clinical topic updates

Preventing an Epidemic of New Osteoporotic Fractures in America

by Tom Iarocci, MD

Overview

The long-standing gap in osteoporosis care is poised to usher in an epidemic of new fractures, threatening a return to high rates of hip fracture among older postmenopausal women. But there is hope for a trend reversal.

Expert Commentary

Tom Iarocci, MD

Editor-in-Chief, Expert Perspectives in Medicine
University of Maryland School of Medicine
Baltimore, MD

“A 68% increase in the annual osteoporotic fracture rate is projected to occur over the next 2 decades, and the upsurge in related morbidity and mortality might have already begun.”

Tom Iarocci, MD

The burden from postmenopausal osteoporosis is expected to worsen in the very near future. The potential epidemic of new fractures is driven by an aging population, a trend toward decreased bone density screening, and, importantly, a decline in the diagnosis and treatment of high-risk patients. Concerns about the rare side effects of bisphosphonates, some of which date back to 2006, are still operative in today’s milieu of patient-centered care and health care consumerism. Further, there is no public awareness campaign to offset treatment reluctance or any direct-to-consumer advertising expected from the industry, as bisphosphonates are off-patent.

A 68% increase in the annual osteoporotic fracture rate is projected to occur over the next 2 decades, and the upsurge in related morbidity and mortality might have already begun. A 2018 analysis of US Medicare claims data from 2002 to 2015 for women aged 65 years and older shows that hip fracture rates were higher than expected from 2013 to 2015, with an excess of 11,000 hip fractures reported. Although hip fractures represent just 14% of all osteoporotic fractures, the downward spiral in older patients with fractures, especially of the hip, is a feared and widely recognized clinical entity with the potential for substantial morbidity and an increased risk of mortality in the year following fracture.

Postmenopausal osteoporosis treatment rates are low, even for individuals at the highest risk. A Medicare analysis published in 2016 found that, of 145,185 individuals with a fragility fracture, only approximately 30% received treatment over 12 months following the fracture. This finding is especially relevant in that, in patients with prior fractures, osteoporosis treatment can result in a 50% reduction in the risk of future fractures. Sustaining a vertebral fracture (the most common of all osteoporotic fractures) results in an approximate 5-fold increased risk of future fractures. However, most vertebral fractures are asymptomatic, they are often overlooked in radiographs, and a high percentage of mild vertebral fractures remain undiagnosed. Detection of vertebral fractures is even more challenging in the setting of undiagnosed osteoporosis and in patients who have not received screening for poor bone quality.

“The underdiagnosis/undertreatment of osteoporosis is a multifaceted problem. Physician-led Fracture Liaison Services have been successful, highlighting the importance of systemic factors and of a collaborative systems-based approach.”

Tom Iarocci, MD

From a population perspective, the benefits of osteoporosis treatment in appropriately selected patients are undeniable. Antiresorptive and anabolic medications have improved the physical health of patients by reducing the risk of fracture. Decades of data from randomized controlled trials have shown that osteoporosis medications have reduced vertebral fractures by 40% to 70%, nonvertebral fractures by 20% to 36%, and hip fractures by up to 40%, and these successes have been reproduced in real-world analyses.

However, the underdiagnosis/undertreatment of osteoporosis is a multifaceted problem. Physician-led Fracture Liaison Services have been successful, highlighting the importance of systemic factors and of a collaborative systems-based approach. That is, the problem of the underdiagnosis/undertreatment of osteoporosis has been described as a “Bermuda Triangle of orthopedists, primary care physicians and osteoporosis experts” whereby fracture patients disappear. Thus, a singular focus on any one facet of the problem, such as osteoporosis treatment reluctance among patients or quality improvement metrics among providers, may be inadequate. Fracture Liaison Services have been shown to be effective at identifying patients with recent fragility fractures and capturing these patient encounters so that the appropriate diagnostic workup, treatment, and follow-up can take place. For instance, the Rush Fracture Liaison Service was developed as a highly educational, interdisciplinary, physician-run model without additional costs to the institution. This approach captured missed opportunities in the form of previously undiagnosed osteoporosis in 73.1% (163/223) of patients with fragility fractures. These integrated services and other innovative approaches promise to help reverse long-standing trends and improve osteoporosis care.

References

Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475.

Cannada LK, Hill BW. Osteoporotic hip and spine fractures. Geriatr Orthop Surg Rehabil. 2014;5(4):207-212.

Corrigendum to how to define an osteoporotic vertebral fracture. Quant Imaging Med Surg. 2019;9(11):1922-1931.

Curtis JR, Silverman SL. Commentary: the five Ws of a Fracture Liaison Service: why, who, what, where, and how? In osteoporosis, we reap what we sow. Curr Osteoporos Rep. 2013;11(4):365-368.

Gupta MJ, Shah S, Peterson S, Baim S. Rush Fracture Liaison Service for capturing “missed opportunities” to treat osteoporosis in patients with fragility fractures. Osteoporos Int. 2018;29(8):1861-1874.

Harrington J. Dilemmas in providing osteoporosis care for fragility fracture patients. US Musculoskeletal Review-Touch Briefings. 2006;2:64-65.

Keshishian A, Boytsov N, Burge R, et al. Examining the treatment gap and risk of subsequent fractures among females with a fragility fracture in the US Medicare population. Osteoporos Int. 2017;28(8):2485-2494.

Lewiecki EM, Ortendahl JD, Vanderpuye-Orgle J, et al. Healthcare policy changes in osteoporosis can improve outcomes and reduce costs in the United States. JBMR Plus. 2019;3(9):e10192.

Lewiecki EM, Wright NC, Curtis JR, et al. Hip fracture trends in the United States, 2002 to 2015 [published correction appears in Osteoporos Int. 2018;29(11):2583]. Osteoporos Int. 2018;29(3):717-722.

Yusuf AA, Matlon TJ, Grauer A, Barron R, Chandler D, Peng Y. Utilization of osteoporosis medication after a fragility fracture among elderly Medicare beneficiaries. Arch Osteoporos. 2016;11(1):31.

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