Osteoporosis Rx Rates Continue Downwards Trajectory

Pam Harrison

July 24, 2018

Prescribing rates for osteoporosis medications continue to spiral downwards to the point where only a fraction of patients with clear evidence of osteoporosis receive the drugs, new data show.

The study, based on a US population of commercially insured patients, was published online July 20 in JAMA Network Open.

In 2004, only 9.8% of patients who had sustained a hip fracture were prescribed an osteoporosis medication, Rishi Desai, PhD, an instructor of medicine at Harvard Medical School and associate epidemiologist, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, and colleagues report.

In 2015, only 3.3% of patients who sustained a hip fracture were prescribed any osteoporosis medication within 180 days of being hospitalized.

The authors estimate that for every 100 patients followed for 1 year, there was an excess of 4.2 nonvertebral fractures among untreated patients compared with patients who received appropriate therapy.

"To give you an analogy, some people may be taking a statin prior to a heart attack, but once they have a heart attack, statins are recommended for virtually every patient. And in that situation, at least 70% to 75% of patients get put on a statin," Desai told Medscape Medical News.

"So if you compare that scenario to this situation, it's actually pretty bad because prescribing initiation rates were not great to begin with, and now almost nobody is getting put on these treatments, which is unfortunate because a lot of future fractures are preventable," he added.

In an accompanying editorial, Douglas Bauer, MD, professor of medicine, epidemiology, and biostatistics at the University of California, San Francisco, observes that it is almost universally agreed that patients who have had a hip or vertebral facture have osteoporosis. As such, they are at high risk for future fracture and should be routinely treated for osteoporosis.

"These dismal treatment rates from as recent as 2015, despite a wealth of evidence about the markedly elevated fracture risk and the availability of effective and safe treatments, can only be described as a shocking failure to provide adequate care to a high-risk population," Bauer writes. He adds that many other patients at high risk of fracture should also be considered for treatment.

"Undertreatment of patients following hip fracture is an important age-related health disparity that must be addressed by health systems and individual clinicians," Bauer states.

This point is underscored by the fact that after years of declining US rates of hip fracture, the "incidence in the United States is no longer declining," he stresses.

"To reverse these trends, we need to actively screen selected patients for osteoporosis risk factors, and in particular, use information technology to identify those who have had a hip or other osteoporotic fracture," Bauer suggests.

Once identified, patients who have had a prior fracture should receive drug therapy to avoid additional fractures, he emphasizes.

Observational Cohort Study

The observational cohort study involved 97,169 patients with a history of hip fracture between 2004 and 2015. Participants were a mean age of 80.2 years and 66% were women. None of the patients were receiving treatment for osteoporosis prior to their hip fracture.

The mean age among patients who received treatment was slightly younger, at 78 years, than among those who did not receive treatment, at 80 years.

Among those who did initiate osteoporosis treatment, 12.3% received a formal diagnosis of osteoporosis, compared with 6.8% of those in whom treatment was not initiated.

To assess the rate of nonvertebral fractures during a mean follow-up of 1.6 years, the authors used an instrumental variable analysis to account for both measured and unmeasured confounding factors.

They identified 203 nonvertebral fractures among patients who initiated treatment over 3798 person-years of follow-up versus 1737 nonvertebral fractures among patients who did not receive treatment over 26,688 person-years of follow-up. The incidence rates of fracture were 5.34 and 6.50 per 100 person-years, respectively.

"There are many factors that contribute to poor prescribing rates," Desai observed. For example, many of the patients included in the analysis were very elderly and had multiple comorbidities, including Alzheimer's disease.

Desai also noted that patients who are hospitalized for a hip fracture are likely to be seen by many different providers and are at risk of falling through the cracks as they proceed through the continuum of care from hospitalization to discharge, he added.

Nevertheless, this is not the first time that poor prescribing rates for osteoporosis medication have been reported, as he also pointed out.

"All of these patients would be recommended for treatment," Desai emphasized.

"I think there is definitely a concern about the rare side effects [reported for osteoporosis medications] which has led to a lot of publicity, and which the Food and Drug Administration has warned about — and that has had a direct effect on prescribing rates," he suggested.

As Bauer points out, evidence indicates that for every 1000 patients treated for 3 years with one of the antiresorptive agents, 1.3 atypical femoral fractures may occur while 100 osteoporotic fractures will be prevented.

Maine Senator Comments

Writing in her blog, Maine Senator Susan Collins emphasizes that early diagnosis — and treatment — of osteoporosis "dramatically" reduces future fracture rates.

Seniors, who are most at risk for fracture, are often covered by Medicare, at least in the United States.

Thus, "it is essential that Medicare reimbursement rates adequately cover the tests that measure bone mass and predict fracture risk, particularly in rural or underserved areas," Collins writes.

Unfortunately, she continues, Medicare reimbursement for osteoporosis screening has declined from $140 in 2007 to $42 in 2018 — a 70% reduction in reimbursement fees for physicians who are in charge of screening.

"As a result of reduced screening due to declining reimbursements, it is estimated that more than 40,000 additional hip fractures occur each year, resulting in nearly 10,000 additional hip fracture deaths," Collins states.

Reimbursement rates have similarly declined, although not as dramatically, for dual-energy X-ray absorptiometry (DXA) — the gold standard for screening, she points out, resulting in a 22% decline in the diagnosis of osteoporosis since 2009.

Collins has introduced legislation to remove barriers to proper screening, maintaining that the Increasing Access to Osteoporosis Testing for Medicare Beneficiaries Act would improve reimbursement rates, at least for the DXA scan.

The legislation is endorsed by the American Association of Clinical Endocrinologists, National Osteoporosis Foundation, and more than 40 other national medical societies and patient organizations.

"As osteoporosis is already under-diagnosed in the Medicare population, it is clear that we must change this trajectory," Collins writes.

"Increasing Medicare reimbursement to an adequate level will increase patient access to osteoporosis screening and diagnosis while lowering costs and consequences resulting from a lack of diagnosis," she writes.

The study was funded by Merck. Desai has reported receiving grants from Merck. Disclosures for the other authors are listed in the article. Bauer has reported no relevant financial relationships.

JAMA Network Open. Published online July 20, 2018. Full text, Editorial

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