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Strong bones, improved quality of life for women: Controlling osteoporosis after a fracture

March 1, 2012

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An estimated 55 percent of Americans over age 50 (44 million individuals) currently have osteoporosis or are at risk for the condition due to dangerously thinning bones (osteopenia).1 Over 2 million fractures of the hip, wrist, or spine were attributed to osteoporosis in 2005 ? a number that is expected to rise 50 percent within the next two decades. For individuals in the 65 to 74 age group, the increase is projected to top 87 percent.2 The price tag for direct medical care for osteoporotic fractures is also steep, approaching $15 billion annually3, but the cost in individual pain, disability, and reduced quality of life can be immeasurable.2

Especially vulnerable are women over 50, who account for 80 percent of osteoporosis cases. Plummeting hormone levels during the five to seven years following menopause can result in a 20 percent loss of bone density during this period.1 Since early-stage bone thinning produces no obvious symptoms, a fracture is often the first indicator of a problem. By this time, the condition can be quite advanced. For example, women who suffer a hip fracture have a four times greater risk of subsequent osteoporotic fractures.1

Tracking intervention after a fracture

Despite this evidence, many women do not receive bone mineral density (BMD) testing or osteoporosis treatment in the months following a fracture.3 In an effort to shed light on this disparity, the National Committee for Quality Assurance (NCQA) reports the percentage of women over age 67 who receive a BMD test or are prescribed osteoporosis medication within six months following a fracture. Exceptions include women who have had BMD testing within the last year or who already take osteoporosis drugs.4

In order to receive a 4-star rating from the Centers for Medicare & Medicaid Services (CMS), a health plan must fulfill the above NCQA measure at least 60 percent of the time. However, only four CMS contracts achieved this goal for 2012. The majority provided screening and intervention to less than 24 percent of patients for whom it was appropriate, earning only a 1- or 2-star rating.5 Keystone 65 HMO and Personal Choice 65SM PPO currently have a 2-star rating for this measure, with both plans at 14 percent.

Treatment of osteoporosis and osteopenia

The National Osteoporosis Foundation (NOF) guidelines recommend that women age 50 and older receive pharmacological therapy for bone loss if they have a history of hip or spine fracture or have experienced another type of fracture and show reduced bone mass (a T-score between -1.0 and -2.5) when tested using dual-energy X-ray absorptiometry (DXA).6

A bisphosphonate drug is the primary medication choice for most women. Multiple studies confirm the effectiveness of bisphosphonates in preventing vertebral, non-vertebral, and hip fractures. The drug alendronate, now available in generic form, has been shown to cut in half the number of hip and spine fractures over three years in women who have had a previous fracture. It is also approved for use in women with early bone loss.

Additional medications are also available, but the choice of drug ultimately depends on the individual patient's risk profile and preference. When possible, physicians should consider formulary options so members can maximize their health plan benefits. For more information about coverage and precertification requirements for treatment options, please refer to our medical policy website. Select Accept and Go to Medical Policy Online, and then type "osteoporosis" in the Search box.

To supplement the medication regimen, physicians may wish to counsel their patients on the importance of diet and exercise in maintaining bone health:

  • Calcium. All adults need at least 1,200 mg of calcium a day. Since people age 50 and older often do not consume more than 600 to 700 mg in their daily diets, calcium supplements are recommended.
  • Vitamin D. Vitamin D is equally important. The NOF advises regular daily intake of 800 to 1,000 IU of vitamin D daily for most adults, but individuals who have health conditions that limit vitamin D absorption may need as much as 2,000 IU a day to maintain adequate levels. Following a fracture, patients should be tested for vitamin D deficiency and treated with therapeutic doses of the vitamin until blood levels reach a normal range.
  • Exercise. Since weight-bearing exercise is critical in preserving bone mass, rehabilitation is often recommended following a fracture to help patients resume activities of daily living and establish a regular exercise routine. Improvement in strength and balance can also help prevent falls and future fractures.
  • Alcohol and tobacco cessation. Physicians should discourage health habits that are linked to bone loss, such as tobacco use and heavy alcohol consumption. Efforts should be made to steer the patient to smoking cessation programs or other suitable treatment options.8

Physicians may also wish to review the patient's current medication list to see if they can eliminate drugs that increase the risk of osteoporosis, such as corticosteroids, heparin, aromatase inhibitors, and some anti-epilepsy medications. The patient should also be evaluated for conditions that exacerbate bone loss, including hyperparathyroidism, hyperthyroidism, malnutrition, malabsorption, and liver disease. In addition, the question of whether to perform routine DXA testing on patients taking bisphosphonate medications has been the subject of controversy. Analysis from the Fracture Intervention Trial, however, indicates that there is no benefit to repeating scans within the first three years of treatment.7

It is important for physicians to follow up after therapy is initiated to ensure that patients continue their treatment regimen. One of the major obstacles to osteoporosis treatment is patients' failure to take their medication due to restrictive dosing schedules or unpleasant side effects. Medication adherence can be markedly improved by regular phone calls or direct contact with the patient to address these problems.8 Patients may also benefit from health coaching to support healthful diet, exercise, and lifestyle choices and assess ongoing fracture risk.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, Indemnity, etc.), and/or employer groups. Providers should call Provider Services for the member's applicable benefits information. Members should be instructed to call the Customer Service telephone number on their ID card.

References

1National Osteoporosis Foundation. Fast Facts. 2011. www.nof.org/node/40

2Burge R, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. Journal of Bone and Mineral Research 2007;22:465-475.

3Agency for Healthcare Research and Quality. Osteoporosis management in women who had a fracture: percentage of women 67 years of age and older who suffered a fracture, and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. National Quality Measures Clearinghouse. July 2010. http://qualitymeasures.ahrq.gov/content.aspx?id=33607&search=osteoporosis

4Gunter MJ, et al. Management of osteoporosis in women aged 50 and older with osteoporosis-related fractures in a managed care population. Disease Management 2003 Summer;6(2):83-91.

5Centers for Medicare & Medicaid Services. Medicare Health & Drug Plan Quality and Performance Ratings 2012 Part C & Part Technical Notes. Updated 10/11/2011.

6Health Dialog. Information for the healthcare provider: Osteoporosis testing after fractures. 2011.

7Bell KJ, et al. Value of routine monitoring of bone mineral density after starting bisphosphonate treatment: secondary analysis of trial data. BMJ. 2009; 338:b2266.

8Waalen J, et al. A telephone-based intervention for increasing the use of osteoporosis medication: a randomized controlled trial. American Journal of Managed Care 2009 August; 15(8):e60-e70.

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