Secular trends of use of anti-osteoporotic treatments in Spain: A population-based cohort study including over 1.5million people and more than 12years of follow-up

[Cost-effectiveness analysis of fracture liaison services in Catalonia]

OBJECTIVE

To assess the cost-effectiveness of Fracture Liaison Service (FLS) compared to the standard of care for secondary prevention of fragility fractures form the perspective of the Catalan Health Service.

METHODS

Cost-utility assessment through a Markov model that simulated disease progression of a patients' cohort candidates to initiate antiosteoporotic treatment after a fragility fracture. A time horizon of 10 years and a 6-month duration per cycle was established. Clinical, economics and quality of life parameters were obtained from the literature and derived from four Catalan FLS. The Catalan Health Service perspective was adopted, considering direct health costs expressed in 2022 euros. A 3% discount rate was applied on costs and outcomes. Uncertainty was assessed through multiple sensitivity analyses.

RESULTS

Compared to the standard of care, FLS would promote antiosteoporotic initiation and persistence, reducing the incidence and mortality associated with subsequent fragility fractures. This incremental clinical benefit was estimated at 0.055 years and 0.112 quality-adjusted life years (QALYs) per patient. A higher cost (€1,073.79 per patient) was estimated, resulting into an incremental cost-utility ratio of €9,602.72 per QALYs gained. The sensitivity analyses performed were consistent, corroborating the robustness and conservative approach of the base-case.

CONCLUSIONS

The introduction of FLS for the secondary prevention of FF would represent a cost-effective strategy from the Catalan Health Service perspective.

Trend and Seasonality of Hip Fractures in Catalonia, Spain: Exploring the Influence of Climate

To describe the secular trend and seasonality of the incidence of hip fracture (HF) and its relationship with climatic variables during the period 2010-2019 in Catalonia in people aged ≥ 65 years. The results were analyzed by sex, age groups (65-74, 75-84, and ≥ 85), and types of fracture (extracapsular and intracapsular). Data on sex, age, type of fracture, year, and month of hospitalization of patients admitted with a diagnosis of HF between January 1, 2010 and December 31, 2019 were collected. Crude and standardized HF incidence (HFi) rates were obtained. Data on the monthly mean of climatological variables (temperature, insolation, icy days, rain, relative humidity, atmospheric pressure, and wind force) were obtained from the network of meteorological stations in Catalonia. Time series analytical statistics were used to identify trends and seasonality. Linear regression and a seasonal autoregressive integrated moving average (ARIMA) were used to analyze the relationship of each climatic parameter with fracture rates. In addition, generalized additive models were used to ascertain the best predictive model. The total number of HF episodes was 90,149 (74.1% in women and 25.9% in men). The total number of HFs increased by 6.4% between 2010 and 2019. The median age (SD) was 84.5 (7.14) and 54% of patients were ≥ 85 years of age. Extracapsular fractures were the most common (55%). The standardized incidence rates decreased from 728.1/100,000 (95% CI 738.6-769.3) to 624.5/100,000 (95% CI 648.7-677.0), which represents a decrease of 14.2% (p < 0.05). The decline was greater at older ages. There were seasonal variations, with higher incidences in autumn (27.2%) and winter (25.7%) and lower rates in summer (23.5%) and spring (23.6%). Seasonality was more pronounced in elderly people and men. In the bivariate regression analysis, high temperatures and greater insolation were negatively associated with the HF rate, while the number of icy days, rainy days, and high relative humidity were associated with a higher incidence of fractures in all age groups and sexes. In the regression analysis using the seasonal ARIMA model, only insolation had a consistently significant association with overall HFi, after adjusting by trend and other climatic parameters. While the global number of HFs grew in Catalonia due to increases in the elderly population, the standardized HF rate decreased during the years 2010-2019. There was a seasonal trend, with predominance in the cold months and correlations with climatic parameters, especially with insolation.

Trends in osteoporosis medication use in US postmenopausal women: analysis of the National Health and Nutrition Examination Survey 1999-2000 through 2017-2018

OBJECTIVE

This study aimed to examine trends in the use of osteoporosis medications in postmenopausal women between 1999-2000 and 2017-2018.

METHODS

National Health and Nutrition Examination Survey data were analyzed to describe trends in the use of osteoporosis medications in US women 50 years and older. Joinpoint regression software was used to detect points at which significant changes in the direction and magnitude of the trends occurred over time. Logistic regression models adjusted for potential confounders were assembled to determine the independent association between time period (2007-2008 vs 2017-2018) and osteoporosis medication use.

RESULTS

Of 13,826 postmenopausal women, about 7% reported taking osteoporosis medications. Joinpoint regression demonstrated that the prevalence of women taking osteoporosis medications significantly decreased by -23.3% on average (95% confidence interval [CI], -23.3% to -37.7%) per survey cycle between 2007-2008 and 2017-2018. Similarly, bisphosphonate use decreased by -22.6% on average (95% CI, -38.8% to -2.1%) from 2007 to 2008 onward. Logistic regression demonstrated that, after adjustment for potential confounders including bone mineral density and self-reported hip or spine fractures, postmenopausal women were 61% and 56% less likely to use any osteoporosis medications and bisphosphonates in 2017 to 2018 compared with their counterparts in 2007 to 2008, respectively.

CONCLUSIONS

The use of osteoporosis medications in postmenopausal US women has significantly decreased since 2007 to 2008 onward. This finding was mostly attributed to a low prescription rate of bisphosphonate drugs. Moreover, the treatment of osteoporosis in postmenopausal women was suboptimal and decreased over time.

Trends in postmenopausal osteoporosis treatment in France during the period 2007-2016: A nationwide claims database analysis

PURPOSE

To describe the trends in the pharmacological management of postmenopausal osteoporosis in France during the period 2007-2016.

METHOD

This cross-sectional, yearly repeated study of patients in France used the nationwide claims database 'Échantillon Généraliste de Bénéficiaires' (EGB), covering a 1 in 97 representative sample of approximately 600,000 individuals insured by the main French public insurance scheme. For women aged 50-89 years, prescriptions for all anti-osteoporosis medications (AOMs) marketed in France during the study period (bisphosphonates alone or used in combination with calcium, selective estrogen receptor modulators, strontium ranelate, teriparatide or denosumab) were identified in each calendar year. Initiation of any AOM in a calendar year was defined by the absence of a prescription for any AOM within the 2 previous calendar years. Incidence was calculated for all AOM prescriptions and initial prescriptions for AOM.

RESULTS

Marked changes were observed in the rates of women receiving any AOM, with a slight increase from 2007 to 2009 (from 10.22 to 10.42 per 100 patient-years [PY]), then a plateau in 2009-2010, followed by a rapid and more than twofold decrease until 2016 (from 10.39 to 5.02 per 100 PY). The decrease in the overall rate of women initiating an AOM showed a rapid halving from 2007 to 2012 (from 2.56 to 1.15 per 100 PY), followed by a plateau in the range of 0.90-1.0 per 100 PY during the period 2013-2016. In contrast, the use of calcium/vitamin D has been rapidly increasing as the only prevention and exclusive intervention for postmenopausal osteoporosis, from 10.6% of women in 2007 to 47.7% in 2016. The profile of patients initiating AOM changed substantially over the 10-year period. Despite a stable mean age of approximately 69 years, an increasing proportion of women with severe chronic comorbidities (from 34.9% to 43.3%), history of fractures (from 7.8% to 13.3%) or high-dose steroid use (from 2.9% to 8.4%) was observed. The decline of AOM initiation was associated with a marked reduction of prescriptions during the study period: by 64.2% for primary care physicians; by 36.7% for specialty doctors; and by 18.4% for rheumatologists.

CONCLUSION

These findings suggest a general trend toward an AOM uptake that is increasingly limited to a fraction of patients who are at high risk of fractures. In the context of an aging population and declining prescription rates for AOM, these data highlight an increasing treatment gap among women in France with osteoporosis, which is similar to that seen in other European countries and in the USA.

The miR-4739/DLX3 Axis Modulates Bone Marrow-Derived Mesenchymal Stem Cell (BMSC) Osteogenesis Affecting Osteoporosis Progression

Osteoporosis is a complex multifactorial disorder linked to various risk factors and medical conditions. Bone marrow-derived mesenchymal stem cell (BMSC) dysfunction potentially plays a critical role in osteoporosis pathogenesis. Herein, the study identified that miR-4739 was upregulated in BMSC cultures harvested from osteoporotic subjects. BMSCs were isolated from normal and osteoporotic bone marrow tissues and identified for their osteogenic differentiation potential. In osteoporotic BMSCs, miR-4739 overexpression significantly inhibited cell viability, osteoblast differentiation, mineralized nodule formation, and heterotopic bone formation, whereas miR-4739 inhibition exerted opposite effects. Through direct binding, miR-4739 inhibited distal-less homeobox 3 (DLX3) expression. In osteoporotic BMSCs, DLX3 knockdown also inhibited BMSC viability and osteogenic differentiation. Moreover, DLX3 knockdown partially attenuated the effects of miR-4739 inhibition upon BMSCs. Altogether, the miR-4739/DLX3 axis modulates the capacity of BMSCs to differentiate into osteoblasts, which potentially plays a role in osteoporosis pathogenesis. The in vivo and clinical functions of the miR-4739/DLX3 axis require further investigation.

Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP): A data resource for pharmacoepidemiology in Spain

PURPOSE

Base de Datos para la Investigación Farmacoepidemiológica en Atención Primaria (BIFAP) is a population based database administered by the AEMPS (Spanish Agency for Medicines) of longitudinal electronic medical records (EMR) of patients attended in primary care. Its main purpose is to serve as source of information for independent studies on drug safety and support of medicines regulation activities. This article aim is to describe the characteristics of BIFAP, how to access the database and a summary of its potential for research.

METHODS

Health problems are registered by primary care physicians as episodes of care and include socio-demographic data, results of diagnostic procedures, lifestyle data, general data, and interventions. A proportion of data on hospitalizations and specialist care are currently available through linkage with other data sources. EMRs of the Spanish healthcare system are provided by the regional administrations. Specific data extraction and standardization processes are performed.

RESULTS

BIFAP includes data from 12 million patients starting in 2001 and updated annually. Validation of drug and diagnosis definitions has been ascertained. Participation in international collaborative projects and a number of articles in peer reviewed journals reflect its contribution to the knowledge of the risks associated with medicines and drug utilization patterns.

CONCLUSIONS

BIFAP is a useful tool for generating scientific evidence on medicines related issues, helping regulatory decision making in Europe. The main strengths of BIFAP are related to large sample size, population-based, longitudinal nature and annual update of data. BIFAP shares common challenges with similar data sources including accurate and efficient identification of health outcomes and of treatment exposure.

General and Specific Considerations as to why Osteoporosis-Related Care Is Often Suboptimal

PURPOSE OF REVIEW

The assessment of fracture risk and use of antiosteoporosis medications have increased greatly over the last 20-30 years. However, despite this, osteoporosis care remains suboptimal worldwide. Even in patients who have sustained a fragility fracture, fewer than 20% actually receive appropriate antiosteoporosis therapy in the year following the fracture. There is also evidence that treatment rates have declined substantially in the last 5-10 years, in many countries. The goal of this article is to consider the causes for this decline and consider how this situation could be remedied.

RECENT FINDINGS

A number of possible reasons, including the lack of prioritisation of osteoporosis therapy in ageing populations with multimorbidity, disproportionate concerns regarding the rare side effects of anti-resorptives and adverse changes in reimbursement in the USA, have been identified as contributing factors in poor osteoporosis care. Improved secondary prevention strategies; screening measures (primary prevention) and appropriate, cost-effective guideline and treatment threshold development could support the optimisation of osteoporosis care and prevention of future fractures.

Impact of Drug Safety Warnings and Cost-Sharing Policies on Osteoporosis Drug Utilization in Spain: A Major Reduction But With the Persistence of Over and Underuse. Data From the ESOSVAL Cohort From 2009 to 2015

Background: Recent studies in several countries show a significant decrease in the consumption of osteoporosis drugs from a peak around 2009, mainly attributed to bisphosphonate safety warnings issued by regulatory agencies on jaw osteonecrosis, atypical fractures, and esophageal cancer, but no studies have assessed the impact of these warnings by risk of fracture strata. Aim: The aim of this work is to assess changes in the utilization of osteoporosis drugs in the region of Valencia (Spain) after safety warnings from regulatory agencies and cost-sharing changes, according to patient socio-demographic and risk of fracture characteristics. Patients and Methods: We constructed a monthly series of osteoporosis drug consumption for 2009-2015 from the ESOSVAL cohort (n = 11,035; women: 48%; mean age: 65 years old) and used interrupted time series and segmented linear regression models to assess changes in osteoporosis drug utilization while controlling for previous levels and trends after three natural intervention dates: the issue of the Spanish Agency for Drugs and Medical Products (AEMPS) Osteonecrosis Jaw Warning (Sept 2009), the AEMPS Atypical femur Fracture Warning (Apr 2011), and the modification of the cost-sharing scheme (Jul 2012). Results: The AEMPS Osteonecrosis Jaw Warning was not associated with a decline in the consumption of osteoporosis drugs, while the warning on atypical fracture (a downward trend of 0.11% fewer people treated each month) and the increase in the cost-sharing scheme (immediate change level of -1.07% in the proportion of people treated) were associated with a strong decline in the proportion of patients treated, so that by the end of 2015 osteoporosis drug consumption was around half that of 2009. The relative decline was similar in people with both a high and low risk of fracture. Conclusion: The AEMPS Atypical femur Fracture Warning of Apr 2010 was associated with a significant decrease in the number of people treated, reinforced by the increase in the pharmaceutical cost-sharing in 2012. Decreases in treatment affected patients both at a low and higher risk of fracture.

Analysis to Improve the Strength of Beds Due to the Excess Weight of Users in Slovakia

Good quality sleep is a prerequisite for regenerating the human body, hence, beds should be optimized for specific group of users, taking into consideration their size or age. Current research studies show similar trends in adult populations around the world, where increases in height as well as in weight can be observed. Not only the ergonomics but also the safety of beds, which is determined by the quality and dimensions of structural elements, must be taken into account in bed design. Designing the structural elements for users with a high body weight is presented in the paper. The properties of a bed’s structural elements, which ensure comfort as well as the safety of a bed are affected by the excess weight of users. New requirements for cross sections, suitable materials and construction of structural elements were set in accordance with the standard EN 1725:1998 [1]. Also, an analysis of stresses was done using the finite element method (FEM) and the calculation of allowable stresses related to a user weighing 150 kg. The results of our research provide complete standards and regulations associated with the safety requirements of bedroom furniture for users with a weight more than 110 kg to ensure that the manusfacture of quality products in Slovakia.

Positive Secular Trend in Slovak Population Urges on Updates of Functional Dimensions of Furniture

The presented study is focused on the evaluation of the changes in weight and height of the adult population in Slovakia to provide updated information on the secular growth trend. The main objective was to identify and quantify the pace of gradual changes in the dimensions of the Slovak adult population, which is key ergonomic information for multiple disciplines. The measurements of weights, heights and body mass indices of the current adult population of Slovakia ranging from 26 to 94 years of age that were obtained in period 1993–2017 were compared with a sample of students studying at four Slovak universities during the same years (aged 18 to 25). The increase of mean heights was app. 0.104–0.203 cm per one year (or app. 1–2 cm per decade) for males and app. 0.031–0.178 cm per one year (or app. 0.3–1.8 cm per decade) for females was statistically confirmed at different age classes covering the age structure of the whole adult population. The positive secular height trends were manifested in weight and BMI increases too. The changes in means and variation of distributions of selected variables also cause changes in quantile values. For example, the 95% quantiles of heights derived for the period 1993–2003 only cover 92–93% of the heights in the current population. This fact could have a major impact on proposals for optimal and safe arrangement of work, residential and non-residential space, including the furniture production.

Variations in osteoporosis medication utilization. A population-based ecological cross-sectional study in the region of Valencia, Spain

Little is known about the contextual variability in osteoporosis medication utilization. Our aims were 1) to describe variations in utilization and spending on osteoporotic medication between the Primary Care Health Zones (PHZ) of the Valencia region, Spain, 2) to analyze observed variations using Small Area Variation Analysis methods, and 3) to quantify the influence of the specialized care level on variations in utilization. We conducted a population-based cross-sectional ecological study of expenditure and utilization of five therapeutic groups marketed as osteoporosis treatments in Spain in 2009. The unit of analysis was the PHZ (in total 240) nested in the 23 Hospital Healthcare Departments (HHD) of the region of Valencia, covering a population of about 4.9 million inhabitants. Drug utilization was measured by dispensed Defined Daily Dose per 1000 women aged 50 years old and over and day (DID) per PHZ and cost was measured by the annual osteoporosis drug cost per woman aged 50 and older as well as the average price of DDD (Defined Daily Dose) in each PHZ. We calculated Indirect Standardized Drug Utilization Ratios (ISR) and we used Spearman's correlation to analyze associations between the ISRs of the different therapies. The average osteoporosis drug consumption was 119.1 DID, ranging from 77.6 to 171.3 DID (2.2 times higher) between PHZs in the 5th and 95th percentiles. Annual expenditure also showed a two-fold variation among PHZs. Average prices of the DDD by therapeutic group showed very low or no variation, although they differed substantially among therapeutic groups. Regarding the standardized consumption of osteoporotic drugs, HHDs explained a substantial part (39%) of the variance among PHZs. In conclusion, there is considerable variability in the volume and choice of anti-osteoporotic treatments between PHZs. with HHDs explaining an important proportion of the variation in utilization. Interventions aimed at reducing variation to improve appropriate care should take into account both the PHZ and HHD levels of care.

Variation in Antiosteoporotic Drug Prescribing and Spending Across Spain. A Population-Based Ecological Cross-Sectional Study

Introduction: Evidence has shown that utilization of antiosteoporotic medications does not correspond with risk, and studies on other therapies have shown that adequacy of pharmaceutical prescribing might vary between regions. Nevertheless, very few studies have addressed the variability in osteoporotic drug consumption. We aimed to describe variations in pharmaceutical utilization and spending on osteoporotic drugs between Health Areas (HA) in Spain.

Methods: Population-based cross-sectional ecological study of expenditure and utilization of the five therapeutic groups marketed for osteoporosis treatment in Spain in 2009. Small area variation analysis (SAVA) methods were used. The units of analysis were the 168 HA of 13 Spanish regions, including 7.2 million women aged 50 years and older. The main outcomes were the defined daily dose (DDD) per 1000 inhabitants and day (DDD/1000/Day) dispensed according to the pharmaceutical claims reimbursed, and the expenditure on antiosteoporotics at retail price per woman ≥50 years old and per year.

Results: The average osteoporosis drug consumption was 116.8 DDD/1000W/Day, ranging from 78.5 to 158.7 DDD/1000W/Day between the HAs in the 5th and 95th percentiles. Seventy-five percent of the antiosteoporotics consumed was bisphosphonates, followed by raloxifene, strontium ranelate, calcitonins, and parathyroid hormones including teriparatide. Regarding variability by therapeutic groups, biphosphonates showed the lowest variation, while calcitonins and parathyroid hormones showed the highest variation. The annual expenditure on antiosteoporotics was €426.5 million, translating into an expenditure of €59.2 for each woman ≥50 years old and varying between €38.1 and €83.3 between HAs in the 5th and 95th percentiles. Biphosphonates, despite accounting for 79% of utilization, only represented 63% of total expenditure, while parathyroid hormones with only 1.6% of utilization accounted for 15% of the pharmaceutical spending.

Conclusion: This study highlights a marked geographical variation in the prescription of antiosteoporotics, being more pronounced in the case of costly drugs such as parathyroid hormones. The differences in rates of prescribing explained almost all of the variance in drug spending, suggesting that the difference in prescription volume between territories, and not the price of the drugs, is the main source of variation in this setting. Data on geographical variation of prescription can help guide policy proposals for targeting areas with inadequate antiosteoporotic drug use.