Osteoporosis and Fractures: Treatment Costs Versus Benefits

Peter L. Salgo, MD: What is the cost, if you know, of 1 fracture to an individual and to the system? How much does it cost?

Andrea J. Singer, MD, FACP, CCD: Depends on what type of fracture we’re talking about.

Peter L. Salgo, MD: Let’s say a hip fracture.

Andrea J. Singer, MD, FACP, CCD: Let’s take hip. When you’re talking about all costs—so inpatient hospitalization, the direct costs, and then the follow-up indirect costs—we’re probably talking about somewhere upward of $35,000 to $40,000, maybe up to $50,000. It depends on the payer.

Peter L. Salgo, MD: I would think higher, frankly, because of the surgeon’s fee, the hospital fee.

Andrea J. Singer, MD, FACP, CCD: That’s for the first year. That’s not for subsequent years in terms of additional care that’s needed.

Peter L. Salgo, MD: I will again put this out there. For a $20,000 1-year expense, you could reduce hip fractures—if I remember the number you told me—50%. Is it 50%?

Thomas P. Olenginski, MD, FACP, CCD: Thirty-eight percent.

Peter L. Salgo, MD: Thirty-eight percent. So $20,000 gives you a saving of—38% of the time—$50,000...

Claire Gill: It’s also interesting when you think about it compared with other disease states. And maybe, again, going back to ageism or something to do with that, when we look at the population for osteoporosis. But if you’re looking at a multiple sclerosis patient for whom the treatment is $80,000 a year, but the population is younger and that gets cleared pretty easily, why is it that for our older patients we’re not able to do that?

Peter L. Salgo, MD: But there’s the dreadful number. What you hear all the time is, years of life. In other words, the cost per year of life. That’s ageism, no?

Thomas P. Olenginski, MD, FACP, CCD: But I think the way we have to start looking at hip fractures is, what if 1 year later, what if someone is really, really functional? That is an incredible success story, and I think there’s more onus on us to treat that patient differently because they’ve done so well. We don’t see it. In our fracture population, 15% of patients, all fractures together, 15% are dead by 6 months. If we talk about men, it is 20%. So No. 1, it’s an incredibly severe event, life-threatening, and it’s balancing that. It’s balancing long-term cost. It’s balancing being stewardly. Clearly, we do not want every patient with osteoporosis on these drugs. I think it gives us strategies for the more severe, more risky patient that, over time, we will modify and be better with.

Peter L. Salgo, MD: Wait. I want you to run that back for me. Those are numbers. I’ve heard a lot of numbers. I haven’t heard the death numbers. What were those percentages again?

Thomas P. Olenginski, MD, FACP, CCD: This is just in our program, and it’s consistent over the last 10 years. All fractures, we just started to say, “Where are they at 6 months?” We don’t even know why we chose 6 months as opposed to 1 year, but that’s the way we did it. Fifteen to 20% of those fractured patients are dead because of comorbidities, the kind of things that happen in the immediate postfracture period.

Peter L. Salgo, MD: So let’s recast this. We have been discussing osteoporosis in terms of lifestyle, impingement on the things you want to do, going forward being someone who is less than you would like to be. You told me that a fair number of these people, in the 20% range, are simply dead 6 months later.

Thomas P. Olenginski, MD, FACP, CCD: Six months to a year, yeah.

Peter L. Salgo, MD: That is a number that nobody has heard. I haven’t heard it. It’s huge. And if we’re talking $20,000 for a drug that will have a significant impact on death, now you’re up there—heart disease, breast cancer, other lethal diseases.

Claire Gill: Well, we actually beat those numbers. Nationwide, it’s about 25%. We see 25% of people die within the first year after hip fracture, so that’s 75,000. There are 300,000 hip fractures. That’s 75,000 people a year. That is more than women who die from breast cancer, yet we as a society spend so much time and concern on breast cancer. We have to, but this is also happening every day in osteoporosis and people do not know.

Peter L. Salgo, MD: That’s called burying the lede in the news business. “Oh, it’s bad. You’re going to have to use a walker. You’re going to have height loss. You’re going to have pain. You’re going to be dead!” Why am I shocked by this? Did I miss this?

Thomas P. Olenginski, MD, FACP, CCD: You know, we’re all looking for the way to get this message out.

Peter L. Salgo, MD: I think you just found it.

Thomas P. Olenginski, MD, FACP, CCD: And it resonates.

Claire Gill: But I think, again, we talk about where the patient falls in this, and obviously I’m from the patient advocacy organization, so that’s where our focus is. We’ve put out these messages several times to patients because I think the same thing. I think 1 of the problems with this disease state is, unlike breast cancer, we don’t have an army of women demanding DEXA [dual-energy x-ray absorptiometry test], and demanding treatment options, and demanding these things as they did when that movement happened for breast cancer. And I think part of that is because, as Andrea has said, they don’t want to hear that message.

So we’ve tested messages with patients—and I anticipated it would be this. When we actually did the survey…we told them they’re going to die because 25% of people die within the first year of a hip fracture. Half of the patients responded, “How dare you give me these scare-mongering statistics. You’re supposed to be hopeful.” And half of the patients said, “Oh, my God. I had no idea. Thank you. I’m going to my doctor right now.” So it really depends on the patient. And as we talk about personalized care, I know the burden that physicians have trying to get all this information to patients. But it is an individual message for the patient. It’s determining whether the patient will be inspired by “Hey, you might die” or “Hey, I want to keep you mobile. Let’s look at your, as you said, activity level and all those things and determine what’s best.”