Peter L. Salgo, MD: Of all of these folks now, let’s take a look at the nation. How many people actually have this disease, whether diagnosed or not? How prevalent is the disease?

Claire Gill: Our prevalence at the National Osteoporosis Foundation shows that about 10 million Americans have osteoporosis.

Peter L. Salgo, MD: One in 30.

Claire Gill: Over the age of 50, yeah. And then another 44 million have low bone mass. So 54 million Americans should be concerned about their bone health.

Peter L. Salgo, MD: Well, we should all be concerned.

Claire Gill: But they should be very concerned.

Peter L. Salgo, MD: When you take a look at this huge number, that’s a lot of folks. That’s a big number, in terms of dollars and cents. What’s the economic burden here? How much is it costing us?

Andrea J. Singer, MD, FACP, CCD: There is a huge economic burden when we think about this. We actually published a recent paper looking at what the costs are now and what the projected costs over the next number of years are, because that’s clearly a concern when we’re talking about these kind of prevalence rates.

So over $50 billion currently, annually, when you take into account all direct and indirect costs. And if we do nothing to stem the tide with this microsimulation model that we use, by 2040 it’s estimated we’ll be at about $95 billion a year.

Peter L. Salgo, MD: That’s federal government kind of money—billion dollars.

Andrea J. Singer, MD, FACP, CCD: That’s a lot of money no matter how you slice it.

Peter L. Salgo, MD: Can you sort of break this down? How much of this is because people fracture, and how much of this is related to the comorbidities of osteoporosis all taken together?

Andrea J. Singer, MD, FACP, CCD: Most of what we’re looking at when we talk about cost is related to fractures. Fracture-related costs, some of the largest of which follow hip fractures, and inpatient hospitalizations drive the bulk of the costs. And then, follow-up care, particularly for post—hip fracture patients where you’re talking about the need for skilled nursing facilities, rehabilitation facilities, and nursing homes.

Peter L. Salgo, MD: Where I work, and I’m sure it’s pretty much everywhere, the mantra is: Hip fracture, in, nailed within 24 hours, out. They know that once you’re in and you’re stuck, the cost goes up both economically and personally. It’s a terrible burden.

Thomas P. Olenginski, MD, FACP, CCD: So Peter, what we need to make sure that those hip fractures get is a medical risk evaluation and something after their hip surgery.

Peter L. Salgo, MD: So when I say “Out,” you say, “Out, but follow.”

Thomas P. Olenginski, MD, FACP, CCD: Absolutely.

Peter L. Salgo, MD: Don’t just kick them out the door.

Thomas P. Olenginski, MD, FACP, CCD: Absolutely. And getting back to the prevalence, there are more fractures annually related to osteoporosis in this country than new incidences of invasive breast cancer diagnoses and combined cardiovascular events. The condition suffers from, let’s just say, a clearly unified national spokesperson, and it is just a bad thing. When you see people in the hospital with fractures, and back in the hospital with fractures, and the morbidity and mortality, it is a very bad thing.

Peter L. Salgo, MD: Let me throw a softball up here, because something you said struck a chord. It’s a disease of older folks. Not necessarily old people, but older people. It’s not millennials at this moment. Is it ageism? They don’t want to talk about folks as they get to age 50, 60, 70?

Claire Gill: Well, we’ve actually been looking at that and talking about some of the programs that we could do to raise awareness about this. It is a little bit of a stigma of the people not wanting to admit when they’re older that they have osteoporosis.

Peter L. Salgo, MD: Well, I’m not going to get it.

Claire Gill: “That’s an old person’s disease,” or that’s what they think. We’ve done a lot of work to try to reverse that. And so, for instance, as we talked about with the peak bone mass, it’s really a pediatric disease that manifests itself as you age. If you do not build peak bone mass by the time you’re 20, you are going to have issues later on in life. So I think, again, looking at that spectrum is a little bit different.

Peter L. Salgo, MD: It’s like, “You better get your IRA [individual retirement account] going when you are 20.”

Claire Gill: That’s it.

Peter L. Salgo, MD: Because when you’re 70, you’re not going to eat.

Claire Gill: That’s a really good analogy. We use that bank analogy all the time. You have to put in the good nutrition, the exercise, and all of those things to build your bank when you’re younger. That’s going to try to sustain you for the rest of your life, and make sure that your skeleton stays strong.

Andrea J. Singer, MD, FACP, CCD: There’s a stigma attached. Osteoporosis is not sexy. As [comedian] George Burns once said, “You can’t help getting older, but you don’t have to get old.” Fractures make you old. And so, people don’t want to think about osteoporosis and fractures. That’s your grandmother’s disease. That’s somebody else’s disease. So there is a lot of denial that goes on, even following a classic osteoporotic fracture. “Anybody who fell that way would have broken a bone. It was a really bad fall on a really hard surface.” Someone who falls from a standing height should not break a bone. Usually that means that there’s something else going on.

Peter L. Salgo, MD: Even while ice skating?

Andrea J. Singer, MD, FACP, CCD: Even potentially while ice skating, yes. It depends.

Peter L. Salgo, MD: That was a personal question. We talked a little bit about money here. What about the question that comes up, and you hear this from, I don’t know, therapeutic nihilists, for lack of a better phrase? What’s the cost of treating versus the cost of, “Let them fall?” Does it make sense financially, not in terms of humanity, but financially, to get on this, give them medications, get their bones stronger, and keep them from fracturing?

Thomas P. Olenginski, MD, FACP, CCD: It makes sense because, first of all, most of our data suggest that patients who already have a fracture benefit from our therapy. Most of our data are really with secondary fracture prevention. We do not see people in the emergency department who fracture and not treat them. The cost of the hospitalization and the cost…I mean, let’s pick on hip fracture.

When you look at the cost of therapy and what we’re trying to prevent downstream, while we’ve not easily and convincingly been able to show that we’re doing the right thing in that regard, I think over time we’ll be able to show that. If you look at the projections, they are staggering. They’re scary. And part of the issue with the patient who minimizes is they’re not able to enjoy that point in their life. They want to be independent. They want to enjoy their grandchildren. They want to enjoy whatever life phase they are in, whatever they’re doing. And what we see is the condition not only affects the patient and the immediate family, but the extended family. It has really far-reaching effects.

Peter L. Salgo, MD: I don’t hear this question about many other diseases, which is, “Gee, I’ve got a left anterior descending 90% lesion.” “Ah, let them infarct.” But you do hear it sometimes about osteoporosis. What’s up with that?

Andrea J. Singer, MD, FACP, CCD: I think it’s just really level setting—bringing osteoporosis to the level that it should be recognized. We did a study several years ago that looked at the burden of disease as characterized by inpatient hospitalizations. We looked at that in women 55 years of age or older and compared it with rates of hospitalization for heart attack, stroke, and breast cancer. Care is not the only driver, but you can compare the data across from a similar database. Osteoporotic fractures were by far much greater in terms of numbers, in terms of length of stay, and in terms of total cost than the other diseases.

So part of it is really putting these on equal footing, and then realizing that you’re right. If we screen more people and do more tests, and if we treat them, that raises the cost, but it doesn’t come near to overtaking the benefit from reducing fracture costs.

Peter L. Salgo, MD: What I hear a lot from older folks is, “Gee, I put off everything until I retired. We were going to travel. We were going to do this. And then I fell and now I can’t do anything.” And that, to me, is a tragedy.

Claire Gill: It really is, and it can be rendered. Again, we’re treating to 100 now? At least that’s what all of my doctors tell me. So if we are, then we need to make sure that’s a mobile and independent life, as Andrea said.