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Original Investigation |

Patterns of Prescription Drug Use Before and After Fragility Fracture ONLINE FIRST

Jeffrey C. Munson, MD, MSCE1,2; Julie P. W. Bynum, MD, MPH1,2; John-Erik Bell, MD, MS1,3; Robert Cantu, MD, MS3; Christine McDonough, PT, PhD4; Qianfei Wang, MS1; Tor D. Tosteson, ScD1,5; Anna N. A. Tosteson, ScD1,2
[+] Author Affiliations
1The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
2Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
3Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
4Boston University School of Public Health, Boston, Massachusetts
5Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
JAMA Intern Med. Published online August 22, 2016. doi:10.1001/jamainternmed.2016.4814
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Importance  Patients who have a fragility fracture are at high risk for subsequent fractures. Prescription drugs represent 1 factor that could be modified to reduce the risk of subsequent fracture.

Objective  To describe the use of prescription drugs associated with fracture risk before and after fragility fracture.

Design, Setting, and Participants  Retrospective cohort study conducted between February 2015 and March 2016 using a 40% random sample of Medicare beneficiaries from 2007 through 2011 in general communities throughout the United States. A total of 168 133 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder, or wrist were included. Cohort members were required to be enrolled in fee-for-service Medicare with drug coverage (Parts A, B, and D) and to be community dwelling for at least 30 days in the immediate 4-month postfracture period.

Exposures  Prescription drug use during the 4-month period before and after a fragility fracture.

Main Outcomes and Measures  Prescription fills for drug classes associated with increased fracture risk were measured using Part D retail pharmacy claims. These were divided into 3 categories: drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism. Drugs that increase bone density were also tracked.

Results  A total of 168 133 patients with a fragility fracture (141 569 women; 84.2%) met the inclusion criteria for this study; 91.8% were white. Across all fracture types, the mean (SD) age was 80.0 (7.7) years, and 53.2% of the fracture cohort was hospitalized at the time of the index fracture, although this varied significantly depending on fracture type (100% of hip fractures, 8.2% of wrist fractures, and 15.0% of shoulder fractures). The frequency of discharge to an institution for rehabilitation following hospitalization also varied by fracture type, but the mean (SD) duration of acute rehabilitation did not: 28.1 (19.8) days. Most patients were exposed to at least 1 nonopiate drug associated with increased fracture risk in the 4 months before fracture (77.1% of hip, 74.1% of wrist, and 75.9% of shoulder fractures). Approximately 7% of these patients discontinued this drug exposure after the fracture, but this was offset by new users after fracture. Consequently, the proportion of the cohort exposed following fracture was unchanged (80.5%, 74.3%, and 76.9% for hip, wrist, and shoulder, respectively). There was no change in the average number of fracture-associated drugs used. This same pattern of use before and after fracture was observed across all 3 drug mechanism categories. Use of drugs to strengthen bone density was uncommon (≤25%) both before and after fracture.

Conclusions and Relevance  Exposure to prescription drugs associated with fracture risk is infrequently reduced following fragility fracture occurrence. While some patients eliminate their exposure to drugs associated with fracture, an equal number initiate new high-risk drugs. This pattern suggests there is a missed opportunity to modify at least one factor contributing to secondary fractures.

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Use of Drugs That Affect Fracture Risk Before and After Fracture
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