Incidence of Osteoporosis-Related Fractures Among 40- to 69-Year-Old Women
Incidence of Osteoporosis-Related Fractures Among 40- to 69-Year-Old Women
Objective: To determine the trend in incidence of fractures among perimenopausal and postmenopausal women during the periods immediately before and after publication of the Women's Health Initiative and Heart and Estrogen/Progestin Replacement Study (HERS) II data.
Design: This was an ecological study using a claims database for multiple healthcare plans. The cohort of women aged 40 to 69 years was included. Diagnostic codes for fractures likely to be osteoporosis related and prescriptions for hormone therapy and other bone-modifying medications were identified. Annual incidence rates and trends in incidence over time for fractures and prescriptions were determined for the period 2000 through 2005.
Results: Enrollment among women aged 40 to 69 years increased from 919,389 in 2000 to 2,872,372 in 2005. A total of 43,017 new fractures were identified. There was a significant increasing trend in age-adjusted rates of radius and ulna, vertebra, ribs, hip, pelvis, multiple, and pathologic fractures during the period from 2003 through 2005 (P < 0.03). The incidence of each fracture type was significantly greater during 2004 to 2005 than 2000 to 2001 (P < 0.04). The use of estrogen, estrogen plus progestin, and other hormones declined over the period from 2000 to 2003, whereas the use of other bone-modifying drugs increased from 2003 through 2005.
Conclusions: The incidence of fractures among perimenopausal and postmenopausal women increased significantly in the 3 years after publication of Women's Health Initiative and Heart and Estrogen/Progestin Replacement Study II results. This trend followed a decline in the use of hormone therapy, concurrent with an increase in the use of other bone-modifying agents.
Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. Thesefractures are associated with considerable morbidity and economic burden, particularly in developed countries. In 2000, there were an estimated 9 million osteoporotic fracturesworldwide, resulting in a loss of 5.8 million disability-adjusted life-years. The incidence and costs of these fractures and their sequelae will continue to rise as the population ages; by the year 2025, costs related to osteoporotic fractures are projected to reach $25.3 billion in the United States alone.
Disturbances in bone remodeling have been implicated in the pathogenesis of osteoporosis. Normal bone turnover involves a balance between bone resorption (osteoclasts remove bone by acidification and proteolytic digestion) and bone formation (osteoblasts make osteoid that fills in the resorption cavity). In postmenopausal women, however, bone turnover increases dramatically and remains elevated for up to 40 years after cessation of ovarian function, leading to progressive loss of bone mass. Additional slower age-related bone loss affects both elderly men and women. The osteoporotic bones that are the result of this process are vulnerable to fracture; bone mineral density has been found to be predictive of fracture risk at most skeletal sites, including the distal forearm, vertebrae, ribs, hip, and pelvis.
Although hormone therapy (HT) is well known to decrease the risk of osteoporotic fracture in postmenopausal women, the use of HT has changed considerably in recent years. A report of a national claims database study showed that annual prescriptions for HT in the United States increased from 58 million in 1995 to 90 million prescriptions for 15 million women in 1999; this prescription rate remained relatively stable through June 2002. However, after publication of the Heart and Estrogen/Progestin Replacement (HERS) II (HERS II) follow-up data and the Women's Health Initiative data, both in July 2002, the use of HT fell dramatically: relative to the period from January to June 2002, US prescriptions for the period January to June 2003 declined 66% for PremPro (estrogen plus progesterone) and 33% for Premarin (estrogen only).
Given this decline in the use of HT, a corresponding increase in the incidence of osteoporosis-related fractures might be expected unless other interventions with comparable efficacy had been substituted. However, there is a lack of published information regarding recent trends in the incidence of osteoporosis-related fractures in postmenopausal women, particularly for the periods immediately before and after publication of the WHI data (January 1, 2000-June 30, 2002, and January 1, 2003-December 31, 2005). We conducted an ecological study at the population level to evaluate the trend in annual incidence rates of osteoporosis-related fractures in women aged 40 to 69 years during these periods. We also evaluated the trend in use of HT and drugs used for the prevention and/or treatment of osteoporosis during the same periods.
Objective: To determine the trend in incidence of fractures among perimenopausal and postmenopausal women during the periods immediately before and after publication of the Women's Health Initiative and Heart and Estrogen/Progestin Replacement Study (HERS) II data.
Design: This was an ecological study using a claims database for multiple healthcare plans. The cohort of women aged 40 to 69 years was included. Diagnostic codes for fractures likely to be osteoporosis related and prescriptions for hormone therapy and other bone-modifying medications were identified. Annual incidence rates and trends in incidence over time for fractures and prescriptions were determined for the period 2000 through 2005.
Results: Enrollment among women aged 40 to 69 years increased from 919,389 in 2000 to 2,872,372 in 2005. A total of 43,017 new fractures were identified. There was a significant increasing trend in age-adjusted rates of radius and ulna, vertebra, ribs, hip, pelvis, multiple, and pathologic fractures during the period from 2003 through 2005 (P < 0.03). The incidence of each fracture type was significantly greater during 2004 to 2005 than 2000 to 2001 (P < 0.04). The use of estrogen, estrogen plus progestin, and other hormones declined over the period from 2000 to 2003, whereas the use of other bone-modifying drugs increased from 2003 through 2005.
Conclusions: The incidence of fractures among perimenopausal and postmenopausal women increased significantly in the 3 years after publication of Women's Health Initiative and Heart and Estrogen/Progestin Replacement Study II results. This trend followed a decline in the use of hormone therapy, concurrent with an increase in the use of other bone-modifying agents.
Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. Thesefractures are associated with considerable morbidity and economic burden, particularly in developed countries. In 2000, there were an estimated 9 million osteoporotic fracturesworldwide, resulting in a loss of 5.8 million disability-adjusted life-years. The incidence and costs of these fractures and their sequelae will continue to rise as the population ages; by the year 2025, costs related to osteoporotic fractures are projected to reach $25.3 billion in the United States alone.
Disturbances in bone remodeling have been implicated in the pathogenesis of osteoporosis. Normal bone turnover involves a balance between bone resorption (osteoclasts remove bone by acidification and proteolytic digestion) and bone formation (osteoblasts make osteoid that fills in the resorption cavity). In postmenopausal women, however, bone turnover increases dramatically and remains elevated for up to 40 years after cessation of ovarian function, leading to progressive loss of bone mass. Additional slower age-related bone loss affects both elderly men and women. The osteoporotic bones that are the result of this process are vulnerable to fracture; bone mineral density has been found to be predictive of fracture risk at most skeletal sites, including the distal forearm, vertebrae, ribs, hip, and pelvis.
Although hormone therapy (HT) is well known to decrease the risk of osteoporotic fracture in postmenopausal women, the use of HT has changed considerably in recent years. A report of a national claims database study showed that annual prescriptions for HT in the United States increased from 58 million in 1995 to 90 million prescriptions for 15 million women in 1999; this prescription rate remained relatively stable through June 2002. However, after publication of the Heart and Estrogen/Progestin Replacement (HERS) II (HERS II) follow-up data and the Women's Health Initiative data, both in July 2002, the use of HT fell dramatically: relative to the period from January to June 2002, US prescriptions for the period January to June 2003 declined 66% for PremPro (estrogen plus progesterone) and 33% for Premarin (estrogen only).
Given this decline in the use of HT, a corresponding increase in the incidence of osteoporosis-related fractures might be expected unless other interventions with comparable efficacy had been substituted. However, there is a lack of published information regarding recent trends in the incidence of osteoporosis-related fractures in postmenopausal women, particularly for the periods immediately before and after publication of the WHI data (January 1, 2000-June 30, 2002, and January 1, 2003-December 31, 2005). We conducted an ecological study at the population level to evaluate the trend in annual incidence rates of osteoporosis-related fractures in women aged 40 to 69 years during these periods. We also evaluated the trend in use of HT and drugs used for the prevention and/or treatment of osteoporosis during the same periods.