A nationwide study on the consumption and expenditure of osteoporosis medications in Iran during the period from 2001 to 2021.

Strategies for the prevention and treatment of osteoporosis during early postmenopause

Anti-osteoporosis medication (AOM) use in patients exposed to glucocorticoids is thought to reduce fractures. We found post-menopausal women using glucocorticoids for at least 90 days who also used an AOM within 90 days had 48 % fewer fractures by 1 year and 32 % fewer fractures by 3 years compared to non-AOM users. The purpose of this study is to explore the effectiveness of adherence to quality measures by estimating the effect of anti-osteoporosis medication (AOM) initiation within 90 days after chronic (≥90 days) glucocorticoid (GC) therapy on osteoporotic fracture. A new-user cohort was assembled using the MarketScan databases between 2000 and 2012. Included patients were female, age ≥50 at GC initiation, had a first GC fill daily dose ≥10 mg and persisted for at least 90 days. During a 365-day baseline period, patients were excluded for prior GC or AOM (bisphosphonate, denosumab, teriparatide) use, fracture, or cancer diagnosis. Initiators of an AOM in the 14 days pre- or 90 days post-GC fill were characterized as AOM users; those without, AOM non-users. Follow-up began 91 days after GC fill with patients followed until fracture, loss of continuous enrollment, initiation of AOM by AOM non-users, or end of study period. A propensity score was estimated for AOM receipt using all measured covariates and converted to a stabilized inverse probability of treatment weights (IPTW). Weighted hazard ratios (HR) and associated 95% confidence intervals (95% CI) were estimated using weighted Cox proportional hazard models. Of the 7885 women eligible for the study, 12.1% were AOM users. AOM use was associated with lower fracture incidence: weighted HR of 0.52 (95% CI 0.29, 0.94) at 1 year and weighted HR of 0.68 (95% CI 0.47, 0.99) at 3 years. AOM initiation within 90 days of chronic GC use was associated with a fracture reduction of 48% at 1 year and 32% at 3 years.

Publication of the Women's Health Initiative (WHI) resulted in a 39% reduction in hormone therapy utilization and a 29% increase in the use of new anti-osteoporosis medications. Overall, the prevalence of prescription anti-osteoporosis medication use declined following the WHI. This has important implications for osteoporosis prevention and treatment. Women who discontinued hormone therapy (HT) following the Women's Health Initiative (WHI) may have been more likely to initiate treatment with newer anti-osteoporosis medications (AOM). The objective of this study was to examine the influence of the WHI on AOM utilization among a nationally representative sample of older adult women in the U.S. We used the Medical Expenditure Panel Survey (MEPS) to examine AOM utilization among women aged 50 years and older. National estimates of AOM utilization were predicted from a sample of 2089 women interviewed five times between 2002 and 2003. AOM utilization was dichotomized for HT and newer AOM. Generalized estimating equations were used to predict odds ratios (OR) for AOM utilization controlling for potential predisposing, enabling, and need confounders. Prior to the WHI, there were 8.7 and 3.6 million U.S. women using HT and newer AOM, respectively. One year following publication of the WHI, 5.3 million HT users persisted [OR 0.638 (95% CI: 0.617, 0.756)] while 4.7 million women used newer AOM [1.337 (95% CI: 1.120, 1.597)]. Although reductions in HT utilization were accompanied by increased utilization of newer AOM, treatment prevalence for osteoporosis remains sub-optimal.

The goal of the current study is to explore trends in assessment, diagnosis after fragility fractures, and osteoporosis treatment among hospitalized patients in Xiamen, China, between 2012 and 2021. We conducted a retrospective cross-sectional study, using the Cochran-Armitage trend test to describe trends. Logistic regression was performed to identify the influencing factors of anti-osteoporosis medication (AOM) treatment. We performed a sensitivity analysis to verify the robustness of our findings. From 2012 to 2021, the rates of dual-energy X-ray absorptiometry (DXA) scans and bone turnover marker (BTM) examinations increased from 0 to 37% and 36.5%, respectively. 29.3% of patients with fragility fractures were diagnosed with osteoporosis. The use rate of AOM was only 22.7%. There was an upward trend in the prescription of bisphosphonates, increasing from 1% in 2012 to 16.8% in 2021. The use of calcitonin ranged from 4.1% (2014) to 32.7% (2021). Calcium and vitamin D supplementation prescribing increased significantly from 5.6% in 2012 to 78.7% in 2021. Logistic regression analysis showed that old age, female sex, history of fractures, DXA scans, and osteoporosis diagnosis were significantly associated with increased AOM use. Tobacco use, hypertension, diabetes, congestive heart failure, cerebral vascular accidents, and severe liver diseases were associated with a reduced likelihood of AOM treatment. Although assessment, diagnosis after fragility fractures, and osteoporosis treatment have increased over the past decade, there are still deficiencies in the management of osteoporosis. In the future, it will be necessary to further strengthen management of osteoporosis.

Despite prevalent anti-osteoporosis medication (AOM) switching in real-world osteoporosis management, few studies have evaluated the impact of persistent AOM treatment, allowing for AOM switching, on the risk of subsequent fracture. We examined the association between persistence in AOM and subsequent fractures, allowing for medication switching among patients with osteoporotic fractures. This retrospective cohort study used Taiwan National Health Insurance claims data to select patients who initiated AOM between 2013 and 2016. Treatment persistence was defined as use of any AOM on a given day of interest with a 45-day grace period. Medication switch was allowed for persistence if remaining on treatment. AOMs with long-lasting inhibition of bone resorption (zoledronate and denosumab) were categorized as high-potency; others as low-potency. Multivariate Cox models were used to evaluate risk of subsequent fractures ≥3 months after initiating AOM. A total of 119 473 patients were included (mean [SD] follow-up 46.4 [15.6] months), and 26.8% switched from the index AOM. Within 1 year, 52% remained persistent with AOM. Compared to patients with persistent AOM, those not persistent had higher risk of subsequent hip (adjusted hazard ratio [aHR] = 1.31; 95% CI, 1.21-1.42), vertebral (aHR = 1.17; 95% CI, 1.13-1.22), and radius fractures (aHR = 1.16; 95% CI, 1.08-1.25). Patients with persistent AOM who switched from high- to low-potency AOM had higher risk of subsequent vertebral fractures than those with persistent AOM and no potency switch (aHR = 1.28; 95% CI, 1.02-1.60). Patients with non-persistent AOM had higher risk of subsequent fractures than persistent users when allowing AOM switch. Switching AOM potency may influence the risk of subsequent vertebral fractures and warrants further investigation.

Publication of the Women's Health Initiative (WHI) study has changed our understanding on the effects of hormone replacement therapy. This study was designed to evaluate patterns of antiosteoporosis medication (AOM) use in a Medicaid population before and after the release of the WHI study results. A descriptive time series analysis was conducted among women 50 years of age and older who were enrolled in the Pennsylvania Medicaid program from December 1, 2001, through December 31, 2002. All AOMs were identified, including estrogens, bisphosphonates, selective estrogen receptor modulators (SERMs), and calcitonin. The monthly prevalence of each AOM and drug class was estimated. Comparisons between pre-WHI (December 1, 2001-July 30, 2002) and post-WHI (August 1, 2002-December 31, 2002) study periods were made for overall AOM use by AOM drug class as well as by recipient characteristics. The overall prevalence of AOM did not change between pre-WHI and post-WHI study publication. However, there were significant changes in the prevalence of certain AOM drug classes. Estrogen use decreased significantly after the WHI study release for all age and racial groups. The prevalence for bisphosphonates and SERM increased significantly in the post-WHI period. The WHI study influenced patterns of use of all types of AOM, decreasing estrogen and increasing nonestrogen use among postmenopausal women in a Medicaid program. These results suggest that the WHI study affected patterns of use of bone protective pharmacotherapy, with a shift in bone protection therapy use from estrogen to nonestrogen AOMs.

BackgroundThere is a gender difference in the acceptance of osteoporosis diagnosis and treatment in patients after fragility fractures, but this difference is rarely assessed during hospitalization, and it is unclear whether these differences are age-dependent. This study aimed to evaluate the differences between male and female fragility fracture patients of different age groups who received the diagnosis and treatment of osteoporosis during hospitalization.Methods31,265 fragility fracture patients aged ≥ 50 years from the Fragility Fracture Management Database in a high-volume orthopedic hospital from December 2019 to February 2023 were included in this study. We compared the differences in the rates of men and women with fragility fracture who received the measurement of bone mineral density (BMD) and bone metabolism biochemical markers (BMBMs) and treatment with anti-osteoporosis medications (AOMs), and follow-up to the internal medicine clinic within 3 months after discharge, across all age groups and across different age stages (50–59, 60–69, 70–79, and ≥ 80 years).ResultsThe detection rates of female patients receiving BMD and BMBMs during hospitalization were 31.88% and 5.30%, respectively, compared with 22.23% and 2.69% for men. The rate of receiving any AOMs treatment was 44.63% for women and 31.60% for men. The follow-up rate of returning to the internal medicine clinic within 3 months after discharge was 9.79% for women compared to 3.00% for men. There was a significant difference between males compared to females (P < 0.0001). Analysis of patients by different age group revealed that differences in the diagnosis and treatment of osteoporosis were found only in patients under 80 years of age, while gender differences in the return to the internal medicine clinic for follow-up after discharge were present in all age groups.ConclusionsGender differences present in osteoporosis management in patients with fragility fracture during hospitalization, especially for patients under 80 years of age. This finding suggests that orthopedic surgeons neglect to manage osteoporosis in male patients with fragility fracture during hospitalization.

Osteoporosis incur substantial disease and healthcare cost. Despite the relative safe and effective treatment of osteoporosis, there are treatment gaps of osteoporosis existed worldwide. This study aims to provide real-world updated evidence for disease burden of osteoporosis, evaluate treatment patterns and the proper timing of initiation of anti-osteoporosis medications (AOMs) in Taiwan. By using the National Taiwan Insurance Research Database, we conduct a cross-sectional study to evaluate the epidemiology and economic burden of osteoporosis for overall Taiwanese population. Second, among those encountered major osteoporotic fractures, we evaluated the treatment rate and visualized the differences in unmet treatment needs. Finally, we evaluated the effectiveness of AOMs initiated in different timing post hip fracture by conducting multivariate time-dependent survival analysis within a cohort study design. In 2013, there are 253,565 and 82,648 women and men with a diagnosis of osteoporosis, respectively. The prevalence of osteoporosis and related fractures increased with age and the prevalence up to 23% among patients older than 80 years old. Major osteoporotic fractures incurred subsential incremental costs (men: 3935 USD; women:3352 USD), and the annual direct medical cost of patients with osteoporotic fracture was 2-6 times higher than that of the general population. The treatment rate of AOMs was diverse and suboptimal; range from 32% among female with vertebral fracture to 6% among male with hip fracture. Counties in the mid-southern Taiwan had the highest treatment rate, ranged from 30% to 35%. Older age, female sex, and a vertebral fracture were significantly associated with a higher probability of initiating AOMs. Among those initiated AOMs therapy, AOM initiation later than 252 days after the incident hip fracture was associated with significantly increased risk of subsequent osteoporotic fracture-related hospitalization compared to patients who started AOMs between 15 and 84 days. (Hazard ratios (HR) = 1.93, 95% confidence intervals (CI) 1.29‒2.89) Noteworthy, among patients with a medication possession ratio ≥ 80% (high AOM adherence) within 1 year after initiating AOMs, the risk of subsequent osteoporotic fracture-related hospitalization was even higher for very late users compared with the original cohort (HR = 2.56 vs. 1.93). After adjusting factors associated with AOM initiation timing and patients’ adherence, the anti-fracture benefit of AOMs still depends crucially on the timely initiation of AOMs. In summary, among every 10 patients encountered osteoporotic fracture in Taiwan, only 3 patients initiated AOMs within 1-year post fracture. In addition, when further considering the proper initiation of AOMs, less than 2 patients could realize the optimal benefit of AOMs therapy. Further studies and continued clinical applications help policymakers allocate resource appropriately and make clinical improvement of osteoporosis care a reality.

BackgroundPatients with proximal femoral fracture (PFF) have high mortality and many complications. Osteoporosis increases the risk of subsequent fractures, leading to subsequent contralateral PFF. This study was performed to analyze the features of individuals with subsequent PFF following surgical therapy of first PFF and to ascertain whether such patients received an examination or treatment of osteoporosis. The reasons for lack of examination or treatment were also analyzed.MethodsThis retrospective study involved 181 patients with subsequent contralateral PFF who underwent surgical treatment in Xi'an Honghui hospital from September 2012 to October 2021. The patients’ sex, age, hospital day, mechanism of injury, surgical procedure, fracture interval, fracture type, fracture classification, and Singh index of the contralateral hip at the time of the initial and subsequent fractures were recorded. Whether the patients took calcium and vitamin D supplements, used anti-osteoporosis medication, or underwent a dual X-ray absorptiometry (DXA) scan was recorded, as was the start time of each. Patients who had never undergone a DXA scan or received anti-osteoporosis medication took part in a questionnaire.ResultsThe 181 patients in this study comprised 60 (33.1%) men and 121 (66.9%) women. Patients with initial PFF and subsequent contralateral PFF had a median age of 80 years (range 49–96 years) and 82 years (range 52–96 years), respectively. The median fracture interval was 24 (7–36) months. Contralateral fractures occurred at the highest incidence between 3 months and 1 year (28.7%). The Singh index was not significantly different between the two fractures. In 130 (71.8%) patients, the fracture type was the same. No significant difference was found in the fracture type or fracture stability classification. A total of 144 (79.6%) patients had never received a DXA scan or anti-osteoporosis medication. The main reason for not treating osteoporosis further was concern about the safety of drug interactions (67.4%).ConclusionsPatients with subsequent contralateral PFF were of advanced age, had a higher proportion of intertrochanteric femoral fractures, had more severe osteoporosis, and had longer hospital stays. The difficulty managing such patients requires multidisciplinary involvement. Most of these patients were not screened or formally treated for osteoporosis. Advanced-age patients with osteoporosis need reasonable treatment and management.

With long-dose-interval anti-osteoporosis medications (AOMs) available for osteoporosis management, it is important to evaluate persistence of any AOM as long as it is continuously used. The purpose of this study was to investigate the treatment pattern and persistence of AOMs, allowing for medication switch. This study was an observational retrospective cohort study using Taiwan's National Health Insurance claims data. We selected patients who first initiated an AOM between January 1, 2013, and June 30, 2016. AOM therapy included alendronate, raloxifene, teriparatide, denosumab, zoledronate, and ibandronate; the latter three were categorized as long-dose-interval medications. Persistence was defined as continual prescription of any AOM at a given time point with a grace period of 45days within which to obtain prescription refill. The competing risk model was used to examine the factors affecting patients switching their initial AOM. During the study period, 126,539 patients with mean age of 75years met the inclusion criteria; 85% were female. For initial AOM, 43.3%, 25.6%, 14.6%, 9.3%, 5.3%, and 1.9% of the patients received alendronate, denosumab, raloxifene, zoledronate, ibandronate, and teriparatide, respectively. During a mean 36-month follow-up, 29.6% of the patients who received at least two AOM pharmacy claims throughout the study period have ever switched their initial medication. Long-dose-interval medications, mainly denosumab and zoledronate, were the preferred choice for medication switch. Treatment persistence was higher in patients who initiated with long-dose-interval AOMs. The real-world data reveal long-dose-interval therapy as an initial treatment or at the first switch stage may improve management of persistent AOM treatment.

Osteoporosis is a major cause of morbidity and death in older persons. For women who are 50 years of age, the estimated lifetime risk for osteoporotic fracture is 54%, and studies suggest that the ...

Accelerated bone loss is a well-known outcome of chronic treatment with glucocorticoids, making glucocorticoid-induced osteoporosis a significant cause of morbidity and a burden on health care resources. Recommendations for prevention and treatment of glucocorticoid-induced osteoporosis include therapy with a bisphosphonate or calcitonin for patients taking a prednisone equivalent of 5 mg per day or more for 3 months or more. To evaluate the effects of a targeted member and physician educational intervention on the use of anti-osteoporotic drug therapy in patients using chronic oral glucocorticoid therapy. Pharmacy claims were analyzed for a 4-month period in each of 3 years, for claims with dates of service from April 1 through July 30, 2003, May 1 through August 31, 2004, and February 4 through May 5, 2005, to identify all adult members of a health plan of approximately 1.3 million members who received an oral glucocorticoid (e.g., prednisone, dexamethasone) for at least 90 of 120 days (chronic use) and did not receive a medication for osteoporosis prevention (e.g., risedronate, ibandronate, etidronate, raloxifene, alendronate, calcitonin) during the same 120-day time period. The intervention involved direct-to-patient mailing of a cover letter and a 2-page educational brochure, and a physician mailing that included the same 2-page educational brochure, a 1-page table of recommended drug therapies for prevention of osteroporosis, and an invitation for physicians to request by fax-back a list of at-risk patients. Follow-up claims analyses were conducted for 120 days after each of the 3 intervention periods to determine the number and percentage of target patients who were initiated and maintained on a medication to prevent osteoporosis. The prevalence of health plan members at risk of glucocorticoidinduced osteoporosis was 0.28% in 2003, 0.29% in 2004, 0.29% in 2005, and 0.29% during the 3 years combined. Approximately 47.5% of patients (n = 5,140) during the 3-year period who received chronic glucocorticoids also received drug therapy for prevention or treatment of osteoporosis. Women made up 59.6% (6,450/10,822) of patients who received chronic glucocorticoid therapy during the 3 years; 50.9% (3,285/6,450) of the female patients, and 54.8% (2,397/4,372) of the male patients on chronic glucocorticoid therapy were at risk because of the absence of preventive therapy with an anti-osteoporosis medication. During the 3 years, 404 (7.1%) of the total 5,682 male and female patients at risk because of chronic glucocorticoid therapy and who were the subjects of the educational intervention were started on an osteoporosis medication following the mailings. Of these, 84.9% (343/404) continued on both the glucocorticoid therapy and an anti-osteoporosis medication in the subsequent 4-month follow-up period. During the 3 years, only 4.9% of targeted physicians (n = 196), affecting 6.8% of at-risk patients (n=387), requested a list of their patients at risk via the fax-back opportunity. A simple intervention program that screened at-risk patients and reached out to these patients and their physicians via a target-mailing intended to reduce the risk of glucorticoid-induced osteoporosis was associated with a modest increase in the proportion of at-risk patients receiving preventive drug therapy for osteoporosis.

Background: Since 2011, Taiwan’s National Health Insurance Administration (NHIA) issued a regulation on the reimbursement to anti-osteoporosis medications (AOMs). This study aimed to evaluate the impact of this regulation in reimbursement on the utilization of AOMs, clinical outcomes and associated medical expenditures of patients with incident hip fractures.Methods: By using the National Health Insurance Research Database (NHIRD), patients with incident hip fracture from 2006 to 2015 were identified as our study cohort. Patients younger than 50 years old or prescribed with AOMs within one year prior to incident fracture were excluded. Outcomes of interest were quarterly estimates of the proportion of patients who received bone mineral density (BMD) examination, who were prescribed AOMs, as well as who encountered subsequent osteoporotic fracture-related visits and associated medical expenditures. Particularly, age- and gender specific estimates were reported. An interrupted time series study design with segmented regression model was used to quantitatively explore the impact of the changes of the reimbursement criteria on the level (immediate) and trend (long-term) changes of these outcomes.Results: Our study enrolled 118 493 patients with incident hip fracture with those patients aged older than 80 years old accounting for the largest proportion. A significantly decreased trend of AOMs prescription rates was observed immediately post regulation except for female aged between 65 and 80, while the long-term pattern showed no significant difference. However, the percentage of patients encountered subsequent osteoporotic fracture-related visit was not statistically different between pre- and post-regulation periods. Noteworthy, the policy regulation was associated with an increasing trend of osteoporotic fracture associated medical expenditures, especially for patients older than 80 years old.Conclusion: The regulation on the reimbursement for AOMs decreased the prescribing rate of AOMs immediately although the effect did not sustain thereafter. However, higher subsequent osteoporotic fracture-related medical expenditures were introduced, especially among those very old population.

Women experience rapid bone loss following menopause. Currently available guidelines recommend lifestyle counseling and pharmacotherapy for osteoporosis prevention and treatment in postmenopausal women. We analyzed 2 years of National Ambulatory Medical Care Survey data (1997-1998), a national representative survey evaluating recent national patterns of antiosteoporosis medication (AOM) use and lifestyle counseling among office visits made by nonpregnant women 40 years and older. Women 40 years and older made an estimated 267 million office visits annually. Of those visits, about 10% were associated with AOM therapy. Estrogen replacement therapy was the most prevalent form of AOM therapy (80%) followed by therapy with calcium and/or cholecalciferol (vitamin D) supplements (15%). Visits for AOM were more likely to be associated with women in their 50s and 60s, white race, and having private insurance or Medicare. Women at AOM visits were twice as likely to receive concurrent lifestyle counseling than women at visits without AOM therapy. Women are particularly at risk for osteoporosis as they experience menopause, with estimates of 20 million women with osteoporosis or osteopenia. Despite the high prevalence, our study showed that only 10% of all visits were associated with 1 or more AOM therapy prescribed, provided, or continued in 1997 and 1998. These data also suggest that women with Medicaid or self-pay status were less likely to receive AOMs than women with other forms of insurance. The status of AOM therapy and lifestyle counseling in ambulatory care practice in the United States during 1997 and 1998 was less than optimal.

Bridging the Osteoporosis Quality Chasm