The trend of osteoporosis and osteoporotic fragility fractures in inpatients: results from a national database

Trends in osteoporosis diagnosis and management in Australia

Trends in bone mineral density monitoring, and drug treatment for osteoporosis, in Australia were examined. Rates of DEXA scanning have increased in response to changes to government policy affecting reimbursement. The drug denosumab is being utilised at an increasing rate, while bisphosphonate use has declined. Osteoporosis prevalence remained stable over the same timeframe, while rate of hip fractures declined, suggesting that introduction of osteoporosis screening was associated with a reduction in adverse osteoporosis outcomes, but may also have been associated with overutilisation.

INTRODUCTION

Radiology interventions to diagnose and medications to manage osteoporosis in Australia are reimbursed under the Medicare benefits schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). Monitoring of these databases enables changes in utilisation of these practices to be monitored over time.

METHODS

This study examined rates of utilisation for bone mineral density (BMD) measurement and osteoporosis pharmacotherapy subsidised under the MBS. Rates of osteoporosis and hip fracture were estimated using data reported by the Australian Bureau of Statistics (ABS) and Australian Institute for Health and Welfare (AIHW).

RESULTS

Rates of BMD measurement increased since the technology was first reimbursed, with changes to policy regarding reimbursement for screening for individuals over 70 leading to an increase in BMD measurement after 2007. Prescribing rates also increased over time, initially with the introduction of oral bisphosphonates and subsequently for denosumab, which has subsequently become the most commonly prescribed agent for osteoporosis management in Australia, while bisphosphonate use has declined. Osteoporosis prevalence in Australia has remained relatively static at 3-4% of the population since 2001 to 2017, while rates of minimal trauma hip fracture hospitalisations have declined from 195 per 100,000 to 174 per 100,000 in the same timeframe.

CONCLUSION

Available data indicates that osteoporosis screening rates changed over time from 2001 to 2018 and that changes to government policy had a significant effect on the rates at which screening was performed. Over the same timeframe, there was a sustained reduction in hip fracture hospitalisation rates, with no change to reported osteoporosis prevalence. This suggests that policy changes permitting unlimited access to BMD measurement were associated with a reduction in osteoporotic fractures, but may also have been associated with overutilisation. Prospective studies to assess the efficacy of specific policies to ensure screening is performed in accordance with best-practice guidelines may be desirable.

Clinical features and burden of osteoporotic fractures among the elderly in the USA from 2016 to 2018

This study provides a national estimate of the incidence of hospitalizations and assesses the clinical features and outcomes during inpatient admission due to osteoporotic fractures diagnosed by ICD-10-CM/PCS among the elderly in the USA, using the US Nationwide Inpatient Sample, 2016-2018.

PURPOSE

To provide a national estimate of the incidence of hospitalizations and assess the clinical features and outcomes during inpatient admission due to osteoporotic fractures (OFs) among the elderly in the USA.

METHODS

The study included all inpatients aged 65 years and older who participated in the US Nationwide Inpatient Sample (NIS). We conducted a retrospective analysis of hospitalizations with OFs diagnosed by the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS), using the US NIS, 2016-2018. Trends in epidemiological characteristics and outcomes were calculated by annual percentage change (APC).

RESULTS

From 2016 to 2018, there were an estimated 0.16 million hospitalizations for OFs, and the estimated annual incidence rate changed from 995 cases per 1 million persons in 2016 to 1114 cases per 1 million persons in 2018 (APC, 5.8% [95% CI, 0.0 to 12.0]; P > 0.05). Over two-thirds of the patients (68.2%) were age-related osteoporosis with current pathological fracture, and OFs were more likely to occur in vertebra (51.7%) and femur (34.7%). During the hospitalization, the average length of stay (LOS) was 5.83 days, the average cost reached $60,901.04, and the overall mortality was 2.3%. All outcomes including LOS, average cost and mortality did not change significantly in 2016-2018 (all P values for trend were over 0.05).

CONCLUSION

Between 2016 and 2018, the incidence rate of OFs remained relatively stable, but the total number of cases was huge. OFs was predominantly age-related, mostly in vertebrae and femurs, with relatively stable cost and mortality during hospitalization.

Quantitative proteomic analysis comparing grades ICRS1 and ICRS3 in patients with osteoarthritis

Osteoarthritis (OA), which is caused by joint damage, is the most common form of arthritis, affecting millions of people worldwide. This damage can accumulate over time, which is why aging is one of the main contributors to joint damage associated with OA. The OA-related proteins that have been reported to date have been identified by the comparative analysis of OA patients with normal controls, following surgical or pharmacological treatment. For the first time, the present study analyzed OA-related proteins in patients with OA according to the International Cartilage Repair Society (ICRS) scale. Changes in protein expression can be observed during the OA process. The present study demonstrated differential protein expression patterns in articular cartilage from ICRS1- and ICRS3-graded OA patients. ICRS grade-matched OA knee samples from 12 OA patients, 6 ICRS grade 1 patients and 6 ICRS3 patients were subjected to proteomic analysis using the LTQ-Orbitrap mass spectrometry system. A total of 231 unique proteins were identified as expressed across the ICRS1 and ICRS3 OA patient groups. Relative differences in protein expression associated with the following classifications were observed: Biological adhesion, cell killing, cellular process, development process and molecular function. Although some of these proteins have been previously reported to be associated with rheumatoid arthritis, including cartilage oligomeric matrix protein, collagen types, angiogenin, complement C5 and CD59 glycoprotein, numerous additional proteins were newly identified, which may further help our understanding of disease pathogenesis. These findings suggested that these proteins may be used to develop novel therapeutic targets for OA.

Which Drug Next? Sequential Therapy for Osteoporosis

The proliferation of drugs with unique modes of action for treating osteoporosis has been most welcome. Fear of complications, even though rare, associated with long-term bisphosphonates (BPs) changed prescribing patterns. The BPs are stored in bone for years. Drugs not stored in bone; for example, abaloparatide, teriparatide, denosumab, and romosozumab have expanded our armamentarium for treating osteoporosis but have brought new challenges. Bone accrued during treatment with the last 3 drugs, and perhaps abaloparatide, is lost rapidly after their withdrawal due to rebound increase in bone resorption. Treatment with these drugs must be followed by administration of an antiresorptive agent. The article by Kendler et al. (1) in this issue of JCEM reports alendronate preserves bone accrued during administration of denosumab.