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Public, policymakers underestimate risk from osteoporosis
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Despite the availability of robust diagnostic tools and effective medications, we are doing a poor job of treating patients at high risk for low-trauma, or osteoporotic, fractures.
The Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare have established that older women should undergo bone mineral density testing and/or initiation of fracture-preventing drug therapy within 6 months of a low-trauma fracture. Recent data available from the National Committee for Quality Assurance indicate that this is achieved in only 30% of eligible cases, in marked contrast with other recommended care, such as breast cancer screening (approximately 70%) and use of beta-blockers after myocardial infarction (approximately 85%).
Low-trauma fractures are common and costly, with more than 2 million events per year in the United States, and medical costs totaling $20 billion annually. Even restricting attention to hip fracture, the incidence exceeds that of breast cancer, and the 5-year mortality of 20% to 25% far exceeds that of breast cancer.
Robert D. Blank
Why is our performance so poor? Below, I summarize some of the factors that I believe contribute to the current situation.
Lack of awareness
Poor awareness of the scope of the problem is, in my opinion, a major contributor to the underuse of fracture prevention treatment. Few physicians, and fewer lay people, appreciate how common and how morbid low-trauma fractures are.
I often ask women who see me in an academic, metabolic bone disease referral practice whether they are more fearful of a hip fracture or of developing breast cancer. Nearly all are more fearful of breast cancer. Simultaneously, I ask whether they fear ending their lives in a nursing home, and most do. Elders highly value their ability to live independently, yet despite this — and despite many having experienced family members or close friends who were institutionalized after fractures — they persist in fearing breast cancer more.
In my experience, physicians are only marginally better informed than patients regarding the burden of low-trauma fractures.
Lack of advocacy
Poor patient awareness leads to poor advocacy. HIV/AIDS, Alzheimer’s disease, breast cancer and cystic fibrosis all gain visibility from strong lay advocacy groups. Their efforts lead to research support and more effective treatment mandates than exist for low-trauma fractures. Payers and health care organizations devote substantial resources to developing centers of excellence for visible health problems. As a low visibility problem, low-trauma fractures garner little support from most clinical practices.
Lack of new therapies
The relative paucity of the drug development pipeline for new fracture-prevention drugs distinguishes the present situation from that existing in the 1990s. While there are currently two promising agents in late-stage development, these are not garnering comparable attention to that bestowed on bisphosphonates, selective estrogen receptor modulators (SERMs) and Forteo (teriparatide, Eli Lilly) immediately prior to their approval by the FDA.
Moreover, much more attention is devoted at present to the small degree of risk attending the use of these agents rather than their substantial therapeutic efficacy, which has been documented in multiple well-conducted trials. In the minds of many, the 0.1% risk of atypical fracture is more compelling than the 40% risk reduction for ordinary fractures.
Lack of coordinated care
Fragmentation of care also contributes to the low treatment rate. Orthopedists treat the fractures, whereas primary care physicians, rheumatologists and endocrinologists typically order care to prevent future fractures. The American Orthopaedic Association’s “Own the Bone” initiative is a laudable effort to improve communication between the specialties, but more will be needed to bridge the treatment gap. Accountable care organizations may help with this obstacle to secondary prevention by shifting the focus from episodic to global care.
Lack of understanding
Our own profession also has actively contributed to undertreatment of adults with low-trauma fractures. The American Board of Internal Medicine’s “Choose Wisely” campaign has stated that DXA is an overused, low-value test.
The argument is based in large part by generalizing the findings from a report by the Study of Osteoporotic Fractures Research Group beyond the authors’ stated limitations of their work. These authors modeled the rate of transition from normal BMD or various densitometrically defined strata of osteopenia to osteoporosis, inferring that those with T-scores exceeding –1.5 might require follow-up testing only every 15 years in the absence of sentinel clinical events. They explicitly limited their analysis to women who had not experienced fractures, and their follow-up monitoring recommendations were predicated on women remaining fracture-free.
This publication served as the foundation for restrictive public policy decisions in Oregon and Washington that are inconsistent with scientific evidence. For example, in Washington, neither a low-trauma fracture nor initiation of therapy for fracture prevention is a qualifying event to allow follow-up testing. These public policies will undoubtedly harm some patients.
It is important to recall the following facts. Approximately 300,000 hip fractures occur in the United States each year, with an attendant 1-year mortality of about 20% and an even higher rate of subsequent nursing home admission. Approximately 700,000 vertebral fractures occur each year, of which only one-third are recognized at the time of occurrence. Vertebral fracture assessment performed in conjunction with DXA would allow many of these to be recognized, with attendant restratification of the patient’s future fracture risk. A similar number of wrist fractures also occur.
All of these numbers are limited to low-trauma fractures, provoked by a fall from standing height or less. Prior fracture is a powerful risk factor for future fracture.
Since 2001, treatment of osteoporosis has declined in the United States. It is time that we make the effort to educate our patients and our policymakers so that this trend can be reversed.
References:
- Gourlay ML, et al. N Engl J Med. 2012;doi:10.1056/NEJMoa1107142.
- National Committee for Quality Assurance. Osteoporosis testing and management in older women. Available at: www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2014TableofContents/Osteoporosis.aspx. Accessed May 5, 2015.
For more information:
- Robert D. Blank, MD, PhD, is Chief of Endocrinology and a Professor of Medicine in the Division of Endocrinology in the Department of Medicine at the Medical College of Wisconsin. He can be reached at 8701 Watertown Plank Road, Milwaukee, WI 53226; email: roblank@mcw.edu. He reports no relevant financial relationships.
Perspective
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Nelson Watts, MD, FACP, MACE
Osteoporosis seems to be the “Rodney Dangerfield” of chronic diseases — it “don’t get no respect.” Many patients are more worried about side effects and safety issues with drugs than they are about the consequences of osteoporosis, and they fail to fully appreciate that fractures can be life-shortening or life-changing events and a major threat to quality of life and independent living. And I’m only having those sorts of conversations with patients who have had at least one bone density test. Many patients (and providers) don’t ever get tested, even after having a fracture — even though having a fracture should be the equivalent of ringing an alarm bell. The news media don’t help, failing to point out when a fracture due to osteoporosis has affected a news-worthy individual but quick to provide “scary stories” about rare events that may or may not be side effects of medications used to treat osteoporosis.
Perspective
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Steven M. Petak, MD, JD, MACE, FACP, FCLM, CCD
Osteoporosis is still considered by many to be an inevitable consequence of aging. The depiction of fractures is invariably linked to frailty and is not nearly as appealing an image as the noble fight against cancer or the workaholic with a heart attack. This preventable and treatable disease is cast aside in the struggle to stay on time and deal with other pressing problems contained in a patient-physician encounter. The recent excitement over fracture liaison services — targeting the most vulnerable and highest fracture risk patients — is certainly workable in a closed system, such as Kaiser, where the economic forces are aligned to help prevent fractures and save money. This may be more difficult in open systems. The significant decrease in DXA reimbursement has resulted in large numbers of expert physicians abandoning their DXA units and patients that have resulted in a growing problem of access to quality bone density studies. EMR systems compound the problem by only presenting an interpretive report instead of the actual studies needed to assess quality. This editorial is a noble effort to draw attention to the growing desperation in a medical field that has flowered over the past 20 years and is now suffering a slow premature demise. As physicians, we must continue to fight and advocate for what is best for our patients in an increasingly cynical and fragmented health care landscape. This is what connects us to our noble past and is our best hope for the future.
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