Economic Costs of Severe Osteoporotic Fractures Continue to Increase at Expense of Refracture

The cost of the medical, economic, and societal burden of severe fractures remains high in most developed countries and is substantially increasing in other countries around the world. Recent estimates of the annual cost of fractures are $17.9 billion in the US and £4 billion in the UK. Multiple estimates of the cost of fractures in France have been published over the last 20 years. Most of these studies show that fractures add substantially to cost of overall health care in France. These findings have prompted recognition of the fact that fractures are a public health concern. In this issue of JBMR, Thomas and colleagues use data on health care resource utilization in France showing that the current economic burden of fractures in France continues to rise and mostly at expense of refracture. This study evaluated data from adults aged 50 years or older from the French national health care database (Système National des Données de Santé [SNDS]), including all health care utilization between the index date of hospitalization for first fracture during the enrollment period of 2009–2014, and December 31, 2016, or death of the patient. Costs were restricted to direct costs and determined from the payer perspective. Variables related to costs were identified through multivariate logistic regression analysis. This study evaluated fractures in a total of 356,895 patients, followed for a median of 39.1 months. In the year after index fracture, 36,622 patients (10.5%) were rehospitalized for fracture-related reasons. A total of 18,474 patients (5.3%) had bone density testing, and 58,220 patients (16.7%) received specific treatment during this first year. Total annual per capita osteoporosis-related cost in the year after the index severe osteoporotic fracture was €18,040, ranging from €8598 for multiple rib fractures to €21,085 for hip fractures. Of the total annual per capita osteoporosis-related cost in the first year, €17,905 was attributed to fracture-related costs and cost attributable to management of osteoporosis very much lower at €135. In follow-up during years 2 to 5, mean annual per capita cost of fracture treatment was €806, mostly attributable to treatment of refractures, whereas cost of management was much less at €99. The total annual cost of care for these fractures was €1260 million in 2014. Variables associated with higher cost were older age, male sex, site of fracture, history of prior osteoporotic fracture, and number of refracture events. The study concluded that the 5-year cost of severe osteoporotic fractures to the French health care system is higher than most previous estimates and mostly attributable to the cost of treatment of refractures. The authors emphasized that improved fracture prevention measures in patients with osteoporosis would help reduce the economic burden of disease. This important study further clarifies 5-year costs of severe osteoporotic fractures in the French population, advancing earlier findings. The 18-month study by Coassy and colleagues reported an estimate of total direct medical costs for severe osteoporotic fractures of €1.26 billion in 2014, with the annual per capita cost of fracture and osteoporosis management €18,040 in the year after fracture, given an average of more than 75,000 severe osteoporotic fractures requiring hospitalization annually. The findings in the current study show that the earlier study by Maravic and colleagues of the cost of osteoporosis in the French National Hospital Database (PMSI) in 2008, which included women older than 50 years with mostly hip fractures, had lower costs for hospitalization and follow-up and rehabilitation, with lower mean annual per capita costs of hospitalization but higher costs of rehabilitation. Another earlier study by Maravic and colleagues showed that in 2001, median inpatient per capita costs for hip fracture were €8727, with an overall cost to the health system of €715 to €763million. The current study data are more compatible with the ICUROS study, which showed total costs over 18 months after index fracture cost of €23,926 for hip fracture, €14,561 for vertebral fracture, and €10,319 for humeral fracture. These findings suggest that the actual cost burden of osteoporosis and related fractures in France is much higher than previously described. After initial fracture, subsequent fracture-related costs accounted for the vast majority of expenditures on osteoporosis, with the cost of prescription of specific medications less than 5% of the cost. This was partly attributable tomedications being prescribed in the community not requiring hospitalization and partly attributable to the low percentage of patients treated. In addition, only 8% of patients sought care with an osteoporosis specialist, 5% had bone density testing, and 17% received treatment with a specific osteoporosis agent. It is anticipated that more active management of osteoporosis and more active prescription of specific treatments and regular follow-up with bone densitometry will reduce the economic burden of fractures in France. Multivariate analysis of variables potentially increasing cost showed that older age, male sex, fractures at certain fracture sites leading to mobility impairment, and previous osteoporotic fractures increased cost. These findings are consistent with results in other studies, and emphasize that repeated fractures are a major driver of increased cost during longitudinal assessment.