Osteoporosis is underdiagnosed and undertreated in older men

November 06, 2020

ATLANTA -- A new study reveals that many older men who experience a fracture are still underdiagnosed with and undertreated for osteoporosis. Details of the study was presented at ACR Convergence, the American College Rheumatology's annual meeting (ABSTRACT #0533).

Osteoporosis is a common condition that results from a loss of bone mass, measured as bone density, and from a change in bone structure. Bone is living tissue that is in a constant state of regeneration. By their mid-30s, most people begin to slowly lose more bone than can be replaced. As a result, bones become thinner and weaker in structure. This accelerates in women at the time of the menopause. In men, bone loss usually becomes more of an issue around age 70.

Osteoporosis can cause significant burden upon patients, including physical symptoms, increased cost of healthcare and mortality. Approximately one quarter of patients with fractures are male, and emerging evidence suggests that men with osteoporotic fractures have worse outcomes than women. This new study looked at the baseline characteristics of male Medicare patients who have had an osteoporosis-related fracture. Addressing the absence or gap in undergoing bone density screening was the major reason for the study.

"Men are typically not part of routinely recommended screening with DXA and so they are both underdiagnosed and undertreated. While many comorbidities (i.e., cardiovascular disease) are commonly recognized and treated in men, sometimes even more than women, osteoporosis is not one of them. Even post fracture for major fractures like a hip, rates of treatment are disappointingly low, leaving men at risk for yet another fracture," says the study's co-author, Jeffrey Curtis, MD, MS, MPH, Professor of Medicine, Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham. "There is also a lack of consistent guidelines for osteoporosis screening recommendations for men. Among women, the World Health Organization, American Association of Clinical Endocrinologists, United States Preventive Services Task Force, National Osteoporosis Foundation (NOF) and the American Academy of Family Physicians all recommend screening women over 65 years of age. However, among men, these groups do not make any recommendation at all, except for the NOF which recommends that all men over 70, and those between the ages of 50 to 69 who have risk factors, must be screened."

The researchers studied Medicare fee-for-service (FFS) beneficiaries who had a closed-fragility, or osteoporosis-related, fracture between January 2010 and September 2014. The inclusion criteria for the study included age 65 or older at the time of the index date, and continuous enrollment in Medicare FFS with medical and pharmacy benefits for a minimum of one year before the index date through at least one month after. Medicare beneficiaries were excluded if they died within 30 days of the index date. They also excluded patients with either Paget's disease or any malignancy, except non-melanoma skin cancer, at baseline. Patients were divided into four groups based on their diagnoses and/or treatment of osteoporosis at baseline. Osteoporosis diagnoses could be listed in any position on any medical claim.

The study included 9,876 Medicare beneficiaries. Sixty one percent were 75 or older and 90% were white. Fewer than 6% had a bone mineral density test with DXA, the standard test, in the two years before their fracture. Researchers also found that two-thirds (62.8%) of the patients had a history of musculoskeletal pain and nearly half (48.5%) had a history of opioid use one year prior to their fracture. The most common sites of fractures were the spine, hip and ankle. Of all patients with a qualifying fracture, about 92% did not have any claim for a DXA test or prescription claim for osteoporosis treatment in the two years prior to their index fracture. At baseline, 2.8% had been tested and not treated, 2.3% were treated but not tested, and only 2.1% were both tested and treated. The decline in the DXA scans in 2012 to 2014 was particularly high among men 75 years and older who are more likely to be at risk of fracture.

Based on the study's conclusions, earlier identification of high-risk male patients who might benefit from targeted osteoporosis screening and therapies would be of great value, the researchers say.

"There is a need for consistent osteoporosis screening recommendation in men," says Dr. Curtis. "Incorporation of these recommendations in quality-of-care measures for osteoporosis management and post-fracture care are warranted to improve health outcomes in this population. As for the next steps for research in this area, there is a need for better characterization of high-risk patients including existing comorbidities that may have shared etiology or risk factors that may enable earlier identification and treatment."
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About ACR Convergence

ACR Convergence, the ACR's annual meeting, is where rheumatology meets to collaborate, celebrate, congregate, and learn. Join ACR for an all-encompassing experience designed for the entire rheumatology community. ACR Convergence is not just another meeting - it's where inspiration and opportunity unite to create an unmatched educational experience. For more information about the meeting, visit https://www.rheumatology.org/Annual-Meeting, or join the conversation on Twitter by following the official hashtag (#ACR20).

About the American College of Rheumatology

The American College of Rheumatology (ACR) is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.

ABSTRACT:

Characterization of Older Male Patients with a Fragility Fracture

Background/Purpose:

Osteoporosis is associated with significant burden in terms of adverse patient outcomes, mortality, and cost; and is particularly common in the older Medicare population. Approximately a quarter of patients with fractures are male. Emerging evidence suggests worse outcomes related to osteoporotic fractures in male compared to female patients. The objective of this study was to examine baseline characteristics of male Medicare patients who experienced a fragility fracture.

Methods:

We studied Medicare fee-for-service (FFS) beneficiaries with a closed fragility (or osteoporosis-related) fracture between 01 January 2010 and 30 September 2014 (identification period). Additional inclusion criteria included age ?65 years as of the index date, continuous enrollment in Medicare FFS with medical and pharmacy benefits (parts A+B+D-C) for a minimum of one year prior to the index date, through at least 1 month after (i.e. beneficiaries were excluded if they died within 30 days of the index date). Patients with Paget's disease or malignancy (except for non-melanoma skin cancer) at baseline were excluded. Patients were classified into four cohorts based on the observed diagnoses and/or treatment of osteoporosis at baseline. Diagnoses of osteoporosis could be in any position on any medical claim.

Results:

A total of 9,876 beneficiaries met eligibility criteria. Sixty-one percent were ?75 years of age and 90.3% were white. Fewer than 6% had undergone bone mineral density testing with DXA in the 2 years prior to their fracture. 62.8% had a history of musculoskeletal pain and 48.5% had a history of opioid use 1 year prior to index fracture. The most commonly observed fracture sites were spine (n=3,060; 31.0%), hip (n=2,759; 27.9%), and ankle (n=965; 9.8%). Of all patients with a qualifying fracture, approximately 92.8% (n=9,163) did not have a claim for diagnosis or treatment of osteoporosis at baseline. 2.8% (n=279) were diagnosed but not treated, 2.3% (n=227) were treated but not diagnosed, and only 2.1% (n=207) were diagnosed and treated. There was a trend in declining DXA scans from 2012 to 2014 (65-69 years; 6.3 to 5.5% AND 70-74 years; 4.7 to 4.0%) especially pronounced in the ?75 age group (6.0 to 4.3%).

Conclusions:

Our findings suggest a high level of underdiagnosis and undertreatment of osteoporosis in the older male population who experience fracture. Further documentation of cost of illness following an osteoporosis-related fracture, including identification of drivers of high costs and earlier identification high risk patients who may benefit from more targeted screening and osteoporosis therapies, will be of value.

American College of Rheumatology

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