As a related issue, the blog http://gmodestmedblogs.blogspot.com/2018/02/vitamin-d-deficiency-and-suggested.html highlights the importance of vitamin D supplementation, not only in increasing serum 25(OH) D levels but also decreasing PTH levels as well as markers of bone turnover.

So, the bottom line is that very few patients who have had osteoporotic hip fractures were put on anti-osteoporosis medications, and this number has been decreasing over time. The studies are reasonably clear that these medications do prevent further non-vertebral fractures, especially in this quite high risk population. Other studies have reinforced that the benefit of these medications far outweighs the risks of osteonecrosis of the jaw or atypical femoral fractures. This study added that hospital preference was an important factor in prescribing these medications, reinforcing that such prescriptions, as well as many other interventions, typically reflects the local institutional medical culture as well as the differences in the evidence-based approach to care, or perceived fear of adverse events/malpractice claims, which may vary significantly from one site to another even within the same region. Studies such as this one hopefully will lead to more aggressive approaches to bone health before (vitamin D and calcium) and after an osteoporotic fracture...

geoff

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