Predictors of Treatment with Osteoporosis Medications After Recent Fragility Fractures in a Multinational Cohort of Postmenopausal Women

Abstract

OBJECTIVES To determine the proportion of untreated women who reported receiving treatment after incident fracture and to identify factors that predict treatment across an international spectrum of individuals. DESIGN Prospective observational study. Self-administered questionnaires were mailed at baseline and 1 year. SETTING Multinational cohort of noninstitutionalized women recruited from 723 primary physician practices in 10 countries. PARTICIPANTS Sixty thousand three hundred ninety-three postmenopausal women aged 55 and older were recruited with a 2:1 oversampling of women aged 65 and older. MEASUREMENTS Data collected included participant demographics, medical history, fracture occurrence, medications, and risk factors for fracture. Anti-osteoporosis medications (AOMs) included estrogen, selective estrogen receptor modulators, bisphosphonates, calcitonin, parathyroid hormone, and strontium. RESULTS After the first year of follow-up, 1,075 women reported an incident fracture. Of these, 17% had started AOM, including 15% of those with a single fracture and 35% with multiple fractures. Predictors of treatment included baseline calcium use (P = .01), baseline diagnosis of osteoporosis (P < .001), and fracture type (P < .001). In multivariable analysis, women taking calcium supplements at baseline (odds ratio (OR) = 1.67) and with a baseline diagnosis of osteoporosis (OR = 2.55) were more likely to be taking AOM. Hip fracture (OR = 2.61), spine fracture (OR = 6.61), and multiple fractures (OR = 3.79) were associated with AOM treatment. Age, global region, and use of high-risk medications were not associated with treatment. CONCLUSION More than 80% of older women with new fractures were not treated, despite the availability of AOM. Important factors associated with treatment in this international cohort included diagnosis of osteoporosis before the incident fracture, spine fracture, and to a lesser degree, hip fracture.

Declining Rates of Osteoporosis Management Following Fragility Fractures in the U.S., 2000 Through 2009

“…A recent study of men revealed treatment rates of 7% to 9% following any fracture and 7% following hip fracture 32 , with older studies showing lower rates 33 . Consistent with our findings, previous investigators observed higher treatment rates among women than among men 30,33 and among those with a vertebral fracture than among those with another type of fracture 31,33 . Similar to our study, systematic reviews of adherence to bisphosphonate therapy have shown that the average twelve-month medication possession ratio is typically 60% to 70%, and ‡43% of patients achieve a ''high'' twelve-month adherence of >80% 10,11,13 .…”

“…Similarly, U.S. studies using data from the 1990s and early 2000s showed that <5% of female patients who sustained a fracture underwent DXA testing and 20% to 45% started or initiated osteoporosis treatment following the fracture [27][28][29][30] . A recent multinational study demonstrated that 17% of 1075 postmenopausal women initiated treatment following an incident fracture 31 . A recent study of men revealed treatment rates of 7% to 9% following any fracture and 7% following hip fracture 32 , with older studies showing lower rates 33 .…”

High rate of non-treatment among osteoporotic women enrolled in a US Medicare plan

“…In the current study, we observed that the percentage of those with a baseline fracture who received OP treatment (24.1%) was lower than that of the entire cohort (28.6%). The finding that those whose OP was identified from diagnosis codes (instead of a fracture) had higher levels of OP treatment parallels results from a previous study that observed that the presence of an OP diagnosis was associated with a greater likelihood of receiving OP pharmacotherapy 9 . Logistic regression analysis revealed that, in the overall cohort, prior use of OP medications was the strongest predictor of OP treatment which is consistent with a previous study of Medicare patients that observed that patients with prior OP treatment had over a nine-fold increase in the odds of appropriate OP management (pharmacological treatment or diagnostic testing) following a fracture, versus those without prior OP treatment 27 .…”

“…Previous studies have demonstrated that non-treatment of osteoporosis is common [8][9][10][11][12][13][14][15][16][17][18][19][20] , whether assessed after clinical or self-reported OP diagnosis 10,20 , before OP-related fractures 8,11,16 , or after fractures 9,[11][12][13][14][15][16][17][18][19] . Common barriers to treatment initiation include: concerns over side effects 21 including gastro-intestinal (GI) events [22][23][24][25] , cost 26 , and patient frailty 26 .…”

“…Common barriers to treatment initiation include: concerns over side effects 21 including gastro-intestinal (GI) events [22][23][24][25] , cost 26 , and patient frailty 26 . While some previous studies have attempted to identify characteristics associated with the likelihood of OP treatment [8][9][10]19 , most published studies have focused on treatment among patients newly indicated for treatment and did not include patients with prior use of therapy, even though prior osteoporosis therapy has been shown to be predictive of future treatment 27 . Additionally, few studies of OP nontreatment focus on a Medicare population.…”