Impact of the Requirement of Bone Mineral Density Evidence on Utilization of Anti-osteoporosis Medications, Clinical Outcome and Medical Expenditures of Patient With Hip Fracture in Taiwan.

BACKGROUND: Since 2011, Taiwan's National Health Insurance Administration (NHIA) issued a regulation on the reimbursement to anti-osteoporosis medications (AOMs). This study aimed to evaluate the impact of this regulation in reimbursement on the utilization of AOMs, clinical outcomes and associated medical expenditures of patients with incident hip fractures. METHODS: By using the National Health Insurance Research Database (NHIRD), patients with incident hip fracture from 2006 to 2015 were identified as our study cohort. Patients younger than 50 years old or prescribed with AOMs within one year prior to incident fracture were excluded. Outcomes of interest were quarterly estimates of the proportion of patients who received bone mineral density (BMD) examination, who were prescribed AOMs, as well as who encountered subsequent osteoporotic fracture-related visits and associated medical expenditures. Particularly, age- and gender specific estimates were reported. An interrupted time series study design with segmented regression model was used to quantitatively explore the impact of the changes of the reimbursement criteria on the level (immediate) and trend (long-term) changes of these outcomes. RESULTS: Our study enrolled 118 493 patients with incident hip fracture with those patients aged older than 80 years old accounting for the largest proportion. A significantly decreased trend of AOMs prescription rates was observed immediately post regulation except for female aged between 65 and 80, while the long-term pattern showed no significant difference. However, the percentage of patients encountered subsequent osteoporotic fracture-related visit was not statistically different between pre- and post-regulation periods. Noteworthy, the policy regulation was associated with an increasing trend of osteoporotic fracture associated medical expenditures, especially for patients older than 80 years old. CONCLUSION: The regulation on the reimbursement for AOMs decreased the prescribing rate of AOMs immediately although the effect did not sustain thereafter. However, higher subsequent osteoporotic fracture-related medical expenditures were introduced, especially among those very old population.

Real-world cost-effectiveness analysis of the fracture liaison services model of care for hip fracture in Taiwan.

BACKGROUND: This study was to perform an economic evaluation to understand clinical outcomes and health resource use between hip fracture patients receiving hospital-based postfracture fracture liaison service (FLS) care and those receiving usual care (UC) in Taiwan. METHODS: This cohort study included hospital-based data of 174 hip fracture patients who received FLS care (FLS group) from National Taiwan University Hospital, and 1697 propensity score-matched patients who received UC (UC group) of National Health Insurance claim-based data. Two groups had similar baseline characteristics but differed in hip fracture care after propensity score matching. Clinical outcomes included refracture-free survival (RFS), hip-refracture-free survival (HRFS), and overall survival (OS). Health resource use included inpatient, outpatient, and pharmacy costs within 2 years follow-up after the index of hip fracture. The economic evaluation of the FLS model was analyzed using the net monetary benefit regression framework based on the National Health Insurance perspective. RESULTS: The FLS group had longer RFS than the UC group, with an adjusted difference of 44.3 days (95% confidence interval: 7.2-81.4 days). Two groups did not differ in inpatient and outpatient costs during follow-up, but the FLS group had a higher expenditure than the UC group on osteoporosis-related medication. The probability of FLS being cost-effective was >80% and of increasing RFS, HRFS, and OS was 95%, 81%, and 80%, respectively, when the willingness-to-pay threshold was >USD 65/gross domestic product per day. CONCLUSION: FLS care was cost-effective in reducing refracture occurrence days for patients initially diagnosed with hip fractures.

Visualisation of the unmet treatment need of osteoporotic fracture in Taiwan: A nationwide cohort study.

AIMS: Recent clinical guidelines have suggested that patients experience an osteoporotic fracture should initiate anti-osteoporosis medications (AOMs). However, whether clinical guidelines translate well in "real-world" practices remain questioned. This study aimed to evaluate the "real-world" prescription pattern of AOMs and visualise the unmet treatment needs in different geographical areas in Taiwan. METHODS: Using Taiwan's National Health Insurance Research Database, we identified patients diagnosed with a hip or vertebral fracture between 2009 and 2012. The treatment rate was defined as the proportion of patients receiving AOMs within 1 year after their index fracture. The qualitative geographical information systems approach was adopted to visualise the treatment needs of postfracture patients in different geographical areas. RESULTS: Our study included 276,492 patients diagnosed with a hip or vertebral fracture between 2009 and 2012. The proportion of patients who received AOMs within 1 year after their index fracture increased with age and differed with fracture types and sex. For patients with hip fractures, the treatment rate ranged from 3.43% to 20.88% for female patients and from 0.69% to 10.04% for male patients in different age groups. For patients with vertebral fractures, the treatment rate ranged from 3.23% to 37.08% for female patients and from 1.85% to 23.05% for male patients. Cities in the mid-northern and southern areas of Taiwan had the highest unmet treatment need, with a treatment rate of less than 15%. CONCLUSION: The treatment rate of osteoporotic fractures with AOMs was diverse and suboptimal in Taiwan, especially among male patients. This study used a visualisation technique to display information about the treatment status in different geographical areas and help policymakers allocate resource appropriately.

Age- and gender-specific epidemiology, treatment patterns, and economic burden of osteoporosis and associated fracture in Taiwan between 2009 and 2013.

This nationwide study investigated the epidemiology, treatment patterns, and economic burden of osteoporosis and associated fracture in Taiwan. The treatment of osteoporosis is alarmingly suboptimal, considering the significantly increased economic burden of major osteoporotic fracture. Osteoporosis men received lesser anti-osteoporosis drugs but had higher incremental costs attributable to osteoporotic fractures. PURPOSE: This nationwide study investigated the epidemiology, treatment patterns, and economic burden of osteoporosis and associated fracture between 2009 and 2013 in Taiwan. METHODS: We used the National Health Insurance Research Database as our data source. The prevalence of diagnosed osteoporosis and major osteoporotic fractures was calculated annually from 2009 to 2013, stratified by age and gender. Osteoporosis patients who received any prescription of anti-osteoporosis drugs during each fiscal year were defined as osteoporosis patients under treatment. Healthcare utilization and associated direct medical costs were used to quantify the economic burden of osteoporosis. For patients who encountered major osteoporotic fracture, the incremental changes of direct medical costs attributable to fracture using a pre- and post-quasi-experimental design were estimated. Furthermore, we compared the annual direct medical costs of patients who encountered major osteoporotic fracture with those diagnosed osteoporosis only and with the general population. RESULTS: The prevalence of diagnosed osteoporosis increased with age, with the highest rate among those aged 80 and older. Overall, less than one-third of women and only 10% of men received anti-osteoporosis drugs among osteoporosis patients. The annual direct medical costs for osteoporosis patients increased steadily from 2009 to 2013. The total medical costs and incremental change of direct medical costs were higher in men than those in women. CONCLUSION: We found the treatment of osteoporosis to be alarmingly suboptimal, considering the significantly increased economic burden of major osteoporotic fracture also identified in this study. Osteoporosis men received lesser anti-osteoporosis drugs but had higher incremental costs attributable to major osteoporotic fractures.

Establishing and evaluating FRAX® probability thresholds in Taiwan.

BACKGROUND/PURPOSE: The Taiwanese FRAX® calculator was launched in 2010. However, cost-effectiveness thresholds for the prescription of antiosteoporosis medications were not established. This study aims to establish and evaluate FRAX®-based probability thresholds in Taiwan. METHODS: Using previous data from Taiwan and literature, we determined cost-effectiveness thresholds for prevention of osteoporotic fractures by alendronate with a Markov model, as well as using two other translational approaches. Sensitivity analysis was applied using different alendronate prices. A clinical sample was used to test these Taiwan-specific thresholds by determining the percentages of high-risk patients who would be qualified for current National Health Insurance reimbursement. RESULTS: With the Markov model, the intervention threshold for hip fracture was 7% for women and 6% for men; for major osteoporotic fracture, it was 15% for women and 12.5% for men. Both translational approach models were cost effective only for certain age groups. However, if branded alendronate was reimbursed at 60% of the current price, they became cost effective in almost all age groups. This clinical screening study showed that the National Health Insurance Administration model identified the highest proportion (44%) of patients qualified for National Health Insurance reimbursements, followed by the Markov model (30%), and the United States model (22%). CONCLUSION: Three FRAX®-based models of alendronate use were established in Taiwan to help optimize treatment strategies. The government is encouraged to incorporate FRAX®-based approaches into the reimbursement policy for antiosteoporosis medicines.

Optimal Analysis to Discriminate Males' Osteoporosis With Simple Physiological Indicators: A Cutoff Point Study.

Males account for one third of global hip fracture patients, and their hip fracture-related mortality rate is higher than that of females. Scholars have primarily investigated self-evaluation indicators for elderly Caucasians and other ethnicities, and have rarely conducted large-scale cutoff point studies on Asian males. In this study, a large-scale database on bone mineral density (BMD) examinations was used to conduct a cutoff point study on males with osteoporosis. This study involved a retrospective research design. Males who accepted BMD examinations from 2009 to 2012 at a large teaching hospital in Taiwan were sampled in this study. This study used the database for analyzing effects with using osteoporosis self-assessment indicator, age, body weight, and body mass index (BMI) to discriminate osteoporosis in males, specifically focusing on accuracy, cutoff point, sensitivity, specificity, and positive and negative predictive values. Overall, receiver operating characteristic curve for the samples reached 70%. These cutoff points included: a body weight is less than 58.8 kg, BMI is 23 kg/m2, and the osteoporosis self-assessment score is -1.86, to identify osteoporosis. Involving body weight and BMI as optimal assessing indicators for assessing osteoporosis among males younger than 65 years, and the osteoporosis self-assessment tool was ideal for measuring males older than 65 years. Professional health staff should apply convenient, low-cost, and accurate evaluation tools that can assist Asian males in planning preventive osteoporosis strategies to avoid osteoporotic fractures and death.

Determining the cut-off point of osteoporosis based on the osteoporosis self-assessment tool, body mass index and weight in Taiwanese young adult women.

AIMS AND OBJECTIVES: To examine the cut-off point of the osteoporosis self-assessment tool, age, weight and body mass index for osteoporosis among young adult Taiwanese women, using a large-scale health examination database containing bone mineral density tests. BACKGROUND: The cut-off points of osteoporosis risk factors identified earlier focus on menopausal or senior Caucasian and Asian women. However, young adult Asian women have seldom been identified. DESIGN: A retrospective historical cohort study. METHODS: Using the 2009-2011 health examination database of a large-scale medical centre in northern Taiwan, this study investigated young adult Asian women (i.e. range in age from 30-49 years) in Taiwan who had received dual-energy X-ray absorptiometry test. This study also explored the cut-off point, sensitivity, specificity and diagnostic accuracy of receiver operating characteristics of osteoporosis among young adult females in Taiwan. RESULTS: This study collected 2454 young adult Asian women in Taiwan. Cochran-Armitage analysis results indicated that the prevalence of osteoporosis increased with decreasing weight, body mass index and osteoporosis self-assessment method quartiles. According to the results of receiver operating characteristics, weight, body mass index and osteoporosis self-assessment tool approaches can generally be used as indicators to predict osteoporosis among young adult Asian women. CONCLUSIONS: Results of this study demonstrate that Taiwanese women contracting osteoporosis tend to be young and underweight, as well as having a low body mass index and osteoporosis self-assessment scores. Those results further suggest that the assessment indicators for cut-off points are appropriately suitable for young adult women in Taiwan. RELEVANCE TO CLINICAL PRACTICE: Early detection is the only available means of preventing osteoporosis. Professional nurses should apply convenient and accurate assessment procedures to help young adult women to adopt preventive strategies against osteoporosis early, thus eliminating the probability of osteoporotic fracture.

Factors associated with falls among community-dwelling older people in Taiwan.

INTRODUCTION: Falls are common among older people. Previous studies have shown that falls were multifactorial. However, data regarding community-dwelling Chinese population are minimal. We aimed to study factors associated with falls among community-dwelling older Chinese people. MATERIALS AND METHODS: We conducted a cross-sectional study in a community hospital in Taiwan in 2010. Our sample included 671 elders from the 3680 examinees of the free annual Senior Citizens Health Examination. Participants were interviewed with a detailed questionnaire, and 317 elders were further invited for serum vitamin D tests. The main outcome was falls in the previous 12 months. Predictor variables included sociodemographic characteristics, lifestyle risk factors, body stature, frailty, serum 25 (OH) D levels, and medications. RESULTS: The mean age of the 671 participants was 75.7 ± 6.4 years old, and 48.7% of which were female. Fallers comprised 21.0% of the study population. In multivariate models, female gender (adjusted odds ratio (aOR): 2.32), loss of height in adulthood (aOR: 1.52), low body weight (aOR: 2.69), central obesity (aOR: 1.67), frailty (aOR: 1.56), polypharmacy (aOR: 2.18) and hyperglycaemia (aOR: 1.56) were factors associated with falls. Vitamin D insufficiency (serum 25 (OH) D levels <30 ng/mL) was not associated with falls (OR: 0.78; 95% CI, 0.38 to 1.60) (n = 317) in this study. CONCLUSION: Among community-dwelling older people in Taiwan, falls were mainly associated with female gender, polypharmacy, frailty, reduced body height, low body weight or central obesity, and hyperglycaemia. In addition to other risk factors, body stature should be considered as a novel risk factor when screening elders at risk for falls.

A 12-year ecological study of hip fracture rates among older Taiwanese adults.

Hip fracture rates in Taiwan are among the highest in the world. The aim of this study was to describe the trends of hip fracture hospitalizations among Taiwanese elderly (aged ≥ 65 years) and the trends of antiosteoporosis medication expenditure from 1999 to 2010. We conducted an ecological study using inpatient health care-utilization data from the Department of Health, and medication expenditure data from the IMS Health, Taiwan. The International Classification of Disease, Clinical Modification, 9th version, code 820 was used to identify hip fracture hospitalizations. Medications included alendronate, calcitonin, ibandronate, raloxifene, strontium ranelate, teriparatide, and zoledronic acid. Year 2010 was assigned as the reference point for age-standardized rates, currency exchange (to the US dollar), and discount rates. Over the 12-year study period, age-standardized hip fracture hospitalizations decreased by 2.7 % annually (p for trend < 0.001) for Taiwanese elders. The decline was more obvious among those aged ≥75 years (6.1 %). However, the number of hip fracture hospitalizations increased from 14,342 to 18,023. Total hospitalization costs increased by US$0.6 ± 0.2 million annually (p for trend = 0.002); however, the per capita costs decreased by US$23.0 ± 8.0 (p for trend = 0.017). The total medication expenditure increased 7.2-fold, from US$8.1 million to US$58.9 million, accounting for an increase in the overall pharmaceutical market by fivefold, from 3.4 to 15.9 ‰ (both p for trend < 0.001). From 1999 to 2010, there was a decline in hip fracture rates among elderly Taiwanese adults with a concomitant increase in antiosteoporosis medication expenditure.