HIP FRACTURES AND DECLINING DXA TESTING: AT A BREAKING POINT?

Abstract

Background. Hip fracture incidence rates have generally decreased over the last 15 years in the U.S. and other developed countries. The dramatic decline has been ascribed to improvements in osteoporosis evaluation and fracture prediction via DXA and the advent of generally safe and effective drugs, starting with oral bisphosphonates in 1995. We sought to examine the latest national trends in hip fracture rates. Methods. We used health care claims and enrollment data from the 2002-2014 5% sample of Medicare fee-for-service beneficiaries to identify persons with at least one Medicare-paid DXA scan in each year. DXA providers were counted based on the presence of any paid DXA service with technical component for office-based and freestanding providers, and any DXA bill for hospital outpatient departments, during a year. Presence of hip fracture was identified by any ICD-9-CM diagnosis code of 820.0x, 820.2x, or 820.8x on a hospital acute inpatient facility claim, excluding those with mention of trauma. Coding for a diagnosis of osteoporosis (ICD-9-CM 733.0) was assessed. Results. Age-adjusted hip fracture rates declined linearly (Figure) from 2002 to 2012. In 2013 and 2014, hip fracture rates were greater than predicted trends. DXA testing and diagnosis of osteoporosis started declining in 2009, two years after Medicare decreased office-based DXA reimbursement to levels below the cost of providing the service. Conclusion. This analysis suggests the trend of decreasing hip fracture rates in the US may be over. Other studies have shown a decrease in osteoporosis prescriptions over this period of time. Although causality cannot be clearly established, there is a plausible chain of events from reduced DXA reimbursement to fewer DXA providers to fewer DXAs performed to fewer women diagnosed to fewer being treated, all leading to an increase in fractures above expected levels. The increase in fracturerelated expenses is likely to outweigh the modest savings to Medicare from decreased DXA reimbursement and fewer DXAs performed.