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Comparative Study
. 2010 Oct;11(8):584-91.
doi: 10.1016/j.jamda.2009.12.004. Epub 2010 Jun 30.

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

Jeffrey R Curtis  1 , Tarun Arora, Robert S Matthews, Allison Taylor, David J Becker, Cathleen Colon-Emeric, Meredith L Kilgore, Michael A Morrisey, Kenneth G Saag, Monika M Safford, Amy Warriner, Elizabeth Delzell
Affiliations
Comparative Study

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

Jeffrey R Curtis et al. J Am Med Dir Assoc. 2010 Oct.

Abstract

Introduction: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

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Conflict of interest statement

Conflicts of interest

JC: Research grants: Merck, Procter & Gamble, Eli Lilly, Amgen, Novartis; Consulting: Roche, UCB, CORRONA, Amgen, Eli Lilly; Speakers bureau: Proctor & Gamble, Eli Lilly, Roche, Novartis

ED: Research grants: Amgen

CCE: Research grants: Novartis, Wyeth; Consultant: Novartis

KGS: research grants: Novartis, Amgen, Aventis, Merck, Procter & Gamble, Eli Lilly, Roche; consulting or speaking: Merck, Proctor and Gamble, Eli Lilly, Roche, Novartis, Amgen

All other coauthors: none

Figures

Figure 1
Figure 1
Time-Dependent Risk (i.e. Cumulative Incidence) for Second Fracture Depending on Site of First Fracture for an 81 year old Caucasian Woman
Figure 2
Figure 2
Comparison of the Risk (i.e. Cumulative Incidence) for Second Fracture after a Hip Fracture, Depending on Whether Death is Considered a Competing Risk or a Censoring Event
See this image and copyright information in PMC

References

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    1. Curtis JR, Carbone L, Cheng H, Hayes B, Laster A, Matthews R, et al. Longitudinal trends in use of bone mass measurement among older americans, 1999–2005. J Bone Miner Res. 2008 Jul;23(7):1061–7. - PMC - PubMed
    1. Quick Reference Information: Medicare Preventive Services. The Medicare Learning Network (MLN) 2007. [updated 2007; cited 2008 March 19]; Second:[page 243]. Available from: http://www.cms.hhs.gov/MLNProducts/downloads/mps_guide_web-061305.pdf.
    1. National Committee for Quality Assurance. State of Health Care Quality. Washington, DC: 2006. Contract No.: Document Number|.

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