Brutal Toll of Osteoporotic Fractures Revealed in New NOF Report

Nancy A. Melville

September 20, 2019

A new report provides striking details about the toll osteoporotic fractures take on the individual and at a societal level in the United States, showing that as many as 2 million Medicare beneficiaries sustained 2.3 million osteoporotic fractures in 2015.

Moreover, nearly one in five died within 12 months of a new fracture.

This latest report from the National Osteoporosis Foundation (NOF) "provides real-world data from Medicare claims that shows how the healthcare system is failing the 55 million Americans who have or who are at high risk of osteoporosis," Elizabeth Thompson, CEO of the NOF, told Medscape Medical News.

The data show that, remarkably, "osteoporotic fractures are responsible for more hospitalizations than heart attacks, strokes, and breast cancer combined."

"The biggest surprise from this report is that things are worse than we thought," Bart Clarke, MD, president of the American Society for Bone and Mineral Research (ASBMR), told Medscape Medical News.

"We've known the risk of a secondary fracture is high, that if people don't take therapy they will continue to have fractures and that many people don't get bone density testing after their first fracture," said Clarke, who is a clinician and researcher with the Division of Endocrinology, Metabolism, Diabetes, and Nutrition at the Mayo Clinic College of Medicine in Rochester, Minnesota.

Now, it's obvious from these new figures that "in some cases, these rates are worsening, so this is...of great interest," he added.

The findings send the message that fractures can have more detrimental implications than many realize, Clarke stressed.

"People tend to think 'this is normal for me — my mother had a fracture, as did my grandmother, and now I have one,' and so they're not overly concerned," he explained.

"But we, as clinicians, see these as sentinel events for future fractures."

"We know that when you break a bone, your risk of having a second fracture in the next 2 years is at least double the risk for the first fracture," he emphasized.

"This not something I think a lot of patients or even physicians realize."

Those With a Hip Fracture Had Highest Mortality Rate a Year Later

The report focused on "new" osteoporotic fractures by excluding beneficiaries who had another osteoporotic fracture in the prior 6- to 12- months.

According to the analysis, female beneficiaries had a 79% higher rate of osteoporotic fracture than males, after adjusting for age, and the most common fractures involved the spine and hip, representing 40% of all osteoporotic fractures in the Medicare population in 2015.

The rates are alarming because hip fractures are in fact among the most detrimental of osteoporotic fractures, and the analysis supports that, showing hospitalization rates were more than 90% among those sustaining a hip fracture.

Overall, nearly 20% of patients died within 12 months of a new osteoporotic fracture, and those with a hip fracture had the highest mortality, with 30% dying within 12 months.

In addition, approximately 15% of those who experienced a new osteoporotic fracture had one or more subsequent fractures within 12 months of the initial fracture.

And clinical follow-up after a first fracture — seen as critical in the prevention of a secondary fracture — is low, as supported by the finding of the analysis that only 9% of women who suffered an osteoporotic fracture were screened for osteoporosis with a bone mineral density test within 6 months following their initial fracture.

Prevention Efforts Could Be Boosted by Fracture Liaison Service

Indeed, NOF's Thompson noted, patients sometimes don't even report fractures to their primary care physician.

"One of the things we learn over and over again is people will present at the emergency room with a fracture such as a broken wrist, toe, or shoulder, and they will have it fixed there, but may never even tell their primary care doctor about it, and right now the onus is not on that hospital or orthopedic surgeon to initiate or provide osteoporosis care," she explained. 

But introducing fracture liaison services could substantially improve matters, the experts say.

As part of these services, dedicated staff follow-up with patients to make sure their primary care provider is informed of the fracture and that proper preventive measures, such as a bone density evaluation, are being offered.

Centers reporting success with such programs include the Geisinger Health System's High-Risk Osteoporosis Clinic (HiROC), which in a recent study reported increases in bone density tests in women over age 65 years, from 40% to 74%, in their program, so as many as 75% of eligible patients received prescriptions for osteoporosis drugs compared with just 13.8% in the primary care population as a whole.

Thompson added that "Medicare needs to incentivize the use [of programs such as fracture liaison services] by helping to defray any upfront costs and/or creating a bundled payment model."

Key measures could also make an important difference at the primary level, Thompson asserted.

"We recommend physicians put a check-off box in their chart asking patients questions, including whether they have had a fracture, if so, when? What body part?" she said.

"We also recommend a check-off box asking if the patient has had a bone density test. It's recommended that every woman starting at age 65 and man at age 70 should have a baseline bone mineral density," Thompson explained.

Extensive details for the prevention of secondary fractures are outlined in new consensus guidelines published by the ASBMR.

Costs of Second Fractures Are Substantial

In addition to the health effects, the economic costs associated with second fractures are also substantial.

According to the report, the incremental medical cost to Medicare of a subsequent fracture over the 180-day period following a new osteoporotic fracture was more than $20,700.

Translated to the estimated 307,000 Medicare Fee For Service (FFS) beneficiaries who suffered a subsequent fracture during a follow-up of 2- to 3 years and survived at least 180 days after the second fracture, the amount would exceed $6.3 billion in allowed cost to Medicare FFS, the authors note.

However, reductions of just 5% to 20% in the rate of subsequent fractures could have led to savings of $310 million to $1.2 billion, respectively, they estimate.

Thompson is the CEO of the NOF. Clarke is the president of the ASBMR and has reported no relevant financial relationships.

NOF. Published September 11, 2019. Full text

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