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Association of Osteoporosis Medication Use After Hip Fracture With Prevention of Subsequent Nonvertebral Fractures
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This study assessed the frequency and effectiveness of initiating osteoporosis medication following a hip fracture for the prevention of subsequent fractures. The study included data of 97,169 individuals aged ≥50 years from a commercial insurance claims database. The study found a continuous decline in initiation of osteoporosis medication over a period of 10 years.
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These findings highlight the need for the public health awareness regarding the effectiveness of osteoporosis medication in decreasing the risk of subsequent fractures.
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Osteoporosis medication treatment is recommended after hip fracture, yet contemporary estimates of rates of initiation and clinical benefit in the patient population receiving routine care are not well documented.
Objectives
To report osteoporosis treatment initiation rates between January 1, 2004, and September 30, 2015, and to estimate the risk reduction in subsequent nonvertebral fractures associated with treatment initiation in patients with hip fracture.
Design, Setting, and Participants
In this cohort study, data from a commercial insurance claims database from the United States were analyzed. Patients 50 years and older who had a hip fracture and were not receiving treatment with osteoporosis medications before their fracture were included.
Exposure
Prescription dispensing of an osteoporosis medication within 180 days of a hip fracture hospitalization.
Main Outcomes and Measures
Each initiation episode was matched with 10 nonuse episodes on person-time after the index hip fracture event to preclude immortal time bias and followed up for the outcome of nonvertebral fracture until change in exposure or a censoring event. An instrumental variable analysis using 2-stage residual inclusion method was conducted using calendar year, specialist access, geographical variation in prescribing patterns, and hospital preference.
Results
Among 97 169 patients with a hip fracture identified, the mean (SD) age was 80.2 (10.8) years, and 64 164 (66.0%) were women. A continuous decline over the study years was observed in osteoporosis medication initiation rates from 9.8% (95% CI, 9.0%-10.6%) in 2004 to 3.3% (95% CI, 2.9%-3.8%) in 2015. In the effectiveness analyses, the hospital preference instrumental variable had a stronger association with treatment (pseudo R2 = 0.20) than the other 3 instrumental variables (specialist access: pseudo R2 = 0.04; calendar year: pseudo R2 = 0.05; and geographic variation: pseudo R2 = 0.07). Instrumental variable analysis with hospital preference suggested a rate difference of 4.2 events (95% CI, 1.1-7.3) per 100 person-years in subsequent fractures associated with osteoporosis treatment initiation compared with nonuse in an additive hazard model.
Conclusions and Relevance
Low rates of osteoporosis treatment initiation after a hip fracture in recent years were observed. Clinically meaningful reduction in subsequent nonvertebral fracture rates associated with treatment suggests that improving prescriber adherence to guidelines and patient adherence to prescribed regimens may result in notable public health benefit.
This cohort study examined insurance claims of 97,169 US patients >50 years of age, mean age 80.2, with a hip fracture, not previously on osteoporosis medications. Osteoporosis medication initiation rates were measured within a half year of hip fracture hospitalization and declined continuously over the study years from 9.8% in 2004 to 3.3% in 2015. Osteoporosis treatment initiation reduced subsequent fractures by 4.2 (95% CI, 1.1–7.3) per 100 person-years compared with nonuse.
An insufficiency fracture makes the diagnosis of osteoporosis, regardless of the bone-density test result. The National Osteoporosis Foundation reports that 50% of women and 25% of men >50 sustain an osteoporotic fracture during their lifetime. It affects all of us personally or our families. Hip fractures are the most feared as they lead to loss of independence in half of patients.1
This observational study may be more representative of the percentage of patients who are treated in real life than within the context of randomized controlled trials, which may not include frail, institutionalized, or cognitively impaired patients.
Over 10 years until 2012, osteoporotic fractures declined, as oral bisphosphonates became available and then generic; however, between 2012 and 2015 this decline has plateaued.2 This is possibly due to reporting of atypical subtrochanteric femoral fractures (STF) and osteonecrosis of the jaw with bisphosphonate use that has scared many of my patients. Osteonecrosis of the jaw occurs in 1 of 100,000 patients, with 94% of those occurring in high-dose bisphosphonate users treated for cancer.3 Recalculating the occurrence for most of our osteoporosis users, the incidence drops to 1 in 2.4 million. STF are more common, with incidence of 3.2 to 50 cases per 100,000 person‐years, translating to a number needed to harm of 2000 per year of use. This risk drops 70% each year after stopping bisphosphonates.4 Another reason that we may see a decline in use are the results of the FLEX trial, which showed treatment of 5 years vs 10 years with bisphosphonates to result in similar fracture risks, prompting many patients to stop after 5 years.5
Patients with an osteoporotic hip fracture have a high risk of another fracture, which is reduced by 40% with treatment compared with placebo (HR, 0.60; 95% CI, 0.3–-0.93).6 The benefits of treatment far outweigh the risks. More medications effective for hip fracture prevention are available; we must pay closer attention to starting treatment for our patients with, or at risk for, osteoporotic fractures.
References