Bone-health experts are making a new push to reduce rates of osteoporosis, with a particular focus on controlling the bone-wasting disease in men.
An important goal is to get greater numbers of men to be tested for osteoporosis when they come to a hospital or clinic with a fracture to the wrist, vertebrae or other bones that wasn’t from a major accident or trauma. Doctors call this a fragility fracture—one that results from a decrease in bone density.
A recent study of about 440 people over 50 years old found women were about three times as likely as men (53% versus 18%) to be tested using a bone-density scan after suffering a distal-radial fracture, or broken wrist, a common warning sign of early osteoporosis. The study, conducted by researchers at Beth Israel Deaconess Medical Center in Boston, was published in the Journal of Bone and Joint Surgery.
The National Bone Health Alliance, a public-private partnership managed by the nonprofit National Osteoporosis Foundation, is nearing completion of a year-long pilot project at three hospitals to test programs called fracture-liaison services that make bone-density tests routine for patients over 50 with fragility fractures.
Such tests currently are recommended in the treatment guidelines of various medical groups. They also are regularly performed at some U.S. managed-care organizations, including Kaiser Permanente Southern California, and some national health-care systems, such as in the U.K. But experts say the majority of patients in the U.S., especially men, don’t get tested for osteoporosis after suffering a fragility fracture.
Osteoporosis is commonly thought of as a women’s disease, but as many as one in four men in the U.S. over the age of 50 will break a bone as a result of the condition, more than will have prostate cancer, according to the National Osteoporosis Foundation. By comparison, one out of two women will break a bone from osteoporosis. The disease also is a common cause of hip fractures, and men are twice as likely as women to die in the year after suffering a broken hip, says the Switzerland-based International Osteoporosis Foundation. The IOF made men the focus of World Osteoporosis Day in October and released an in-depth report called “Osteoporosis in Men: Why Change Needs to Happen.”
Robert Spezzano, 54, an assistant principal at an independent high school in Washington, D.C., fell off his bicycle in the fall, breaking his wrist and elbow. After surgery at MedStar Georgetown University Hospital, which is participating in the pilot project, he got a call from the hospital’s fracture-liaison-service coordinator suggesting he make an appointment for a bone-density test. “I was real skeptical, got real defensive about the term fragility fracture,” says Mr. Spezzano. “I fell hard, so I wasn’t surprised my arm broke.”
When the test results clearly showed osteoporosis, Mr. Spezzano says he was “blown away. My mind was racing. You just think it’s a woman’s disease.” Although his doctor recommended prescription medication, Mr. Spezzano says he plans first to sharply step up his exercise regimen and take vitamin D supplements to see if that helps.
Andrea Singer, leader of the project at MedStar Georgetown, says results of the pilot haven’t yet been compiled, but the number of patients post-fracture who are identified, assessed for osteoporosis and put on treatment if needed is up significantly.
Patients “aren’t necessarily thrilled with the diagnosis, but they’re thrilled that someone is looking at the whole person,” Dr. Singer says.
Bone tissue is always breaking down. When it isn’t replaced fast enough, bones become less dense and prone to breakage, even with a relatively minor fall or bump. Tests for osteoporosis include a bone-density scan, a type of X-ray of the hip, wrist or spine, and blood or urine tests to check calcium and vitamin D levels.
Bone density declines gradually as people age, and especially for women after menopause. Factors like family history and lifestyle contribute to people’s risk for getting osteoporosis. Some medications, such as corticosteroids or androgen-deprivation therapy for prostate cancer, and some underlying medical conditions also can promote the condition.
When osteoporosis isn’t too severe or the patient is relatively young, doctors may recommend calcium or vitamin D supplements, diet changes or more weight-bearing exercise, which strengthens bones. People with a greater risk of future fractures may be put on medications called bisphosphonates, which slow bone breakdown and slightly increase bone mass. Bisphosphonates, sold under brand names such as Fosamax and Actonel, are highly effective. But because of some possible, rare side effects—an unusual type of fracture of the thigh bone and a deterioration of the jaw bone—the medication often isn’t prescribed for more than five years.
Many men “think they can’t get osteoporosis. A man will say, ‘Oh, it was a really bad fall’,” says Richard Dell, head of Kaiser Permanente Southern California’s fracture-liaison service until he retired last year. Care managers at Kaiser order a bone-density scan for everyone over 50 whose fracture results from a simple fall. A clinic sees patients who have abnormal scans, does lab tests and prescribes treatment if needed.
Since the service was launched in 1997, the rate of hip fractures at Kaiser is down 40%, says Dr. Dell, an improvement he attributes in large part to the fracture-liaison service. Dr. Dell currently advises the National Osteoporosis Foundation on its effort to get more hospitals to adopt the services.
A key goal of the hospital pilot project, which is funded by Merck & Co., the maker of Fosamax, is to find out if a fracture-liaison service can be effective in a non-managed-care environment. Among other things, the project has been testing systems to keep track of patients who might receive follow-up care from multiple providers. It eventually plans to make the systems available to hospitals launching such services.
Although managed-care-hospital networks can save money by reducing hip fractures in their patients, other hospitals stand to forgo $25,000 or more for every hip surgery they don’t perform. Many experts believe fracture-liaison services will be more widely adopted once Medicare, the big government insurer, pegs more of its payments to patients’ overall health outcomes.
“When they put in more pay-for-performance programs, that’s when it will really get attention,” says Douglas Dirschl, chairman of orthopedic surgery and rehabilitation at University of Chicago Medicine, which isn’t participating in the pilot project. Fracture-liaison services represent “the best chance we have” for getting men and women evaluated and treated for osteoporosis, he says.
Osteoporosis, commonly thought of as a women’s disease, also affects many men.
Sources: National Osteoporosis Foundation
This story is so well researched and written that it covers a lot of ground in a short amount of space. It summarizes decades of science related to bone health and left us wanting a closer look at some of the more recent evidence, particularly the study that sets the stage at the top of the story. Without any mention of costs, the potential harms of over-screening, or the quality of the evidence in that study or others, readers may be left with the impression that they should make sure to have a bone density screening at their next available opportunity. The story also should have clued readers in to the commercial motivations that may underlie a push for more osteoporosis screening in men.
This story emphasizes the fact that men who suffer fragility fractures — fractures not associated with trauma or following a fall from standing height or less — aren’t as likely to be assessed for osteoporosis as women in the same situation. The article goes on to nicely describe why this may matter and provides some patient examples. It also mentions that relevant expert groups recommend screening in all people over 50 with a potential fragility fracture. The problem here is that we don’t really know if following these recommendations will decrease the likelihood of men having future fractures. Experts think it will, but there is no real evidence to say this is in fact the case. It requires extrapolating from studies done in women, and while that may be a logical approach, it would be nice to see some acknowledgment of this evidence gap.
Why haven’t studies been done in men? That would be a great question for the experts quoted in this article. It is possible that it isn’t on the radar screen of specialists who care for these patients. Or it may be that such studies are hard to do, and that drug companies would prefer not to spend the money needed to perform them when their drugs are already approved and available. While the recommendations seem reasonable, there are many examples where expert opinion doesn’t hold up under the light of evidence. Demonstrating that men benefit from identifying and treating osteoporotic fractures would go a long way to convincing doctors to make screening a part of routine care.
There is not enough discussion of costs in the story The costs one needs to consider — in addition to the cost of the initial bone scan — are any treatment-related costs (e.g. drug therapy), as well as follow-up care, monitoring, etc. These would be offset by potential savings in terms of less need for future treatments for a new fracture. The story does mention that hip surgeries cost $25,000 or more, which may help explain why hospitals are not clamoring to set up screening programs for men to prevent fractures.
The story starts with the premise that screening for bone density is recommended by many health care organizations and that doing so will lead to fewer bone fractures and, in the case of hip fractures, perhaps reduce deaths in men whose health declines after a fracture. The story says that the study “found women were about three times as likely as men (53% versus 18%) to be tested using a bone-density scan.” But that doesn’t tell us the benefits of doing the scan. The assumption is that scanning everyone who comes in with a fracture for bone density will lead to health improvement. Some proof to back that up would have been nice. The closest the story comes to this is an anecdotal reference to Kaiser Permanente in Southern California, which apparently started a screening program in 1997 and, since then, “the rate of hip fractures at Kaiser is down 40%.”
To be clear, our understanding is that evidence supporting a fracture prevention benefit for screening in men doesn’t exist, so the best the story could have done would be to extrapolate from studies involving women. The story doesn’t go that far or acknowledge an evidence gap in this area. But that’s an omission we’ll penalize the story for below in the Evidence section, while ruling the Benefits description satisfactory.
There’s no explanation of the potential harms from unnecessary screening, the intervention that’s at the heart of this story. Unnecessary screening can produce false positive results that may lead to anxiety, unnecessary curtailing of activities, and needless treatment and follow-up that can cause harm. We acknowledge that the story does mention the harms from some specific bone density drugs. For example: “Bisphosphonates, sold under brand names such as Fosamax and Actonel, are highly effective. But because of some possible, rare side effects—an unusual type of fracture of the thigh bone and a deterioration of the jaw bone—the medication often isn’t prescribed for more than five years.” But we’d note that it isn’t clear how one should extrapolate data on potential harms seen in post-menopausal women to men.
The story could have gone a little deeper into the underlying evidence behind the push to get more men screened for bone density. The story says that 440 people were included in this most recent study. But the story does not say that these people were not put into separate groups with a control, were not monitored for several years, and were not randomized. Here’s how the researchers themselves describe what they did: “We retrospectively reviewed the medical records of ninety-five men and 344 women over the age of fifty years who were treated for a distal radial fracture at a single institution over a five-year period. We assessed whether the patients had received a dual x-ray absorptiometry (DXA) scan and osteoporosis treatment within six months following the injury.” That means that fewer than 100 men were included in this group. Of those, 17 were scanned, and nine were diagnosed with osteoporosis. That’s a pretty small number to start pushing new national protocols. That caveat and the fact that the study was a backward looking review of medical records should have been mentioned.
We also question the story’s failure to explore the evidence underlying the expert and society recommendations that it references to support the benefits of screening. Because fragility fractures are much less common in men than they are in women, they have not been studied in randomized trials in the same way that they have in women. The story never acknowledges this. The story could have simply stated that the evidence supporting these recommendations comes from expert opinion, and that there is a lack of studies in men that provide direct data to prove the benefits of screening and treatment in men.
There’s no disease mongering in the story. Instead, it provides some nice descriptions of bone health and bone health measurement to help put osteoporosis in context. “Bone tissue is always breaking down. When it isn’t replaced fast enough, bones become less dense and prone to breakage, even with a relatively minor fall or bump. Tests for osteoporosis include a bone-density scan, a type of X-ray of the hip, wrist or spine, and blood or urine tests to check calcium and vitamin D levels.”
To earn extra points here, the authors could have stated that screening asymptomatic older men for bone density, similar to women, is controversial. However, for individuals who have already had a fracture that may be due to osteoporosis, experts suggest that screening both men and women is warranted — although the data supporting this only comes from studies involving women.
The reporter sought out opinions from two clinicians not connected to the study, a patient, the Mayo Clinic, and the National Osteoporosis Foundation. But the story was not transparent about the relationships that these sources have with commercial interests. Dr. Amy Singer has disclosed significant financial ties to Amgen, which makes an osteoporosis drug. We’d also note that the National Osteoporosis Foundation receives funding from a “Corporate Advisory Roundtable” that includes makers of bone scanning machines and osteoporosis drugs. And the Foundation has previously been called out for its failure to educate consumers about the harms of bisphosphonate drugs when those problems were first coming to light. This context should make us wary of a push to screen more men for osteoporosis without evidence that it is beneficial. Is this drive totally about the patient or could there be a commercial motivation?
Ideally, we’d like to see some mention here of the option not to perform BMD testing, since there is no real evidence supporting this recommendation. But the story gets high marks for talking about a range of treatment options for osteoporosis and general bone health, and we applaud that. It’s rare to see a story try to pack in so much treatment information into one story, which is why we often ding stories in this part of the review.
It’s clear from the story that bone density screenings are common and done in a variety of ways.
What’s new here is the recent push to improve osteoporosis treatment in men, sparked in part by the study referenced in this story. The article is clear about this.
This story does not rely on any press release.[SJA: agree]