Treatment rates and healthcare costs of patients with fragility fracture by site of care: a real-world data analysis.

In a characterization of treatment rates and healthcare costs among patients with an osteoporotic-related fragility fracture overall and by site of care, costs were high and treatment rates were low. PURPOSE: Osteoporotic fractures can be debilitating, even fatal, among older adults. The cost of osteoporosis and related fractures is projected to increase to more than $25 billion by 2025. The objective of this analysis is to characterize disease-related treatment rates and healthcare costs of patients with an osteoporotic fragility fracture overall and by site of fracture diagnosis. METHODS: In this retrospective analysis, individuals with fragility fractures were identified in the Merative MarketScan® Commercial and Medicare Databases among women 50 years of age or older and diagnosed with fragility fracture between 1/1/2013 and 6/30/2018 (earliest fracture diagnosis = index). Cohorts were categorized by clinical site of care where the diagnosis of fragility fracture was made and were continuously followed for 12 months prior to and following index. Sites of care were inpatient admission, outpatient office, outpatient hospital, emergency room hospital, and urgent care. RESULTS: Of the 108,965 eligible patients with fragility fracture (mean age 68.8), most were diagnosed during an inpatient admission or outpatient office visit (42.7%, 31.9%). The mean annual healthcare costs among patients with fragility fracture were $44,311 (± $67,427) and were highest for those diagnosed in an inpatient setting ($71,561 ± $84,072). Compared with other sites of care at fracture diagnosis, patients diagnosed during an inpatient admission also had highest proportion of subsequent fractures (33.2%), osteoporosis diagnosis (27.7%), and osteoporosis therapy (17.2%) during follow-up. CONCLUSION: The site of care for diagnosis of fragility fracture affects treatment rates and healthcare costs. Further studies are needed to determine how attitude or knowledge about osteoporosis treatment or healthcare experiences differ at various clinical sites of care in the medical management of osteoporosis.

Cost effectiveness of romosozumab versus teriparatide for severe postmenopausal osteoporosis in Japan.

This study assessed the cost effectiveness of romosozumab versus teriparatide, both sequenced to alendronate, for the treatment of severe postmenopausal osteoporosis in Japan, using bone mineral density (BMD) efficacy data. Results show that romosozumab/alendronate produces greater health benefits at a lower cost than teriparatide/alendronate. INTRODUCTION: This study aims to assess the cost effectiveness of romosozumab versus teriparatide, both sequenced to alendronate, for the treatment of severe postmenopausal osteoporosis in Japanese women previously treated with bisphosphonates. METHODS: A Markov model was used to assess the relative cost effectiveness of 1 year of romosozumab versus 2 years of teriparatide, both sequenced to alendronate for a total treatment duration of 5 years. Outcomes for a cohort of women with a mean age of 78 years, a T-score ≤-2.5 and a previous fragility fracture were simulated over a lifetime horizon. The analysis was conducted from the perspective of the Japanese healthcare system and used a discount rate of 2% per annum. To inform relative fracture incidence, the bone mineral density (BMD) advantage of romosozumab over teriparatide was translated into relative risks of fracture, using relationships provided by a meta-regression of osteoporosis therapy trials. Outcomes were assessed in terms of lifetime costs (2020 US dollars) and quality-adjusted life years (QALYs). RESULTS: Base case results showed that, compared with teriparatide/alendronate, romosozumab/alendronate reduced costs by $5134 per patient and yielded 0.045 additional QALYs. Scenario analyses and probabilistic sensitivity analysis confirmed that results are robust to uncertainty in model assumptions and inputs. CONCLUSION: Results show that romosozumab/alendronate produces greater health benefits at a lower total cost than teriparatide/alendronate.

Perspectives on the non-invasive evaluation of femoral strength in the assessment of hip fracture risk.

We reviewed the experimental and clinical evidence that hip bone strength estimated by BMD and/or finite element analysis (FEA) reflects the actual strength of the proximal femur and is associated with hip fracture risk and its changes upon treatment. INTRODUCTION: The risk of hip fractures increases exponentially with age due to a progressive loss of bone mass, deterioration of bone structure, and increased incidence of falls. Areal bone mineral density (aBMD), measured by dual-energy X-ray absorptiometry (DXA), is the most used surrogate marker of bone strength. However, age-related declines in bone strength exceed those of aBMD, and the majority of fractures occur in those who are not identified as osteoporotic by BMD testing. With hip fracture incidence increasing worldwide, the development of accurate methods to estimate bone strength in vivo would be very useful to predict the risk of hip fracture and to monitor the effects of osteoporosis therapies. METHODS: We reviewed experimental and clinical evidence regarding the association between aBMD and/orCT-finite element analysis (FEA) estimated femoral strength and hip fracture risk as well as their changes with treatment. RESULTS: Femoral aBMD and bone strength estimates by CT-FEA explain a large proportion of femoral strength ex vivo and predict hip fracture risk in vivo. Changes in femoral aBMD are strongly associated with anti-fracture efficacy of osteoporosis treatments, though comparable data for FEA are currently not available. CONCLUSIONS: Hip aBMD and estimated femoral strength are good predictors of fracture risk and could potentially be used as surrogate endpoints for fracture in clinical trials. Further improvements of FEA may be achieved by incorporating trabecular orientations, enhanced cortical modeling, effects of aging on bone tissue ductility, and multiple sideway fall loading conditions.

Assessment of bone status using speed of sound at multiple anatomical sites.

Studies in vitro and in vivo have shown that quantitative ultrasound (QUS) is a valid tool for the assessment of bone status. Current QUS methods using the transmission technique are limited to one peripheral bone site. A new system, Sunlight Omnisense (Omnisense, Sunlight Medical Ltd., Rehovot, Israel), measures speed of sound (SOS, in m/s) along the surface of the bone based on an axial transmission technique. The Omnisense can measure SOS at several anatomical sites. This study evaluated the SOS at different anatomical sites in a healthy population. A total of 334 adult women from three research centers in the USA and Canada with a mean (+/- SD) age of 48.8 (+/- 17.4) years were enrolled in this study. SOS was measured at the proximal third phalanx, distal one third radius, midshaft tibia, and fifth metatarsal. The mean SOS (+/- SD) values for the phalanx, radius, tibia and metatarsal were 3984 (+/- 221), 4087 (+/- 147), 3893 (+/- 150) and 3690 (+/- 246) m/s, respectively. Each anatomical site SOS was significantly different (p < 0.001) from that of the other sites. SOS at the different anatomical sites was modestly, but significantly, correlated (r = 0.31 to 0.56, p < 0.001). Similar correlation coefficients were obtained for the T scores. The mean T scores for subjects over the age of 60 years were -1.94, -2.01, -0.97 and -1.42 for the phalanx, radius, tibia and metatarsal, respectively. The age of peak SOS and the rate of change thereafter varied with anatomical site, implying that the prevalence of osteopenia and osteoporosis was site-dependent if only one T score cut-off point was used. Comparing individuals, 10% to 17% of patients had T scores that differed by more than a factor of 2 between sites. Weight and age were some of the contributing factors to this heterogeneity. The Omnisense provides an opportunity to assess bone status at different anatomical sites. Whether or not combining measurements from all these anatomical sites will improve osteoporosis management still needs to be determined.

Suicide cases in civil law: do the legal tests make sense?

The legal 'tests' for suicide liability in negligence and workmen's compensation law have developed along parallel, but not identical, lines to the tests for criminal responsibility. Current legal precedent has shifted the focus from cognitive awareness and irresistible impulse theories to the ability of a negligent act or injury to cause an abnormal mental state. The courts, in their variable interpretation of these mental state tests, leave no clear guidelines for the psychiatric expert asked to address suicidal behavior from the standpoint of responsibility.