30. Declining trend in osteoporosis screening and medical management following primary vertebral compression fractures: a national analysis of commercial and Medicare advantage beneficiaries

Abstract

BACKGROUND CONTEXT Despite its increasing national incidence, osteoporosis and its associated co-management often remain an overlooked issue in the orthopedic world. In the majority of the scenarios, screening and associated management of osteoporosis is only considered by providers when patients present with multiple fragility fractures. Current evidence with regards to the trends in screening and medical co-management/antiresorptive therapy of osteoporotic vertebral compression fractures (VCFs) remains limited. PURPOSE To understand trends in osteoporosis screening and subsequent antiresorptive medical management of patients presenting with index/primary VCFs. STUDY DESIGN/SETTING Retrospective review of administrative claims from the Humana Administrative Claims (HAC) database. PATIENT SAMPLE The 2007-2015Q3 Humana Administrative Claims (HAC) database, a national database of Commercial and Medicare Advantage beneficiaries, was queried using International Classification of Diseases 9th Edition (ICD-9) diagnosis codes 733.13, 805.2 and 805.4 combined with concurrent codes for osteoporosis (733.0, 733.00-733.09) to identify patients with primary closed osteoporotic thoracolumbar VCFs. Patients with a concurrent diagnosis of trauma and/or malignancy were excluded to ensure that the cohort was relevant of isolated fragility fractures only. Patients experiencing a fragility fracture of the hip, distal radius or proximal humerus in the year prior to the VCF were excluded to prevent an overlap in the screening and/or antiresorptive medication rates. Finally, only those patients who had active enrollment up to two years following the VCF were included. OUTCOME MEASURES To study trends, proportions and costs in the screening and medical management of osteoporosis. We also analyzed differences in the rates of experiencing a second fragility fracture of the vertebrae, hip, distal radius and proximal humerus between those patients who received antiresorptive medication vs those who did not. We also carried out an analysis to identify risk factors associated with no prescription of antiresorptive medication within the year following the index/primary VCF. METHODS Descriptive analysis was used to report trends and costs of osteoporosis screening and medical management following VCFs. Pearson-chi square tests were used to identify significant differences in rates of secondary fragility fractures between individuals who received antiresorptive medication vs those who did not. Multivariate logistic regression analyses were used to identify independent risk factors associated with no prescription of antiresorptive medication within the year following the VCF. RESULTS Based on inclusion/exclusion criteria, a total of 6,464 primary osteoporotic VCFs were retrieved from the database. Majority of the VCFs were seen in females (N=5,199; 80.4%) followed by males (N=1,265; 19.6%). Only 28.8% (N=1,860) of patients received some form of antiresorptive medication in the year following the VCF, with an average cost of treatment/per patient to be $1,511 and median adherence/medication possession rate to be 69.5%. The most commonly prescribed treatment and associated average cost was alendronate sodium (N=1,239; 66.6% - $120). The most costly prescribed treatment was Forteo (N=177; 2.7%) with an average cost/patient of $12,074. Only 36.7% (N=2,371) received a DEXA/bone density scan in the year following the VCF with an average cost/patient to be $76. The proportion of patients receiving a DEXA scan rose from 33.0% in 2008 to 35.0% in 2014. Risk factors associated with no prescription of antiresorptive medication 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), 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 antiresorptive medication. Patients on antiosteoporotic/resorptive medication vs those not taking any medication were significantly less likely to receive a second fragility fracture (17.1% vs 43.3%; p CONCLUSIONS The proportion of patients starting antiresorptive medication within a year after a VCF remains low (28.8%). Furthermore, a declining trend of antiresorptive medication prescription was noted over time. Understanding this gap in care can allow providers to launch enhanced bone health/fracture prevention programs in their institutions to reduce the financial burden of osteoporotic fractures on the health care system. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.