Estimating the Opportunity Costs of Osteoporosis in the United States:

Healthcare Policy Changes in Osteoporosis Can Improve Outcomes and Reduce Costs in the United States

In the United States, osteoporosis affects over 10 million adults, has high societal costs ($22 billion in 2008), and is currently being underdiagnosed and undertreated. Given an aging population, this burden is expected to rise. We projected the fracture burden in US women by modeling the expected demographic shift as well as potential policy changes. With the anticipated population aging and growth, annual fractures are projected to increase from 1.9 million to 3.2 million (68%), from 2018 to 2040, with related costs rising from $57 billion to over $95 billion. Policy‐driven expansion of case finding and treatment of at‐risk women could lower this burden, preventing 6.1 million fractures over the next 22 years while reducing payer costs by $29 billion and societal costs by $55 billion. Increasing use of osteoporosis‐related interventions can reduce fractures and result in substantial cost‐savings, a rare and fortunate combination given the current landscape in healthcare policy. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Lifetime, untreated isolated GH deficiency due to a GH-releasing hormone receptor mutation has beneficial consequences on bone status in older individuals, and does not influence their abdominal aorta calcification

The GH/IGF-I axis has essential roles in regulating bone and vascular status. The age-related decrease in GH secretion ("somatopause") may contribute to osteoporosis and atherosclerosis, commonly observed in the elderly. Adult-onset GH deficiency (GHD) has been reported to be associated with reduced bone mineral density (BMD), increased risk of fractures, and premature atherosclerosis. We have shown the young adult individuals with isolated GHD (IGHD) due to a homozygous for the c.57+1G>A GHRH receptor gene mutation have normal volumetric BMD (vBMD), and not develop premature atherosclerosis, despite adverse risk factor profile. However, the bone and vascular impact of lifetime GHD on the aging process remains unknown. We studied a group of ten older IGHD subjects (≥60 years) homozygous for the mutation, comparing them with 20 age- and gender-matched controls (CO). Areal BMD was measured, and vBMD was calculated at the lumbar spine and total hip. Vertebral fractures and abdominal aortic calcifications (expressed as calcium score) were also assessed. Areal BMD was lower in IGHD, but vBMD was similar in the two groups. The percent of fractured individuals was similar, but the mean number of fractures per individual was lower in IGHD than CO. Calcium score was similar in the two groups. A positive correlation was found between calcium score and number of fractures. Untreated lifetime IGHD has beneficial consequences on bone status and does not have a deleterious effect on abdominal aorta calcification.

The burden of illness of osteoporosis in Canadian men

There is a dearth of information about the burden of osteoporosis in Canadian men. To fill this gap, we conducted a burden of illness study aimed at estimating the economic burden attributable to osteoporosis in Canadian men aged 50 years and older. Five national data sources were used to estimate health care resource utilization and costs (in 2010 Canadian dollars) associated with osteoporosis in men. Any information gap was supplemented by using data from provincial and community sources. Direct medical costs included costs associated with hospitalizations, same day surgeries, emergency room visits, rehabilitation, chronic care, long-term care, home care, physician visits, and prescribed medications. The value of lost productivity from patients and informal caregivers was also determined to provide a societal perspective. Sensitivity analyses were conducted to evaluate the impact of key assumptions on the results. In fiscal year 2007/2008, the total economic burden of treating and rehabilitating male osteoporotic fractures was estimated at $570 million per year, where direct medical costs accounted for 86%. Acute care utilization was responsible for 70% of all direct costs. About 51% of all hospitalizations were for hip fractures and hip fractures alone accounted for 54% of the acute care spending. If a proportion of Canadian men were assumed to live in long-term care facilities due to osteoporosis, the overall annual cost of osteoporosis would increase from $570 million to $910 million. Male osteoporosis has a substantial economic burden on the Canadian society.

Review of osteoporosis pharmacotherapy for geriatric patients

BACKGROUND

Fractures are a significant problem in geriatric patients, and understanding the evidence for benefit and possible harm of osteoporosis treatments is critical to appropriate management of this patient population.

OBJECTIVE

The purpose of this article was to review the evidence and treatment considerations related to use of the approved osteoporosis treatments in the United States across the continuum of ages in the geriatric population.

METHODS

MEDLINE and the Web of Science were searched to find English-language articles published from 2000 through July 2009. Search terms included: practice guideline, osteoporosis, calcium, vitamin D, pharmacoeconomics, ethnicity, and treatment. The generic names of each of the osteoporosis treatments approved in the United States were searched to find relevant clinical trials and randomized controlled trials (RCTs). Pivotal trials that included fracture data or focused specifically on elderly patients (> or = 60 years of age) were selected. Bibliographies in the identified articles were searched for additional articles, and the prescribing information for each of the approved treatments was reviewed.

RESULTS

Many osteoporosis studies have a mean patient age >60 years, but data for older patients are limited. Subanalyses of older patient groups have found risedronate to be beneficial for vertebral fractures in patients aged 70 to 79 years (absolute risk reduction [ARR], 8.4%; P < 0.001) and teriparatide to be beneficial for both vertebral (ARR, 6.4%; P < 0.05) and new nonvertebral fragility fractures (ARR, 9.9%; P < 0.05) in women aged > or = 75 years. However, no RCTs of geriatric patients who were either nonambulatory or had multiple comorbidities were identified in the literature.

CONCLUSIONS

Evidence indicates that the osteoporosis treatments currently available in the United States are beneficial for treating osteoporosis in geriatric patients. However, data are limited for the oldest patients (> or = 80 years) and those with significant comorbidities. Because of the limited availability of data for geriatric patients with significant comorbidities, the properties of the various agents, including efficacy, tolerability, and potential contraindications, should be considered carefully for each geriatric patient.

A Calibration Procedure for a Bone Loading System

Trabecular bone tissue is a three-dimensional structure that is difficult to duplicate with in vitro cell cultures or animal models. In an attempt to better understand the underlying mechanisms of tissue response to load, a system to load isolated bone preparations was developed. This ex vivo bone culture and loading system, given the name of ZETOS, compressively loads trabecular bone (10mm diameter, 5.0mm height) to evaluate its morphological and physiological responses while keeping cells viable. Compliance of the system may change with time, thus requiring recalibration. The purpose of this research was to develop and validate a recalibration protocol for the ZETOS system. Ten reference bodies (RBs) were designed and machined out of aluminum 7075-T6, with a structural rigidity range representative of trabecular bone (0.628–28.3N∕μm, or apparent elastic modulus of 40MPa–1.80GPa). Finite element analysis (FEA) was used to calculate the rigidity of each RB and was validated with physical testing in a universal testing machine. Results from FEA were then used to calibrate the system and relate force, piezoelectric actuator expansion, and specimen compressive deformation through a surface generated by spline interpolation, thus creating a calibration table. Calibration of ZETOS was verified by testing the RBs as well as three custom-made, metal springs and comparing measured rigidity to that calculated by FEA. Mean percent difference of FEA results with respect to those from physical testing was 3.28%. The mean percent difference of RB rigidity found with ZETOS with respect to rigidity found with FEA was 1.12% and for the metal springs, the mean percent difference was 1.74%. The calibration procedure for the ZETOS bone loading system has been successfully applied and verified. The use of RBs and FEA allows users to easily and periodically evaluate and recalibrate the system. Accuracy in studies of human bone mechanotransduction in a controlled environment can therefore be achieved. The recalibration procedure is relevant for other ZETOS users and may serve as the basis for calibration of other testing systems for small specimens of compliant materials.

Excess mortality following hip fracture: the role of underlying health status

We evaluated the long-term excess mortality associated with hip fracture, using prospectively collected data on pre-fracture health and function from a nationally representative sample of U.S. elders. Although mortality was elevated for the first six months following hip fracture, we found no evidence of long-term excess mortality.

INTRODUCTION

The long-term excess mortality associated with hip fracture remains controversial.

METHODS

To assess the association between hip fracture and mortality, we used prospectively collected data on pre-fracture health and function from a representative sample of U.S. elders in the Medicare Current Beneficiary Survey (MCBS) to perform survival analyses with time-varying covariates.

RESULTS

Among 25,178 MCBS participants followed for a median duration of 3.8 years, 730 sustained a hip fracture during follow-up. Both early (within 6 months) and subsequent mortality showed significant elevations in models adjusted only for age, sex and race. With additional adjustment for pre-fracture health status, functional impairments, comorbid conditions and socioeconomic status, however, increased mortality was limited to the first six months after fracture (hazard ratio [HR]: 6.28, 95% CI: 4.82, 8.19). No increased mortality was evident during subsequent follow-up (HR: 1.04, 95% CI: 0.88, 1.23). Hip-fracture-attributable population mortality ranged from 0.5% at age 65 among men to 6% at age 85 among women.

CONCLUSIONS

Hip fracture was associated with substantially increased mortality, but much of the short-term risk and all of the long-term risk was explained by the greater frailty of those experiencing hip fracture.

Economic burden of osteoporosis-related fractures in Medicaid

OBJECTIVE

There are limited studies concerning the economic burden of osteoporosis in the Medicaid population. This study estimated the direct cost of osteoporosis-related fractures (OPFx) to state Medicaid budgets.

METHODS

This retrospective analysis utilized Medicaid claims databases from three states, which included approximately 8 million Medicaid recipients. The study sample had at least one claim for an osteoporosis diagnosis (733.0x) between January 1, 2000 and December 31, 2001. Beneficiaries with a fracture and a diagnosis of osteoporosis were assigned to the case cohort. A propensity score-based matching method was used to select a cohort of controls with osteoporosis but without a fracture. An exponential conditional mean model was used to estimate the incremental annual cost associated with fractures.

RESULTS

The study cohort (n = 7626) and a 1:1 matched control group were identified. The study cohort was 85.8% female, had an average age of 65 years, were 53.2% white, and 48.9% were eligible for Medicare. There were significant increases (all P < 0.05) from the preperiod to study period for this cohort in the proportion that had at least one hospital admission (14.0% vs. 26.5%), nursing home admission (9.2% vs. 17.2%), home health (39.1% vs. 49.3%), or emergency room visit (21.3% vs. 31.9%). In contrast, the control cohort had very little increase in utilization. The regression-adjusted incremental cost for osteoporosis-related expenses in the year after fracture was estimated at $4007 per patient. The estimated incremental cost was $5370 for the subset of patients who were eligible for Medicare.

CONCLUSION

The economic burden of osteoporosis-related fractures on state Medicaid budgets is substantial.

Homocysteine and bone loss in epilepsy

Epidemiological studies reveal fracture incidence in epilepsy is twice that of the normal population. Much interest has been focused on Vitamin D, however, considering mixed results on non-enzyme inducing anti-epileptic drugs (AEDs) and bone mineral density (BMD) additional metabolic effects may be to blame. AEDs increase serum homocysteine (s-Hcy) by lowering blood folate levels. An association between elevated homocysteine, BMD and increased fracture incidence has been found in non-epilepsy populations. Additionally, folate and Vitamin B12 levels are independently related to bone mineral density in various non-epilepsy populations. This study supports previous research, which found elevated s-Hcy in subjects taking AEDs and that bone loss is related to the use of enzyme-inducing AEDs and changes in alkaline phosphatase. By one-way ANOVA, subjects on phenytoin monotherapy had significantly higher levels of s-Hcy than those on other AEDs (F=5.89, p=.016). Regression analyses revealed homocysteine, fracture history, length of years on AEDs, ethnicity were predictors of spine T scores. Weight and BMI were predictors of both BMD and DEXA T scores. Use of enzyme-inducing AEDs was a negative predictor of spine BMD and T scores, while phenytoin monotherapy was a positive predictor of spine BMD. Lamotrigine was found to be a negative predictor of spine T score. Ambulatory status, menopause and alcohol consumption were predictors of BMD but not T scores. In this study, persons with epilepsy who take nutritional supplementation have 25% lower s-Hcy levels than those who do not. Supplementation continues to be important in preventative epilepsy care.

Self-efficacy, knowledge, health beliefs, quality of life, and stigma in relation to osteoprotective behaviors in epilepsy

It is well reported in the epilepsy literature that use of antiepileptic drugs (AEDs) leads to bone loss. Validated instruments were administered to assess knowledge, health behavior, quality of life, and stigma, to determine their effects on self-efficacy for osteoprotective and self-management behaviors. This adult epilepsy population had a mean age of 45, with 20 years of AED exposure. Fifty subjects were Caucasian and 44 were non-Caucasian. By one-way ANOVA, there were significant differences in self-efficacy based on ethnicity, medical assistance, status, and seizure frequency. Differences in knowledge based on ethnicity, education, and income were also noted. Regression analysis revealed that the factors that most predict self-efficacy for calcium, exercise, and self-management do not parallel each other. Age and ethnicity were predictive of self-efficacy for epilepsy self-management only. Medical management factors varied among the models. Overall quality of life was a positive predictor for both calcium and exercise self-efficacy.

Bone loss in epilepsy: barriers to prevention, diagnosis, and treatment

In epilepsy populations there are multiple barriers to the prevention, diagnosis, and treatment of metabolic bone disease. This study explored issues that may be unique to inner-city care. We screened 101 consecutive patient charts from our clinic to identify barriers to optimal care. According to the Health Belief Model, when patients view a condition as not severe and their perceived susceptibility is low, they are unlikely to comply with screening and/or adopt preventative behaviors. Despite routine communications to primary care doctors regarding bone health, its importance is still overlooked. In addition, the managed care referral process makes it difficult for a specialist to prevent, screen, and treat a primary care condition with no symptoms. For optimal patient care and to stimulate prevention and screening compliance, a communication style adapted to the patient's knowledge, beliefs, and attitudes toward antiepileptic drug-induced bone loss is crucial to help reduce barriers against change.