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Tighter Government purse strings could reverse gains in Hip Fracture Prevention

Newswise — Future federally-mandated decreases in DXA reimbursement could lead to increased hip fractures among senior citizens, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in San Francisco, Calif.

Osteoporosis is a silent disease of the bones that makes them weaken and prone to fracture.

By their mid-30s, most people begin to gradually lose bone strength as the balance between losing bone (resorption) and adding new bone (formation) shifts, so that more bone is lost than can be replaced.

As a result, bones become thinner and structurally weaker.

Dual energy X-ray absorptiometry, or DXA as it is more commonly called, is considered the “gold standard” in diagnosing osteoporosis as it is the best way to track this silent disease over time.

Researchers studied time trends in the prevalence of non-traumatic hip fractures—such as a fall from standing height—among senior citizens and studied how these trends correlate to community screening and treatment efforts.

 Using the Nationwide Inpatient Sample—derived from a random sampling of U.S. community hospitals—researchers examined all inpatient hospitalizations between 1988 and 2005 with a primary diagnosis of non-traumatic hip fractures in patients 50 years or older.

Researchers reported 5.2 million hospitalizations for non-traumatic hip fractures in 1.3 billion person years of observation; 76 percent of these hip fractures occurred in women.

During this time, overall prevalence of hip fracture hospitalizations decreased from 428.1 per 100,000 patients in 1988 to 328.1 in 2005 – a decline of almost 23 percent.

In women, prevalence rates were essentially consistent from 1988 to 1996 and then began a steep decline from 635.9 per 100,000 patients in 1996 to 437.3 in 2004.

The researchers noted two important occurrences that correlated with the decline in fractures among women: the approval of the first bisphosphonate for osteoporosis treatment in 1995, and federal legislation (the “Bone Mass Measurement Act”) mandating osteoporosis screening benefits for women.

This legislation resulted in a large surge in DXA Medicare claims from 1994 to 2004.

It was determined that both of these occurrences encouraged the widespread use of screening, prevention and treatment methods from 1996 to 1998 and likely led to the decline. Conversely, researchers worry that decreasing payments could lead to decreased use of DXA for screening and assessment, possibly reversing this decline.

Another important finding form the study, according to Alka Mithal, MD; primary care physician and epidemiologist, Institute of Clinical Outcomes Research and Education, Palo Alto, Calif.; and lead investigator in the study, is the difference between the prevalence rates of men and women.

“Women showed a greater decrease in hip fracture hospitalization as compared to men probably because access to bone density screening is available to all women above the age of 65,” explains Dr. Mithal. “Men did not have [a] similar advantage – even though the fracture rate in 70 year-old men is same as in 65 year-old women,”

The ACR is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy and practice support that foster excellence in the care of people with or at risk for arthritis and rheumatic and musculoskeletal diseases. For more information on the ACR’s annual meeting, see www.rheumatology.org/annual.

Presentation Number: 2103

War on Osteoporosis: Are we giving up back hard-won victories?

Alka Mithal1, Gurkirpal Singh2, Shweta Vadhavkar1, Ajitha Mannalithara1, George Triadafilopoulos2. 1Institute of Clinical Outcomes Research and Education, Palo Alto, CA; 2Stanford University School of Medicine, Palo Alto, CA

Purpose: To study time-trends in prevalence of nontraumatic hip fractures in the US from 1988-2005 in the elderly, and correlate to community screening and treatment efforts.

Methods: The Nationwide Inpatient Sample (NIS) is a stratified random sample of US community hospitals, with information on all patients, regardless of payer.

We examined all inpatient hospitalizations with a primary diagnosis of non-traumatic hip fractures in patients 50 years or older from 1988 to 2005.

Hospitalizations were excluded if there was any evidence of major trauma, open fractures or primary or secondary femoral tumors. Age- and gender stratified US population data was obtained from the US census bureau.

All prevalence rates are expressed per 100,000 US population. Data on DXA Medicare claims were obtained from CMS and ISCD.

Results: There were 5.2 million hospitalizations for non-traumatic hip fractures in 1.3 billion person-years of observation from 1988 to 2005 in the US.

Of these, 76% occurred in women. Prevalence of hip fracture hospitalizations decreased from 428.1 per 100,000 in 1988 to 328.1 in 2005, a decline of almost 23% (p<0.0001).

In women, prevalence rates were essentially constant from 1988 to 1996, and then started a steep decline till 2004 (635.9 per 100,000 in 1996 to 437.3 per 100,000 in 2004) (figure). In 2005, the decline appears to have flattened (444.7 per 100,000).

The decline in men was less steep, resulting in a narrowing of the “gender gap” by 2005. Of note, the first bisphosphonate for osteoporosis was approved in 1995.

Federal legislation mandating osteoporosis screening benefit for women (Bone Mass Measurement Act) was passed in 1998, resulting in a large surge in DXA Medicare claims from 1994 to 2004 (77,133 in 1994, 1,265,496 in 1996, and 2,426,361 in 2004).

The growth of DXA Medicare claims has slowed recently (2,583,981 in 2006; 447,934 in first quarter of 2006 and 450,128 in first quarter of 2008).

Conclusion: Non-traumatic hip fracture hospitalizations in elderly women declined in the US, corresponding with widespread use of screening, prevention and treatment, starting in 1996-1998.

The decline in men has been less noticeable, perhaps reflecting the lack of awareness and mandated federal screening guidelines.

As the growth of screening efforts has slowed, so has the decline in hip fracture prevalence. It is possible that future federally-mandated decrease in screening reimbursement would result in even less screening, and thus a decrease in early diagnosis and treatment, causing a reversal of decline in hip fracture hospitalizations.