Is withholding osteoporosis medication after fracture sometimes rational? A comparison of the risk for second fracture versus death

• Published in: Journal of the American Medical Directors Association Vol. 11; no. 8; p. 584
• Main Authors: Curtis, Jeffrey R, Arora, Tarun, Matthews, Robert S, Taylor, Allison, Becker, David J, Colon-Emeric, Cathleen, Kilgore, Meredith L, Morrisey, Michael A, Saag, Kenneth G, Safford, Monika M, Warriner, Amy, Delzell, Elizabeth
• Format: Journal Article
• Language: English
• Published: United States 01.10.2010
• Subjects: Aged; Aged, 80 and over; Centers for Medicare and Medicaid Services, U.S; Death; Female; Fractures, Bone - epidemiology; Fractures, Bone - etiology; Humans; Insurance Claim Review; Male; Osteoporosis - drug therapy; Risk Assessment; Secondary Prevention; Statistics as Topic; United States - epidemiology; Withholding Treatment; United States
• ISSN: 1538-9375
• DOI: 10.1016/j.jamda.2009.12.004

Undertreatment of osteoporosis is common, even for high-risk patients. Among the reasons for undertreatment may be a clinician's perception of a lack of treatment benefit, particularly in light of patients' expected future mortality. Among US Medicare beneficiaries, we evaluated the risk for second fracture versus death in the 5 years following a hip, clinical vertebral, and wrist/forearm fracture. Using data from 1999 to 2006 for a random 5% sample of US Medicare beneficiaries, we identified individuals who experienced an incident hip, clinical vertebral, or wrist/forearm fracture in 2000 or 2001. We evaluated the risk for a second incident fracture versus death in the following 5 years. Results were stratified by age, gender, race/ethnicity, and medical comorbidities. In light of the competing mortality risk, and assuming 30% efficacy of an osteoporosis medication to prevent a second fracture, we calculated the number of individuals needed to treat (NNT) for 5 years after first fracture to prevent 1 additional subsequent fracture. We identified 18,853, 12,751, and 7635 persons with an incident hip, clinical vertebral, and wrist/forearm fracture, respectively. Although the 5-year risk of death usually exceeded the risk for second fracture across age, gender, racial groups, and primary fracture type (median ratio of death to second fracture=1.4, interquartile range 0.9, 2.0), the 5-year risk for second fracture was high, varying from a low of 13% to a high of 43%. Across demographic groups, the NNT to prevent a second fracture was low, ranging from 8 to 46. Among older persons with hip, clinical vertebral, or wrist/forearm fracture, although the risk for death was usually greater than the risk for a second fracture, both were high. The relatively low NNT to prevent 1 additional subsequent fracture fell within a range generally considered acceptable for secondary prevention strategies.