Report of the Senate Ad Hoc Committee on Osteoporosis

              Report of the
Senate Ad Hoc Committee
on Osteoporosis
November 2004
Committee Members
Senator Toni Hellon, Chair
Senator Robert Cannell
Ms. Jane Canby
Ms. Renea Gentry
Dr. Jeffrey Lisse
Dr. Timothy Lohman
Ms. Margie Tate
Ms. Terri Verason
RECEIVED
OCT 2 3 2004
,-SPEAKER'S OFfiCE
Report ofthe Senate Ad Hoc Committee on Osteoporosis
INTRODUCTION
This report summarizes the efforts of the Senate Ad Hoc Committee on Osteoporosis. This
report is being submitted to the Governor, the Speaker of the House of Representatives and the
President ofthe Senate.
PURPOSE
The Senate Ad Hoc Committee on Osteoporosis, established by the President of the Senate on
December 2, 2002, was charged with the following:
(1) Research and collect information on osteoporosis;
(2) Evaluate the various approaches used by the state and local governments to increase public
awareness ofthe risk, treatment and prevention ofosteoporosis;
(3) Identify areas where public awareness, public education, research and coordination about
osteoporosis need improvement; and
(4) Study ways to:
(a) Increase the number of individuals in this state who are regularly screened for
osteoporosis,
(b) Increase research and funding at state institutions that are studying osteoporosis, and
(c) Improve coordination between state agencies and institutions that are involved in
research and treatment of osteoporosis.
The Committee is repealed from and after December 1, 2004.
MEMBERSHIP
Senate Two members ofthe Senate, from different political parties and one designated as
Chair, appointed by the President of the Senate:
Bellon (Chair), Cannell
Seven members of the public, appointed by the President ofthe Senate:
Ms. Jane Canby
Ms. Renea Gentry, Arizona Osteoporosis Coalition, Executive Director
Dr. Jeffrey Lisse, Arizona Arthritis Center
Dr. Timothy Lohman, University of Arizona
Ms. Margie Tate, Office of Chronic Disease Prevention and Nutrition
Services
Ms. Terri Verason, Director of Nutrition Services, Dairy Council of Arizona
Vacant
1
Report ofthe Senate AdHoc Committee on Osteoporosis
COMMITTEE ACTIVITIES
The Committee held two meetings during the past two years. The following provides a summary
of each meeting, but please see the attached minutes and handouts for the Committee discussions
and testimony.
December 16, 2002
The first meeting of the Committee began with introductions and a review of the committee
charge and concluded with discussions of a plan of action for the following 12 months. There
were two presentations given to the Committee:
�� Overview of osteoporosis and its effect on the population of Arizona - Jennifer Koslo, M.S.,
R.D., Arizona Department of Health Services, Nutrition and Chronic Disease Prevention
Services
• Overview of costs and projections over the years 2000 to 2025 and osteoporosis programs in
Arizona and other states - Kathy Brewer, PT, GCS, Med, Arizona Osteoporosis Coalition
September 22, 2004
The second meeting of the Committee began with introductions. There were two presentations
given to the Committee:
• Presentation on the research commissioned by the Arizona Osteoporosis Coalition entitled
Arizona Hip Project - Dr. Jeffrey Lisse, Arizona Arthritis Center
• Presentation on the various resources for information about osteoporosis across Arizona,
including its disparities and challenges, and recommendations regarding services - Renea
Gentry, Arizona Osteoporosis Coalition
The Committee did not adopt any recommendations. Senator Cannell, who chaired the meeting
in Senator Hellon's absence, stated that there are still outstanding issues, and felt that this
meeting should not be the final meeting. Senator Cannell stated that he will meet with the
President ofthe Senate to request a continuance ofthe Committee into next session.
ATTACHMENTS
• Meeting agenda/minutes/handouts - December 16, 2002
• Meeting agenda/minutes/handouts - September 22, 2004
2
Agendas can be obtained via the Internet at http://wwW.azleg.state.az.us/iagenda/iagenda.htm
ARIZONA STATE LEGISLATURE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE AD HOC COMMITTEE ON OSTEOPOROSIS
Date:
Time:
Place:
Monday, December 16, 2002
1:30 p.m.
Senate Hearing Room 1
AGENDA
1. Introductions
2. Presentation by the Department of Health Services
Jennifer Koslow
3. Presentation by the Osteoporosis Coalition
Kathy Brewer
4. Review Committee Charge and Begin Developing a Plan for the Next 12 Months
5. Call to the Public
6. Adjourn
Members:
Senator Virginia Yrun, Chair
Kathy Brewer
Oscar Gluck
Timothy Lohman
Terri Verason
Senator Toni Hellon
Jane Canby
Jeffrey Lisse
Margie Tate
Persons with a disability may request a reasonable accommodation such as a sign language interpreter, by contacting the
Senate Secretary's Office: (602)542-4231 (voice). Requests should be made as early as possible to allow time to arrange the
accommodation.
JK/cd 12/09/02
ARIZONA STATE LEGISLATURE
AD HOC COMMITTEE ON OSTEOPOROSIS
Minutes of Meeting
Monday, December 16,2002 -1:30 p.m.
Senate Hearing Room 1
Members Present:
Senator Virginia Yrun, Chair
Oscar Gluck
Timothy Lohman
Terri Verason
Members Absent:
Senator Toni Hellon
Jeffrey Lisse
Kathy Brewer
Jane Canby
Margie Tate
Staff: Julie Keane, Senate Health Analyst
Brandy Martin, Senate Assistant Analyst
Chair Yrun called the meeting to order at 1:40 p.m., and attendance was noted. She
asked the members to introduce themselves and to comment and identify the outcomes
that they would like to see for the Committee.
Jennifer Koslo, M.S., R.D., Arizona Department of Health Services (DHS), Nutrition
and Chronic Disease Prevention Services (NCDPS), presented an overview of
osteoporosis and its effect on the population of Arizona. She provided an outline of her
presentation to the Committee (Attachment A). She emphasized that osteoporosis is a
pediatric disorder that manifests itself in the. aging process; however, it is never too
early to begin prevention efforts. She said after age 30 a gradual decline in bone mass
occurs, and a healthy lifestyle is critically important to maintaining strong bones. She
commented that bone fractures significantly increase health care costs and decrease
the quality of life. She said osteoporosis is known as the "silent disease" because the
loss of bone occurs over a long period of time. She noted that while there are
treatments for osteoporosis, there currently is no cure. The four important steps in the
prevention of osteoporosis are diet, activity, lifestyle and bone density testing. .
Ms. Koslo identified the risk factors as modifiable and non-modifiable. The modifiable
factors are calcium intake, weight-bearing exercise, smoking and medications. The
non-modifiable factors are age, gender, ethnicity and genetics. She indicated that
certain medications used in treating other chronic conditions could also contribute to the
thinning of bones.
Senate Ad Hoc Committee
On Osteoporosis
December 16, 2002
Page 1
Ms. Koslo commented on the prevalence and incidence data outlined on page 2 of the
handout.
Presentation by the Osteoporosis Coalition
Kathy Brewer, PT, GCS, MEd, Arizona Osteoporosis Coalition, presented an
overview on Item " of Attachment A pertaining to costs and projections for the years
2000-2025. She noted that the role of bone mineral testing is critical. She commented
on the human factor statistics regarding bone fractures as highlighted in the handout.
Ms. Brewer reviewed the findings of surveys taken of various health plans regarding
insurance reimbursement issues.
In response to Senator Yrun's inquiry regarding bone replacement therapy, Dr. Gluck
outlined the various treatments currently available.
Ms. Brewer stated that there are various programs in other states, which are listed in
the handout. She said Arizona is involved in several programming activities that have
been successfully implemented throughout the country. She addressed three
osteoporosis program efforts currently underway in Arizona:
• Maricopa County Office of Nutrition Services
• Healthy Women for a Lifetime
• Arizona Osteoporosis Coalition
Ms. Brewer noted that web site resources are available as listed on the handout. She
stated that proposals have been submitted to various sources of funds for expansion of
the public awareness programs.
Senator Yrun asked whether any data is available on the number of eligible women in
Arizona who actually receive Medicare-sponsored screening. Ms. Brewer responded
that information could possibly be extrapolated from a national database through the
Medicare system. She suggested that the percentage is probably fairly low, which
indicates there is room for improvement.
In response to Ms. Verason, Ms. Brewer presented an overview on the programs in
Arizona regarding possible continuance and funding.
Senator Yrun asked whether a medical standard exists to indicate that bone screening
should begin prior to age 65. Dr. Gluck responded that the National Prevention Task
Force pUblished two months ago that all women over 65 should be screened. Also,
women 60 years of age or older with a risk factor should be screened. Dr. Lohman
stated that it is preferable for screening to occur sooner because women at 65 have
already lost 10% to 25% of bone density during their late twenties.
Ms. Verason commented on the importance of having bone density testing. She stated
that the Academy of Pediatrics has emphasized the importance of teenagers to exercise
Senate Ad Hoc Committee
On Osteoporosis
December 16, 2002
Page 2
and to have enough calcium in their diets to help prevent osteoporosis and related costs
later in life.
Review Committee Charge and Begin Developing a Plan for the Next 12 Months
Senator Yrun asked the members to comment on the outcomes they would like to see
on this issue during the next twelve months. Ms. Canby responded that the issue of
data collection needs to be addressed, and the best way to use the available resources
to collect the data. Senator Yrun asked Ms. Koslo to address the issue of collecting
incidence data and to distinguish the differences between prevalence and incidence
data. Ms. Koslo responded that prevalence data indicates the portion of population that
has the disease obtained through available data. Incidence data indicates new cases
within a period of time, which involves screening and re-screening. She noted that data
is very costly to collect. Ms. Canby remarked a previously-funded program that could
possibly be expanded is the Behavioral Risk Factor Survey. She indicated new
questions could be added to the survey regarding osteoporosis risk factors. Ms. Koslo
noted that the added cost would amount to $1,200 per question on the survey, and she
described some examples of questions. In response to Senator Yrun, Ms. Tate said the
survey is administered by DHS, but is nationally sponsored by the Center for Disease
Control (CDC). She noted that CDC provides some funding to the states for a core
module of the survey, and the cost for any additional questions would have to be funded
by the states.
Ms. Brewer added that a data research committee conducted a study in 2000. She
indicated it was an attempt to capsulate the issues related specifically to Arizona, and
said it would be the intention to repeat and update the study every two to three years.
Dr. Gluck stated a primary outcome that would be helpful is to partner with Arizona
hospitals in accumulating data on routine bone fractures. He said it would be helpful to
have a baseline of knowledge regarding the patients who experience bone fractures
along with intervention with other partnering entities. He stated that the Center of
Medicare and Medicaid Services (CMS) would likely be interested in partnering.
Ms. Verason stated that Dr. Gary Chan at the University of Utah is currently conducting
research on children and bone density, and similar research is underway in other parts
of the country. She commented that the issue of children and adolescence leads to the
topic of primary and secondary prevention. Primary prevention is building strong bones
and appropriate health behaviors. Secondary prevention is the prevention of fracture.
She said there are many approaches and perspectives to address this issue through
public and private means.
Ms. Tate stated that osteoporosis is perceived as a disease of the elderly; however, it is
important to note that it is a life-spaning disease. She said primary prevention takes
place with elementary and school-age children, and then evolves into a secondary and
treatment-type prevention.
Senate Ad Hoc Committee
On Osteoporosis
December 16, 2002
Page 3
Dr. Lohman stated statistics indicate that those treated with fractures are not generally
tested for bone density at the time of the treatment. Dr. Gluck stated it could be feasible
within a year to collaborate with other entities to conduct a study on patients treated for
bone fractures. He said data gathering could be undertaken in the form of a
questionnaire at the time a patient receives treatment for a common bone fracture.
Senator Yrun stated that a representative from the Hospital Association should be
included on the Committee when Senator Bennett reappoints the members. Dr. Gluck
suggested that Anita Murcko would also be a welcome addition to the Committee.
Dr. Gluck indicated that the cost of the project would depend on the amount of data
obtained. He suggested including women over age 50 and men over age 60, and
anyone who is treated for a bone fracture at a hospital facility would be given the
questionnaire. Senator Yrun wanted to know if data exists regarding the percent of all
fractures that are treated at a hospital versus another facility. Dr. Gluck responded that
approximately 90 percent of hip fractures are treated at hospitals, and only a third of
spine or vertebrae fractures are discovered clinically. He said the focus should be
based on hip fractures or those fractures that require intervention by a surgeon.
Senator Yrun commented another factor to consider is lost productivity as a result of
fractures. She asked whether any data is available on loss of work due to fractures. Dr.
Gluck responded such data exists, but may not be available in Arizona. He indicated
that if the hospital project is successful, the study could also be expanded at a later date
to include children and other age groups.
Ms. Canby noted that the Committee report is due in November 2004. Dr. Gluck stated
there is enough time to conduct the project before the report is due.
Dr. Lohman stated that screening is one of the most important factors, and he
suggested examples of how to conduct the screening.
Senator Yrun suggested that the members could be divided into two groups. One group
would focus on the hospital study, and another group could handle the screening issue.
Liana Martin, Legislative Liaison, DHS, responded to Senator Yrun regarding the
hospital project and costs. She said depending on how the project is handled, any
possible federal funding to Arizona would be a decision of CMS.
Senator Yrun commented that the screening survey would be an expensive
undertaking, but perhaps private grants may be available. She said it is doubtful that
any State funds would be available due to the current budget deficit. Ms. Canby said
perhaps some private funding sources may be interested, such as pharmaceutical
companies. She said another issue to consider is who would be analyzing the data,
writing the report and duplicating the report.
Senate Ad Hoc Committee
On Osteoporosis
December 16, 2002
Page 4
Dr. Gluck stated that the project would include data gathering, intervention and other
issues, which would require certain expertise. He said the results of the project could
be divided into certain geographical areas, and the ultimate results would improve the
quality of care for the State.
Ms. Verason referred to the screening portion of the project. She said many groups
handle screenings throughout the State. She asked whether there is a way to survey
those groups with respect to the data being collected.
Dr. Lohman said although he is not sure how comprehensive it would be, but certainly
those groups would have data that could be useful to this project.
Dr. Gluck commented that a recent nationwide Nora Project sponsored by certain
pharmaceutical companies worked in conjunction with physicians' offices to measure
patient bone density. He said 300,000 women were screened and the bone density
findings were published in the Nora Project report, which is available. He noted that
Arizona is unique in terms of population and needs. He added there is a significant
elderly population, and he is interested in knowing how Boswell Hospital data compares
with that of other hospitals regarding the required information for this project.
Senator Yrun suggested dividing the Committee into two groups. One group would
consist of Dr. Gluck, Ms. Tate, Dr. Lisse, and Dr. Anita Murcko. Dr. Gluck indicated he
would contact Dr. Murcko. He would also like input from the University of Arizona. Dr.
Gluck also suggested adding Dr. Michael Maricic to the group, and said he would
contact him. Ms. Koslo would also be a member of that group.
Senator Yrun said she will also contact the Hospital Association to find out how to
proceed. Ms. Keane indicated she will have a representative from the Hospital
Association contact Dr. Gluck. Senator Yrun asked Ms. Keane to provide a directory of
Committee members, their telephone numbers and email addresses for the
Committee's use.
The other group will include Dr. Lohman, Ms. Canby, Ms. Brewer, and Ms. Verason.
Senator Yrun stated that Senator Hellon will probably be chairing the full Committee
henceforth. When Senator Bennett reappoints the Committee, a suggestion will be
made to include the additional names of Dr. Anita Murcko and Dr. Michael Maricic.
In response to Senator Yrun, Ms. Liana Martin stated that today's meeting provided a
good discussion on the issue. She said as progress develops, DHS could provide some
advice on funding needs and other issues for the Committee. Senator Yrun asked Ms.
Martin to check with the Director of DHS to see if partnering could be provided as needs
are identified and developed in this project regarding epidemiology input.
Dr. Lohman asked whether an interim report would be available as the project moves
along. Senator Yrun stated that the Committee is required to submit a final report, but is
not prohibited from issuing an interim report. Dr. Lohman suggested an interim report
Senate Ad Hoc Committee
On Osteoporosis
December 16, 2002
Page 5
would be very helpful, and Senator Yrun agreed. She said as most of the survey work
will be completed in the first year, it could lead to suggestions for revisions or initiating
public policy in the second year. Therefore, an interim report would be very beneficial
as back-up data.
At Senator Yrun's request, Ms. Keane introduced herself and explained her role with the
Committee. Senator Yrun explained that the groups would meet at their convenience.
Public Testimony
There was no public testimony.
There being no further business, the meeting adjourned at 3:10 p.m.
Respectfully submitted,
j(~ / 12z-);Y~
Nancy L. DeMichele, Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115)
Senate Ad Hoc Committee
On Osteoporosis
December 16, 2002
Page 6
Arizona State Legislature
AD HOC Committee on Osteoporosis
Monday December 16, 2002
Contacts:
Jennifer Koslo, M.S., R.D., Arizona Department ofHealth Services, NCDPS
Kathy Brewer, PT, GCS, MEd, Arizona Osteoporosis Coalition
1. OSTEOPOROSIS AND ITS EFFECT ON THE PEOPLE OF ARIZONA
Objectives:
1. To better understand the scope and impact of osteoporosis in Arizona
2. To define osteoporosis
3. To state several risk factors
4. To identify the ethnic populations at the highest risk
5. To understand the value of prevalence and incidence data
6. To gain information on programs in other states
7. To describe current progranuning in Arizona
8. To understand the scope of cost and reimbursement issues related to the disease
Disease Overview:
Definition: Osteoporosis is a chronic disease characterized by decreased bone mass with
decreased density and enlargement ofbone spaces producing porosity and fragility
resulting from a disturbance in nutrition and mineral metabolism.
• Bone Mineral Density (BMD) achieved when an individual reaches twenties
• After this point a gradual decline occurs
• Both modifiable and non-modifiable factors affect this process
• Decreased BMD associated with increased risk of fracture, especially in the
elderly
• Most common sites of fractures include hip, spine, forearm, or wrist
• Fractures significantly decrease quality of life and increase health care costs
• Also known as the "Silent Disease"
• This disease is thought to be preventable for most people. While there are
treatments for osteoporosis, there is currently no cure
• Four important steps in the prevention ofosteoporosis: diet, activity, lifestyle,
bone density testing
1
Pathology:
First step in prevention is to detennine risk factors.
Risk factors: Can be categorized as both modifiable and non-modifiable.
Non-modifiable factors:
• Age
• Gender
• Ethnicity
• Genetics
Modifiable factors:
• Calcium intake
• Weight bearing exercise (WBE)
• Smoking
Etiology: Disturbances in nutrition and bone metabolism related to the occurrence of one
or more risk factors results in a gradual loss ofbone which occurs over a long period of
time. The disease is generally asymptomatic until fractures occur.
Prevalence and incidence data:
Prevalence data: Tells us the proportion ofthe population that has the disease
2002 Prevalence Data for Arizona
Totals: Total Women with Total Men with !Grand Total for I
Osteoporosis and Osteoporosis and Men and Women
Low Bone Mass Low Bone Mass I
State of Arizona 543,800 263,900 807,700
By Congressional
District:
District 1 65,900 31,300 97,200
District 2 64,400 30,800 95,200
District 3 131,200 65,300 196,500 I
District 4 76,100 36,000 112,100
District 5 99,200 47,900 147,100
District 6 107,500 54,000 161,500
Incidence data: Indicates new cases within a period oftime. Important because it assess
how quickly the disease is developing among the population at risk showing the trend.
This type of data is very costly to collect which has resulted in a dearth of osteoporosis
incidence data.
2
II. COSTS
Arizona Proiections for 2000-2025:
Data source: Agency for Healthcare Policy Research and Quality
Analysis: Pharmacoeconomics Department, Procter and Gamble Pharmaceuticals
Hospitalization (1977)
• 1997 - 6,077 patients identified by primary diagnosis fracture by 1CD·9
coding for hosp admission
• $97 million in charges
• 31,000 hospital days
• 51% discharge to long term care
Total medical costs (2000)
• 1npatient - $136 million (acute care, physician costs, acute rehab)
• Outpatient - $18.4 million (home care, physician visits, out patient therapy
and services)
• Long term care· $83 million
• Total: $237 million for all fracture types, both male and female
Projections
I 2000 2005 2010 2025
COST $237 mill $275 mill $309.3 mill $438.2mill
FRACTURES 19k 22k 25k 35.5k
Role of Bone Mineral Density (BMD) Testing:
(presented 10102 - American College of Rheumatology)
• Based on BMD testing done in 2001 on women age 65 and older with
osteoporosis or osteopenia
• Cost and fracture outcomes were assessed over 3 years (2001-2003)
• 10% increase in Bl'vID testing (an additional 180,000 women) could reduce the
incidence of hip, spine and wrist fracture by 6,683
• Reduction in direct medical costs of fractures estimated at $32.3 million
o $12.1 million in testing costs
o $4.7 million in costs for medical therapy initiated
o resultant $15.5 million Medicare savings
The Human Factor:
• One woman in 2 and 1 in 8 men over age 50 will have an osteoporotic fracture in
their lifetime
• For women, thissk is greater than for breast, uterine and ovarian cancer combined
• An osteoporosis fracture occurs every 20 seconds in the US
• 1 in 5 women who sustain an osteoporotic fracture will have a second fracture
within one year
3
• 75% ofwomen aged 45 - 75 have never discussed osteoporosis with their
physician
• 24% ofhip fracture patients die within one year
• 28% ofpatients with hip fracture will require institutionalization
lnsurance Reimbursement Issues:
Source: Healthy Women for a Lifetime Coalition - 2000-2001 Health Plan
Survey of Women's Health Services ins AZ Health Plans
• 7 health plans surveyed: BC/BS, Cigna, Health Choice, Maricopa County Heatlh
System, Mercy Care, Pacificare
• All offer BMD screening, 1 limited to specific age group (over 60)
• Initial referral and frequency ofrepeat testing is determined by physician and/or
prior authorization for all (not criteria driven)
• Factors include family history, over age 60, specific benefit coverage
• None ofthe 7 were able to report the % of women who receive BMD in their plan
• Drug therapy availability:
o HRT covered by all, most SERMs and bisphosphonates require prior
authorization
o 2 plans - all drugs prescribed at physician discretion, no limitations.
o 5 plans - formulary drugs must be tried first. Prescriber must then
submit patient's clinical information for review by Medical Director
showing need for non-fonnulary and failed trials of formulary
equivalents.
III. PROGRAMS IN OTHER STATES
2000 report from Women's Health Council ofthe Association of State and Territorial
Chronic Disease Program Directors
• National legislation has required Medicare Part B to cover BMD testing since
July 1, 1998
• 50% of states require the state to conduct public education; in 1998 14 states
had earmarked separate funds and 7 states used existing health department
dollars
• 8 states have passed laws requiring private insurance to cover BMD testing
• Federal funds have supported osteoporosis via grants under various units of
the CDC
2002 report from the Elder Floridians Foundation
• 24 states programs listed: housed under various departments
o State DHS
o Health and Human Services
o Office ofNutrition Services
o Older Adult Health
o Department of Aging
o Office ofWomen's Health
o Department ofPublic Health
4
o Department of Agriculture
• Other partners integrating osteoporosis programs
o Worksite wellness programs
o Cooperative extension networks
o Fall prevention programs
o State Medical Association and other health professions groups
o Arthritis centers
o Women's health groups
o Cancer centers
o Maternal and child and family health
o Physical activity initiatives
o Anti-smoking initiatives
• State programming
o Media campaigns
o PSA's for radio and TV
o Toll free information lines
o Written public awareness and educational materials
o Screening programs
o Consumer education programs
o Healthcare provider and physician education
o Web sites
o Support groups
o Pre-adolescent cuniculurn
o Older adult exercise classes
o Surveillance systems - BRFSS
IV. ARIZONA OSTEOPOROSIS PROGRAMS
Maricopa County Office of Nutrition Sen'ices:
"Building Better Bones" curriculum for 5th and 6th graders
• Arizona Nutrition Network and state health department funding currently
provides for programming in low-income schools, in 6 AZ counties
• Arizona Osteoporosis Coalition - collaboration for development of a kids
interactive website www.buildingbetterbones.org
• After school and community based programming in Maricopa County provided
by grant funding
Healthy Women for a Lifetime:
• 4 issues: Depression, Heart Health, Breast Cancer and Osteoporosis
• Health Plan Survey information
• Collaboration with Cigna - professional staff inservice training on osteoporosis
• Planning May event on osteoporosis
Arizona Osteoporosis Coalition:
Mission: To raise awareness ofthe impact of osteoporosis on residents of Arizona
through education, communication and public activity.
5
The coalition has been in existence since 1998, begun with a small seed-grant from the
American Public Health Association. Membership is comprised of more than 650
interested organizations and individuals. AzOC is incorporated in Arizona and received
federal nonprofit status in 2001.
AzOC developed many of its programs recently under a two-year contract (7/99-6/01)
with the Arizona Department ofHealth Services. Through this work, AzOC established
the following resources and programs:
• Through a partnership with the Maricopa County Cooperative EX1ensio~ the
Bone Builders train the trainer prevention education program for young adult
individuals was expanded to 8 AZ counties
• A health care provider curriculum designed to address the issues of
osteoporosis prevention, diagnosis and management in more than 15
d~c~lines .
• The fITst data monograph about osteoporosis in Arizona
• A public awareness message and plan for a campaign including a professional
brochure in both Spanish and Englis~ a 30-second television advertisement
along with a radio version for public service announcements
• A statewide directory of prevention, screening and treatment resources
• A web site for osteoporosis information and coalition activities, feature
articles and documents such as the monograph and resource directory listed
above (www.fitbones.or~)
• A toll free number of taped information on 13 osteoporosis topics in both
English and Spanish (1-800-611-3410 or 602-470-0961)
The design and implementation of these projects were the first steps in establishing a
presence in the AZ public health community regarding the critical issue of osteoporosis.
Current projects and programs in addition to those stated above.
• Development of a kids interactive website www.buildinQbetterbones.org,
expanding and enhancing the classroom curriculum, in collaboration with the
Maricopa County Office ofNutrition Services
• Bone Builders trained 80 volunteers in the past year. Statewide, Bone Builders
staff and volunteers taught 403 classes to 9724 people, participated in 72 health
fairs, taught 2335 individuals and provided BMD screening to 2346 people,
reaching a total of 28, 161 people with an osteoporosis message.
• A health care provider training program was presented in July 2002 utilizing
videoconferencing and telemedicine networks across the state. The target
audience was physician assistants, nurse practioners, physical therapists and
dieticians
• The "fitbones" web site continues to receive apx. 1000 visits per month
• The Foundation for Osteoporosis Research and Education (FORE) was awarded a
grant from the Administration on Aging to develop an action plan for a national
osteoporosis awareness campaign for post-menopausal women. AzOC will be a
participating partner on the planning committee, council and final report.
6
Proposals have been submitted to various funders for expansion of our public awareness
campaign, distribution of brochures and written information, additional Bone'Builders
volunteer training and additional opportunities to present osteoporosis education to health
care providers across Arizona.
V. WEB SITE RESOURCES
1. vlww.nof.org (National Osteoporosis Foundation)
2. www.fitbones.org (Arizona Osteoporosis Coalition)
3. www.bonebuilders.orQ
4. www.fore.org (Foundation for Osteoporosis Research & Educ)
5. www.4women.gov
6. www.obgyn.net/osteoporosis
7. www.endocrineweb.com
8. www.osteorec.com
9. W\\'W.osteo.org (NIH osteoporosis and related bone diseases)
10. navigator.tufts.edu (nutrition information)
11. nutritiononestop.com (nutrition information)
12. www.asbmr.org (Am Society ofBone and Mineral Research)
7
Osteoporosis and
its Effect on
the people of
Arizona
Prepared by:
Arizona Osteoporosis Coalition
Data Committee
Chair - Linda Larkey, PhD
Ralph Renger, PhD
Omar Passons, BA, MPH candidate
Jody Carver, BS MPH candidate
--"'-1-" ~ ..- ._.. ,'--.. _ -._.. -.-_. -._.._ _._ _-_ ',_._.,.. - _ __ -.- --.- .~. "- _._ ..'.._ -
Executive Summary
• In 1996, 14% of Arizona's population, age 50 and over was diagnosed with osteoporosis.
• Conservative estimates using 1998 Arizona hospital discharge data place the cost of
osteoporosis in the state at about $177 million. This does not include the costs after
being discharged, which can include significant costs for long-tenn. care and/or health
care. It also does not account for the significant impact on quality of life. Given the
projected population growth and the rising cost of health care it appears that efforts need
to be directed toward prevention and early detection.
• The few prevention and education programs currently operating in the state focus on
adults. Much greater effort must be directed toward youth education programs..
• Education programs for adults need to focus on the importance of screening and early
detection. Programs targeting older adults should include a fall prevention component. A
reduction in falls is likely to minimize the number of fractures.
• Bone mineral density screening should be marrlatory for all post-menopausal women
under 65 and all women over 65 regardless ofthe number of risk factors.
• Better data is needed about modifiable risk factors of osteoporosis. It is recommended
that a question pertaining to calcium intake be added to the BRFSS, perhaps in the
women's health section. It is suggested that the physical activity data gathered in the
BRFSS be recoded to delineate weight-bearing from non-weight bearing exercise.
Table of Contents
Introduction: Osteoporosis defmed and its importance .4
Section 1. Prevalence and incidence data 7
Section 2. Risk of developing osteoporosis among Arizona residents 8
Nonrnodifiable factors 8
Age 8
Gender 9
Etbnicity '" 10
Genetics 10
Modifiable factors 11
Calcium intake 11
Weight bearing exercise 12
Smoking 13
Section 3. Cost to the State - Arizona hospital discharge data (1998) 14
Section 4. Prevention, screening and treatment of osteoporosis under Arizona's managed care..16
Section 5. Survey of services provided statewide 17
Section 6. Conclusions and recommendations 19
References 21
Appendix A. Detailed analysis of 1998 Arizona hospital discharge data .23
Osteoporosis is the technical name for a disease in which bones become extremely thin and
frail. I The body typically has fully developed skeletal (bone) mass by the time an individual has
reached the early twenties.2 After this point, a gradual loss ofbone mass (known as bone
mineral density or BMD) occurs throughout the rest of natural life. There are several factors that
scientists believe affect this process. These include smoking, excessive alcohol consumption,
calcium and vitamin D intake, presence ofappropriate exercise, and family history.
The figure on the next page is taken from the Physician's Guide to Prevention and Treatment of
Osteoporosis and published by the National Osteoporosis Foundation (NOF). The figure shows
the difference between a healthy bone and an osteoporotic bone. Once a person's BMD has
decreased below a certain level, the risk of breaking a bone increases dramatically. Even the
slightest slip or fall in a person with osteoporosis can result in fractures of the hip, spine,
forearm, or wrist. These fractures decrease mobility, functionality and independence in the
person suffering the fracture. In short osteoporosis can significantly degrade one's quality of
life. The fact that most osteoporosis related fractures occur in the elderly also places tremendous
burden on the caregivers who are often immediate family.
Osteoporosis is often undetectable because loss of bone mass typically occurs over a long period
oftime and is asymptomatic until fractures occur. Thus osteoporosis is referred to as ''the silent
disease".
The bones most frequently broken are the hip and spine. Breaks ofthis type often require costly
hospital stays. In 1995 approximately $14 billion, or 1.5% of the nation's health care budget, was
spent caring for those with the osteoporosis.3 Such fractures also have long lasting ani
debilitating effects on those afflicted. The good news is that the disease is thought to be
preventable. This means that increased prevention efforts could result in both a significant cost
savings and improvement in quality of life.
The purpose ofthis report is to better understand the scope and impact of osteoporosis in the
state of Arizona: To meet this goal the report is divided into six sections. Section 1 presents the
available prevalence (number of cases at anyone time) and incidence (number ofnew cases)
data at a national and state leveL
Section 2 presents the factors that place individuals at risk for thinning bones. These risk factors
include age, gender, ethnicity, genetics, calcium intake, weight-bearing exercise, and smoking.
5
This report pieces together existing data to show the estimated number ofArizonans with these
risk factors. Since our current data collection vehicles for statewide health information do not
currently focus on osteoporosis as a critical disease risk, the data fro Arizonans are sporadic.
The report will make recommendations for a more systematic data collection vehicle for tracking
osteoporosis risk and potential impact.
In Section 3 the report documents the financial impact of osteoporosis related health care to the
state. Arizona hospital discharge data from 1998 is used in conjunction with empirically based
attribution probabilities to arrive at a conservative estimate of the cost of the disease in Arizona.
Again recommendations are made for improving methods of data collection statewide to help us
better assess the impact of osteoporosis.
Section 4 reports data collected from a survey of managed care organizations to understand the
range of osteoporosis prevention, screening and treatment services available to those covered
under the top 12 plans in Arizona. These are compared to the physician's guide to prevention
and treatment of osteoporosis published by the National Osteoporosis Foundation (NOF).
Section 5 focuses on the breadth and depth of osteoporosis services available in Arizona..
Members of the Arizona Osteoporosis Coalition (AZOC) representing academia, health services,
government, public health nursing and others, were contacted about their knowledge ofprograms
currently operating in the state. Information is provided about the location and type programs
running in the state. This data together with the information provided in Section 4 provides a
comprehensive overview of the number and types ofprograms in the state targeting osteoporosis.
In Section 6 the report provides concluding recommendations based on an analysis ofthe
previous sections.
6
Prevalence data tells us the proportion ofthe population that has the disease. Incidence data
indicates new cases within a period of time. It is valuable because it assesses how quickly the
disease is developing among the population at risk showing the trend. Unfortunately, incidence
data is very costly to collect. This is because the population at risk must be screened and .
followed over time to discover new cases. This may explain why there is a dearth of
osteoporosis incidence data.
• It is estimated that in 1996 approximately 10 million Americans had osteoporosis.4
• Approximately 20 million Americans have low bone mass, placing them at risk for
osteoporosis.5
• In 1996, estimates of the percent ofAmerican men and women with osteoporosis range
from 12% (AK) to 15% (lA, ME, NE, NDRI, SD, WV). Comparable figures are reported
for Arizona where 14% ofthe population age 50 and over was diagnosed with
osteoporosis.6
• The National Institutes of Health (NIH) report that 50% of all women will suffer from an
osteoporosis-related fracture during their lifetime.7 This is equal to a woman's risk of
having breast cancer and uterine and ovarian cancers.
• Hip fractures result in five to 20 percent higher mortality rates compared to uninjured
women ofthe same age group.8
7
There are many risk factors that contribute to osteoporosis. Risk factors can be categorized as .
being either modifiable or non-modifiable. Modifiable factors are those related to your lifestyle
that you can presumably change ifso motivated. Non-modifiable factors are clmacteristics of the
individual that cannot usually be changed. A brief explanation of each risk factor and its impact
in Arizona is included below.
Non-Modifiable Factors
Age An individual's risk for developing osteoporosis increases with age. The
increased risk is most dramatic after menopause for women and past age 50 for
men.
A.wPo~Gmwtti 1y.·GrDvI-~oft_Data..JIrojedIou,to2Gl.D
tOOO-..,-----~~ .......- ......._--------
800 -111-....--11-....._ .....--1 1-----•••
~. --------1- m .6ol)
JllirIdrtd
~ 400,
100
it @ 10;.1' }O". ».~ ~.~ .79·"
-------~liGia.:-·-------
SioIml:,.._~~~tlloodt_
• From the above figure it can be seen that Arizona's elderly population is
expected to rise significantly in the next twenty years. Projections have the
population in Arizona between 50 and 59 years doubling and between 60 and
69 years almost tripling. This means that about two to three times as many
people as there are now will be at risk for osteoporosis in 2020.
8
Gender Women possess a significantly greater risk of developing osteoporosis than men.
Projected Number of Cases of Osteoporosis by
Gender in Arizona
Number of
Cases
_1996
_2015
males
Gender
females
• The number of women, aged 50 and over, who have osteoporosis or are at risk
for developing the disease will increase at least an estimated 80% in the next
ten years.9
• The number of men, aged 50 and over, who have osteoporosis or are at risk
for developing the disease will increase at least an estimated 30% in the next
ten years. lO
9
Ethnicity The primary risk group is women of CaucasianlNorthem European decent
followed by Asian American, then Hispanic populations. Recent data, however,
is showing that even the group ofwomen considered to be at lowest risk, African
American, is still experiencing alarming rates of osteoporosis incidence.
Projections of Ethnic Breakdown for Arizona
2 3
80...-----------------------,
g 70 :=
.; 60
l5' SO
Q.,
OS 40
.~s 30
5 20
yt
10
Q., o
Caucasian Hispanic American African- Asian
Indian American
Ethnic Group
.1998
.2015
Genetics
• The U.S. Census Bureau provides the data above. Although the proportion of
Hispanics is expected to increase the largest proportion of Arizona's
population in 2015 is expected to be Caucasian. Thus the majority of
Arizona's population is and will be in the highest risk categ>ry for
osteoporosis.
Genetic heritage is a strong determinant ofbone mass accumulation during
youth. 11 Thin women or those with small frames have a greater risk for
developing the disease. 12 While genetics is a strong determinant ofthe
accumulation of bone mass it is not the only detenninant. Bone mass can be
significantly affected by changes in lifestyle factors too. These are now
discussed.
Modifiable Factors
Calcium Intake A strong relationship exists between diet! calcium intake and risk for
osteoporosis. People who do not consume calcium-rich foods during childhood,
adolescence and early adulthood are at much greater risk for developing the
disease. This is because calcium intake affects bone mass development. The
average woman acquires 98% of skeletal mass by approximately age 20.13
National surveys show that young girls and women consume less than half the
recommended amount of calcium needed to grow and maintain healthy bones. I4
• In Arizona, only 22.5% of the population in 1995 consumed greater than or
equal to the United States Recommended Daily Allowance (USRDA) of
calcium.IS
• Within the 45-54 year old age group, nearly one third of Arizonans consumed
only 33-65% of the USRDA. I6
WBE Weight Bearing Exercise (WBE) during childlDod and adolescence contributes to
obtaining peak bone mass. "Weight-bearing exercise (in which bones and muscles
work against gravity as feet and legs bear the body's weight) includes walking,
jogging, stair climbing, dancing, and tennis. Weight lifting improves muscle
mass and bone strength".17
Percentage of Arizonan's Reporting that they did
not Participate in any Physical Activity or Exericse
in the Past Month
60
50
40
Percent
30
20
10
0
1994 1995 1996
BRFSS Year
1997
51.3
1998
• In 1998 Arizona's population was the most sedentary in the nation. About
49% ofArizona's adult population, over 18 years old, was physically active.
The alanning trend shown in the figure above holds across age and gender.
• Dr. Timothy Flood, medical director ofthe Arizona Department of Health
Services Bureau of Public Health Statistics declared a statewide "epidemic of
sedentary lifestyle". 18
12
Smoking Studies have shown that people who smoke tend to have a lower bone density and
increased risk of hip and wrist fracture than their nOIrsmoking counterparts.
• A person who has ever smoked has as much as a 50% greater risk of
developing a hip fracture due to a decrease in bone density related to smoking
than those who have never smoked.19
Percentage of Males and Females Indicating that
they Currently Smoke
40
30
Percent 20
10
o
1996 1997
BRF55 Year
1998
.Male
.Female
• Smoking rates differ across age groups. There are slightly larger percentages
ofyounger smokers than older smokers.
• The data suggests that a significant percentage of Arizonans are self-reported
smokers and at increased risk for osteoporosis.
IJ·--············-
This section of the report uses 1998 Arizona Hospital discharge data to estimate the cost of
Osteoporosis to the state ofArizona. Hospital discharge records include data about a patient's
diagnoses (often more than one), medical procedures/ laboratory tests performed, cost of
treatment to the patient, expected source ofpayment, and demographic data. Diagnoses are
coded using the International Classification of Diseases, or ICD9 codes. The difficulty with
using these codes is that they often do not represent the true reason or underlying cause for the
visit. For example, consider an elderly woman presenting with a hip fracture. If a bone mineral
density screening is done it may uncover that the underlying cause for the fracture was brittle
bones due to osteoporosis. However, if the bone mineral density screening is not completed then
the visit maynot be coded as osteoporosis. The result is that the cost attributable to osteoporosis
is underestimated.
Using the Delphi technique an expert physician panel developed osteoporosis attribution
probabilities that are a consensus about the percentage of cases coded as fractures that could be
"attributed" to osteoporosis. The probabilities vary as a function of age, ethnicity, and fracture
type (e.g., hip, spine, foreann, wrist). The attribution probabilities can be found in Appendix A.
The attribution probabilities were applied to the 1998 Arizona Hospital Discharge Data base.
Tables detailing the cost as a function of gender, age, and fracture type are located on Appendix
A
• The total cost attributable to osteoporosis in 1998 alone is estimated at $177
million.
• The estimate is conservative, as it does not include some cases for which
attribution probabilities could not be applied and does not include costs after
being discharged
14
• 60% ($103 million) ofthe cost represents the age range of 65 to 84.
• The amount covered by Medicare varies as a function of fracture type and
ranges between 40% and 60%. These are denoted in parentheses under total
cost in each table in Appendix A.
15
The purpose of this section of the report is to examine the types of osteoporosis-related services
provided by Arizona's Health Care Providers. In 1999 the Healthy Women for a Lifetime
coalition completed a survey of the 12 major health care providers in Arizona.20 The survey
asked about prevention and treatment of several postmenopausal women's healthissues such as
breast and cervical cancer, heart disease, depression, and osteoporosis.
The table below compares the survey [mdings to the recommendations in the Physician Guide
published by the National Osteoporosis Foundation.
Recommendations in NOF Physician Guide Results from survey of Arizona health care
providers
Counsel all women on
• risk factors for osteoporosis
• adequate calcium intake
• weight-bearing exercise
• avoiding tobacco and alcohol use
Bone mineral density screening should be done:
• all postmenopausal women under 65 who
have one or more risk factors
• all women over 65, regardless of risk
factors
FDA approved pharmacologic options for
osteoporosis prevention and/or treatment are
Hormone Replacement Therapy, alendronate,
calcitonin, and raloxifene
Eight of the 12 plans have limited education
programs for osteoporosis prevention.
Bone mineral density screenings for women over
40 are available with a range of restrictions in all
plans. Screenings are provided when
• the PrirmlIY Care Physician makes a referral
or
• prior authorization criteria are met, after
requiring "medical indications". Women
with risk factors may still be prevented from
receiving screenings in some plans when the
PCP does not consider it medically indicated.
Most plans provide coverage for most estrogen­based
medications, but the other drugs of choice
are sporadically covered. This limits the options
for women in some plans who have medical
reasons to avoid Hormone Re lacement Thera .
-16---
The purpose of this section is to gain an understanding of the number and types of osteoporosis
related programs and services provided by organizations and agencies other than the health plans
examined in Section 3. Each of the 250 members of the Arizona Osteoporosis Coalition was
contacted about their knowledge of osteoporosis programs in the state. The Coaliti:>n consists of
members in health service/delivery and education, public health nursing, private health-related
associations, state legislators and academic institutions. A one-page survey was mailed to
members representing all 15 counties asking them to document any osteoporosis related
programs ofwhich they were aware.
• 40 of the 100 responders provided infonnation about osteoporosis related
programs and services
• AduII Ed-mn
• Youth Edu<:atioJl
III FaIlP1wonlion
.~ .oo.r
• Adult education activities are concentrated in Maricopa, Pima, Pinal, Santa Cruz, and
Yuma counties primarily through the Bone Builders Program.
17
• There are limited numbers of youth education, fall prevention, and screening activities.
Note: An extensive inventory of educational programs and osteoporosis services in the state is
being prepared in a Resource Directory, available in the fall of 2000 through ADHS and AZOC.
18
��� Conservative estimates using hospital discharge data place the cost of osteoporosis in
1998 at about $177 million. This does not include the costs after being discharged, which
can include significant costs for long-term care and/or health care. It also does not
account for the significant impact on quality of life. Given the projected population
growth and the rising cost of health care it appears that efforts need to be directed toward
prevention and early detection.
• The few prevention and education programs currently operating in the state focus on
adults. Much greater effort must be directed toward youth education programs. This
recommendation is based on the following fact:
o Maximum bone density is reached by twenty years of age.
o Many of the modifiable behaviors that affect the accumulation ofbone bass are
shaped during adolescents (e.g., smoking, weight-bearing exercise, calcium
intake).
o Survey results of members of the Arizona Osteoporosis Coalition indicate that
. .
there is only one youth education program in Mohave county.
• Education programs for adults need to focus on the importance of screening and early
detection. Programs targeting older adults should include a fall prevention component. A
reduction in falls is likely to minimize the number of fractures.21
• Bone mineral density screening should be mandatory for all post-menopausal women
under 65 and all women over 65 regardless of the number of risk factors. The National
Osteoporosis Foundation (NOF) has already made this recommendation.22 However, in
many health plans women will only receive screening if referred by the primary care
physician: Early detection tlrough routine screening and appropriate subsequent
intervention will significantly decrease the number of fractures.
19
Better data are needed about modifiable risk factors of osteoporosis. It is recommended that a
series of questions pertaining to calcium intake be added to the BRFSS, perhaps in the women's
health section. The BRFSS does collect data about the types ofphysical activity in which people
engage. It is suggested that this data be recoded to delineate weight-bearing from non-weight
bearing exercise.
20
References
1Osteoporosis Website. National Osteoporosis Foundation, URL: http://www.nof.org
2 Osteoporosis Overview. National Institutes of Health, Osteoporosis and Related Bone
Diseases-National Resource Center. Washington, D.C. 1999
3 Medical Expenditures for the Treatment of Osteoporotic Fractures in the United States in 1995: Report
from the National Osteoporosis Foundation. Ray, Chan, et al, Journal ofBone and Mineral Research vol.
12, No.1 1997
41996 and 2015 Osteoporosis Prevalence Figures, State-by-State Report. National Osteoporosis
Foundation, 1/1997 (p 1)
5 ibid
6 1996 and 2015 Osteoporosis Prevalence Figures, State-by-State Report. National Osteoporosis
Foundation, 1/1997 (p 5)
7 Internet page at URL: http://www.nrc@nof.org. National Institute ofArthritis and Musculoskeletal and
Skin Diseases. Washington, D.C.: National Institutes ofHealth. National Resource Center for
Osteoporosis and Related bone Diseases, 1997.
8 ibid
9 1996 and 2015 Osteoporosis Prevalence Figures, State-by-State Report. National Osteoporosis
Foundation, 1/1997 (p 5)
10 ibid (p 11)
11 Genetic Studies in Osteoporosis. M Shiraki. Nippon Rinsho 56 (6): 1374-81 6/98
12 Osteoporosis Website. National Osteoporosis Foundation, URL: http://www.nof.org
13 ibid
14 ibid
15 Dietary Profile ofthe State: Nutrition Intake and Fruit and Vegetable Consumption Taren, D. Arizona
Department ofHealth Services and the University of Arizona College of Public Health (table m.B.1)
1995
16 ibid (table m.B.3)
17 Physician's Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation.
(p. 17) Excerpta Medica, Inc: Belle Meade, NJ 1999
18 Arizona's Health Paradox: We're Sedentary Yet Slim. The Arizona Daily Star, p. 1a January, 28, 2000
21
19 The Effect of Cigarette Smoking on the Development of Osteoporosis and Related Fractures. Molly T.
Vogt, Ph.D. Medscape Orthopaedics and Sports Medicine 3(5) 1999
20 Healthy Women for a Lifetime: Summary of Managed Care Organization Survey Results. Larkey and
Keller. Arizona Cancer Center/Arizona Prevention Center. University ofArizona. Draft 1/20/99.
21 Osteoporosis International. National Osteoporosis Foundation, Supplement 4, 1998
22 Physician's Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation.
(p 1) Excerpta Medica, Inc: Belle Meade, NJ 1999
2T _._---.-._--,." .-_.. _.__..,.._-._- __._---_ ,-.-.-_..-.
I.-C---
\
BUilding Osteoporosis National Education Summit
Boca Raton, Florida
January 7-9. 2000
OSTEOPOROSIS ATTRIBUTION PROBABILITIES
Median attribution probab~ity.. by Age group
Sex Race Fracture Site 45-64 years 64-84 years 85+ years
Women White Hip 0.80 0.90 0.95
Spine 0.80 0.90 . 0.95
Forearmlwrist 0.70 0.70 0.80
Other 0.45 0.50 0.60
Hip 0.65 0.80 0.95
Spine 0.65 0.80 0.90
Forearmlwrist 0.55 0.60 0.70
Other 0.35 0.40 0.45
Other" Hip 0.75 0.85 0.95
Spine 0.75 0.85 0.95
Forearmlwrist 0.60 0.70 0.70
Other 0.35 0.40 0.45
Men While • Hip 0.60 0.80 0.85
Spine 0.70 0.90 0.90
Forearm/wrist 0.40 0.45 0.45
Other 0.15 0.30 0.45
Black Hip 0.30 0.65 0.75
Spine 0.55 0.75 0.85
Forearmlwrist 0.20 0.30 0.35
Other 0.15 0.15 025
Other" Hip 0.55 0.75 0.85
Spine 0.60 0.75 0.85
Foreannlwrist 0.30 0.35 0.40
Other 0.15 020 0.30
Notes:
" Includes AsianlPacific Islanders, American Indians, and other races.
.. Attribution probabilities serve as adjustment factors III the total number of events. For example. if·there were 1.000
spine fractures in wMe women age 45-64. the probability of 0.80 would be multiplied by 1,000 to yield 800 (80%)
cases that were due to underlying osteoporosis. Intuitively, attribution probabilities increase with age.
Attribution probabilities were derived from an expert physician panel with broad experience treating and diagnosing
osteoporosis fractures based on a three-round Delphi process. See Melton et aI., 1997 tor methodological deta~.
Source: Tables 2, 3 and 4 from Melton, U, et al., "Fractures Attributable to Osteoporosis: Report from the National
Osteoporosis Foundation; Journal of Bone and Minaral Research 12(1): 16-23. 1997.
The Co$! of Osteoporosis to /he stIIte
RButVe,PhD
24
Only one type of osteoporosis related diagnosis 14,739
Two different types of osteoporosis related diagnoses 1,168
Three different types of osteoporosis related diagnoses 94
Four different types of osteoporosis related diagnoses 1
Total Cases 16,002
Note: Since discharge records include up to nine diagnoses for any individual patient, methods were used to ensure
that each patient was counted only once.
Only one type of osteoporosis related diagnoses
Hip 6,609
SnineNertebrae 2,528
ForearmlWrist 474
Other 5,128
Total 14,739
Hip
White 175 2,017 1,385 3,577
Black 4 9 3 16
Other 38 368 243 649
Sub Total 217 2,394 1,631 4,242
White 96 806 335 1,237
Black 2 7 1 10
Other 25 150 79 254
Sub Total 123 963 415 1,501
Spine
White 133 818 371 1,322
Black 8 3 11
Other 29 93 32 154
Sub Total 162 919 406 1,487
White 109 429 110 648
Black 2 2
Other 23 48 11 82
Sub Total 134 477 121 732
Forearm and Wrist
White 46 106 30 182
Black
Other 11 19 7 37
Sub Total 57 125 37 219
White 25 19 6 50
Black 1 1
Other 10 2 1 13
Sub Total 36 21 7 64
Other - Number of Cases
White 324 688 285 1,297
Black 7 8 15
Other 60 98 26 184
Sub Total 391 794 311 1,496
White 117 192 62 371
Black 5 5
Other 60 32 12 104
Sub Total 182 224 74 480
27
Hip
White 3098,464 37,087,324 24,399,248 64,585,036
Black 140,650 154,468 54,882 350,000
Other 579,437 6,426,305 3574763 10,580,505
Sub Total 3,818,551 43,668,097 28,028,893 75,515,541
White 1,742,847 16,683,261 5,951,149 24,377,257
Black 14,283 108,329 15,217 137,829
Other 1,109,864 2,930,462 1347143 5,387,469
Sub Total 2,866,994 19,722,052 7,313,509 29,902,555
Spine
White 3,006,792 11,856,397 4,175275 19,038,464
Black * 59,315 25,547 84,862
Other 816,945 1,178354 328,052 2,323,351
Sub Total 3,823,737 13,094,066 4,528,874 . 21,446,677
White 2,876,370 7,383,984 1,159521 11,419,875
Black 59,232 * * 59,232
Other ·783,152 1,091,266 225,364 2,099,782
Sub Total 3,718,754 8,475,250 1,384,885 13,578,889
* Not enough cases to apply attribution probabilities
Foreann and Wrist
White 635,056 1,178,665 365,578 2197,299
Black * * *
Other 118,544 176,974 59332 354,850
Sub Total 771,600 1,355,639 424910 2552,149
White 466,072 189,696 68,151 723,919
Black 13,142 * * 13,142
Other 121,351 21291 5,394 148036
Sub Total 600,565 210,987 73,545 885097
*Not enough cases to apply attribution probabilities
Other
White 6,343,755 10,754,360 3,875,778 20,973,893
Black 136,358 114,270 * 250,628
Other 1,189,158 1,483,527 275,297 2947,982
Sub Total 7,669,271 12,352,157 4,151,075 24,172,503
White 2,428,156 3,472,559 755,708 6,656,423
Black 93,061 * * 93,061
Other 1,666,929 687,825 106,509 2,461,263
Sub Total 4,188,146 4,160,384 862,217 9,210,747
* Not enough cases to apply attribution probabilities.
Hip
White
Black
Other
Spine
18,154
7,191
44 395
20,699
15,476
19536
17,765
15,217
17052
Black
Other
29,616
34,050
•
22,735
•
20,487
• Not enough cases to apply attnbution probabilities
30
..
Forearm and Wrist
Black
Other
13,142
12135
*
10 646
*
5394
* Not enough cases to apply attribution probabilities
Other
Black
Other
18,612
27,758
*
21,495
*
8,876
* Not enough cases to apply attnlmtion probabilities
31
REVISED REVISED REVISED
Interim agendas can be obtained via the Internet at http://www.azleg.state.az.usJlnterimCommittees.asp
ARIZONA STATE SENATE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE AD HOC COMMITTEE ON OSTEOPOROSIS
~ Date:
Time:
Place:
Wednesday, September 22, 2004
10:00 a.m.
Senate Hearing Room 1
AGENDA
1. Opening Remarks
2. Presentation and Committee Discussion of Final Report on the State of Osteoporosis
in Arizona - Jeff Lisse, M.D. and Renea Gentry, M.C.
3. Presentation and Committee Discussion on Legislation Ideas for Next Session
- Tim Lohman, Ph.D. .
4. Adoption of the Final Report
5. Closing Remarks
6. Adjourn
Members:
Senator Toni Hellon, Chair Ptr.:.~;·>"C
Senator Robert Cannell
Jane Canby hb;;M'"t;
Renea Gentry
8/10/04
cd
Dr. Jeffrey Lisse
Dr. Timothy Lohman
Margie Tate
Terri Verason
Persons with a disability may request a reasonable accommodation such as a sign language interpreter, by contacting the
Senate Secretary's Office: (602)926-4231 (voice). Requests should be made as early as possible to allow time to arrange the
accommodation.
CORRECTED CORRECTED
ARIZONA STATE LEGISLATURE
AD HOC COMMITIEE ON OSTEOPOROSIS
Minutes of Meeting
Wednesday, September 22,2004 -10:00 a.m.
Senate Hearing Room 1
CORRECTED
Members Present:
Senator Robert Cannell
Renea Gentry
Margie Tate
Members Absent:
Senator Toni Hellon, Chair
Jane Canby
Dr. Jeffrey Lisse
Dr. Timothy Lohman
Terri Verason
Staff: Julie Keane, Senate Health Analyst
In the Chair's absence, Senator Cannell called the meeting to order at 10:00 a.m., and
attendance was noted. Introduction of the members took place.
Dr. Jeffrey Lisse gave a presentation on the research commissioned by the Arizona
Osteoporosis Coalition (Coalition), and distributed a handout entitled "Arizona Hip
Project" (Attachment A). Dr. Lisse described osteoporosis and indicated it is an
important issue that warrants further attention. He pointed out the various types of bone
fractures and highlighted statistical results of the study conducted at the University
Medical Center in Tucson as outlined in the handout. He said the key to osteoporosis is
prevention and is best treated in the pediatric age group. He emphasized that
education of patients and health care providers as well as screening for early detection
are critical issues in the prevention of osteoporosis.
Renea Gentry commented on the following charges to the Committee:
• To conduct research, which has been ongoing at the Medical Center at the
University of Arizona in Tucson.
• To look at what has been accomplished in the State to date on osteoporosis and
determine the goals on this issue.
Ms. Gentry distributed a report on the survey conducted entitled "Senate Ad Hoc
Committee on Osteoporosis," and highlighted key segments of that report (Attachment
B). She said that the research involved various agencies, and the unfortunate result
was that very little work is being accomplished in the area of osteoporosis. She noted
that despite scientific advances in the prevention, diagnosis and treatment of
osteoporosis, there are significant disparities in both recognition and dedicated
Senate Ad Hoc Committee
On Osteoporosis
September 22, 2004
Page 1
resources to effectively impact the prevalence of osteoporosis and its serious
implications for the aging population, Arizona communities and the healthcare system
statewide. She highlighted some of the challenges facing the Coalition and the State of
Arizona as outlined in the handout.
Ms. Gentry referred to page 4 of the handout and pointed out that the Coalition and
other individuals have suggested key recommendations as follows:
• A "clearinghouse" is needed for the integration of resources statewide~
• Funding is needed for a statewide screening program, especially in the rural
areas.
• There is a need to gather more osteoporosis specific data at the State level.
• It is important to combine osteoporosis with other major initiatives, such as
obesity and falls prevention.
• There is a need for managed care reform.
• There is a need for a pediatric standard of care for early prevention of
osteoporosis.
Margie Tate, Arizona Department of Health Services (DHS), commented there is a
financial impact on many of the recommendations that would need to be discussed with
the Director of DHS prior to any support.
Dr. Lisse stated that the recommendations would be costly; however, prevention is less
expensive than therapy.
Dr. Lohman commented on prevention, and stressed the importance of good nutrition
and exercise. He said that the message is not getting out either at the child or adult
level regarding the critical importance of proper nutrition and proper exercise to help
prevent osteoporosis. .
Ms. Tate stated she believes that progress is being made in the arena of good nutrition
and physical activity with the development of a State plan to address those issues.
Senator Cannell stated that it appears that there are still outstanding issues, and he
does not believe the final report is ready for approval today. He said he discussed the
matter with Chair Hellon and she is willing to continue to chair these efforts. He
commented that he needs to discuss this issue with the President of the Senate and
believes the Committee should meet with DHS before making any final
recommendations. He suggested that the Committee could undertake some steps,
such as inviting physicians from the Arizona Medical Association and the Academy of
Pediatrics on how to educate their members. He said discussions could take place with
the Director of the Arizona Health Care Cost Containment System (AHCCCS) regarding
managed care plans for preventing osteoporosis. He noted that DHS is a key player in
this issue. He indicated that pending approval of the President, the Committee may
want to extend its work into the next session and undertake additional work prior to
submitting the final report.
Senate Ad Hoc Committee
On Osteoporosis
September 22, 2004
Page 2
Ms. Gentry responded that it is a good idea to bring in more people so that the Coalition
can be as effective as possible with the recommendations.
Dr. Lohman stated that the Surgeon General's Report on Osteoporosis is due to be out
within the next couple of weeks, which would lend major support to the Committee's
goals.
In response to Senator Cannell, Wendy Baldo, Senate Senior Policy Advisor, stated that
it would be in order to request President Bennett to extend the Committee.
Terri Verason commented that the National Institute for Child Health and Human
Development has recognized osteoporosis as a problem and has instituted a campaign
called "Milk Matters" targeted at parents of teenagers and pediatricians to educate them
about the incidence of osteoporosis and the need for pediatric intervention for
prevention. She said there is a clearinghouse and educational materials that are
available for parents, families and health professionals.
Senator Cannell stated that based on these discussions, if everyone agrees, the final
report would be tabled for approval at a future date. He said the Committee will hold at
least one additional meeting to discuss these issues and to adopt the final report. He
suggested meeting with Director Eden of DHS within the next couple of months to
discuss the recommendations and funding needs as outlined today.
Ms. Verason emphasized the need for statewide screening programs that are available
at grocery stores and other facilities. She explained the screening procedures and
stressed the need for women and men to be educated regarding osteoporosis.
Senator Cannell stated that osteoporosis is an important issue and commended
Senator Yrun for initiating this topic. He said he is willing to continue working on this
issue and Chair Hellon has indicated her desire to continue as well. He said he would
meet with President Bennett to request a continuance of the Committee into the next
session.
There being no further business, the meeting adjourned at 10:39 p.m.
Respectfully submitted,
Nancy L. DeMichele
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115)
Senate Ad Hoc Committee
On Osteoporosis
September 22, 2004
Page 3
ARIZONA HIP PROJECT
RESEARCH COMMISSIONED BY
The Arizona Osteoporosis Coalition for
THE ARIZONA STATE SENATE
AD HOC COMMITTEE ON OSTEOPOROSIS
Principal Investigator: Jeffrey R. Lisse, M.D.
Sub-Investigators: Deborah Jane Power, D.O., Isidro Villanueva,
M.D., Timothy Lohman, Ph.D., Scott Going, Ph.D., B Austin Vaz,
M.D., Ph.D., Janet Campion, M.D., M.P.H., Belinda Botzong, R.T.,
Michael Maricic, M.D., Oscar Gluck, M.D.
9/22/04
AZ Hip Project
09/17/2004
During the five year time period 1998 - 2003 there were 729 patients treated for
fractures at the University Medical Center in Tucson, Arizona. At this time, 473 of the
729 patient charts with ICD-9 diagnostic codes for fractures have been reviewed. 150 of
the 473 charts meet the non-traumatic fragility fracture inclusion criteria for .the AZ Hip
Study. This means that the fractures were not incurred as a result oftrauma more forceful
than falling from a standing height. 118 medical charts have been screened. The collected
information has been entered into a database.
Of the 118 screened patient charts, 82 are female and 36 are male; 69.5% are
female and 30.5% are male. The mean age ofthe patients is 74.6 years old. There are 8
(6.8%) American Indians, 2 (1.7%) Asians, 3 (2.5%) African American and 104 (88.1 %)
Caucasians. 93 (78.8%) ofthe patients are retired. Fractures that occurred prior to the
indexed fracture are categorized into 5 groups: prior trochanter fractures, prior femoral
neck fractures, prior vertebral fractures, prior wrist fractures and prior other fractures.
Prior to their indexed fracture, 5.1% of patients had a trochanter fracture, 8.4 % of
patients had a femoral neck fracture, 36% of patients had at least one prior vertebral
fracture, 5.1% of patients had a wrist fracture and 20% of patients had other fractures.
52% of patients had at least one other (vertebral, hip or other) fragility fracture before the
indexed fracture date. 48% had no prior fragility fracture of any kind. Prior to their
indexed fracture, 12.7% of patients had DXA (the accepted way to diagnose
osteoporosis) examinations. After their indexed fracture, 4.2% of patients had DXA
examinations.
Frequencies
Arizona Hip Project- Patient Profile
Statistics
EMPLOYME MARTIAL
SEX NTSTATUS RACE ETHNICITY STATUS
N Valid 118 118 117 115 118
Missing 0 0 1 3 0
Frequency Table
SEX
Cumulative
Frequency Percent Valid Percent Percent
Valid Female 82 69.5 69.5 69.5
Male 36 30.5 30.5 100.0
Total 118 100.0 100.0
EMPLOYMENTSTATUS
Cumulative
Frequency Percent Valid Percent Percent
Valid 1 1 .8 .8 .8
Full-Time 2 1.7 1.7 2.5
House-person 4 3.4 3.4 5.9
Part-Time 1 .8 .8 6.8
Retired 93 78.8 78.8 85.6
Self-Employed 3 2.5 2.5 88.1
Student 1 .8 .8 89.0
Unemployed 13 11.0 11.0 100.0
Total 118 100.0 100.0
RACE
Cumulative
Frequency Percent Valid Percent Percent
Valid African American 3 2.5 2.6 2.6
Native American 8 6.8 6.8 9.4
Asian 2 1.7 1.7 11.1
White 104 88.1 88.9 100.0
Total 117 99.2 100.0
Missing System 1 .8
Total 118 100.0
ETHNICITY
Cumulative
Frequency Percent Valid Percent Percent
Valid Not Hispanic 100 84.7 87.0 87.0
Hispanic 15 12.7 13.0 100.0
Total 115 97.5 100.0
Missing System 3 2.5
Total 118 100.0
Arizona Hip Project- Patient Profile
MARTIALSTATUS
Cumulative
Frequency Percent Valid Percent Percent
Valid Divorced 5 4.2 4.2 4.2
Married 53 44.9 44.9 49.2
Separated 1 .8 .8 50.0
Single 20 16.9 16.9 66.9
Widowed 39 33.1 33.1 100.0
Total 118 100.0 100.0
Subjects by Sex
100
80
_ 60
c: :;,
o o
40
20
0..........--
Female
SEX
Male
100
80
_ 60
C
:::J o o
40
20
Arizona Hip Project- Patient Profile
Subjects by Ethnicity
Missing Not Hispanic
ETHNICITY
Hispanic
Frequencies
Statistics
Arizona Hip Project- Risk Factors
TOBACCO ALCOHOL
STATUS STATUS
N Valid 115 115
Missing 3 3
Frequency Table
TOBACCOSTATUS
Cumulative
Frequency Percent Valid Percent Percent
Valid Currently 12 10.2 10.4 10.4
In the past 53 44.9 46.1 56.5
Never 50 42.4 43.5 100.0
Total 115 97.5 100.0
Missing System 3 2.5
Total 118 100.0
ALCOHOLSTATUS
Cumulative
Frequency Percent Valid Percent Percent
Valid No 104 88.1 90.4 90.4
Yes 11 9.3 9.6 100.0
Total 115 97.5 100.0
Missing System 3 2.5
Total 118 100.0
Arizona Hip Project- Medication History
ZOLMETAREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 117 99.2 99.2 100.0
Total 118 100.0 100.0
ZOLMETAPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 79 66.9 66.9 100.0
Total 118 100.0 100.0
Arizona Hip Project- Medication History
HORMONESREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 116 98.3 98.3 99.2
Yes 1 .8 .8 100.0
Total 118 100.0 100.0
HORMONESPOST
Cumulative
Frequencv Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 78 66.1 66.1 99.2
Yes 1 .8 .8 100.0
Total 118 100.0 100.0
AREDIAPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 116 98.3 98.3 98.3
Yes 2 1.7 1.7 100.0
Total 118 100.0 100.0
AREDIAREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 111 94.1 94.1 94.9
Yes 6 5.1 5.1 100.0
Total 118 100.0 100.0
AREDIAPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 40 33.9 33.9 33.9
No 75 63.6 63.6 97.5
Yes 3 2.5 2.5 100.0
Total 118 100.0 100.0
ZOLMETAPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 118 100.0 100.0 100.0
Arizona Hip Project- Medication History
FORTEOREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 116 98.3 98.3 99.2
Yes 1 .8 .8 100.0
Total 118 100.0 100.0
FORTEOPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 79 66.9 66.9 100.0
Total 118 100.0 100.0
EVISTAPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 116 98.3 98.3 98.3
Yes 2 1.7 1.7 100.0
Total 118 100.0 100.0
EVISTAREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 116 98.3 98.3 99.2
Yes 1 .8 .8 100.0
Total 118 100.0 100.0
EVISTAPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 79 66.9 66.9 100.0
Total 118 100.0 100.0
HORMONESPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 116 98.3 98.3 98.3
Yes 2 1.7 1.7 100.0
Total 118 100.0 100.0
Arizona Hip Project- Medication History
FOSAMAXREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 100 84.7 84.7 85.6
Yes 17 14.4 14.4 100.0
Total 118 100.0 100.0
FOSAMAXPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 38 32.2 32.2 32.2
No 73 61.9 61.9 94.1
Yes 7 5.9 5.9 100.0
Total 118 100.0 100.0
MIACALCINPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 106 89.8 89.8 89.8
Yes 12 10.2 10.2 100.0
Total 118 100.0 100.0
MIACAlCINREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 104 88.1 88.1 89.0
Yes 13 11.0 11.0 100.0
Total 118 100.0 100.0
MIACALCINPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid No 39 33.1 33.1 33.1
Yes 79 66.9 66.9 100.0
Total 118 100.0 100.0
FORTEOPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 118 100.0 100.0 100.0
Arizona Hip Project- Medication History
VITAMINDREC
Cumulative
Frequencv Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 81 68.6 68.6 69.5
Yes 36 30.5 30.5 100.0
Total 118 100.0 100.0
VITAMINDPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 61 51.7 51.7 84.7
Yes 18 15.3 15.3 100.0
Total 118 100.0 100.0
ACTONELPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 115 97.5 97.5 97.5
Yes 3 2.5 2.5 100.0
Total 118 100.0 100.0
ACTONELREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 114 96.6 96.6 97.5
Yes 3 2.5 2.5 100.0
Total 118. 100.0 100.0
ACTONELPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 77 65.3 65.3 98.3
Yes 2 1.7 1.7 100.0
Total 118 100.0 100.0
FOSAMAXPRE
Cumulative
Frequencv Percent Valid Percent Percent
Valid No 107 90.7 90.7 90.7
Yes 11 9.3 9.3 100.0
Total 118 100.0 100.0
Arizona Hip Project- Medication History
EsTROGENREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 97 82.2 82.2 83.1
Yes 20 16.9 16.9 100.0
Total 118 100.0 100.0
ESTROGENPOST
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 70 59.3 59.3 92.4
Yes 9 7.6 7.6 100.0
Total 118 100.0 100.0
CALCIUMPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 91 77.1 77.1 77.1
Yes 27 22.9 22.9 100.0
Total 118 100.0 100.0
CALCIUMREC
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 1 .8 .8 .8
No 79 66.9 66.9 67.8
Yes 38 32.2 32.2 100.0
Total 118 100.0 100.0
CALCIUMPOsT
Cumulative
Frequency Percent Valid Percent Percent
Valid N/A 39 33.1 33.1 33.1
No 58 49.2 49.2 82.2
Yes 21 17.8 17.8 100.0
Total 118 100.0 100.0
VITAMINDPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 89 75.4 75.4 75.4
Yes 29 24.6 24.6 100.0
Total 118 100.0 100.0
# OP Meds Post·fracture
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 39 33.1 33.1 33.1
1.00 61 51.7 51.7 84.7
2.00 14 11.9 11.9 96.6
3.00 4 3.4 3.4 100.0
Total 118 100.0 100.0
0.70
0.60
0.50
c: 0.40
ca
Q)
~
0.30
0.20
0.10
0.00-'---
On OP Med Pre-fracture OP Mad Recommended On OP Med Post-fracture
Frequency Table
ESTROGENPRE
Cumulative
Frequency Percent Valid Percent Percent
Valid No 97 82.2 82.2 82.2
Yes 21 17.8 17.8 100.0
Total 118 100.0 100.0
1""'\- .......
Arizona Hip Project- Medication History
Frequency Table
On OP Med Pre-fracture
Cumulative
Freauency Percent Valid Percent Percent
Valid .00 77 65.3 65.3 65.3
1.00 41 34.7 34.7 100.0
Total 118 100.0 100.0
# OP Meds Pre-fracture
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 77 65.3 65.3 65.3
1.00 31 26.3 26.3 91.5
2.00 8 6.8 6.8 98.3
3.00 2 1.7 1.7 100.0
Total 118 100.0 100.0
OP Med Recommended
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 73 61.9 61.9 61.9
1.00 45 38.1 38.1 100.0
Total 118 100.0 100.0
# OP Meds Recommended
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 73 61.9 61.9 61.9
1.00 29 24.6 24.6 86.4
2.00 15 12.7 12.7 99.2
3.00 1 .8 .8 100.0
Total 118 100.0 100.0
On OP Med Post-fracture
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 39 33.1 33.1 33.1
1.00 79 66.9 66.9 100.0
Total 118 100.0 100.0
0.14
0.12
0.10
C 0.08
~
:i
0.06
0.04
0.02
O.OO-L-_-
Arizona Hip Project- Fracture and DXA History
DXA Pre-fracture? DXA Post-fracture?
Arizona Hip Project- Fracture and DXA History
PRIORFRACTURESWRIST
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 112 94.9 94.9 94.9
1 4 3.4 3.4 98.3
2 2 1.7 1.7 100.0
Total 118 100.0 100.0
PRIORFRACTURESOTHER
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 94 79.7 79.7 79.7
1 15 12.7 12.7 92.4
2 3 2.5 2.5 94.9
3 4 3.4 3.4 98.3
4 1 .8 .8 99.2
5 1 .8 .8 100.0
Total 118 100.0 100.0
# Prior Fractures
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 57 48.3 48.3 48.3
1.00 20 16.9 16.9 65.3
2.00 6 5.1 5.1 70.3
3.00 17 14.4 14.4 84.7
4.00· 5 4.2 4.2 89.0
5.00 4 3.4 3.4 92.4
6.00 4 3.4 3.4 95.8
7.00 3 2.5 2.5 98.3
8.00 1 .8 .8 99.2
9.00 1 .8 .8 100.0
Total 118 100.0 100.0
Graph
Arizona Hip Project- Fracture and DXA History
# DXA Pre-fracture
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 103 87.3 87.3 87.3
1 7 5.9 5.9 93.2
2 5 4.2 4.2 97.5
3 1 .8 .8 98.3
4 2 1.7 1.7 100.0
Total 118 100.0 100.0
# DXA Post-fracture
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 113 95.8 95.8 95.8
1 4 3.4 3.4 99.2
2 1 .8 .8 100.0
Total 118 100.0 100.0
PRIORFRACTURESFEMORALNECK
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 108 91.5 91.5 91.5
1 9 7.6 7.6 99.2
2 1 .8 .8 100.0
Total 118 100.0 100.0
PRIORFRACTURESVERTEBRAL
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 75 63.6 63.6 63.6
1 14 11.9 11.9 75.4
2 10 8.5 8.5 83.9
3 8 6.8 6.8 90.7
4 4 3.4 3.4 94.1
5 2 1.7 1.7 95.8
6 2 1.7 1.7 97.5
7 2 1.7 1.7 99.2
8 1 .8 .8 100.0
Total 118 100.0 100.0
PRIORFRACTURESTROCHANTER
Cumulative
Frequency Percent Valid Percent Percent
Valid 0 112 94.9 94.9 94.9
1 6 5.1 5.1 100.0
Total 118 100.0 100.0
Arizona Hip Project- Fracture and DXA History
Admission Fracture Vertebra
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 112 94.9 94.9 94.9
1.00 6 5.1 5.1 100.0
Total 118 100.0 100.0
Admission Fracture Collapsed Vertebra
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 70 59.3 59.3 59.3
1.00 48 40.7 40.7 100.0
Total 118 100.0 100.0
Admission Fracture Lumbar Vertebra
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 108 91.5 91.5 91.5
1.00 10 8.5 8.5 100.0
Total 118 100.0 100.0
Admission Fracture Stress Fracture
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 118 100.0 100.0 100.0
Descriptives
Descriptive Statistics
N Minimum Maximum Mean Std. Deviation
# DXA Pre-fracture 118 0 4 .24 .724
DXA Pre-fracture? 118 .00 1.00 .1271 .33453
# DXA Post-fracture 118 0 2 .05 .256
DXA Post-fracture? 118 .00 1.00 .0424 .20230
PRIORFRACTURESF
EMORALNECK 118 0 2 .09 .320
PRIORFRACTURESV
ERTEBRAL 118 0 8 1.00 1.744
PRIORFRACTUREST
ROCHANTER 118 0 1 .05 .221
PRIORFRACTURES
WRIST 118 0 2 .07 .313
PRIORFRACTURESO
THER 118 0 5 .36 .872
# Prior Fractures 118 .00 9.00 1.5678 2.11417
Prior Fractures? 118 .00 1.00 .5169 .50184
Hip Fracture ICD 118 .00 .00 .0000 .00000
Vertebral Fracture ICD 118 .00 1.00 .0678 .25247
Valid N (listwise) 118
Frequency Table
Arizona Hip Project- Fracture and DXA History
Frequency Table
Admission Fracture All Hip (femur, trochanter, closed hip)
Cumulative
Frequency Percent Valid Percent· Percent
Valid .00 66 55.9 55.9 55.9
1.00 52 44.1 44.1 100.0
Total 118 100.0 100.0
Admission Fracture All Vertebral (Vertebra, dorsal, collapsed, lumbar)
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 52 44.1 44.1 44.1
1.00 66 55.9 55.9 100.0
Total 118 100.0 100.0
Admission Fracture Femur
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 110 93.2 93.2 93.2
1.00 8 6.8 6.8 100.0
Total 118 100.0 100.0
Admission Fracture Closed Hip
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 83 70.3 70.3 70.3
1.00 35 29.7 29.7 100.0
Total 118 100.0 100.0
Admission Fracture Trochanter
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 109 92.4 92.4 92.4
1.00 9 7.6 7.6 100.0
Total 118 100.0 100.0
Admission Fracture Dorsal Vertebra
Cumulative
Frequency Percent Valid Percent Percent
Valid .00 114 96.6 96.6 96.6
1.00 4 3.4 3.4 100.0
Total 118 100.0 100.0
Senate AdHoc Committee
on Osteoporosis
I. Executive Summary: Trends, Challenges
and Recommendations page 2
II. Background
• Senate Ad Hoc Committee on·Osteoporosis
• Osteoporosis defined
• National Statistics about Osteoporosis
• Arizona Data '
• Recent national attention
• Evidence supporting the need for aggressive statewide
action
page 6
Report for the Senate Ad Hoc Committee onOsteoporosis
TRENDS
There are good resources for information about osteoporosis across the state, but efforts
to educate and communicate about this condition are fragmented and the consumer has
no pathway to connectfrom one~resource to another. They will either be left with
incomplete information or become frustrated and stop investigating.
Information and services appear to be grouped according to the following resources.
• State: BRFS surveillance, minigrants supporting mandated initiatives from CDC (i.e.
Obesity), no direct program for bone health atthis time.
• County: Nutrition education usually available.
• Cooperative Extension: Funding dependent, nutrition and exercise information by
. Bone Builders (classes, toll free phone information, newsletters, community events)
and some screening.
• Cities: (Department of Parks & Recreation) - General exercise classes, many include
strength training and classes indirectly addressing balance (tai chi).
• Area Agencies on Aging (federal, by state region = multiple counties) - Do not
provide services such as screening. By phone interview, staff was unaware of where
to make referrals for bone health information. Units on Aging! Senior Centers provide
social services & oversight of nutrition programs (disease mgt - DM, heart) w/
guidelines. There is no physical activity programming. They provide more of a
facilitative/supervisory role than providing any direct care or education. Supported
primarily by federal and corporate ;funds. Seniors have aged in place... centers are
not effectively recruiting younger elders.
• Arizona Association ofCommunity Health Care Centers - nonprofit centers provide
healthcare for underserved populations in rural and outlying areas around the state.
Recently surveyed, 31 out of 33 centers do not have screening equipment nor much
access to this service. Only a few of the centers even refer patients out for diagnostic
osteoporosis tests. .
• Private Agencies: Education and awareness materials - minimal funding for
programs.
• HospitaVllealthcare Systems: Provide direct patient services for screening, provide
educational materials and programming to target populations.
• Health related consumer organizations: AzOC is the only organization dedicated to
a focus ofONLY osteoporosis, others include osteoporosis as one of several
initiatives (Arthritis Foundation, Healthy Women for a Lifetime). Funding dependent.
Provide consumer and provider education, public awareness materials and occasional
screening.
2
Report for the Senate Ad Hoc Committee on Osteoporosis
CHALLENGES
In spite ofscientific advances in the prevention, diagnosis and treatment ofosteoporosis,
there are significant disparities in both recognition and dedicated resources to effectively
impact the prevalence ofosteoporosis, and its serious implications for the aging
population, AZ communities and the healthcare system statewide.
• Bone health is not recognized as a compelling issue among policy makers, healthcare
professionals and the general public. Priorities for underserved and disadvantaged
women are many and urgent due to lack of resources, barriers to services and care and
cultural issues. Osteoporosis is a disease with less immediate consequences and may
therefore be less of a priority for action and designation of resources.
• Competition with other healthcare issues exists for both public and private dollars
• There is a lack of coordination or integration ofresources across public and private
organizations /agencies across the state (as described in "trends").
• There is a lack of a single entry point into the osteoporosis network for the public
(consumers) (i.e. AZ Heart Association for heart disease information, Arthritis
Foundation for joint conditions, etc.).
• Insurance coverage for screening/DXA is variable and inconsistent among 3rd party
payers.
• Insurance coverage for pharmaceutical and rehabilitative treatment is variable and
inconsistent among 3rd party payers.
• Transportation/access to community programs for seniors is often unavailable
• Data suggests that osteoporosis is more common in Hispanics than previously
believed. More than a quarter of Arizona's population is Hispanic. Demographic,
ethnic, and economic assessment ofArizona's population tells us that we are not
currently reachingthe state's minority populations with a message of osteoporosis
prevention.
• Guidelines on Bone Mineral Density by credible organizations are inconsistent.
• There is inadequate access to preventative services and treatment across the state.
• Variable knowledge and priority is placed on issues and conditions related to bone
disease by health care providers.
• At the national level, there is limited collaboration between the CDC (responsible for
public health services) and the Administration on Aging (responsible for elder
services). State health departments often focus on specific at-risk populations,
however these programs rarely target older adults. Units on Aging often engage in
health promotion activities and referral, but rarely col~aborate with their public health
counterparts.
• Variables that would further increase the magnitude of the bone health issue for
Arizona would be:
1. a higher fracture incidence rates (esp. hip fx) than currently measured
2. a higher population growth (esp. in the 65+ population) than presently anticipated
3. a higher cost of treating fractures than estimated at this point in time
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Report for the Senate Ad Hoc Committee on Osteoporosis
RECOMMENDATIONS
Identify a coordinating agency/clearinghouse ofosteoporosis programs, research and
initiatives statewide for referral, collaboration, and integration ofservices.
Key Points:
a) The Arizona Osteoporosis Coalition, in collaboration with
ADHS, shall be designated as the state clearinghouse for
education and prevention of osteoporosis and for implementation
of the recommendations ofthe Surgeon General's report on
osteoporosis, 2004.
b) AzOC, in collaboration with ADHS, shall develop a statewide
network for conducting osteoporosis screening, especially in
rural counties and outlying areas, using DXA mobile units.
c) AzOC with ADHS shall develop a pediatric prevention standard
of care to be implemented statewide in conjunction with
pediatricians throughout the state.
d) ADHS will add the CDC module for osteoporosis to Arizona's
Behavioral Risk Factor Survey.
e) AzOC will pursue the need for managed care reform to reflect
appropriate screening, diagnosis and treatment for osteoporosis,
including mandatory screening for all women over 65.
STATE GOVERNMENT ACTIONS
• Ask the Arizona legislature to provide leadership regarding appropriate
legislation: 1) for funding for statewide screening, (see AzOC Actions below);
2) for Managed Care reform that provides patients with appropriate screening,
diagnosis and treatment options. Bone mineral density screening should be
mandatory for all post-menopausal women under 65 and all women over 65
regardless of the number of risk factors. (The National Osteoporosis Foundation (NOF)
has already made this recommendation. (fhvsician's Guide to Prevention and Treatment of
Osteoporosis. National Osteoporosis Foundation. (p 1) Excerpta Medica, Inc: Belle Meade, NJ
1999) However, in many health plans women will only receive screening ifreferred by the
primary care physician. Early detection through routine screening and appropriate subsequent
bitervention will significantly decrease the number offractures. (statement from AzOC monograph
2000)
• Add CDC osteoporosis module to state BRFSS to improve surveillance, (as/ound in
-the Inventory o/State Osteoporosis Activities by Maryland Department o/Health and Mental Hygiene 2004)
• Ask ADHS to provide ongoing collection of statewide data on osteoporosis
prevalence and burden of the disease, including data on non traumatic fractures in
individuals of all ages, utilizing ADHS, managed care organizations and other
routine data collection systems and sources within the state.
-. Ask ADHS to combine osteoporosis with their major initiatives such as Obesity
and Falls Prevention in elderly.
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Report for the Senate Ad Hoc Committee on Osteoporosis
AzOC ACTIONS
• The Arizona Osteoporosis Coalition will develop a statewide osteoporosis
screening/scanning program to reach rural and outlying areas with little access to
healthcare, in conjunction with the County Health Departments and the Arizona
Association of Community Health Centers during the 2004-'06 fiscal years. The
project will also involve an educationlinfonnation component for the rural areas
visited by the screening teams. .
• Plan network structure with the Arizona Department of Health Services to support
coordinating agency functions and bring ADHS to the planning table.
• Agency will become a key player in osteoporosis infonnation at gatherings such as
the Governor's Office for Women and Children meetings, ADHS, Advisory Council
on Aging, Council on Health, Physical Fitness and Sports, etc.
• Utilize existing materials
1. Bilingual Brochures
2. AzOC Newsletter
3. AzOC list serve
4. AzOC website, www.fitbones.org
5. AzOC website for children, www.buildingbetterbones.org
6. Toll-free # for infonnation (Cooperative Extension)
7. Statewide PSA's - organized by ADHS (AzOC tape)
a. Local Radio and TV
8. LatinolNative American stations (see below)
9. Provide osteoporosis infonnation at other health focus events/programs (i.e.
Women's Expo, Well Woman Health Check, other health and wellness
venues)
• New materials/targets
1. Primary care: Messages for healthcare professionals are focused on their desire to
provide appropriate and thorough care to their patients. Provide infonnation to
key support staff that prompt screening for risk factors such as height loss and
fractures.
a. Communicate through existing associations (AzMA, Family Practice etc.)
b. Partner with physician's offices and health clinics in Hispanic and Native
American communities.
2. Reaching the AZ Hispanic and Native American Communities:
a. Distribution of print materials placed at locations where these target
populations acquire other fonns of health services and infonnation.
(chain and grocery pharmacies in target neighborhoods, local food
banks, Maricopa County AHCCCS health plan quarterly member
newsletter, etc.) This will require developing an alliance with key
resources in the community.
b. Spanish radio is a cost efficient way to reach the target of Hispanic
women in AZ. Negotiate PSA spot time on the key radio outlets.
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Report for the Senate Ad Hoc Committee on Osteoporosis
Background
I. Senate Ad Hoc Committee on Osteoporosis
II. Osteoporosis defined
III. National Statistics about Osteoporosis
IV. Arizona Data
V. Recent national attention
VI. Evidence supporting the need for aggressive statewide
action to support osteoporosis programs, research and
initiatives for referral, collaboration and elimination of
barriers to appropriate screening, diagnosis and treatment
options:
-Osteoporosis is under diagnosed and under treated
-Bone Loss, T-Scores and Height Loss
-Bone Mineral Density Scores provide motivation for
behavior change
-Guidelines for BMD screening/testing available
-Current healthcare coverage for diagnosis and treatment
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Report for the Senate Ad Hoc Committee on Osteoporosis
I. Senate Ad Hoc Committee on Osteoporosis
PURPOSE: To : (1) research and collect information on Osteoporosis; (2) evaluate the
various approaches used by the Senate and local governments to increase public
awareness ofthe risk, treatment and prevention of Osteoporosis; (3) identify areas where
public awareness, public education, research and coordination about Osteoporosis need
improvement; and (4) study ways to (a) increase the number of individuals in this State
who are regularly screened for Osteoporosis, (b) increase research and funding at State
institutions that are studying Osteoporosis, and (c) improve coordination between State
agencies and institutions that are involved in research and treatment of Osteoporosis. The
Committee shall submit a written report of its findings to the Governor, the Speaker of
the House of Representatives and the President ofthe Senate, and provide a copy of this
report to the Secretary of State and th~ Director of the Arizona State Library, Archives
and Public Records by November 15,2004.
MEMBERSHIP:
Senate Two members of the Senate, from different political parties and one designated
as Chair, appointed by the President of the Senate:
(Chair) Toni Hellon (R - district 26)
Robert Cannell (D - district 24)
Other: 7 members of the public, appointed bythe President ofthe Senate:
Ms. Jane Canby
Ms. Renea Gentry, Arizona Osteoporosis Coalition
Dr. Jeffrey Lisse, Arizona Arthritis Center, University ofAZ
Dr. Timothy Lohman, University of Arizona
Ms. Margie Tate, Arizona Department of Health Senrices
Ms. Terri Verason, Dairy Council of Arizona
Contact: Julie Keane, Senate Research staff; Pete Wertheim, House Research staff
Report Date:-----
Expiration Date: 12/0112004
Statutory Cite: Created by the President of the Senate in November 2002.
II. Osteoporosis defined
Osteoporosis is the technical name for a disease in which bones become extremely thin
and frail. The body typically has fully developed skeletal (bone) mass by the time an
individual has reached the early twenties. After this point, a gradual loss of bone mass
(known as bone mineral density orBMD) occurs throughout the rest of natural life. Once
a person's BMD has decreased below a certain level, the risk bfbreaking a bone
increases dramatically. Even the slightest slip or fall in a person with osteoporosis can
result in fractures of the hip, spine, forearm, or wrist. These fractures decrease mobility,
functionality and independence in the person suffering the fracture. Consequently,
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Report for the Senate Ad Hoc Committee on Osteoporosis
osteoporosis can significantly degrade one's quality of life. In fact, 25% of patients die
during the first year after a hip fracture. The fact that most osteoporosis related fractures
occur in the elderly also places tremendous burden on the caregivers who are often
immediate family.
t),~~J~ MICROGRAPHS
Micrographs' Of biopsy specimens of normal and osteoporotic bone.
Panel Ais from a 75-year-old normal woman. Panel Bis from a
41-year-old woman who had multiple vertebral compression fractures.
from Dempster OW, et aL J Bone Hiner Res. 1986;1:1S-21.
Osteoporosis is often undetectable because loss of bone mass typically occurs over a long
period of time and is without symptoms until a fracture occurs. Thus osteoporosis is
referred to as "the silent disease". (excerpts from the Arizona Osteoporosis Coalition
monograph titled "Osteoporosis and its effect on the people of Arizona", 5/00
www.fitbones.org/facts )
III. National Statistics about Osteoporosis
• 44 million people in the United States are affected by osteoporosis and low bone
mass, according to the National Osteoporosis Foundation: 80% are women
• 33% ofmen over age 75 are affected
• 50% ofwomen & 13% men older than 50 will have an osteoporosis related
fracture in their lifetime
• ~1 of 5 (19.2 %) of women who suffered a vertebral fracture sustained a second
fracture within 1 year (even with 1000mg Calcium and Vitamin D supplements)
• Patients with vertebral fracture have nearly double the risk for fractures at other
sites
• Medicare beneficiaries significantly underutilize routine BMD testing, a covered
benefit since 7/98 under the 1997 Balanced Budget Act. It is estimated that only
12% ofwomen age 65+ received a Medicare reimbursed BMD test in 2001.
• Hispanic and Native American Populations: Osteoporosis Issues
o Latino/Hispanic Population National Stats
1. There are 36 million Latinos in the US
2. . Latinos are the 2nd largest ethnic group in the US
3. The main immigrant group is Latino
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Report for the Senate Ad Hoc Committee on Osteoporosis
• Incidence of Osteoporotic Fractures in the Hispanic Community
"Differences in fracture incidence according to racial/ethnic group were observed
in NORA. Although the prevalence of osteoporosis was higher among Asian and
Hispanic women than among whites, the likelihood of fracture was no different
for Hispanics and was lower for Asians."
Siris E, Miller P, Barrett Conner E., et aI. Identification and Fracture Outcomes of
Undiagnosed Low Bone Minerai Density in Postmenopausal Women.
JAMA.2001;286:2815-2822.
• NHANES III Study results for Hispanic Women: Key Point - Osteoporosis is
more common in Hispanics than previously believed
Age Criteria >50
White Women 59%
Hispanic Women 49%
BMD site Total Hip
Looker AC, Wahner HW, Dunn WL, et al. Updated data on proximal
femur bone mineral levels ofUS adults. Osteoporos Int. 1998;8:468-489.
IV. Arizona Data
• Arizona has one ofthe nation's fastest growing populations of people over age 50.
Over the next' 10 years, the size of the age-50 population will increase by 40%
(from 1.3 million to 1.9 million). By 2025, there will be an increase ofnearly
85%. The population over age 65 also will show rapid growth from its year 2000
total of 634,500, with increases of27% by 2010, 52% by 2015, 82% by 2020, and.
116% by 2025. .
• The National Osteoporosis Foundation (NOF) estimates that 810,000 women and
men had osteoporosis or low bone mass in 2003. By 2025, the NOF predicts AZ
will have 1.1 million people with osteoporosis and low bone mineral density.
• 1997 Arizona Hospital Admissions for Osteoporosis Fractures:
6,000 osteoporosis fractures
31,000 hospital bed days
4.6 days mean Length of Stay for vertebral fracture patients
41% of vertebral cases and 60% of hip fracture cases were discharged to a
long term care facility
• Conservative estimates using 1998 Arizona hospital discharge data place the cost
of osteoporosisin the state at about $177 million. This does not include the costs
after being discharged, which can include significant costs for long-term care
and/or additional rehabilitation and health care. It also does not account for the
significant impact on quality of life.
• 2002 American Community Survey Profile, US Census Bureau AZ Population:
5 % American Indian and Alaska Native
27% Hispanic. (People of Hispanic origin may be of any race.)
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Report for the Senate Ad Hoc Committee on Osteoporosis
Among people at least five years old living inArizona in 2002, 26 percent spoke a
language other than English at home. Ofthose speaking a language other than
English at home, 77 percent spoke Spanish (20% oftotal AZ population)
• Demographic, ethnic, and economic assessment of Arizona's population tells us
that we are not currently reaching the state's minority populations with a message
of osteoporosis prevention. More than a quarter of Arizona's population is
. Hispanic. Inadequate nutritional intake of calcium and inactivity are two primary
lifestyle behaviors which increase risk for osteoporosis.
o The 1999 Arizona Hunger Advisory Council reported 65% ofthose
requesting emergency food boxes are women. Other populations identified
most likely to be hungry and therefore lacking in adequate nutrition
include the working poor and minorities. 82.2% of Hispanics in Arizona
consume less than the RDA for calcium.
o The Arizona BRFSS demonstrates that 50.3% of Hispanic adults have a
greater risk for sedentary lifestyle as do low income individuals
«lO,OOO/year) at aprevalence of 45.6% .
o Issues of language barriers, low wages and lack of health insurance make
these populations less likely to access healthcare system and services.
Therefore, they are not in the mainstream of health information.
V. Recent national attention
• Healthy People 2010 has set an objective to reduce the proportion of adults with
osteoporosis, reduce hospitalization rates and falls.
• The Surgeon General workshop on Osteoporosis and Bone Health. 12/2002,
began preliminary work for the Surgeon General's Report on Bone Health to be
released in the fall of 2004.
• NIH consensus Development Conference on Osteoporosis Prevention, Diagnosis
and Therapy was held 3/2000.
• US preventative Services Task Force, 2002 prepared a review of indications for
screening.
• The Maryland Department of Health and Mental Hygiene's Osteoporosis
Prevention and Education Task Force released in June 2004 a survey of all 50
states and their legislative and service activities related to osteoporosis. Thirty­two
states have osteopo.rosis laws on the books; Arizona is not among them.
• The Administration on Aging recently (2002) requested an action plan to
implement an osteoporosis awareness campaign, specifically targeting women age
65 and older. The Foundation for Osteoporosis Research and Education headed
the project convening osteoporosis and aging services experts and stakeholders
from around the country in a consensus building process in order to formulate this
plan. The Arizona Osteoporosis Coalition was a member ofthe planning
committee for this national effort.
VI. Evidence supporting the need for aggressive statewide action to support
osteoporosis programs, research and initiatives for referral, collaboration and
elimination of barriers to appropriate screening, diagnosis and treatment options
Osteoporosis is under diagnosed and under treated.
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Report for the Senate Ad Hoc Committee on Osteoporosis
The vast majority ofwomen do NOT receive drug treatment for osteoporosis following a
fracture ofthe hip, wrist or vertebra.
1. Journal of Bone and Joint Surgery 82-A, No.8 1063-1070; 2000.
• Retrospective cohort study wi use of claims database including over 3
million patients from 30 states
• Identification ofALL women age 55+ wi distal radial fracture wlin 12 mo
period: N=1162
• 2.8% received a bone density scan
• 22.9% received a pharmacological intervention
• = ONLY 24% received evaluation or treatment for osteoporosis
2. Arch Internal Medicine Vol 162, 421-426; Feb 2002
• Retrospective cohort study, 343 postmenopausal women mean age 70.5,
Olmstead County, MN wi minimal trauma distal foreann fracture 1993­1997.
• ONLY 18% had any evidence of intervention for osteoporosis within the
following 12 month period
3. Osteoporosis International 11 :577-582, 2000
• Review of chest X-rays obtained for women age 60+ from routine hospital
admissions (N=943)
• 130 had a vertebral fracture present
• 52% were mentioned in the radiology report
• 23% mentioned in the report summary
• 17% mentioned osteoporosis in the medical record
• only 7% received Treatment
4. Archives ofInternal Medicine, 9/22/03
• Retrospective study of 7 HMO databases
• N= 3492 women age 60+ with fx of the hip, wrist or vertebra
• Only 24% received a drug for osteoporosis during the 1 yr period post­fracture
• Increasing age was correlated with a decreased likelihood of receiving
osteoporosis treatment
5. NHANES III 1997
• only 19% of people over 50 with osteoporosis are diagnosed and
treated.
6. Archives ofInternal Medicine, 2003; 163: 2237-46
• 4.6% of older population received osteoporosis treatment after fracture
7. Am Journal of Public Health, 2002; 92:271-3
• PCPs identify less than 10% ofwomen with osteoporosis or vertebral
fractures and of those diagnosed, fewer than 36% are prescribed
medication
Bone Loss, T-Scores and Height Loss. Understanding the objective measures which
describe bone health support the need for early detection and intervention.
1. Bone loss with age
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Report for the Senate Ad Hoc Committee on Osteoporosis·
• Genetic influences account for ~75% of variation in peak bone mass and
rate of bone loss
• Rapid bone loss of 2-3%/year over the 5-10 years after menopause '
• This results in up to 20% bone loss in the first 5-7 years post menopause
• Bone mass continues to decline wi age but at a slower rate than during the
early menopausal years. (female more = to male)
2. Risk of fracture
• T score = a unit of measure expressing the variation from peak bone mass
as a standard deviation score.
• Fracture threshold = standard deviation of 2 (T score -2)
• 2 fold increase in fracture risk for every standard deviation ofreduction in
bone mass (T score -3 = 8x fracture risk)
• Necessary to establish baseline to assess response to treatment, and
enhance compliance wi interventions
• Baseline at age ~35 gives best predictive risk
3. What about height?
• Normal aging ofthe intervertebral discs results in 1-1.5" loss of height
• More than 1.5" loss - suspect silent vertebral compression fracture
• Each compression fracture causes an additional ~1.5" loss of height
• Height should be included in every primary care physical exam.
4. The Vertebral Fracture Cascade
• 3 large clinical trials, 2725 postmenopausal women in control groups
• ~1 of 5 (19.2 %) ofwomen who suffered a vertebral fx sustained a second
fracture within 1 year (even with 1000mg Calcium and Vitamin D
supplements)
• Patients with vertebral fx have nearly double the risk for fractures at other
sites
• Emphasis on the need to prevent the first fracture!
World Congress on Osteoporosis 6/00
5. Pre-menopausal fractures increase risk of subsequent fractures
• Study population 24 years post menopause
• Independent ofage, bone density, body weight, alcohol intake and history
of smoking
• Incidence ofANY fracture between the age of 20-50 increases risk of
fracture after age 50 by 74% (not including motor vehicle accidents)
Arch Intern Med Vol 162, 33-36, 2002
"Despite the accumulated evidence showing the importance of prevalent fractures in
predicting future fracture risk, ...most physicians fail to take diagnostic or therapeutic
steps. Now is the time for the osteoporotic fracture to assume its rightful importance and
signal an appropriate evaluation and treatment" Elliott Schwartz, MD & Risa Keegan,
MD, Foundationfor Osteoporosis Research and Education
Bone Mineral Density Scores provide motivation for behavior change. Studies
demonstrate that to decrease osteoporosis prevalence and the related consequences by
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Report for the Senate Ad Hoc Committee on Osteoporosis
changing bone health behaviors and seeking treatment, we must increase the number of
men and women who are tested, diagnosed and informed about preventive measures.
1. J Bone Min Res Vol 14:12; 2143-2149; 1999
• 669 healthy premenopausal women age 18-35
• Interview questionnaire assessing lifestyle behaviors
• Received BMD testing (20% were low) and written education
• Repeat questionnaire 1 year later
• Results - Those women with low BMD:
More likely to report increase milk intake and supplement Calcium
- Less likely to smoke, consume alcohol and drink >3 caffeinated
beverages/day
2. CalcifTissue Int 66:113-118, 2000
• 701 women age 50+ referred to community osteoporosis prevention
. program, followed for 3 years
• 58% - normal bone mass
• 24% - moderately low bone mass
• 18% severely low bone mass
• Behaviors after bone densitometry
Started HRT
Increased exercise
Decreased caffeine intake
Stopped smoking
Increased dietary calcium and calcium supplements
Increased fall prevention & safety behaviors
• Greater % change w/lower bone density
Guidelines for BMD screening/testing available (*See Appendix 1)
• International; Society for Clinical Densitometry position 2003
• National Osteoporosis Foundation 2002
• Foundation for Osteoporosis Research and Education 2002
• US preventative Services Osteoporosis Screening Recommendations, 2002
• American Association of Clinical Endocrinologists
• American College of Rheumatology
• Surgeon General's Report on Bone Health (pending) 2005
Current healthcare coverage for diagnosis and treatment
• Medicare criteria (*See Appendix I - #8)
• Healthplan Survey of Women's Health Services in AZ Health Plans (*See
Appendix 2 - #7)
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