BRIEF OBSERVATIONS

Underuse of OsteoporosisMedications in ElderlyPatients with FracturesDaniel H. Solomon, MD, MPH, Joel S. Finkelstein, MD,Jeffrey N. Katz, MD, MSc, Helen Mogun, MSc,Jerry Avorn, MD

Fractures related to osteoporosis result in substantialmorbidity, mortality, and costs (1). Patients with aprior fracture are two to five times more likely to

have future fractures than are persons without fractures(2); in these patients, pharmacologic intervention re-duces spine and hip fractures by 40% to 60% (3). Never-theless, the rates of osteoporosis treatment in patientswith previous fracture have been relatively low (4 – 6).Most of these studies involved limited samples, with onlyone or a few hospitals or health care systems, and noneassessed the longitudinal trends in pharmacologic treat-ments before and after fracture. We analyzed osteoporo-sis treatment trends in a large cohort of older adults inPennsylvania.

METHODS

Eligible subjects were drawn from enrollees of the Penn-sylvania Pharmaceutical Assistance Contract for the El-derly (PACE), a pharmaceutical benefits program fundedby the state for lower-income Medicare beneficiaries.Persons enrolled can purchase medications for a smallcopayment; all medications for osteoporosis are availablewithout limitations. Persons were included in the study ifthey had been enrolled in PACE and Medicare for 2 con-secutive years from 1994 to 2000, and had a hip or wristfracture confirmed by inpatient and outpatient diagnosisand procedure codes from Medicare. Prescription datawere examined to determine whether patients received amedication for osteoporosis before or after a fracture.

Data AnalysisWe first examined the characteristics of patients who hada hip or wrist fracture. The proportion of persons whofilled at least one prescription for an osteoporosis medi-cation, including alendronate, calcitonin, estrogen re-placement therapy, etidronate, raloxifene, or risedronate,in the 6 months before or after the fracture was calculatedfor each year. Data on calcium and vitamin D supple-ments were limited and were thus excluded. Patients witha fracture in more than 1 year were considered in eachyear they sustained a fracture. To ensure 6 months offollow-up, only fractures that occurred before July 1,

2000, were included. We then defined the use of osteopo-rosis medications after a fracture, adjusting for potentialpredictors of postfracture osteoporosis medication use(prefracture osteoporosis medication use; age; sex; race;comorbid conditions; prior fractures; and nursing homeresidence, number of physician visits, and number ofmedications used in the prior 12 months) using the LS-MEANS option in SAS (version 8.2; Cary, North Caroli-na). Finally, we constructed multivariable logistic regres-sion models to identify patient characteristics associatedwith postfracture treatment. Data were collapsed acrossyears and for type of fracture. Indicator variables for yearand type of fracture were included in the fully adjustedmodels. Separate models were constructed with andwithout persons who used osteoporosis medications be-fore the fracture.

RESULTS

Of the 392,255 eligible persons, 21,192 comprised thestudy group, of whom 10,279 (49%) had a prior fracture.During the 6-year study period, there were 17,325 hip and11,836 distal forearm fractures. The mean (� SD) age was82 � 7 years, 19,075 (90%) were female, and 20,550(97%) were white. Fourteen percent of patients (n �2967) lived in a nursing home at some point during theyear before the fracture, and 58% (n � 12,274) had ahospitalization during that year. Patients had a mean of9 � 7 physician visits and filled prescriptions for 9 � 5medications in the year before the fracture.

In 1995, only 345 patients (6%) filled a prescription foran osteoporosis medication in the 6 months after a frac-ture, compared with 898 (22%) in 2000 (P for trend�0.001). Use of osteoporosis medications increasedsteadily during this period and was similar for patientssustaining a hip or wrist fracture (Figure). The increase inthe use of osteoporosis medications during the 6 monthsbefore a fracture versus the 6 months after the fracturewas small, averaging 3% during the study. In 2000, 2% ofpersons filling a prescription after a fracture received hor-mone replacement therapy.

Younger patients, women, and whites were more likelyto use a medication for osteoporosis (Table). Other fac-tors associated with filling a prescription included fewercomorbid conditions, a prior fracture, use of oral glu-cocorticoids, and later study year. There was no differ-ence in the likelihood of starting a medication betweenpatients with hip fractures and those with wrist fractures.Use of an osteoporosis medication before a fracture wasthe strongest predictor of postfracture medication use(odds ratio � 21; 95% confidence interval: 19 to 24).

398 © 2003 by Excerpta Medica Inc. 0002-9343/03/$–see front matterAll rights reserved. doi:10.1016/S0002-9343(03)00357-7

DISCUSSION

We examined trends in pharmacologic treatment for alarge cohort of older patients with a hip or distal forearmfracture. Although medication use increased steadily dur-ing the study period, by 2000 approximately 4 of 5 pa-tients who sustained a fracture still did not fill a prescrip-tion for any osteoporosis medication in the 6 monthsafter the fracture. The small (3%) increase in medicationprescribing between the periods before and after the frac-ture suggests that physicians may not recognize fracturesas sentinel events requiring treatment.

Prior studies of osteoporosis management patternshave documented undertreatment, but none have sys-tematically compared medication use before and afterfracture over an extended study period. For example, in astudy of 1162 older women with distal radial fracture (4),23% received prescription treatment for osteoporosis,but there was no increase in treatment during the studyperiod from 1994 to 1997. A study of older adults hospi-talized for hip fracture found that 4% of patients receivedosteoporosis medication on admission, whereas 5% re-ceived medication on discharge (5). A review of the med-ical records of 343 women who sustained a distal forearmfracture during 1993 to 1997 in Olmsted County, Minne-sota, revealed that only 17% of women received advice tobegin or continue treatment for osteoporosis (6). Simi-larly, investigators from Canada surveyed 108 patientswho sustained a fragility-type fracture and found that19% reported taking a bisphosphonate or hormone re-placement therapy during the subsequent year (7).

In contrast with these previous studies, we examinedpharmacy records from before and after the index frac-ture, which allowed us to appreciate the small incrementin osteoporosis medication prescribing after a fracture.Although the proportion of persons treated increasedover time, the increase between before and after the frac-ture was consistent. We also studied a very large cohort ofpatients, suggesting that undertreatment of osteoporosiswas not a local issue. Moreover, all patients had access toprescription medications. Finally, we were able to exam-ine treatment trends over time.

This study has several limitations. We did not haveinformation on over-the-counter vitamin D and calcium

Figure. Trends in osteoporosis medication use in persons over 65 years old who had a hip (A) or wrist (B) fracture. The number ofhip fractures by year was as follows: n � 3359 in 1995; n � 3286 in 1996; n � 2958 in 1997; n � 2707 in 1998; n � 2579 in 1999; andn � 2436 in 2000. The number of wrist fractures by year was as follows: n � 2388 in 1995; n � 2171 in 1996; n � 2025 in 1997; n �1851 in 1998; n � 1781 in 1999; and n � 1620 in 2000. P for trend �0.001. White bars refer to the 6 months before a fracture and blackbars refer to the 6 months after a fracture.

Table. Factors Associated with the Use of a Medication forOsteoporosis after a Hip or Wrist Fracture

Predictor VariableAdjusted Odds Ratio*

(95% Confidence Interval)

Age65–74 years 1.48 (1.35–1.66)75–84 1.42 (1.29–1.54)�85 1.0

Female sex 5.6 (4.4–7.2)White race 1.8 (1.4–2.4)Comorbid conditions

None 1.54 (1.37–1.72)One 1.34 (1.19–1.47)Two or more 1.0

Prior fracture 1.22 (1.10–1.33)Oral glucocorticoid use 1.31 (1.14–1.48)Study year (per year) 1.24 (1.08–1.43)

* Also adjusted for index fracture site; recent hospitalization; and nurs-ing home residence, number of physician visits, and number of differentmedications used in the year before fracture.

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supplementation use. Although these agents are impor-tant in osteoporosis treatment, most guidelines for post-fracture treatment emphasize prescription-strength anti-resorptive medications (8,9). We also did not haveinformation on other fracture prevention measures thatmay have been instituted after the index fracture, such ashome safety evaluations and lower extremity strengthen-ing. The study database contains information only onfilled prescriptions; thus, prescriptions never filled by pa-tients were not included. In addition, patients were rela-tively old and of low-to-moderate income status. We didnot include persons with spine or other types of fracturebecause of concerns about inaccurate coding. It seemsunlikely, however, that the results would differ if we in-cluded patients with other fractures.

These data suggest that osteoporosis is poorly treatedafter a new fracture, and that certain groups of patients,such as men, older persons, nonwhites, and those withmore comorbid conditions, are less likely to receive treat-ments. Why such subgroups are receiving less care is notknown, but treatment for all patients after an initial frac-ture is important because repeat fractures are relativelycommon (2).

ACKNOWLEDGMENTThe authors thank Tom Snedden and the staff of the Pennsyl-vania Pharmaceutical Assistance Contract for the Elderly forhelp with many aspects of the project.

REFERENCES1. U.S. Department of Health and Human Services. Healthy People

2010: Understanding and Improving Health. 2nd ed. Washington,DC: U.S. Government Printing Office; 2000.

2. Klotzbuecher CM, Ross PD, Landsman PB, Abbot TA, Berger M.Patients with prior fractures have an increased risk of futurefractures: a summary of the literature and statistical synthesis. J BoneMiner Res. 2000;15:721–739.

3. Altkorn D, Vokes T. Treatment of postmenopausal osteoporosis.JAMA. 2001;285:1415–1418.

4. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treat-ment of osteoporosis: are physicians missing an opportunity? J BoneJoint Surg. 2000;82A:1063–1070.

5. Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure todiagnose and treat osteoporosis in elderly patients hospitalized withhip fracture. Am J Med. 2000;109:326 –328.

6. Cudhiddy MT, Gabriel SE, Crowson CS, et al. Osteoporosis inter-vention following distal forearm fractures. A missed opportunity?Arch Intern Med. 2002;162:421–426.

7. Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment ofosteoporosis in patients with fragility fractures. CMAJ. 2000;163:819 –822.

8. National Osteoporosis Foundation. Osteoporosis: Review of the Evi-dence for Prevention, Diagnosis, and Treatment and Cost-effectivenessAnalysis. Washington, DC: The Foundation; 1998.

9. National Osteoporosis Society. Guidance on the Prevention and Man-agement of Corticosteroid Induced Osteoporosis. Bath, UnitedKingdom: National Osteoporosis Society; 1998.

From the Division of Pharmacoepidemiology (DHS, HM, JA), Division ofRheumatology, Immunology, and Allergy (DHS, JNK), Brigham andWomen’s Hospital; and Endocrine Unit (JSF), Massachusetts GeneralHospital, Boston, Massachusetts.

Supported by grants AR48616, DK02759, AR47782, and AR02123 fromthe National Institutes of Health, Bethesda, Maryland; and the ArthritisFoundation, Atlanta, Georgia.

Requests for reprints should be addressed to Daniel H. Solomon, MD,MPH, Division of Pharmacoepidemiology, Brigham and Women’s Hospi-tal, 1620 Tremont Street, Suite 3030, Boston, Massachusetts 02120, ordhsolomon@partners.org.

Manuscript submitted December 10, 2002, and accepted in revised formMay 15, 2003.

Association betweenMortality and Occupationamong Movie Directorsand ActorsDonald A. Redelmeier, MD, Sheldon M. Singh, MD

The motion picture industry provides opportuni-ties for research on social inequities and health.We previously observed that Oscar-winning ac-

tors live about 3.9 years longer than those who are onlynominated (1), which suggests that social status is linkedto increased longevity at even exceptional levels ofachievement. In contrast, Oscar-winning screenwriterslive about 3.6 years less than those who are only nomi-nated (2), which suggests that behaviors, and not onlyneuroendocrine and immune factors, are an importantcontributor to health differences in both occupations (3).

In this study, we sought to assess mortality in promi-nent directors and lead actors, two groups of profession-als with several similarities. Specifically, much of theiridentity and life centers on work; they can have successfulcareers without special upbringing or education; reputa-tion is important and early success can perpetuate a ca-reer; and outstanding contributors attain public recogni-tion with a major of loss of privacy. Our intent was todetermine whether the two occupations had the samemortality.

METHODS

We identified all directors and lead actors who had beennominated for an Oscar from the inception of the Acad-emy Awards (1928) to 2001 (amounting to 74 annualaward ceremonies). For each director nominated, weidentified the lead actor in that film; similarly, for eachlead actor nominated, we identified the correspondingdirector. In some cases, the director and actor were thesame. Some persons had more than one nomination over

Association between Mortality and Occupation among Movie Directors and Actors/Redelmeier and Singh

400 October 1, 2003 THE AMERICAN JOURNAL OF MEDICINE� Volume 115