Real-World Management of Patients With Osteoporosis at Very High Risk of Fracture.

INTRODUCTION: Lack of consideration for risk-based assessments that inform osteoporosis treatment decisions may contribute to disease burden. In this study, we examined the prevalence of patients at very high risk of fracture and evaluated real-world treatment practices for these patients. METHODS: This retrospective observational cohort study used real-world data linked to commercial and Medicare medical claims from Symphony Health PatientSource. Patients 50 years and older with osteoporosis (determined by the presence of a diagnosis code) and at very high risk of fracture according to the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) (AACE/ACE) 2020 guidelines between January 1, 2018, and December 31, 2018, were included. The number and proportion of patients treated with any osteoporosis medication were evaluated. RESULTS: Of the 10,739,286 patients with osteoporosis, 5,078,111 (47.3%) were identified as meeting the AACE criteria for very high risk of fracture and were selected for the analysis. Most (5,033,106 [99.1%]) had a high risk of falls and/or a history of falls resulting in injury. Among the 1,667,794 patients (32.8%) eligible for treatment, 280,777 (16.8%) received treatment. Of these, 63.6% received alendronate, an alternative therapy, and 21.2% received a risk-based guideline-recommended medicine (teriparatide, zoledronic acid, denosumab, abaloparatide, or romosozumab). A greater proportion of men were untreated, 161,978 (90.5) compared with 1,185,003 women (81.8). DISCUSSION: Most patients at very high risk of fracture remain untreated. Most of those treated do not receive the appropriate recommended treatments for patients at high risk. Risk-based treatment decisions may allow for more appropriate medication selection.

An Evaluation of Treatment Patterns for Osteoporosis and Outcomes After a Fragility Fracture in a Real-World Setting.

OBJECTIVES: Treatment initiation and persistence after a fragility fracture are critical to reduce the risk of subsequent fractures. The authors evaluated osteoporosis management and outcomes after index fracture. METHODS: This retrospective cohort study used real-world data for patients (≥50 years), including pharmacy claims linked to commercial and Medicare medical claims from Symphony Health Patient Source. Osteoporosis management was evaluated for at least 12 months after the first case-qualifying fracture during the identification period and continued until a second fracture or March 31, 2020 (depending on data availability). Secondary fracture incidence was evaluated overall and for subgroups at very high risk. RESULTS: Of 755,312 eligible patients, the proportion with a claim for bone mineral density testing at 12 months after index fracture was low [64,932 (8.6%)], and 75.3% of those tested were ≥65 years of age. Most patients (88.6%) remained untreated at any time after fracture. Among those treated, most (64.9%) were initially treated with bisphosphonates (oral, 93.7%; IV, 6.3%). Treatment duration and persistence were low for all treatments ranging from 6.5 months with 19.6% persistent for abaloparatide to 11.3 months with 45.0% persistent for denosumab. During follow-up, 13.6% of patients had a secondary fracture at any site, with higher incidence in subgroups considered to be at high risk for fracture than in the overall population. CONCLUSIONS: Low rates of osteoporosis testing and treatment initiation and high secondary fracture rates (particularly among patients at very high risk) highlight the need for better management of patients after a fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone Health Management in Elective Orthopaedic Surgery: A Claims-Based Observational Study.

Introduction: There are limited data on the management of bone health, including bone mineral density (BMD) evaluation and osteoporosis (OP) treatment, in patients undergoing elective orthopaedic surgeries. Methods: This was a retrospective cohort study using administrative claims data from Symphony Health, PatientSource for patients aged ≥50 years with documented kyphoplasty/vertebroplasty (KP/VP), total knee arthroplasty (TKA), and total hip arthroplasty (THA). Risk stratification to identify patients at very high risk for fracture (VHRFx) was based on clinical practice guideline recommendations to the extent information on variables of interest were available from the claims database. Results: A total of 251 919 patients met inclusion criteria: KP/VP (31 018), TKA (149 849), and THA (71 052). The majority were female (80.3%) with a mean (SD) age of 68.5 (7.5) years. Patients undergoing KP/VP were older and had a greater comorbidity burden associated with risk for falls, mobility issues, muscle weakness, and respiratory and cardiovascular diseases. In the 6 months before surgery, 11.8% of patients were tested and/or received treatment for OP. Patients undergoing KP/VP were more likely to be tested and/or treated (17.5%) than patients undergoing TKA (11.0%) or THA (10.9%). Overall, men had a lower rate of testing and/or treatment than women (4.6% vs 13.5%). In the 12 months before surgery, patients with an OP diagnosis and at VHRFx (30.8%) had a higher rate of treatment and/or testing than those without OP (11.5%), or those without OP but with a fracture in the year preceding surgery (10.2%). Conclusions: Bone health management is suboptimal in patients undergoing elective orthopaedic surgeries and is worse in men than in women. Proper management of OP before and after surgery may improve outcomes.

Development and validation of a one year predictive model for secondary fractures in osteoporosis.

The number of osteoporosis-related fractures in the United States is no longer declining. Existing risk-based assessment tools focus on long-term risk. Payers and prescribers need additional tools to identify patients at risk for imminent fracture. We developed and validated a predictive model for secondary osteoporosis fractures in the year following an index fracture using administrative medical and pharmacy claims from the Optum Research Database and Symphony Health, PatientSource. Patients ≥50 years with a case-qualifying fracture identified using a validated claims-based algorithm were included. Logistic regression models were created with binary outcome of a second fracture versus no second fracture within a year of index fracture, with the goal of predicting second fracture occurrence. In the Optum Research Database, 197,104 patients were identified with a case-qualifying fracture (43% commercial, 57% Medicare Advantage). Using Symphony data, 1,852,818 met the inclusion/exclusion criteria. Average patient age was 70.09 (SD = 11.09) and 71.28 (SD = 14.24) years in the Optum Research Database and Symphony data, respectively. With the exception of history of falls (41.26% vs 18.74%) and opioid use (62.80% vs 46.78%), which were both higher in the Optum Research Database, the two populations were mostly comparable. A history of falls and steroid use, which were previously associated with increased fracture risk, continue to play an important role in secondary fractures. Conditions associated with bone health (liver disease), or those requiring medications that impact bone health (respiratory disease), and cardiovascular disease and stroke-which may share etiology or risk factors with osteoporosis fractures-were also predictors of imminent fractures. The model highlights the importance of assessment of patient characteristics beyond bone density, including patient comorbidities and concomitant medications associated with increased fall and fracture risk, in alignment with recently issued clinical guidelines for osteoporosis treatment.