Declining Trend in Osteoporosis Management and Screening Following Vertebral Compression Fractures - A National Analysis of Commercial Insurance and Medicare Advantage Beneficiaries.
Spine J. 2019 Nov 01;: Authors: Malik AT, Retchin S, Phillips FM, Xu W, Peters K, Yu E, Khan SN
BACKGROUND CONTEXT: Despite the increasing national incidence, osteoporosis and its associated co-management, often remain an overlooked issue in the orthopaedic world. Screening and associated management of osteoporosis is often only considered by providers when patients present with multiple fragility fractures. Current evidence with regard to the trends in screening and medical co-management/anti-osteoporotic therapy of osteoporotic vertebral compression fractures (VCFs) remains limited. PURPOSE: To understand trends, costs and clinical impact associated the utilization of anti-osteoporotic medication and screening with the one year following occurrences of sentinel/primary osteoporotic vertebral compression fractures (VCFs). STUDY DESIGN/SETTING: Retrospective review of 2008-2015Q3 Humana Administrative Claims (HAC) database. PATIENT SAMPLE: The 2008-2015Q3 HAC database was queried using International Classification of Diseases 9th Edition (ICD-9) diagnosis codes 805.2 and 805.4 to identify patients with primary closed osteoporotic thoracolumbar VCFs. Patients with a concurrent diagnosis of trauma and/or malignancy were excluded. Patients experiencing a fragility fracture of the hip, distal radius or proximal humerus and/or those already on osteoporotic medication within the year prior to the VCF were excluded to prevent an overlap in the screening and/or anti-resorptive medication rates. Finally, only those patients who had complete two year follow-up data were analyzed. OUTCOME MEASURES: To understand trends over time in the utilization of medication for osteoporosis and screening within one year following sentinel VCFs. The study also aimed to report per-prescription and per-patient average costs associated with different anti-osteoporotic medications. As secondary objectives, we also assessed 1) risk factors associated with not receiving anti-osteoporotic medication within the year following sentinel VCFs and 2) Differences in rates of experiencing a secondary fragility fracture of vertebrae, hip, distal radius and proximal humerus between patients who received medication following the sentinel VCF versus those who did not receive any medication. RESULTS: A total of 6,464 primary osteoporotic VCFs were retrieved from the database. A majority of the VCFs were seen in females (N=5,199; 80.4%). Only 28.8% (N=1,860) patients received some form of medication for osteoporosis medication in the year following the VCF. Over a six-year interval, treatment with medication for osteoporosis declined from 38% in 2008 to 24% in 2014. The average cost of anti-osteoporotic treatment per patient was $1,511. The most commonly prescribed treatment and associated average cost/patient was alendronate sodium (N=1,239; 66.6% - $120/patient). The most costly prescribed treatment was Forteo (N=177; 2.7%) with an average cost/patient of $12,074 and cost/injection being $2,373. Only 36.7% (N=2,371) received a DEXA/bone density scan in the year following the VCF with an average cost/patient of $76. Risk factors associated with no prescription of medication for osteoporosis within 1 year of VCF were male gender (OR 1.17 [95% CI 1.01-1.35]; p=0.027), history of CVA/stroke (OR 1.56 [95% CI 1.08-2.32]; p=0.022), history of diabetes mellitus (OR 1.28 [95% CI 1.04-1.58]; p=0.023). Of note, patients in the West vs. Midwest (OR 1.26 [95% CI 1.04-1.51]; p=0.016) and commercial insurance beneficiaries (OR 1.95 [95% CI 1.08-3.52]; p=0.027) were more likely to receive anti-osteoporotic medication. Patients who were placed on anti-osteoporotic medication were significantly less likely to suffer a second fragility fracture compared to patients that did not receive medication (OR 0.27 [95% CI 0.24-0.31]; p=0.033). CONCLUSIONS: The proportion of patients starting anti-osteoporotic medication within a year after a VCF remains low (28.8%). Furthermore, a declining trend of anti-osteoporotic medication prescription was noted over time. Providers who care for patients with sentinel VCFs need to be more diligent in their efforts to diagnose and treat the underlying osteoporosis to reduce the burden of future fragility fractures. PMID: 31683068 [PubMed - as supplied by publisher]