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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

Asked to name the chronic diseases of older age that burden the healthcare system, most people would say cardiovascular disease, cancer, diabetes, obesity, arthritis, and maybe mental health conditions such as depression and Alzheimer's.

Few would likely answer osteoporosis. Even a recent on the costs of noncommunicable diseases in the U.S. failed to mention this widespread age-related bone disease in the top contenders.

Yet brittle bone disease is a major consumer of healthcare resources and a driver of lost work productivity, disability, and mortality.

Approximately have osteoporosis, and an additional 44 million have low bone density, placing them at increased vulnerability. Some 54 million – half of all adults ages 50 and older – are at risk of breaking a bone.

Fractures

In the U.S., osteoporosis is responsible for two million broken bones and $19 billion in related costs every year, according to the . By 2025, osteoporosis is predicted to cause approximately three million fractures and account for $25.3 billion in annual costs. Osteoporotic fractures are responsible for more hospitalizations than heart attacks, strokes, and .

Following an index fracture, the within 12 months is 6.6%, with the cumulative incidence increasing to 20.9% after 4 years. Furthermore, costs increase incrementally with subsequent bone breakages.

Then there's the inestimable price of premature deaths. "There's a mortality risk of 20% or more in the first year after a hip fracture, and mortality risk is even worse for men, who are less likely than women to be screened early for bone density and who tend to older with more comorbidities at the time of fracture," said Jennifer K. Kelly, DO, director of the Metabolic Bone Program at the University of Vermont Medical Center in South Burlington.

In Canada, Europe, and the U.S. cumulatively, the average direct annual costs of treating osteoporotic fractures, including surgery and hospitalization, reportedly range from $5,000 to $6,500 billion USD, according to a – not taking into account indirect costs such as disability and loss of economic productivity. "Prevention of this disease can significantly reduce the costs incurred by the health system," the researchers wrote.

According to data from the hip fractures cause the greatest morbidity, with reported mortality rates of as much as 20-24% in the first year after fracture. Survivors face loss of function and independence, with 40% unable to walk independently and 60% requiring assistance a year later. Because of these losses, 33% of this group are totally dependent or in a nursing home in the year following their hip fracture.

In Europe, the disability due to osteoporosis is greater than that caused by most cancers (lung cancer excepted) and is comparable to that of rheumatoid arthritis, asthma, and hypertension-related heart disease.

Altogether, the healthcare, personal, and indirect economic consequences of osteoporosis are considerable: "Elderly patients need to understand that having an osteoporotic fracture is like having a heart attack of the bone," said Kendall F. Moseley, MD, clinical director of the Division of Endocrinology, Diabetes & Metabolism at Johns Hopkins Medicine in Baltimore.

Parsing Fracture Costs

The high medical price tag of fractures – the main impetus for healthcare-related costs – is made clear in a 2020 study in which compared the costs for elderly U.S. Medicare fee-for-service members who had an osteoporosis-related fracture with a non-fracture reference group.

Unsurprisingly, mean all-cause costs were greater in the fracture than the non-fracture cohort at $47,163 vs $16,034 overall. For men with fractures the costs were $52,273 vs $17,352.

The highest mean costs were incurred for skilled nursing ($29,216); inpatient costs ($24,190); and hospice care ($20,996). The highest incremental costs in the fracture group compared with the non-fracture cohort were for hip ($71,057 vs $16, 807); spine ($37,543 vs $16,860); and radius/ulna ($24,505 vs $14,673).

Total medical plus pharmacy costs for patients who experienced a second fracture were higher compared with those who did not ($78,137 vs $44,467).

Proportionally more patients in the fracture than non-fracture cohort died (18% vs 9.3%), with higher death rates among men (20% vs 11%).

With the most significant driver of costs being fragility fractures in the 12 months following a fracture, patients can expect to incur healthcare costs of more than $30,000, of which an average of $3,000 will be paid by the patient, according to a 2020 analysis in the (AJMC). This study also found that approximately 75% of fracture patients received rehabilitation services at a mean cost of $18,025.

It's essential to identify and treat at-risk patients early and prevent a first fracture and subsequent ones, Moseley stressed. "The biggest predictor of having a future fracture is already having had one."

Medication Costs

While it's difficult to get precise current figures on the aggregated pharmaceutical costs of osteoporosis, expenditures can vary widely, from a few dollars a month for older generics such as bisphosphonates to several thousands for the newer anabolic bone-building drugs designed for patients at high risk for fracture, Moseley noted.

A of a large cohort of elderly Medicare patients with osteoporosis found that half of non-fracture osteoporosis patients received drug treatment averaging $500 per treated patient, or $2 billion nationwide. The AJMC study also estimated that after-fracture pharmacy services averaged $3,089.

"Getting exact figures is complicated because Medicare pays for medications differently than regular insurance," said Kelly. "For instance, with Medicare, if the injection is given at a facility, it goes under Part B versus Part D."

As with drugs for other conditions, out-of-pocket costs to patients vary with the level of coverage in the individual's healthcare plan, but it can be an uphill battle to get some commercial insurers to cover the costs of newer drugs unless deemed necessary, Moseley added.

According to a 2023 analysis in new prescriptions for osteoporosis overall increased fourfold from 2003 to 2021, but anabolic medications did not keep pace with that growth, and anabolics were more often prescribed to white patients and those of higher socioeconomic status – probably since out-of-pocket costs to patients are higher for these agents.

Median out-of-pocket costs were $17 higher for anabolic than antiresorptive medications, though costs for anabolic medications decreased significantly from 2003 to 2020 at a compound annual growth rate of −0.6%.

Personal Costs

Productivity is a significant casualty of fracture, since after downtime during fracture treatment and recovery, patients will often continue to lose work-related income. "In cases where there is ongoing pain, there are also often challenges with mobility or worsening of other medical conditions," Moseley said. "I have seen some patients retire early to have the time to manage their new health problems following a fracture."

This also affects quality of life, with the resulting change in lifestyle and loss of independence. Moreover, family members and even friends may be faced with the burden of having to step in for non-paid care.

Osteoporosis patients will be advised to invest in refitting their homes with fall prevention in mind, removing obstacles and installing grab bars, railings, non-slip flooring, and better lighting. They may need to update their eyeglasses, purchase more supportive and slip-proof orthopedic-style footwear, and buy assistive walking devices or even scooters. They might pay more for household help and have higher transportation and delivery fees. Physiotherapy, exercise rehabilitation, and psychological counseling are possible added expenses, Moseley noted.

All these macro and micro financial considerations underscore the need to increase efforts for early screening, diagnosis, and treatment in order to stop bone loss and prevent fractures -- with benefits to the healthcare system and patients alike.

Read previous installments in this series:

Part 1: New Insights Into the Complex Biology of Osteoporosis

Part 2: The Latest on Osteoporosis Treatment and Diagnosis

Part 3: Osteoporotic Fragility Fractures

Part 4: Case Study: First-Time Mom's Severe Low Back Pain After Breastfeeding

Part 5: As Men Live Longer, Osteoporosis Looms Larger

Part 6: These Other Medical Conditions and Treatments Can Also Increase Osteoporosis Risk

Part 7: Talking to Patients About Osteoporosis

Part 8: Case Study: Shocking Development of Osteoporosis in a Teenager

Part 9: Osteoporosis and Oral Health

Park 10: Osteoporosis Patients Need Daily Physical Activity and 'Purposeful' Exercise

Part 11: Nutrition Can't Be Ignored in Osteoporosis