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Economic Burden of Osteoporotic Fractures in US Managed Care Enrollees
Setareh A. Williams, PhD; Benjamin Chastek, MS; Kevin Sundquist, MS; Sergio Barrera-Sierra, MD; Deane Leader Jr, PhD, MBA; Richard J. Weiss, MD; Yamei Wang, PhD; and Jeffrey R. Curtis, MD
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Economic Burden of Osteoporotic Fractures in US Managed Care Enrollees

Setareh A. Williams, PhD; Benjamin Chastek, MS; Kevin Sundquist, MS; Sergio Barrera-Sierra, MD; Deane Leader Jr, PhD, MBA; Richard J. Weiss, MD; Yamei Wang, PhD; and Jeffrey R. Curtis, MD
Osteoporotic fractures are associated with a significant economic burden, including costs of rehabilitation services and a high total all-cause cost of care.
ABSTRACT

Objectives: To examine healthcare resource utilization (HRU) and costs in a population of managed care enrollees who experienced an osteoporotic fracture.

Study Design: Retrospective cohort study using the Optum Research Database (January 2007 to May 2017).

Methods: All-cause and osteoporosis-related HRU and costs were analyzed in patients 50 years and older with a qualifying index fracture and continuous enrollment with medical and pharmacy benefits for 12 months preindex (baseline period).

Results: Of 1,841,263 patients with fractures during the identification period, 302,772 met eligibility criteria. Two-thirds (66.6%) were 65 years and older, 71.6% were women, and 41.2% were commercial (not Medicare Advantage) enrollees. The most common fracture sites were spine (21.9%), radius/ulna (19.5%), and hip (13.7%). Mean (SD) total all-cause healthcare cost was $34,855 ($56,094), with most paid by health plans ($31,863 [$55,025]) versus patients ($2992 [$2935]). Most healthcare costs were for medical ($31,766 [$54,943]) versus pharmacy ($3089 [$6799]) services. Approximately 75% of patients received rehabilitation services (mean [SD] cost = $18,025 [$41,318]). Diagnosis of index fracture during an inpatient stay versus an outpatient visit (cost ratio, 2.16; 95% CI, 2.13-2.19) and fractures at multiple sites (cost ratio, 1.23; 95% CI, 1.21-1.26) were the leading predictors of cost. Kaplan-Meier estimated cumulative second-fracture rates were 6.6% at 1 year, 12.3% at 2 years, 16.9% at 3 years, and 20.9% at 4 years after index fracture.

Conclusions: These findings suggest a significant economic burden associated with fractures, including a high total all-cause cost of care. Early identification and treatment of patients at high risk of fractures are of paramount importance to reduce fracture risk and associated healthcare costs.

Am J Manag Care. 2020;26(5):e142-e149. https://doi.org/10.37765/ajmc.2020.43156
Takeaway Points

This retrospective database study identified increased healthcare resource utilization and significant economic burden for both all-cause and osteoporosis-related healthcare costs during the 12 months following index fracture. These findings highlight the need for effective fracture prevention strategies in patients at high risk of fracture.
  • In the 12 months following a fracture, all-cause healthcare costs exceeded $30,000, of which an average of $3000 was paid by the patient.
  • In this sample, 6.6% of patients with a fracture had at least 1 additional fracture within 12 months of index fracture, with cumulative incidence increasing to 20.9% after 4 years.
  • The current findings suggest a need for better management of fragility fractures to reduce osteoporosis cost of illness.
Osteoporosis is characterized by compromised bone strength due to loss of bone mass and deterioration of bone quality, resulting in increased fracture risk.1 Based on 2005-2010 National Health and Nutrition Examination Survey (NHANES) data, an estimated 10.2 million adults 50 years and older in the United States have osteoporosis.2 Fracture Risk Assessment Tool–based estimates of the 10-year probability of hip and major osteoporotic fractures from an evaluation of 2013-2014 NHANES data indicate that 18.9% of adults 50 years and older (24.7% of women and 12.9% of men) are at a 3% or greater 10-year risk of hip fracture and 8.3% (14.1% of women and 2.2% of men) are at a 20% or greater 10-year risk of major osteoporotic fractures.3 The number of older adults with osteoporosis is projected to increase by more than 30% between 2010 and 2030, based on population estimates and aging of the US population.2

Globally in both men and women, osteoporosis and osteoporotic fractures are important public health concerns because of related morbidity and mortality,4,5 diminished health-related quality of life,6,7 and associated costs.8 In women, osteoporotic fractures account for more hospitalizations than myocardial infarction, stroke, or breast cancer (individually) and are more costly than breast cancer in aggregate.8 Between 2006 and 2025, annual osteoporotic fracture events and costs for both men and women in the United States are projected to grow by more than 48%.9

There are a limited number of studies on the cost of illness associated with osteoporotic fractures.8,10-16 More recent data help inform payer evidence requirements and help in the allocation of scarce healthcare resources. The current study used recent data through 2017 to estimate costs across care settings for both commercial and Medicare Advantage health plan members using the same methodology. The current study was undertaken to examine healthcare resource utilization (HRU) and costs related to office visits, outpatient visits, emergency department (ED) visits, acute hospital stays, long-term care, and pharmacy claims among patients who experienced an osteoporotic fracture in the year following the index fracture to better understand osteoporotic fracture costs from the payer and patient perspective. Appropriate management of chronic conditions improves overall health and reduces associated healthcare costs. Many patients who incur a fragility fracture also have existing comorbid conditions (ie, chronic obstructive pulmonary disease, heart failure), which can destabilize after fracture, leading to worse long-term outcomes. Therefore, the proposed study evaluated all-cause and osteoporosis-related HRU and costs.

METHODS

Data Source

This retrospective cohort study used a database of administrative medical and pharmacy claims and enrollment information available to Optum. The study included commercial and Medicare Advantage health plan members with evidence of a case-qualifying fracture between January 1, 2007, and May 31, 2017 (identification period). As of 2017, the database included data for approximately 66.3 million individuals and an additional 7.4 million (10%) Medicare Advantage enrollees. Both types of health plans have a wide geographic distribution across the United States. Data were maintained in a deidentified manner, thus were not subject to institutional review board review, and were accessed following protocols compliant with the Health Insurance Portability and Accountability Act. Optum analyzed the data. The funding organization authors participated in drafting the protocol, review and interpretation of results, and drafting and review of the publications prior to submission in collaboration with Optum and coauthors.

Patient Selection

Patients with a fragility or osteoporosis-related fracture during the identification period were selected for the study if they were at least 50 years old (increasing the likelihood that fractures were osteoporosis related) as of the index date. The index date was defined as the first fracture claim during the identification period after continuous enrollment in a commercial or Medicare Advantage health plan with medical and pharmacy benefits for 1 year (preindex period). Patients with Paget disease or malignancy (except nonmelanoma skin cancer) at baseline or during the first month of follow-up were excluded.

Fractures, including pathologic ones, were considered case-qualifying if they occurred during an inpatient stay (in any position on the medical claim) or during an outpatient visit with a repair procedure code, based on a primary or secondary International Classification of Diseases, Ninth Revision or Tenth Revision code listed on the same claim. For spine fractures, noninpatient claims also needed to be accompanied by a claim for imaging test(s) within 30 days of the diagnostic claim. For each fracture site, case-qualifying fracture diagnoses, non–case-qualifying fracture diagnoses, and aftercare codes were used for site-specific fracture episodes and continued until a gap of at least 90 days was observed between consecutive claims related to the specific fracture site. Case-qualifying fracture diagnoses at the same site that occurred after a gap of at least 90 days were used to identify subsequent incident fractures at that same site. This algorithm was run to identify fracture episodes for each of the 9 sites (spine, pelvis, shoulder, radius/ulna, carpal/wrist, hip, femur, tibia/fibula, ankle) and multiple sites. The index date was considered the start of the earliest episode. Up to 2 episodes were identified for each fracture site; subsequent fractures at the same site beyond the second were not included in the analysis. Because some fractures at different sites could come to clinical attention before others that happened simultaneously, all episodes that started within 30 days of the index date were considered part of the initial event and defined as fracture at multiple sites. Episodes that started more than 30 days after the index date at a different fracture site were considered subsequent fractures. This approach has been shown in validation studies to have high accuracy, with a positive predictive value that exceeds 90%.17


 
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