The Osteoporosis Treatment Gap

Abstract

Many guidelines for the assessment and treatment of osteoporosis recommend that intervention be considered in men and women who have sustained a fragility fracture.(1) Guidelines in North America (2,3) specifically refer to a prior hip fracture (and spine fracture) as a condicio sine qua non for treatment because of the marked effect of fractures at these sites on both morbidity and mortality. In addition, hip fractures have large economic consequences. For example, hip fractures account for 17% of all osteoporotic fractures in Europe but comprise 54% of the direct cost of fractures.(1) The need for treatment arises because of the increased risk of a second fracture, (4) which is particularly acute in the immediate postfracture period when fracture rates are substantially increased. Despite a number of advances, particularly in the diagnosis of osteoporosis, the assessment of fracture risk, the development of interventions that reduce the risk of fractures, and the production of practice guidelines, many surveys indicate that a minority of men and women at high fracture risk actually receive treatment. (8)(9)(10)(11)(12)(13)(14) In patients who sustain a fragility fracture, fewer than 20% of individuals receive therapies to reduce the risk of future fracture within the year following the fracture. (11,12,(15)(16)(17)(18) Paradoxically, the therapeutic care gap may be particularly wide in the elderly in whom the importance and impact of treatment is high; studies have shown that as few as 10% of older women with fragility fractures receive any osteoporosis therapy (estrogens not considered). (11,19,20) Furthermore, treatment rates following a fracture are lower for those individuals who reside in long-term care.(12) This contrasts with the situation following myocardial infarction, for which condition a significant care gap has been overcome in the past 15 years: 75% of such individuals now receive beta blockers to help prevent recurrent myocardial infarction. (21) In this issue of the Journal of Bone and Mineral Research, Solomon and colleagues (22) report on the uptake of osteoporosis medications in the year following hip fracture in a large retrospective analysis of nearly 100,000 men and women aged 50 years or more who were hospitalized for hip fracture over a period of 1 year. The study, based on U.S. administrative insurance claims data, followed the uptake of osteoporosis medication within 12 months after discharge from hospital. The estimated probability of receiving osteoporosis medication within 12 months after discharge from hospital was 28.5% over this time period, but varied by year. Indeed, the rates declined significantly over a 10-year interval, from 40.2% in 2002, to 20.5% in 2011.European studies have compared the treatment gap across countries, albeit indirectly. The number of patients treated in each country was computed from IMS Health (Danbury, CT, USA) sales data for 2010, adjusted for suboptimal adherence, and expressed as treatment years.(1) The use of hormone replacement therapy was excl...

Secular trends in fracture incidence in the UK between 1990 and 2012

“…Given the exponential rise of incidence with age for fractures at many sites [23], and the increasingly elderly demographic globally [2], we are clearly facing a growing burden from osteoporotic fracture in future years. Our findings thus add support to the call for global action to detect, assess and appropriately treat those at high fracture risk, and to close the treatment gap [38] for those who experience a low trauma fracture. Incidence (per 10,000 py) of distal forearm, vertebral and hip fractures in men 1990-2012 in the UK, stratified by 5-year age band.…”

“…Indeed in a recent study from the UK using the CPRD only 51.3% of women and 33.6% of men received anti-osteoporosis treatment after a hip fracture, despite this being a marked improvement on 10 years prior where 8.2% of women and 4.1% of men received treatment [37]. This dramatic "treatment gap" has been documented in other populations and should act as a huge incentive to improve identification of treatment of patients for treatment [38]. Interestingly, although there were differences by fracture type, there did not seem to be any overall difference in secular trend between fractures types classified as osteoporotic, compared with those which are not.…”

Odanacatib: a review of its potential in the management of osteoporosis in postmenopausal women

“…The widely publicized issue of ONJ has probably contributed to the decline in the prescription of anti-osteoporosis drugs that has been observed in recent years in various countries, even if their risk-benefit ratio remains favorable [Kanis et al 2014;Solomon et al 2014].…”

Assessment of the antiosteoporotic treatment initiation: A retrospective observational study in Greece

“…According to IOF, the treatment gap in Greece was estimated at 25 % and 31 % for women and men respectively 28 . Furthermore, various studies have shown that of the patients who have had a low trauma fracture just about 20% receive treatment for osteoporosis 29,30 .…”