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


CONCLUSIONS
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.
Curtis
Jeffrey R
JR
Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35294, USA. jcurtis@uab.edu
Arora
Tarun
T
Matthews
Robert S
RS
Taylor
Allison
A
Becker
David J
DJ
Colon-Emeric
Cathleen
C
Kilgore
Meredith L
ML
Morrisey
Michael A
MA
Saag
Kenneth G
KG
Safford
Monika M
MM
Warriner
Amy
A
Delzell
Elizabeth
E
D000368:Aged; D000369:Aged, 80 and over; D014487:Centers for Medicare and Medicaid Services, U.S.; D003643:Death; D005260:Female; D050723:Fractures, Bone / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D007345:Insurance Claim Review; D008297:Male; D010024:Osteoporosis / Q000188:drug therapy*; D018570:Risk Assessment; D055502:Secondary Prevention; D013223:Statistics as Topic; D014481:United States / Q000453:epidemiology; D028761:Withholding Treatment