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 America2, 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.5-7 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.8-14 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, 15-18 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 colleagues22 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 excluded because the majority of women take this treatment for menopausal symptoms rather than for osteoporosis. The proportion of patients eligible for treatment depended on defining an intervention threshold; ie, the risk of fracture above which treatment can be recommended. In this report, the intervention threshold set was at the 10-year fracture probability equivalent to women with a prior fragility fracture without knowledge of bone mineral density (BMD) as adopted in several European guidelines.23-25 Thus, the intervention threshold can be likened to a “fracture threshold” expressed in terms of fracture probability. The study showed a very wide intercountry variation in the treatment penetration of individuals at high risk for osteoporotic fractures. The treatment gap varied from 25% in Spain to 95% in Bulgaria. Large treatment gaps were identified in countries with populations at both high and low risk of fracture. In total in the EU, it was estimated that, out of the 21.3 million men and women who exceeded the risk level, 12.3 million were untreated in 2010.1 These figures are conservative because an undetermined proportion of low-risk women will have received treatment.8 In an international prospective study, low uptakes of pharmacological intervention after hip fracture were also observed. Among 1795 patients who sustained a low-energy hip fracture in 10 countries (Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, and the UK), only 27% were prescribed pharmacological fracture prevention after the hip fracture.26 It is disturbing that so many in our society at high risk of fracture do not receive appropriate treatment and it is scandalous that this treatment gap is so marked in the case of hip fracture. The most worrying finding, however, is the downward trend in the number of patients being treated after hip fracture which, in the study of Solomon and colleagues,22 appears to have decreased by about 50% over a 10-year period. The phenomenon is not confined to hip fracture cases. Nor is it a characteristic only of the United States. In Europe, treatment uptake for osteoporosis increased progressively up to 2008, plateaued thereafter, and has subsequently fallen in more recent years (Fig. 1). The phenomenon is most marked in the case of the bisphosphonates and is evident on a country by country basis.27 None of these studies provide an insight into the causes underlying the substantial and increasing treatment gap. Factors that may play a role in the United States include a decline in BMD testing owing to reimbursement issues and lack of intensive detailing by pharmaceutical companies. Solomon and colleagues22 point the finger at the lay press for raising awareness over the last decade of the potential side effects of the bisphosphonates, such as osteonecrosis of the jaw, atypical femoral fractures, and atrial fibrillation. Indeed, many doctors, dentists, and patients are now more frightened of the rare but serious side effects than they are of the disease and the fractures that arise. Notwithstanding, the lay press is simply the messenger bringing news and opinion from the scientific community, some or much of which may be ill-judged. The paradox arises in that we seek to treat individual patients to the highest standards but at the same time disservice and disadvantage the wider osteoporosis community. It is now time for us all to accept a long overdue collective responsibility for our failures and to work cohesively to improve the management of our patients. One hope in decreasing the treatment gap is the international development of fracture liaison services to better identify patients who have had a fragility fracture.28 All authors state that they have no conflicts of interest. Authors' roles: All authors contributed equally to the content and writing of this manuscript.