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Incidence and Costs to Medicare of Fractures Among Medicare Beneficiaries Aged greater than or equal to 65 Years -- United States, July 1991-June 1992

An estimated 850,000 fractures occur annually in the United States among persons aged greater than or equal to 65 years (1,2). Osteoporosis, an age-associated condition resulting in decreased bone density, is a major cause of these fractures, which typically result from a fall to the floor (2); approximately 25 million persons may be at increased risk for fracture because of low bone mass (3). During 1986-1995, annual medical-care costs for fractures among older adults ranged from $7 billion to $10 billion in 1986 (4) to $13.8 billion in 1995 (5). To determine more accurately the incidence of fractures at 10 anatomical sites among persons aged greater than or equal to 65 years during July 1991-June 1992 and to estimate the excess costs to Medicare of these fractures during the 1-year period following the fracture, claims data were analyzed for a 5% systematic sample (n=1,288,618) of Medicare beneficiaries. This report summarizes the findings, which indicate that excess costs to Medicare for the 10 incident fracture types represent 3% of all Medicare costs for 1992.

Medicare is a national health insurance program that includes coverage for persons aged greater than or equal to 65 years, and the Medicare dataset comprises claims for 97% of persons in this age group (6). Medicare data include claims from inpatient hospitals, physicians/suppliers, outpatient-care facilities, skilled-nursing facilities (SNF), home-health agencies, and hospice care. Claims files for hospital inpatient services, outpatient hospitals, and physicians' services were reviewed to identify persons with a single fracture at one of 10 sites: ankle, nonankle tibia-fibula, patella, nonhip femur, hip, pelvis, distal forearm (wrist), nonwrist radius-ulna, shaft-distal humerus, and proximal humerus. These persons were identified through use of algorithms employing fracture diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and current procedure codes indicating a particular treatment for fracture (6,7).

Denominators used to compute incidence rates were obtained from the annual Medicare denominator files that include demographic and entitlement information for the beneficiary population. Incidence rates were age-adjusted by 5-year age groups to the 1990 U.S. population aged greater than or equal to 65 years. Fracture incidence was analyzed by race because previous studies have documented race-specific differences in age-related fractures. The race categories (black, white, and other/unknown) included in this analysis reflect categories coded in the Medicare dataset. Data were excluded for persons with incomplete information (i.e., health-maintenance organization enrollees, Railroad Retirement Board enrollees, non-U.S. residents, and persons without continuous part A and part B coverage), with bone cancer, or with evidence of previous fracture (i.e., prevalent fractures).

Costs to Medicare were determined for the 10 types of incident fractures by using claims data listing the amount reimbursed by Medicare (including per diem adjustments for inpatient and SNF care) (8). Two types of costs were calculated for three specific time intervals pre- and post-fracture: the 6-month baseline before fracture, an initial 12-week episode of care (i.e., the usual healing time for a simple fracture), and a 40-week follow-up period. Mean costs to Medicare per person per day were computed for each of the 10 fracture sites, and excess costs per person were determined by comparing costs during the initial episode and follow-up periods to baseline costs for the 6-month period before fracture. Excess costs for each fracture site were extrapolated to the entire population that met the criteria for inclusion in this analysis. Incidence Rates

From July 1991 through June 1992, a total of 26,785 single fractures at the 10 sites were identified among the 1,288,618 Medicare beneficiaries in the 5% sample (Table_1). Hip fracture occurred most frequently (incidence rate: 73.9 per 10,000 population), followed by fracture of the wrist (37.8) and of the proximal humerus (21.8). The incidence rate was lowest for fracture of the patella (5.5). Sex-specific rates were higher for women than for men for all fracture sites and for all races: race-specific rates were higher for whites than for blacks and other/unknown races for all fracture sites; for most fracture sites, rates were highest for white women and lowest for blacks. Cost of Fractures

From July 1991 through June 1992, the mean daily cost to Medicare for a beneficiary was greatest during the initial 12-week period following a fracture; the daily costs were highest for persons with a fracture of the hip ($191.50) and of the lower femur ($153.98) (Table_2). Mean daily costs were lower during the 40-week follow-up period; however, for most fracture sites, these costs were higher than mean daily costs during the 6-month baseline preceding the fracture. Total excess costs to Medicare for a person during the year following a fracture ranged from $2564 following wrist fracture to $15,294 following hip fracture. The total excess cost to Medicare for the 10 fracture sites among beneficiaries aged greater than or equal to 65 years meeting inclusionary criteria was $4.2 billion; $2.9 billion (69%) of this excess was associated with hip fracture (Table_3).

Reported by: JA Baron, MD, Dept of Medicine, and Dept of Community and Family Medicine, J Barrett, MSc, Dept of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire. M Berger, MD, Merck & Co., Inc., West Point, Pennsylvania. Prevention Effectiveness Activity, Div of Prevention Research and Analytic Methods (proposed), Epidemiology Program Office; Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The overall national incidence of fractures cannot be readily estimated because many types of fractures are treated in outpatient settings, which are not linked to integrated databases (3). For Medicare beneficiaries aged greater than or equal to 65 years, however, the Medicare dataset provides a means for estimating the occurrence and costs of fractures among nearly the entire population, and for fracture types not previously characterized. The race- and sex-specific fracture incidence rates in this report reflect known differences in bone density between the sexes and among racial groups. For example, women have lower peak bone density and lose bone more rapidly than men; similarly, whites have lower bone mass and may lose bone more rapidly than blacks (2). These findings also highlight the increased risk among older women -- particularly white women -- for fractures later in life.

The total excess costs to Medicare for all fracture sites combined ($4.2 billion) represent 3% of the total annual federal outlay for the Medicare program for 1992 ($138.3 billion) (1). However, the excess costs to Medicare described in this report represent only part of the total costs of health care for fractures among the elderly; these excess costs omit beneficiary deductibles, copayments, and other out-of-pocket expenses (8) and estimates for persons excluded from the study. The number of persons aged greater than or equal to 65 years is projected to increase from 32.0 million to 51.5 million during 1990-2020; with a concomitant increase in the proportion of the U.S. population at risk for age-related fractures, excess costs to Medicare for fracture treatment are likely to increase steadily. Future estimates of the cost impact of fractures also must consider these additional costs to the health-care system and social costs related to functional impairment and disability resulting from fractures.

The findings in this report include cost estimates to Medicare for several fracture types for which specific costs have not previously been characterized. Vertebral compressions, which are among the more common fractures among older persons, were not included in this study because onset often is gradual and painless; in addition, because there are no uniform diagnostic criteria for vertebral compressions, these fractures are likely to be underreported.

The findings in this report emphasize the need for further characterization of modifiable risk factors for fractures at specific sites and improved interventions for fracture prevention. Strategies for primary prevention of fractures optimally should include maximizing bone density during adolescence and young adulthood through measures such as promoting a calcium-rich diet and physical activity, and later in life, by reducing falls. Current efforts for primary prevention, which have especially been directed toward perimenopausal white women, include promotion of adequate dietary intake of calcium, regular weight-bearing physical activity, avoidance of smoking and excess alcohol consumption, and elimination of host and environmental causes of falls (e.g., poor balance or household obstacles, respectively) (2,9,10). Strength and balance training also may effectively reduce the incidence of falls and subsequent fractures among older adults (9). Strategies for secondary prevention for high-risk postmenopausal women include bone-density screening; hormone-replacement therapy; or for women with low bone density, the use of agents that retard bone resorption (9). Reduction of fractures among the elderly requires increased awareness among the public and health-care providers about this problem, therapies, and modifiable risk factors.

References

  1. Bureau of the Census. Statistical abstract of the United States, 1995. 115th ed. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, 1995.

  2. Melton LJ. Epidemiology of fractures. In: Riggs BL, Melton LJ, eds. Osteoporosis: etiology, diagnosis, and management. New York: Raven Press, 1988:133-54.

  3. Institute of Medicine. Osteoporosis. In: The second fifty years: promoting health and preventing disability. Washington, DC: National Academy Press, 1990:76-100.

  4. Peck WA, Riggs BL, Bell NH, et al. Research directions in osteoporosis. Am J Med 1988;84: 275-82.

  5. Ray NF, Chan JK, Thamer M, Melton LJ. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995. J Bone Miner Res (in press).

  6. Ray WA, Griffin MR, Fought RL, Adams ML. Identification of fractures from computerized Medicare files. J Clin Epidemiol 1992;45:703-14.

  7. Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65. Epidemiology (in press).

  8. Lave JR, Pashos CL, Anderson GF, et al. Costing medical care: using Medicare administrative data. Med Care 1994;32:JS77-JS89.

  9. Centre for Review and Dissemination, National Health Service/Nuffield Institute for Health. Preventing falls and subsequent injuries in older people. Eff Health Care 1996;2:1-16.

  10. Black DM. Why elderly women should be screened and treated to prevent osteoporosis. Am J Med 1995;98(suppl 2A):67S-75S.



Table_1
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TABLE 1. Incidence rate * of fractures among Medicare beneficiaries aged >=65 years, by fracture site, race, + and sex -- United
States, July 1991-June 1992 &
============================================================================================================================================================
                          Ankle          Nonankle tibia-fibula         Patella              Nonhip femur               Hip
                         (n=2432)              (n=976)                 (n=712)                (n=924)               (n=10,139)
                    ------------------   --------------------     ------------------     ------------------     ------------------
Characteristic      Rate   (95% CI @)      Rate    (95% CI)       Rate     (95% CI)      Rate     (95% CI)      Rate     (95% CI)
----------------------------------------------------------------------------------------------------------------------------------
Race
  White             19.2   (18.4-20.1)      7.5   ( 7.0- 8.1)      5.6   ( 5.1- 6.1)      6.9   ( 6.3- 7.4)     77.4   (75.8-79.0)
  Black             15.8   (13.2-18.4)      7.0   ( 5.3- 8.8)      3.6   ( 2.3- 4.9)      6.8   ( 5.1- 8.5)     37.0   (33.2-40.9)
  Other/Unknown     17.6   (13.3-22.0)      4.1   ( 1.9- 6.3)      4.5   ( 2.3- 6.7)      4.5   ( 2.1- 6.9)     54.8   (46.2-63.3)
Sex
  Male              10.2   ( 9.3-11.2)      3.7   ( 3.1- 4.3)      2.5   ( 2.0- 3.0)      2.9   ( 2.4- 3.4)     48.0   (45.9-50.0)
  Female            24.8   (23.6-26.0)      9.5   ( 8.8-10.3)      7.4   ( 6.7- 8.0)      8.8   ( 8.2- 9.5)     88.0   (86.0-90.1)
Total               18.9   (18.1-19.7)      7.4   ( 6.9- 7.9)      5.5   ( 5.0- 5.9)      6.8   ( 6.3- 7.3)     73.9   (72.4-75.4)
----------------------------------------------------------------------------------------------------------------------------------

                          Pelvis         Distal forearm (wrist)  Non-wrist radius-ulna  Shaft distal humerus     Proximal humerus
                         (n=1783)               (n=4980)               (n=1100)               (n=831)                (n=2908)
                    ------------------   ----------------------  ---------------------  --------------------    ------------------
Characteristic      Rate    (95% CI)       Rate     (95% CI)      Rate     (95% CI)      Rate     (95% CI)      Rate     (95% CI)
----------------------------------------------------------------------------------------------------------------------------------
Race
  White             13.7   (13.0-14.4)     39.6   (38.4-40.8)      8.8   ( 8.2- 9.4)      6.5   ( 6.0- 7.0)     22.9   (22.0-23.8)
  Black              5.3   ( 3.8- 6.8)     17.3   (14.6-20.0)      3.2   ( 2.0- 4.4)      3.7   ( 2.4- 5.0)      7.6   ( 5.8- 9.4)
  Other/Unknown     11.3   ( 7.5-15.2)     33.5   (27.2-39.8)      7.2   ( 4.3-10.1)      5.3   ( 2.7- 8.0)     22.7   (17.4-27.9)
Sex
  Male               5.1   ( 4.4- 5.8)     11.7   (10.7-12.7)      3.7   ( 3.1- 4.3)      3.2   ( 2.7- 3.8)      9.5   ( 8.5-10.4)
  Female            17.3   (16.3-18.2)     54.0   (52.4-55.7)     11.4   (10.6-12.2)      8.1   ( 7.4- 8.7)     29.2   (28.0-30.4)
Total               13.0   (12.4-13.7)     37.8   (36.7-38.9)      8.4   ( 7.8- 8.9)      6.2   ( 5.8- 6.7)     21.8   (20.9-22.6)
----------------------------------------------------------------------------------------------------------------------------------
* Per 10,000 Medicare beneficiaries. Age-adjusted by 5-year age groups to the 1990 U.S. population aged >= 65 years.
+ The race categories (black, white, and other/unknown) included in this analysis reflect categories coded in the Medicare dataset.
& Data were analyzed for a 5% systematic sample (n=1,288,618) of Medicare beneficiaries. Data were excluded for persons with incomplete information (i.e.,
  health-maintenance organization enrollees, Railroad Retirement Board enrollees, non-U.S. residents, and persons without continuous part A and part B
  coverage), with bone cancer, or with evidence of previous fracture (i.e., prevalent fractures).
@ Confidence interval.
============================================================================================================================================================

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Table_2
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TABLE 2. Estimated mean daily costs and estimated total excess costs to Medicare * per person for beneficiaries aged
>=65 years with an incident fracture, by fracture site -- United States, July 1991-June 1992 +
====================================================================================================================================================================
                                                                                                              Distal
                                        Nonankle                     Nonhip                                  forearm      Nonwrist      Shaft distal    Proximal
Type of Cost/              Ankle       tibia-fibula    Patella       femur          Hip          Pelvis      (wrist)     radius-ulna      humerus       humerus
 Time period              (n=2247)       (n=809)       (n=595)      (n=752)       (n=9343)      (n=1523)     (n=4405)      (n=869)        (n=639)       (n=2477)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------
Mean daily cost
  Baseline
   (6 mos pre-fracture)    $   9.14        $  12.84   $   10.47    $    20.43    $    16.16     $   18.37   $    9.00      $    9.43       $   12.26   $   12.22
   12 wks post-fracture       47.71           82.01       54.00        153.98        191.50         93.62       27.86          38.60           66.86       52.13
   13-52 wks post-            13.37           17.96       15.15         20.52         18.17         16.89       12.48          13.18           16.63       16.36
     fracture

Total excess cost
  12 wks post-fracture     3,240.00        5,811.00    3,656.00     11,218.00     14,729.00      6,321.00    1,584.00       2,450.00        4,586.00    3,352.00
  13-52 wks post-          1,188.00        1,438.00    1,316.00         25.00        565.00       -414.00 &    979.00       1,054.00        1,227.00    1,163.00
    fracture

Total excess
  costs 0-52 wks          $4,328.00       $7,249.00   $4,972.00    $11,242.00    $15,294.00     $5,907.00   $2,564.00      $3,505.00       $5,814.00   $4,515.00
    post-fracture
-----------------------------------------------------------------------------------------------------------------------------------------------------------------
* Medicare costs are the amounts the program paid institutions (inpatient hospitals, outpatient hospitals, skilled-nursing facilities, home-health agencies, and
  hospices) or providers (physicians/suppliers). These costs include costs for fractures plus excess costs of complications or comorbid conditions. Excess
  costs were calculated by subtracting baseline costs from post-fracture costs.
+ Data were analyzed for a 5% systematic sample (n=1,288,618) of Medicare beneficiaries. Data were excluded for persons with incomplete information (i.e.,
  health-maintenance organization enrollees, Railroad Retirement Board enrollees, non-U.S. residents, and persons without continuous part A and part B
  coverage), with bone cancer, or with evidence of previous fracture (i.e., prevalent fractures). The sample size for each type of fracture in this table is lower
  than in Table 1 because of the exclusion of persons with fewer than 6 months of data before the fracture.
& Negative excess costs during the 40-week follow-up period may be the result of a high proportion of deaths among persons with a pelvis fracture.
====================================================================================================================================================================

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Table_3
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TABLE 3. Estimated total excess costs to Medicare * for beneficiaries aged >=65 years who met the inclusionary criteria and
had an incident fracture, by fracture site -- United States, July 1991-June 1992 +
================================================================================================================================================================
                                                                                        Distal                   Shaft
                                    Nonankle                Non-hip                     forearm     Nonwrist     distal    Proximal
Time period              Ankle    tibia-fibula   Patella     femur     Hip    Pelvis    (wrist)   radius-ulna   humerus    humerus     Total
------------------------------------------------------------------------------------------------------------------------------------------------
12 wks post-fracture        146             94         44        169   2,752      193        140            43        59         166     3,806
13-52 wks post-fracture      54             23         16          0     106      -13 &       86            18        16          58       364

Total excess                199            117         59        169   2,858      180        226            61        74         224     4,167 @
  costs 0-52 wks post-
  fracture
------------------------------------------------------------------------------------------------------------------------------------------------
* In millions of dollars. Medicare costs are the amounts the program paid institutions (inpatient hospitals, outpatient hospitals, skilled-nursing facilities,
  home-health agencies, and hospices) or providers (physicians/suppliers). These costs include costs for fractures plus excess costs of complications or
  comorbid conditions. Excess costs were calculated by subtracting baseline costs from post-fracture costs.
+ Data were analyzed for a 5% systematic sample (n=1,288,618) of Medicare beneficiaries. Data were excluded for persons with incomplete information (i.e.,
  health-maintenance organization enrollees, Railroad Retirement Board enrollees, non-U.S. residents, and persons without continuous part A and part B
  coverage), with bone cancer, or with evidence of previous fracture (i.e., prevalent fractures).
& Negative excess costs during the 40-week follow-up period may be the result of a high proportion of deaths among persons with a pelvis fracture.
@ The row total differs from the column total because of rounding.
================================================================================================================================================================

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