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/lp/springer-journals/treatment-rates-and-healthcare-costs-of-patients-with-fragility-iCpFaT0ExX
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- Springer Journals
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- Copyright © The Author(s) 2023
- ISSN
- 1862-3522
- eISSN
- 1862-3514
- DOI
- 10.1007/s11657-023-01229-7
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Abstract
Summary In a characterization of treatment rates and healthcare costs among patients with an osteoporotic-related fragility fracture overall and by site of care, costs were high and treatment rates were low. Purpose Osteoporotic fractures can be debilitating, even fatal, among older adults. The cost of osteoporosis and related frac- tures is projected to increase to more than $25 billion by 2025. The objective of this analysis is to characterize disease-related treatment rates and healthcare costs of patients with an osteoporotic fragility fracture overall and by site of fracture diagnosis. Methods In this retrospective analysis, individuals with fragility fractures were identified in the Merative MarketScan® Commercial and Medicare Databases among women 50 years of age or older and diagnosed with fragility fracture between 1/1/2013 and 6/30/2018 (earliest fracture diagnosis = index). Cohorts were categorized by clinical site of care where the diagnosis of fragility fracture was made and were continuously followed for 12 months prior to and following index. Sites of care were inpatient admission, outpatient office, outpatient hospital, emergency room hospital, and urgent care. Results Of the 108,965 eligible patients with fragility fracture (mean age 68.8), most were diagnosed during an inpatient admission or outpatient office visit (42.7%, 31.9%). The mean annual healthcare costs among patients with fragility fracture were $44,311 (± $67,427) and were highest for those diagnosed in an inpatient setting ($71,561 ± $84,072). Compared with other sites of care at fracture diagnosis, patients diagnosed during an inpatient admission also had highest proportion of subsequent fractures (33.2%), osteoporosis diagnosis (27.7%), and osteoporosis therapy (17.2%) during follow-up. Conclusion The site of care for diagnosis of fragility fracture affects treatment rates and healthcare costs. Further studies are needed to determine how attitude or knowledge about osteoporosis treatment or healthcare experiences differ at various clinical sites of care in the medical management of osteoporosis. Keywords Aged · Bone density/drug effects · Bone density conservation agents · Cost of illness · Female · Health care costs · Hospitalization · Humans · Medicare · Middle aged · Postmenopausal · Risk assessment · USA/epidemiology Background * M. McDermott Osteoporosis is a skeletal disease characterized by the loss mmcder02@amgen.com of bone mass and the deterioration of bone microarchitec- MedStar Georgetown University Hospital, Washington, DC, ture, wherein bone strength is compromised and affected USA patients are predisposed to an elevated risk of fracture [1]. Georgetown University Medical Center, Washington, DC, These fractures, also known as fragility fractures, typically USA occur in wrists, hips, and vertebrae, can often be debili- Oregon Osteoporosis Center, Portland, OR, USA tating, put patients at an increased risk for a subsequent Mary MacKillop Institute for Health Research, Australian fracture, and can even be fatal among older adults [2]. Catholic University, Melbourne, VIC, Australia Globally, women over the age of 50 have a 9.8 to 22.8% Merative, Cambridge, MA, USA lifetime risk of fragility fractures and fractures will occur among 1 in 3 [3]. The Women’s Health Initiative Obser- NYU Grossman School of Medicine, New York, NY, USA vational study projected the number of fractures as similar University of California, San Francisco, CA, USA to or higher than breast cancer, stroke, and cardiovascular Amgen Inc, Thousand Oaks, CA, USA Vol.:(0123456789) 1 3 42 Page 2 of 12 Archives of Osteoporosis (2023) 18:42 disease events combined among women aged 50–79 in the Methods USA [4]. The Bone Health and Osteoporosis Foundation (BHOF; formerly the National Osteoporosis Foundation) Study design and data source estimates 3 million fractures and $25.3 billion in direct healthcare costs per year by 2025 [5]. This observational cohort study was conducted using Due to undertreatment and disease mismanagement, oste- de-identified data from the Merative MarketScan® Com- oporosis and related fractures present a substantial cost bur- mercial Claims Database and the Medicare Supplemental den to the healthcare system. Osteoporotic fracture is a top and Coordination of Benefits Database. The commer- driver of hospitalization-related costs among US women— cial claims database contains the inpatient, outpatient, more costly than breast cancer, myocardial infarction, and and prescription drug experience of employees and their stroke [6]. One study estimated the national cost of osteopo- dependents, covered under a variety of fee-for-service rosis and related fractures to be $22 billion [7], and that cost and managed care health plans, including approximately is expected to escalate to more than $95 billion by 2040 [8]. 89 million lives from 2012 to 2018. The Medicare data- Fracture prevention and earlier osteoporosis diagnosis base contains the healthcare experience of retirees with are essential to initiation of adequate treatment; however, Medicare supplemental insurance paid for by employers, osteoporosis remains underdiagnosed among fragility frac- including 5.5 million lives between 2012 and 2018. These ture patients [9]. Frequency of osteoporosis diagnosis varies databases provided detailed cost, use, and outcomes data by site of care, and we hypothesize diagnosis patterns simi- for healthcare services performed in both inpatient and larly differ across provider specialty type [10]. Undertreat- outpatient settings. Data were extracted using International ment is due in part to underdiagnosis among these patients Classification of Diseases, 9th and 10th Revision, Clinical [11]. Bisphosphonates have been widely used to treat bone Modification (ICD-9-CM and ICD-10-CM) codes, Current diseases since the 1970s and are well established as the first- Procedural Terminology (CPT) 4th edition codes, Health- line treatment for osteoporosis. However, poor adherence is care Common Procedure Coding System (HCPCS) codes, common with oral bisphosphonates. Non-persistent patients and National Drug Codes (NDCs). These de-identified remain at elevated risk for fracture [12]. Low persistence is data were fully compliant with US patient confidentiality due in part to complex dosing instructions and fear of side requirements set forth in the Health Insurance Portability effects [6 , 12, 13]. and Accountability Act of 1996. Osteoporosis is treated by a range of clinicians in a variety of settings [14]. Although there is a high degree of consist- ency and agreement regarding osteoporosis treatment guide- Patient selection and site of care cohort assignment lines, recommendations, and practice among clinicians, there are also significant differences. For example, the American Women aged 50 years of age and older with a fragility College of Physicians recommends against bone density mon- fracture (index date = date of diagnosis of first fracture) itoring during the 5-year pharmacologic treatment period for were identified in the commercial and Medicare Databases osteoporosis in women, whereas the American Association during January 1, 2013 through June 30, 2018. Fragility of Clinical Endocrinologists recommend bone density moni- fracture, osteoporosis, and other clinical conditions were toring every 1–2 years [15, 16]. Currently, there is a lack of identified by ICD-9-CM/ICD-10-CM diagnosis or CPT research describing the relationship between the site of care procedure coding. To determine eligibility, patients had where a patient is diagnosed with a fragility fracture with at least 12 months of continuous enrollment and pharmacy healthcare resource utilization, healthcare costs, osteoporo- benefits prior to the index date (baseline period) and at sis diagnosis, osteoporosis treatment patterns, and subsequent least 12 months of continuous enrollment and pharmacy fragility fracture rates in the following year. benefits following the index date (follow-up period). Patients with Paget’s disease of the bone, osteitis defor- mans, osteogenesis imperfecta, hypercalcemia, cancer, or conditions categorized in ICD-9-CM/ICD-10-CM as Objective “other osteopathy” during the baseline were excluded. Individuals with fragility fracture were categorized To characterize baseline demographic characteristics and into cohorts based on the site of care at diagnosis. Sites clinical conditions and the 12-month patient journey fol- of care of interest were identified a priori by the co- lowing a fragility fracture. Treatment rates and healthcare authors who treat and study osteoporosis and fragility costs of individuals with fragility fracture were reported by fracture: inpatient, outpatient office, outpatient hospital, the site of care where they were diagnosed. emergency room (ER), federally qualified health center 1 3 Archives of Osteoporosis (2023) 18:42 Page 3 of 12 42 (FQHC), rehabilitation facility, nursing facility, urgent fragility fracture during the 12-month follow-up period and care, patient home, rural health clinic, and assisted living type of fracture (hip, vertebra, and non-hip non-vertebral) was facility. Detailed data was not reported for cohorts with also reported. Repeat fractures defined as those that occurred less than 30 individuals. more than 90 days following the index fracture of the identical Individuals were also categorized into cohorts based on fracture type were also reported. the index physician specialty. The index physician specialty Bone density scans were measured in the baseline and fol- was the physician specialty that made the diagnosis of fra- low-up periods. Bone density scans included procedure codes gility fracture. Specialties of interest on the first fragility that describe dual-energy X-ray absorptiometry (DEXA), bone fracture diagnosis were family medicine, internal medicine, density studies on one or more sites, ultrasound bone den- obstetrics/gynecology (OB-GYN), orthopedics, geriatrics, sity measurement and interpretation, and single energy x-ray rheumatology, endocrinology, and emergency medicine. absorptiometry (SEXA) bone density studies. Patient characteristics Statistical analysis Patient demographic characteristics included age, region, Mean and standard deviation (SD) were reported for con- and health plan measured on index date. Clinical characteris- tinuous variables, while frequencies and percentages were tics, including the Deyo-Charlson Comorbidity Index (DCI) reported for categorical variables. All data analyses were [17], were reported during the 12-month baseline period. conducted using WPS version 4.1 (World Programming, UK). Outcomes Results All-cause and disease-related healthcare utilization and costs were measured during the 12-month follow-up period. The Study population index date was included in the follow-up period; therefore, healthcare utilization and costs of the index event are cap- Of the 108,965 eligible patients with fragility fracture, tured in the post-index averages of services and treatment. most were diagnosed during an inpatient admission, outpa- Disease-related healthcare utilization and costs corre- tient office visit, or outpatient hospital visit (42.7%, 31.9%, sponded to medical claims with a diagnosis code for osteo- 24.0%; Fig. 1). All other sites of care identified less than 2% porosis or osteopenia, a diagnosis or procedure code for fra- of the fragility fracture groups. The largest cohort of patients gility fracture (defined by the previously described algorithm with fragility fracture was aged between 50–64 (48.8%), [18]), medical claims with administration (HCPCS codes) with an average age of 68.8 years (Table 1). Patients with for osteoporosis therapies, or outpatient pharmacy claims fragility fracture diagnosed during an inpatient admission (NDC codes) for osteoporosis therapies. This study reports were older on average (75.0 years) compared with the over- all-cause and disease-related healthcare utilization and costs all group (68.8 years); meanwhile, most patients indexed for inpatient, ER, and outpatient health care settings, as well in all other settings were between ages 50 and 64. Most as pharmacy utilization and costs. patients had an Exclusive Provider Organization (EPO) Healthcare costs are reported in 2018 constant US dol- health insurance plan (49.9%). The largest proportion of lars, adjusted using the Medical Care component of the Con- patients originated from the South (35.4%). Ten percent of sumer Price Index. Healthcare costs were measured using the fragility fracture cohort had a diagnosis of osteoporosis the financial fields on administrative claims in the MarketS- during baseline (Fig. 1). Average baseline all-cause health- can Databases. care costs were $18,146 (SD $45,537; Table 1). The mean Proportions of patients with any osteoporosis treatment dur- Deyo-Charlson comorbidity index score was 0.9 (SD 1.4), ing the follow-up period were reported. Osteoporosis treat- and the most common comorbidities included hypertension ments covering multiple classes of anti-resorptive and bone (52.9%), dyslipidemia (40.0%), and respiratory diseases forming agents included denosumab (RANKL inhibitor), (36.6%; Table 1). alendronate (bisphosphonate), ibandronate (bisphosphonate), risedronate (bisphosphonate), zoledronate (bisphosphonate), Descriptive outcomes raloxifene (selective estrogen receptor modulator), and teri- paratide (parathyroid hormone analog) and were measured in Fragility fracture rates, sites of fragility fracture the 12-month follow-up period. The time to subsequent frac- during follow‑up, and bone density scan utilization ture was measured as the number of days from the index date to the earliest fracture diagnosis during the follow-up period. During the follow-up period, rate of a subsequent fragility Anatomical site of fracture was defined by diagnosis of a fracture was high (26.6%; Table 2). The most common type 1 3 42 Page 4 of 12 Archives of Osteoporosis (2023) 18:42 of fracture during the follow-up period was non-hip non-ver- tebral (20.2%; Table 2), with a particularly high number of fractures among patients who indexed in inpatient, ER, and urgent care settings (19.7%, 68.3%, and 35.3%, respectively; Table 3). The wrist/radius-ulna site was the most common site among the non-hip non-vertebral fractures. Patients diagnosed during an inpatient admission (N = 46,507) were more likely to have a subsequent hip (13.3%) or vertebral fracture (4.5%), compared with those diagnosed at any other site (Table 3). Diagnosis and treatment of osteoporosis To understand the patient journey after diagnosis of fragil- ity fracture, physician specialty at time of diagnosis, and the physician specialty for subsequent care are reported in Table 2. Approximately 20% of all individuals with fragil- ity fracture (N = 108,965) were diagnosed with osteoporo- sis during the follow-up period and the rate was notably higher among those diagnosed in an inpatient setting, 27.7% compared with other sites of care (9.5–15.7%) (Table 4). Patients whose index fragility fracture was diagnosed in an inpatient setting also had the highest proportion of osteopo- rosis therapy during follow-up (17.2% vs 8.6–12.9% in out- patient settings). Among the subset of all fragility fracture patients treated with osteoporosis therapy during follow-up (N = 15,342), most were treated with oral bisphosphonates (alendronate 45.6%, ibandronate 11.2%, risendronate 7.6%) despite being a high-risk group for a subsequent fracture (Table 4). Among patients with osteoporosis treatment, the proportion of days covered (during the 12-month follow-up period) was 51.9% and the mean time from index date to therapy initiation was 109 ± 0.2 days (and generally consist- ent across settings with the exception of urgent care where time to treatment was only 48 ± 0.2 days; Table 4). Among individuals who utilized denosumab for osteoporosis treat- ment (N = 2,564), their mean time to treatment initiation was lengthier at 157 ± 94.7 days. The lowest treatment rates occurred among patients in the urgent care, outpatient office, and ER hospital cohorts (8.6%, 10.9%, and 10.9%, respec- tively; Table 4). Of the 108,965 individuals with fragility fracture, most (37.3%) were diagnosed by an orthopedist on the index date, followed by a family practice physician (16.9%; Table 2). Similarly, subsequent care from the index physician spe- cialty was most common among the orthopedists (65.3%) and family practice physicians (48.0%). When subsequent care was obtained from a different physician specialty from the index provider, orthopedists were the most common spe- Fig. 1 Patient selection. Abbreviations: FQHC, Federally Qualified cialist (18.9%). Among index physician specialty, patients Health Center whose index fragility fracture diagnosis was made by rheu- matologists and geriatricians had the highest osteoporosis treatment rates (31.8% and 23.4%, respectively), while 1 3 Archives of Osteoporosis (2023) 18:42 Page 5 of 12 42 Table 1 Demographics and clinical characteristics among patients with fragility fracture (overall and stratified by site of care at diagnosis) All patients Inpatient admis- Outpatient office Outpatient hospital Emergency room Urgent care sion hospital N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N = 108,965 N = 46,507 N = 34,792 N = 26,125 N = 1373 N = 116 (100.0%) (42.7%) (31.9%) (24.0%) (1.3%) (0.1%) Age 68.8 (12.8) 75.0 (12.8) 64.7 (11.1) 63.8 (10.5) 61.6 (9.5) 61.2 (9.1) Age group 50–64 53,125 (48.8%) 13,017 (28.0%) 21,616 (62.1%) 17,305 (66.2%) 1072 (78.1%) 85 (73.3%) 65–74 17,722 (16.3%) 7379 (15.9%) 5971 (17.2%) 4204 (16.1%) 137 (10.0%) 21 (18.1%) 75–84 20,433 (18.8%) 12,704 (27.3%) 4546 (13.1%) 3062 (11.7%) 106 (7.7%) 8 (6.9%) 85 + 17,685 (16.2%) 13,407 (28.8%) 2659 (7.6%) 1554 (5.9%) 58 (4.2%) 2 (1.7%) Insurance plan type Comprehensive 29,252 (26.8%) 17,235 (37.1%) 6825 (19.6%) 5104 (19.5%) 68 (5.0%) 11 (9.5%) EPO/PPO 54,392 (49.9%) 20,528 (44.1%) 19,547 (56.2%) 13,481 (51.6%) 754 (54.9%) 59 (50.9%) POS with Capita- 562 (0.5%) 275 (0.6%) 156 (0.4%) 124 (0.5%) 7 (0.5%) 0 (0.0%) tion HMO 8979 (8.2%) 3529 (7.6%) 2550 (7.3%) 2527 (9.7%) 339 (24.7%) 18 (15.5%) POS 5905 (5.4%) 2227 (4.8%) 1847 (5.3%) 1791 (6.9%) 32 (2.3%) 8 (6.9%) Other 8578 (7.9%) 2067 (4.4%) 3516 (10.1%) 2819 (10.8%) 153 (11.1%) 19 (16.4%) Unknown 1297 (1.2%) 646 (1.4%) 351 (1.0%) 279 (1.1%) 20 (1.5%) 1 (0.9%) Payer Commercial 52,281 (48.0%) 12,662 (27.2%) 21,316 (61.3%) 17,118 (65.5%) 1070 (77.9%) 85 (73.3%) Medicare 56,684 (52.0%) 33,845 (72.8%) 13,476 (38.7%) 9007 (34.5%) 303 (22.1%) 31 (26.7%) Geographic region Northeast 24,828 (22.8%) 10,194 (21.9%) 10,022 (28.8%) 4372 (16.7%) 205 (14.9%) N < 30 North Central 33,375 (30.6%) 14,684 (31.6%) 10,298 (29.6%) 7983 (30.6%) 347 (25.3%) 50 (43.1%) South 38,626 (35.4%) 15,993 (34.4%) 11,958 (34.4%) 9997 (38.3%) 642 (46.8%) 30 (25.9%) West 11,712 (10.7%) 5505 (11.8%) 2352 (6.8%) 3644 (13.9%) 178 (13.0%) N < 30 Unknown 424 (0.4%) 131 (0.3%) 162 (0.5%) 129 (0.5%) N < 30 N < 30 Baseline all-cause $18,146 ($45,537) $23,532 ($59,507) $14,868 ($31,952) $13,377 ($29,425) $9874 ($20,226) $8262 ($19,766) healthcare costs (Mean, SD) Deyo-Charlson 0.9 (1.4) 1.2 (1.7) 0.7 (1.3) 0.6 (1.1) 0.5 (1.1) 0.4 (1.1) Comorbidity Index (DCI) (Mean, SD) Hypertension 57,691 (52.9%) 29,366 (63.1%) 16,387 (47.1%) 11,324 (43.3%) 547 (39.8%) 39 (33.6%) Dyslipidemia 43,536 (40.0%) 19,899 (42.8%) 13,640 (39.2%) 9459 (36.2%) 481 (35.0%) 35 (30.2%) Respiratory 39,897 (36.6%) 16,926 (36.4%) 13,234 (38.0%) 9206 (35.2%) 470 (34.2%) 38 (32.8%) diseases Cardiovascular 30,837 (28.3%) 18,011 (38.7%) 7523 (21.6%) 5065 (19.4%) 213 (15.5%) 13 (11.2%) disease Osteoarthritis 22,916 (21.0%) 11,852 (25.5%) 6366 (18.3%) 4492 (17.2%) 185 (13.5%) 10 (8.6%) Acute respiratory 24,107 (22.1%) 8971 (19.3%) 8763 (25.2%) 6006 (23.0%) 326 (23.7%) 29 (25.0%) diseases Chronic respira- 15,833 (14.5%) 7982 (17.2%) 4626 (13.3%) 3069 (11.7%) 133 (9.7%) 12 (10.3%) tory diseases Rheumatoid 3255 (3.0%) 1710 (3.7%) 894 (2.6%) 623 (2.4%) 25 (1.8%) 2 (1.7%) arthritis Abbreviations: DCI, Deyo-Charlson Comorbidity Index; EPO, Exclusive Provider Organization; HMO, Health Maintenance Organization; POS, Point of Service; PPO, Preferred provider organization; SD, Standard Deviation 1 3 42 Page 6 of 12 Archives of Osteoporosis (2023) 18:42 Table 2 Fragility fracture characteristics during baseline, on index, and follow-up periods (overall cohort) 12-month baseline or on 12-month follow-up index N (%) N (%) N = 108,965 N = 108,965 Site of fragility fracture; on index and during follow-up (N,%) Presence of fragility fracture, any site 108,965 (100.0%) 28,968 (26.6%) Hip 18,414 (16.9%) 6632 (6.1%) Vertebra 10,737 (9.9%) 2719 (2.5%) Non-hip non-vertebra 86,632 (79.5%) 21,966 (20.2%) Femur 5107 (4.7%) 1651 (1.5%) Pelvis 4467 (4.1%) 1448 (1.3%) Clavicle 2365 (2.2%) 545 (0.5%) Wrist/radius-ulna 35,647 (32.7%) 9043 (8.3%) Humerus 14,548 (13.4%) 3379 (3.1%) Tibia-fibular 7105 (6.5%) 1490 (1.4%) Ankle 19,233 (17.7%) 4196 (3.9%) Repeat (same site) fracture occurring > 90 days after index fracture) (N, %) 4849 (4.5%) Physician specialty on index and follow-up care with the same index physician specialty (N, % Family practice (N, %) 18,418 (16.9%) 8846 (48.0%) Internal medicine (N, %) 12,970 (11.9%) 3074 (23.7%) OB/GYN (N, %) 78 (0.1%) 25 (32.1%) Orthopedics (N, %) 40,693 (37.3%) 26,587 (65.3%) Geriatrics (N, %) 47 (< 0.1%) 4 (8.5%) Rheumatologist (N, %) 22 (< 0.1%) 8 (36.4%) Endocrinologist (N, %) 44 (< 0.1%) 12 (27.3%) Emergency medicine (N, %) 12,633 (11.6%) 275 (2.2%) Follow-up care with physician specialty different than index physician specialty Family practice (N, %) 9185 (8.4%) Internal medicine (N, %) 8897 (8.2%) OB/GYN (N, %) 2038 (1.9%) Orthopedics (N, %) 20,624 (18.9%) Geriatrics (N, %) 171 (0.2%) Rheumatologist (N, %) 2173 (2.0%) Endocrinologist (N, %) 1820 (1.7%) Emergency medicine (N, %) 367 (0.3%) Number of unique care physician specialties during follow-up (Mean, SD) 0.6 (0.8) Bone density scan, including DXA; during baseline and follow-up (N, %) 9505 (8.7%) 15,011 (13.8%) Abbreviations: DXA, dual-energy x-ray absorptiometry; OB/GYN, obstetrics/gynecology patients whose index fragility fracture diagnosis was made ER ($26,003 ± $29,304) and highest for those diagnosed by orthopedics had the lowest treatment rate (11.7%). at urgent care ($147,725 ± $323,368) (Fig. 2). Outpatient costs (office visits) were generally lowest for those diag- Healthcare utilization and costs nosed at urgent care and highest for those diagnosed in an inpatient setting (Fig. 3). The mean annual healthcare costs among patients with fra- Mean healthcare costs were lowest for patients whose gility fracture were $44,311 (± $67,427). Annual health- index fracture diagnosis was made by an orthopedist care costs were highest for those diagnosed in an inpatient ($30,538 ± $53,202). Mean inpatient costs were high- setting ($71,561 ± $84,072; Table 5). Among patients with est for those diagnosed by an internal medicine physician at least one inpatient admission, hospitalization costs were ($40,489 ± $64,441). Mean outpatient pharmacy costs were lowest for patients with fragility fracture diagnosed in an lowest for patients whose fragility fracture diagnosis was 1 3 Archives of Osteoporosis (2023) 18:42 Page 7 of 12 42 Table 3 Fragility fracture outcomes during the 12-month follow-up period stratified by site of care at diagnosis Inpatient admission Outpatient office Outpatient hospital Emergency room Urgent care hospital N (%) N (%) N (%) N (%) N (%) N = 46,507 N = 34,792 N = 26,125 N = 1373 N = 116 Site of fragility fracture Presence of fragility frac- 15,434 (33.2%) 4275 (12.3%) 8271 (31.7%) 941 (68.5%) 41 (35.3%) ture, any site Hip 6175 (13.3%) 264 (0.8%) 188 (0.7%) 3 (0.2%) 0 (0.0%) Vertebra 2092 (4.5%) 289 (0.8%) 333 (1.3%) 5 (0.4%) 0 (0.0%) Non-hip non-vertebral 9145 (19.7%) 3909 (11.2%) 7928 (30.3%) 938 (68.3%) 41 (35.3%) Femur 1501 (3.2%) 89 (0.3%) 57 (0.2%) 3 (0.2%) 0 (0.0%) Pelvis 1271 (2.7%) 105 (0.3%) 69 (0.3%) 3 (0.2%) 0 (0.0%) Clavicle 197 (0.4%) 88 (0.3%) 231 (0.9%) 27 (2.0%) 1 (0.9%) Wrist/Radius-Ulna 1443 (3.1%) 2044 (5.9%) 4907 (18.8%) 623 (45.4%) 25 (21.6%) Humerus 1456 (3.1%) 752 (2.2%) 1064 (4.1%) 101 (7.4%) 6 (5.2%) Tibia-Fibular 953 (2.0%) 218 (0.6%) 287 (1.1%) 30 (2.2%) 2 (1.7%) Ankle 1582 (3.4%) 767 (2.2%) 1636 (6.3%) 201 (14.6%) 8 (6.9%) Site of care where N < 30 not reported made by a geriatrician ($3251 ± $4517) and highest for those the most common site of care of fragility fracture diagno- diagnosed by a family medicine physician ($4108 ± $10,502). sis (42.7%), and this cohort was older, sicker (e.g., higher The mean annual disease-related healthcare costs among DCI score, higher baseline costs), more likely to have a fragility fracture patients were $9784 (± $16,086), or 22.1% subsequent fragility fracture, more likely to a severe hip or of overall healthcare costs (Table 5). Patients diagnosed in vertebral type of subsequent fragility fracture, had a higher outpatient hospitals or ERs had a higher proportion of dis- rate of osteoporosis diagnosis and a higher rate of treatment ease-related healthcare costs (45.8% and 45.0%), compared compared with patients diagnosed with fragility fractures with inpatient admissions, outpatient office visits and urgent in outpatient sites of care. Women diagnosed with fragility care (17.0%, 20.5%, 15.3%, respectively). fracture in the inpatient setting incurred the highest health- Mean annual disease-related costs were highest for those care costs ($71,561 ± $84,072) during follow-up which may diagnosed by a geriatrician ($16,078 ± $27,510) or endocri- be attributable to their higher rate of subsequent fractures nologist ($16,397 ± $23,915) and lowest for those diagnosed (26.6%). The lower prevalence of subsequent fractures in the by an orthopedist ($7690 ± $12,866). Higher costs among follow-up period might be due to the younger age of patients those diagnosed by a geriatrician or endocrinologist were diagnosed with fragility fracture in the outpatient settings driven by the larger proportion of patients with a disease- [19]. Hip fractures are among the costliest fracture site and related inpatient admission (12.8% and 15.9%, respectively) are frequently followed by surgery and lengthy rehabilita- and a larger proportion of patients with a disease-related ER tion [20, 21]. Results from this study support the need for visit (36.2% and 40.9%, respectively). earlier osteoporosis screening (leading to earlier diagnosis and treatment) to potentially prevent initial and subsequent fractures (particularly those requiring hospitalization) lead- Discussion ing to increased burden to both patients and costs to society. The high rate of subsequent fractures among older This claims-based analysis of postmenopausal women with women, in general, is supported by several studies of Medi- fragility fracture provides insight into the demographic care and commercial populations [22–24]. In a claims analy- characteristics, clinical conditions, treatment patterns, sis among female Medicare beneficiaries 65 years of age and healthcare costs and utilization during the year following older, 10–31% had a subsequent fracture within 1–5 years fragility fracture overall and stratified by site of care of frac- [22]. Consistent with our analysis, the majority of these sub- ture diagnosis. It was found that 26.6% of the patients had sequent fractures were non-hip/non-vertebral which empha- a subsequent fragility fracture, while rate of osteoporosis sizes the need for physical therapy aimed at preventing falls treatment and diagnosis was notably low (19.6% with diag- leading to subsequent NHNV fractures. Among older men nosis and 14.1% with treatment). The inpatient setting was and women enrolled in Medicare, there was a 2.5 greater risk 1 3 42 Page 8 of 12 Archives of Osteoporosis (2023) 18:42 Table 4 Osteoporosis therapy measured during the 12-month follow-up period; overall and stratified by site of care at fragility fracture diagnosis All patients Inpatient admission Outpatient office Outpatient hospital Emergency room Urgent care hospital N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N = 108,965 N = 46,507 N = 34,792 N = 26,125 N = 1373 N = 116 Patients with an osteo- 21,339 (19.6%) 12,887 (27.7%) 4168 (12.0%) 4090 (15.7%) 176 (12.8%) 11 (9.5%) porosis diagnosis (N,%) during the follow-up period Total number of 15,342 (14.1%) 8007 (17.2%) 3797 (10.9%) 3372 (12.9%) 150 (10.9%) 10 (8.6%) patients with any osteoporosis therapy during the follow-up period (N, %) RANK ligand inhibitor denosumab 2564 (16.7%) 1412 (17.6%) 596 (15.7%) 530 (15.7%) 25 (16.7%) 1 (10.0%) Bisphosphonates Alendronate 6990 (45.6%) 3652 (45.6%) 1734 (45.7%) 1516 (45.0%) 81 (54.0%) 5 (50.0%) Ibandronate 1718 (11.2%) 826 (10.3%) 431 (11.4%) 442 (13.1%) 18 (12.0%) 1 (10.0%) Risedronate 1173 (7.6%) 565 (7.1%) 326 (8.6%) 276 (8.2%) 3 (2.0%) 2 (20.0%) Zoledronate 1139 (7.4%) 606 (7.6%) 266 (7.0%) 263 (7.8%) 3 (2.0%) 0 (0.0%) Selective estrogen receptor modulators Raloxifene 1547 (10.1%) 727 (9.1%) 447 (11.8%) 349 (10.3%) 20 (13.3%) 2 (20.0%) Parathyroid hormone analogues Teriparatide 1207 (7.9%) 765 (9.6%) 201 (5.3%) 231 (6.9%) 10 (6.7%) 0 (0.0%) Time to (days) treatment initiation (Mean, SD) Any osteoporosis 109 (0.2) 112 (0.2) 102 (0.2) 109 (0.2) 106 (0.2) 48 (0.2) therapy denosumab 157 (94.7) 165 (94.0) 146 (94.2) 146 (94.9) 169 (91.7) 110 (0.0) Proportion of days 51.9% (28.1%) 50.5% (27.3%) 53.5% (28.9%) 53.5% (28.7%) 52.3% (29.5%) 59.3% (31.4%) covered (PDC) with any osteo- porosis therapy over the follow-up period (Mean, SD) The percentages calculated for the subsequent rows are calculated out of the total number of patients with any osteoporosis therapy Any osteoporosis therapy includes the following drugs: alendronate, denosumab, ibandronate, raloxifene, risedronate, teriparatide, zoledronic acid PDC is defined as the number of days covered by the reported days’ supply of a pharmacy claim or the days of clinical benefit of an outpatient medical claim, divided by 365 days of fracture within 12 months among those with a history of during an inpatient admission were treated with osteoporosis fracture [23]. Prior hip fracture was identified among 29% therapy during the 12 months following hospital discharge. of women aged 50 + diagnosed with a hip fracture between In that analysis, it was found that 70% of patients were 2008 and 2013 with commercial and Medicare Advantage treated with oral bisphosphonates, 0.3% with denosumab, plans [24]. The low osteoporosis treatment rate after fragil- and 2.6% with teriparatide. Results from the current and ity fracture diagnosis found in this study is also consistent more recent analysis show that even among this highest risk with prior literature [25–27]. In the current analysis, patients cohort (i.e., those diagnosed with fragility fracture during diagnosed with fragility fracture in the inpatient setting had a hospitalization) that treatment rates remain low, and of the highest proportion of osteoporosis treatment initia- those who do receive treatment most are prescribed an oral tion during the follow-up period; however, it was still only bisphosphonate despite non-oral (and more potent) options 27.7%. These results are similar to a claims-based study by available. Solomon et al. using data from 2002 to 2011 which reported In clinical practice, fragility fractures are an indicator of that 24.0% of patients diagnosed with a fragility fracture an osteoporosis; however, less than a quarter of individuals 1 3 Archives of Osteoporosis (2023) 18:42 Page 9 of 12 42 Table 5 All-cause & disease-related healthcare utilization and expenditures during the 12-month follow-up period; overall and stratified by site of care at fragility fracture diagnosis All patients Inpatient admis- Outpatient office Outpatient hospital Emergency room Urgent care sion hospital N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N = 108,965 N = 46,507 N = 34,792 N = 26,125 N = 1373 N = 116 Total all-cause $44,311 ($67,427) $71,561 ($84,072) $20,867 ($41,874) $28,236 ($40,190) $23,193 ($27,846) $26,380 ($103,122) healthcare costs Total costs of $4121 ($11,637) $4694 ($11,275) $3909 ($13,817) $3412 ($8780) $3552 ($11,349) $2414 ($5399) outpatient prescriptions Emergency room (ER) visits Patients with 49,946 (45.8%) 24,052 (51.7%) 10,014 (28.8%) 14,475 (55.4%) 1373 (100.0%) 27 (23.3%) an ER visit Number of 1.8 (1.8) 2.1 (2.0) 1.7 (1.5) 1.6 (1.4) 1.7 (2.4) 1.6 (1.1) ER visits Total ER costs $2471 ($5705) $2506 ($6836) $2355 ($5054) $2425 ($3785) $3171 ($5174) $2460 ($7112) Outpatient office visits Patients with 104,081 (95.5%) 43,186 (92.9%) 34,792 (100.0%) 25,324 (96.9%) 1332 (97.0%) 116 (100.0%) an office visit Number of 10.0 (8.1) 10.8 (8.6) 9.4 (7.8) 9.4 (7.5) 9.0 (6.7) 9.6 (6.4) office visits Total outpa- $1085 ($1008) $1159 ($1094) $1033 ($981) $1006 ($891) $957 ($746) $1143 ($813) tient office visit costs Inpatient admissions Patients with 50,000 (45.9%) 46,507 (100%) 4428 (12.7%) 3274 (12.5%) 172 (12.5%) 10 (8.6%) an admission Number of 1.4 (0.9) 1.3 (0.9) 1.3 (0.8) 1.3 (0.8) 1.3 (0.8) 1.2 (0.4) admissions Average 5.0 (4.8) 4.6 (4.9) 4.5 (4.7) 4.4 (4.4) 4.6 (5.4) 6.3 (8.5) Length of Stay Total inpa- $42,176 ($61,518) $39,334 ($61,278) $36,658 ($51,967) $33,790 ($50,858) $26,003 ($29,304) $147,725 tient costs ($323,368) Total disease- $9784 ($16,086) $12,137 ($20,047) $4280 ($9,174) $12,922 ($13,587) $10,438 ($10,915) $4048 ($6,838) related health- care costs Total costs $1781($4549) $1978($4891) $1499($4073) $1631($4117) $1904($5951) $917($1419) of outpatient prescriptions Emergency room (ER) visits Patients with 28,047 (25.7%) 11,708 (25.2%) 3261 (9.4%) 11,701 (44.8%) 1364 (99.3%) 10 (8.6%) an ER visit Number of 1.2 (0.6) 1.2 (0.8) 1.1 (0.5) 1.1 (0.4) 1.2 (0.6) 1.0 (0.0) ER visits Total ER $1768 ($3292) $1288 ($3531) $1875 ($3527) $2117 ($2883) $2646 ($3300) $327 ($613) Costs Outpatient office visits Patients with 79,539 (73.0%) 30,118 (64.8%) 29,120 (83.7%) 19,011 (72.8%) 1150 (83.8%) 111 (95.7%) an office visit Number of 2.7 (2.3) 3.0 (2.5) 2.3 (1.9) 2.9 (2.4) 3.1 (2.5) 3.2 (2.1) office visits Total outpa- $297 ($340) $316 ($335) $268 ($368) $307 ($302) $327 ($278) $406 ($330) tient office visit costs 1 3 42 Page 10 of 12 Archives of Osteoporosis (2023) 18:42 Table 5 (continued) All patients Inpatient admis- Outpatient office Outpatient hospital Emergency room Urgent care sion hospital N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N/Mean (%/SD) N = 108,965 N = 46,507 N = 34,792 N = 26,125 N = 1373 N = 116 Inpatient admissions Patients with 4242 (3.9%) 4069 (8.7%) 87 (0.3%) 80 (0.3%) 6 (0.4%) 0 (0.0%) an admission Number of 1.0 (0.2) 1.0 (0.2) 1.0 (0.1) 1.0 (0.2) 1.0 (0.0) 0.0 (0.0) admissions Average 4.7 (3.7) 4.8 (3.7) 4.5 (2.8) 4.3 (2.8) 7.3 (8.1) 0.0 (0.0) length of stay Total inpa- $29,656 ($33,754) $29,526 ($33,662) $40,441 ($43,968) $25,770 ($23,336) $13,505 ($4099) $0 ($0) tient costs Abbreviations: ER, Emergency Room; SD, Standard Deviation Average costs of ER visits calculated for just those with at least ER visit Average costs of outpatient office visits calculated for just those with at least one outpatient office visit Average costs of inpatient admissions calculated for just those with at least one inpatient admission $160,000 Fig. 2 Inpatient admission costs $147,725 measured during the 12-month $140,000 follow-up period stratified by $120,000 site of care at fragility fracture diagnosis. Abbreviation: $100,000 ER, Emergency room $80,000 $60,000 $39,334 $36,658 $33,790 $40,000 $26,003 $20,000 $0 URGENT CARE INPATIENTOUTPATIENT OFFICE OUTPATIENT HOSPITAL ER $30,000 Fig. 3 Outpatient costs measured during the 12-month INPATIENT follow-up period stratified by OUTPATIENT OFFICE $25,357 site of care at fragility fracture $25,000 OUTPATIENT HOSPITAL diagnosis. Abbreviation: ER ER, Emergency room URGENT CARE $20,000 $18,388 $15,000 $12,439 $10,783 $9,619 $10,000 $3,412 $3,909 $4,694 $2,355 $3,552 $5,000 $3,183 $2,506 $1,033 $2,414 $2,425 $2,460 $1,006 $1,159 $1,143 $957 $0 ER costsOffice visit costsOther outpa ent costsOutpa ent pharmacy costs 1 3 Archives of Osteoporosis (2023) 18:42 Page 11 of 12 42 with fragility fracture were diagnosed with osteoporosis the outpatient settings were younger and had the lowest during the follow-up period and only approximately 10% rate of osteoporosis diagnosis and treatment rates follow- were diagnosed with osteoporosis during the year prior to ing fracture. Targeting all patients with fragility fracture fracture [28]. The low rate of osteoporosis diagnosis is likely and particularly those diagnosed in the outpatient setting is due to lack of recognition and awareness of the underlying of utmost importance for earlier screening, treatment, and disease (leading to undercoding on healthcare claims). Bone fall prevention therapy to potentially avoid hospitalizations density scans are also indicative of an osteoporosis diag- and subsequent fractures and to improve patient quality of nosis; however, we observed low utilization of these scans life. Understanding initial engagement in care, diagnosis, as well. A literature review of Canadian practice patterns and subsequent sites of care might identify opportunities to observed similarly low osteoporosis diagnosis rates among decrease subsequent fractures and halt the growing health- individuals with fragility fracture [29]. This lack of disease care costs experienced by an aging population. awareness contributes to underdiagnosis of osteoporosis that undermines efforts for appropriate treatment [30, 31]. The Acknowledgements Programming services were provided by Jerry Kagan of Merative, formerly IBM Watson Health. Medical writing majority of patients with fragility fracture were, as expected, services were provided by Danae Black of Merative. These services diagnosed with the initial fracture by an orthopedist. How- were paid for by Amgen Inc. ever, few patients (43.3%) with the fragility fracture had sub- sequent care with their index physician specialty provider. Funding This study was funded by company Amgen Inc. Among those fragility fracture patients in the orthopedics Data availability The data that support the findings of this study are cohort, less than 10% were seen by family medicine or inter- available from Merative. Restrictions apply to the availability of these nal medicine and less than 3% were seen by rheumatology data, which were used under license for this study. and endocrinology specialties. This suggests that patients are not receiving the subsequent care they need for the long- Declarations term management of osteoporosis. Ethics approval and consent to participate All database records are There are several strengths to the analyses presented statistically de-identified and certified to be fully compliant with US here. First, this study used retrospective claims data, which patient confidentiality requirements set forth in the Health Insurance provides a large, heterogeneous patient population. Unlike Portability and Accountability Act of 1996. Because this study used only de-identified patient records and did not involve the collection, clinical trials that are subject to strict inclusion criteria and use, or transmittal of individually identifiable data, this study was surveys that are subject to small groups and memory biases, exempted from Institutional Review Board approval. this study of real-world claims captured medication utili- zation data from a broad group of osteoporosis and fragil- Conflicts of interest • Michele McDermott declares the following con- ity fracture patients in clinical practice. It should be noted, flict of interest: Dr. McDermott is employed by Amgen Inc. however, that this was not a comparative study. Differences • Alon Yehoshua declares the following conflict of interest: At the time of manuscript development, Dr. Yehoshua was employed by Amgen in baseline characteristics varied by site of care cohorts and Inc. results were not adjusted for baseline differences. Claims • Cynthia Morrow declares the following conflict of interest: Dr. Mor - studies are subject to several potential limitations. These row was employed by Merative, formerly IBM Watson Health, which data were subject to data entry errors or miscoding. Claims received funding from Amgen Inc. to conduct this study. Oth Tran declares at the time of manuscript development, Mr. Tran was data can identify that a medication was dispensed, but not employed by Merative, formerly IBM Watson Health, which received that the medication was administered or taken as prescribed. funding from Amgen Inc. to conduct this study. This analysis was performed among patients with commer- • Michael McClung declares the following conflict of interest: Dr. cial or Medicare Supplemental insurance, and therefore may McClung receives consulting fees and honorarium from Amgen Inc. • Andrea Singer declares the following conflict of interest: Dr. Singer not be generalizable to those with other insurance types or receives research funding paid to her institution by Radius Health and without insurance coverage. Finally, patients were not neces- UCB. Dr. Singer serves on consulting/advisory boards for Agnovos, sarily newly diagnosed with fragility fracture in our sample Amgen Inc., Radius Health, and UCB. Dr. Singer is on the Speaker’s given that a full patient history was not accessible. Bureau for Amgen Inc. and Radius Health. • Dr. Goldstein and Dr. Kagan declare they have no conflicts of interest. Open Access This article is licensed under a Creative Commons Attri- Conclusion bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, Patients with a fragility fracture had a high rate of subse- provide a link to the Creative Commons licence, and indicate if changes quent fractures and high cost of care, especially for those were made. The images or other third party material in this article are requiring hospitalization, so screening and prevention are included in the article's Creative Commons licence, unless indicated important to avoid the burden to patients and cost to soci- otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not ety. 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Journal
Archives of Osteoporosis – Springer Journals
Published: Mar 11, 2023
Keywords: Aged; Bone density/drug effects; Bone density conservation agents; Cost of illness; Female; Health care costs; Hospitalization; Humans; Medicare; Middle aged; Postmenopausal; Risk assessment; USA/epidemiology