Senate Ad Hoc Committee on Osteoporosis: final report and recommendations

              SENATE AD HOC COMMITTEE ON OSTEOPOROSIS
FINAL REPORT AND RECOMMENDATIONS
December 2005
Members:
Senator Toni Hellon
Senator Robert Cannell
Jane Canby
Renea Gentry
Dr. Timothy Lohman
Dr. Michael Maricic
Margie Tate
Terri Verason
Dr. Jeffrey Lisse
SENATE AD HOC COMMITTEE ON OSTEOPOROSIS
INTRODUCTION
This report contains the recommendations of the Senate Ad Hoc Committee on
Osteoporosis. The report is being submitted to the Governor, the Speaker of the House of
Representatives and the President of the Senate.
PURPOSE
The Senate Ad Hoc Committee on Osteoporosis, established by the President of the
Senate on November 26,2002, is charged with the following
(l) research and collect information on osteoporosis;
(2) evaluate the various approaches used by the State and local governments to increase
public awareness of the 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The Committee was repealed on January 1,2006.
MEMBERSHIP:
Senate Two members of the Senate, from different political parties and one designated
as Chair, appointed by the President of the Senate:
Cannell, Hellon (Chair)
Other Seven members of the public, appointed by the President of the Senate:
Ms. Jane Canby
Ms. Renea Gentry, Executive Director, Arizona Osteoporosis Coalition
Dr. Jeffrey Lisse, Arizona Arthritis Center
Dr. Timothy Lohman, University of Arizona
Dr. Michael Maricic, Southern Arizona VA Health Care System
Ms. Margie Tate, Office of Chronic Disease Prevention & Nutrition
Services
Ms. Terri Verason, Director of Nutrition Services, Dairy Council of
Arizona
COMMITTEE ACTIVITIES
The Committee issued a final report in November 2004 that did not include
recommendations. Information about Committee activities prior to November 2004 can
be found in that report.
The Committee held a meeting on December 5, 2005 to adopt final recommendations. At
the meeting, the Arizona Osteoporosis Coalition distributed its own report for the
Committee, which is attached. Please also see the attached minutes for detail on the
Committee discussion.
RECOMMENDATIONS
At its December 5, 2005 meeting, the Committee adopted the following
recommendations:
Legislative Actions
The Senate Ad Hoc Committee on Osteoporosis encourages the Legislature to:
1. Provide authorization and ongoing funding to the Arizona Department of Health
Services (ADHS) for the collection of statewide data on the prevalence and
burden of osteoporosis.
2. Provide authorization and funding to ADHS to develop a statewide network for
conducting osteoporosis screening.
3. Provide funding for statewide screening for osteoporosis.
4. Encourage pediatricians to provide greater emphasis on childhood nutrition and
physical activity related to optimal bone development.
5. Encourage physicians and emergency departments who treat patients with a hip,
spine or other fragility fracture to recommend an osteoporosis screening as a
followup.
Arizona Department of Health Services Actions
6. If funding is available, ADHS should establish or designate a statewide
clearinghouse for education and information about the prevention of osteoporosis,
and to provide information and assist individuals and stakeholders in
implementing the strategies outlined in Bone Health and Osteoporosis: A Report
ofthe Surgeon General (2004).
7. If funding is available, ADHS should add the Centers for Disease Control and
Prevention's optional Osteoporosis module to the Behavioral Risk Factor
Surveillance System Survey Questionnaire.
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8. If funding is available, ADHS should collect statewide data on osteoporosis
prevalence and burden, including data on nontraumatic fractures in individuals of
all ages.
9. ADHS should combine strategies for reducing the prevalence and burden of
osteoporosis with other initiatives such as the Obesity Prevention! Nutrition and
Physical Activity Program and the Falls Prevention for Older Adults Program.
10. If funding is available, ADHS should collaborate with County Health
Departments, community health centers and private consumer organizations that
have an interest in osteoporosis to develop a statewide network for conducting
osteoporosis screenings. The network should include a focus on rural and
underserved areas.
Arizona Osteoporosis Coalition Actions
11. The Arizona Osteoporosis Coalition should pursue the strategies identified in its
Reportfor the Senate Ad Hoc Committee on Osteoporosis (attached).
12. The Coalition shall work closely with the Governor's Council on Health, Physical
Fitness and Sports on promotion of physical activity programs, including
osteoporosis prevention education.
ATTACHMENTS
Meeting agenda and minutes - December 5, 2005
Arizona Osteoporosis Coalition report (NOTE: This report includes a portion of the
Committee's 2004 Final Report but does not contain the entire report. For a full copy of
the report please contact the Senate Research Staff.)
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ARIZONA STATE LEGISLATURE
SENATE AD HOC COMMITTEE ON OSTEOPOROSIS
Minutes of the Meeting
Monday, December 5,2005
1:30 p.m., Senate Hearing Room 2
Members Present:
Senator Toni Hellon, Chair
Jane Canby
Dr. Jeffrey Lisse
Members Absent:
Senator Robert Cannell
Renea Gentry
Dr. Timothy Lohman
Margie Tate
Terri Verason
Dr. Michael Maricic
Staff:
Beth Kohler Lazare, Senate Health Research Analyst
Chairman Hellon called the meeting to order at 1:33 p.m. and attendance was taken,
Senator Hellon requested that the members introduce themselves and they did so as
follows:
• Terri Verason, Registered Dietician, Secretary for the Osteoporosis
Coalition, Director of Nutrition Education for the Dairy Council of Arizona.
• Margie Tate, representing the Arizona Department of Health Services
(ADHS).
• Jeffrey Lisse, Chief of Rheumatology at the University of Arizona, Intern
Director of the Arizona Arthritis Center, President of the Osteoporosis
Coalition.
• Senator Hellon, Senator from Tucson, Vice Chairman of the Health
Committee,
• Dr. Timothy Lohman, Professor for Department of Physiology at the
University of Arizona, Chair of the Public Policy for the Osteoporosis
Coalition.
• Jane Canby, Retired, Past Board Member of the Osteoporosis Coalition.
Beth Kohler Lazare, Senate Health Research Analyst, gave the Committee charge
as follows:
• Researching and collecting information on osteoporosis.
• Evaluate the various approaches used by State and local government to
increase public awareness.
• Identifying areas where public awareness, education, research and
coordination about osteoporosis need improvement.
• Studying ways to:
1. Increase the number of individuals in the State who are regularly
screened for osteoporosis.
2. Increase research and funding at State institutions that are studying
osteoporosis.
3. Improve coordination between State agencies and institutions that are
involved in the research and treatment of osteoporosis.
Ms. Kohler Lazare stated that the Committee has met twice, once in December of 2002
and again in September of 2004. She explained that the Committee did not adopt
recommendations in either of those two meetings. She said that in response to her e��mail
of potential recommendations (Attachment A), Dr. Lohman and the ADHS
responded with their own recommendations (Attachment B).
Discussion and Adoption of Committee Recommendations
Senator Hellon thanked the members for attending the meeting on such short notice.
She stated that she met with the ADHS to see what changes would be practical for the
Committee to make.
In regards to Attachment B, Dr. Lohman remarked that he agreed with the ADHS
alternative to his recommendation and also wanted to add the words "or spine" to the
second subtitle under number one. This change would read:
• Encourage physicians and emergency departments who treat patients
with a hip [or spine] fracture to recommend a DXA scan as a follow up.
Ms. Tate said that due to changing technology, "DXA" should be replaced with
"osteoporosis screening" in the second subtitle of number one of Dr. Lohman's
recommendations (Attachment B). This change would read:
SENATE AD HOC COMMITTEE ON
OSTEOPOROSIS
Monday, December 5,2005
Page 2
• Encourage physicians and emergency departments who treat patients
with a hip or spine fracture to recommend an osteoporosis screening as a
follow up.
In response to Senator Hellon, Ms. Verason remarked that having speakers at their
continuing education seminars, putting information in journals and getting articles in
newsletters would be examples of ways to encourage physicians to promote education
of osteoporosis prevention.
In response to Senator Hellon, the Committee agreed on Dr. Lohman's first
recommendation:
• Encourage pediatricians to provide greater emphasis on childhood
nutrition and physical activity related to optimal bone development.
On his second recommendation, Dr. Lohman said that he would like to add "or other
fragility fracture" to make it read:
• Encourage physicians and emergency departments who treat patients
with a hip, spine or other fragility fracture to recommend an osteoporosis
screening as a follow up.
Ms. Verason said that "including osteoporosis prevention education" should be added to
the ADHS recommendation reading:
• The Coalition shall work closely with the Governor's Council on Health,
Physical Fitness and Sports on promotion of physical activity programs
including osteoporosis prevention education.
Senator Hellon listed the new recommendations as follows:
Legislative Actions
The Senate Ad Hoc Committee on Osteoporosis encourages the Legislature to:
1. Provide authorization and ongoing funding to the Arizona Department of
Health Services (ADHS) for the collection of statewide data on the
prevalence and burden of osteoporosis.
2. Provide authorization and funding to ADHS to develop a statewide
network for conducting osteoporosis screening.
3. Provide funding for statewide screening for osteoporosis.
SENATE AD HOC COMMITTEE ON
OSTEOPOROSIS
Monday, December 5,2005
Page 3
4. Encourage pediatricians to provide greater emphasis on childhood
nutrition and physical activity related to optimal bone development.
5. Encourage physicians and emergency departments who treat patients
with a hip, spine or other fragility fracture to recommend an osteoporosis
screening as a followup.
Arizona Department of Health Services Actions
6. If funding is available, ADHS should establish or designate a statewide
clearinghouse for education and information about the prevention of
osteoporosis, and to provide information and assist individuals and
stakeholders in implementing the strategies outlined in Bone Health and
Osteoporosis: A Report of the Surgeon General (2004).
7. If funding is available, ADHS should add the Centers for Disease Control
and Prevention's optional Osteoporosis module to the Behavioral Risk
Factor Surveillance System Survey Questionnaire.
8. If funding is available, ADHS should collect statewide data on
osteoporosis prevalence and burden, including data on non-traumatic
fractures in individuals of all ages.
9. ADHS should combine strategies for reducing the prevalence and
burden of osteoporosis with other initiatives such as the Obesity
Prevention/ Nutrition and Physical Activity Program and the Falls
Prevention for Older Adults Program.
10. If funding is available, ADHS should collaborate with County Health
Departments, community health centers and private consumer
organizations that have an interest in osteoporosis to develop a
statewide network for conducting osteoporosis screenings. The network
should include a focus on rural and underserved areas.
Arizona Osteoporosis Coalition (AzOC) Actions
11. The Arizona Osteoporosis Coalition should pursue the strategies
identified in its Report for the Senate Ad Hoc Committee on
Osteoporosis.
SENATE AD HOC COMMITTEE ON
OSTEOPOROSIS
Monday, December 5,2005
Page 4
12. The Coalition shall work closely with the Governor's Council on Health,
Physical Fitness and Sports on promotion of physical activity programs,
including osteoporosis prevention education.
Senator Hellon moved that the Senate Ad Hoc Committee on
Osteoporosis adopt the revised recommendations. The motion was
CARRIED by voice vote.
There being no further business, the meeting was adjourned at 1:55 p.m.
Respectfully submitted,
Jeff Turner
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115.)
SENATE AD HOC COMMITIEE ON
OSTEOPOROSIS
Monday, December 5,2005
Page 5
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Senate AdHoc Committee
on Osteoporosis
I. Executive Summary: Trends, Challenges
and Recommendations page 2
II. Background page 6
• 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
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'~esource to another. They will either be /eflwith
incomplete information or become frustrated and stop investigating.
Infonnation 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 infonnation by
Bone Builders (classes, toll free phone infonnation, 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 ofthe centers even refer patients out for diagnostic
osteoporosis tests. .
• Private Agencies: Education and awareness materials - minimal funding for
programs.
• Hospital/Healthcare 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.
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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 lagencies 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
Foundationfor joint conditions, etc.).
• Insurance coverage for screeninglDXA 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,
howeyer these programs rarely target older adults. Units on Aging often engage in
health promotion activities and referral, but rarely collaborate with their public health
counterparts.
• Variables that would further increase the magnitude ofthe 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
ofthe recommendations of the SUrgeon General's report on
osteoporosis, 2004.
b) AzOC, in collaboration with ADHS, shall develop a statewide
networkfor 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 minerai 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. (physician's Guide to Prevention and Treatment of
Osteoporosis. National Osteoporosis Foundation. (p J) Excerpta Medica, Inc: Belle Meade, NJ
J999) However, in many health plans women will only receive screening i/referred by the
primary care physician. Early detection through routine screening and appropriate subsequent
ilitervention will significantly decrease the number offractures. (statement from AzOC monograph
2000)
• Add CDC osteoporosis module to state BRFSS to improve surveillance, (asfound in
·the Inventory ofState Osteoporosis Activities by Maryland Department ofHealth 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.
.• AskADHS 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 education/information 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 information 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 information (Cooperative Extension)
7. Statewide PSA's - organized by ADHS (AzOC tape)
a. Local Radio and TV
8. Latino/Native American stations (see below)
9. Provide osteoporosis information 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 information 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 forms ofhealth services and information.
(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 ofindividuals in this State
who are regularly sc!eened 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 the 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) Ton. 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 of AZ
Dr. Timothy Lohman, University of Arizona
Ms. Margie Tate, Arizona Department of Health Services
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 ofbreaking 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.
Microgra.phs' Of biopsy specimens of normal and osteopOrOt1cbone.
Panel Ais from a 75-year-old normal woman. PanelS is from a
47-year-old woman who had multiple vertebral compression fractures.
from Dempster DW, et aL J Bone Miner Res. 1986;1:1So-21•.
Osteoporosis is often undetectable because loss of bone mass typically occurs over a long
period oftime 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 ofosteoporosis 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 al. Identification and Fracture Outcomes of
Undiagnosed Low Bone Mineral 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 ofDS 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 of nearly
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 81 0,000 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 in Arizona 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 ofAIizona'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% of those
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 A:ii.zona BRFSS demonstrates that 50.3% of Hispanic adults have a
greater risk for sedentary lifestyle as do low income individuals
«lO,OOO/year) at a prevalence of 45.6% .
o Issues oflanguage 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 312000.
• US pre.ventative Services Task Force, 2002 prepared a review of indications for. screemng.
• 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 osteoporosis 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 of the 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.
10
..
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 forearm 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 of Internal 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 post-fracture
.
• Increasing age was correlated with a decreased likelihood ofreceiving
osteoporosis treatment
5. NHANES III 1997
• only 19% ofpeople over 50 with osteoporosis are diagnosed and
.treated.
6. Archives of Internal 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
Report for the Senate Ad Hoc Committee on Osteoporosis·
• Genetic influences account for -75% ofvariation in peak bone mass and
rate of bone loss
• Rapid bone loss of2-3%/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 of2 (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 of the 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 6100
5. Pre-menopausal fractures increase risk of subsequent fractures
• Study population· 24 years post menopause
• Independent of age, 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
I
"Despite the accumulated evidence showing the importance ofprevalent 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 con~equences by
12
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. Calcif Tissue 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 coveragefor diagnosis and treatment
• Medicare criteria (*See Appendix 1 - #8)
• Healthplan Survey of Women's Health Services in AZ Health Plans (*See.
Appendix 2 - #7)
13
Report of the
Senate Ad Hoc Committee
on Osteoporosis
November 2004
Committee Members
Senator Toni Bellon, Chair
Senator Robert Cannell
Ms. Jane Canby
Ms. Renea Gentry
Dr. Jeffrey Lisse
Dr. Timothy Lohman
Ms. Margie Tate
Ms. Terri Verason
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 of the 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 localgovemments to increase public
awareness of the 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 is repealed from and after December 1, 2004.
MEMBERSHIP
Senate Two members of the Senate, from different political parties and one designated as
Chair, appointed by the President ofthe Senate:
Hellon (Chair), Cannell
Seven members ofthe public, appointed by the President of the 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 o/the 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 of the Senate to request a continuance of the Committee into next session.
ATTACHMENTS
• Meeting agendalminutes/handouts - December 16, 2002
• Meeting agendalminutes/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 toallow time to arrange the
accommodation.
JKlcd 12109/02
,
/0L<::/'f,tv.:L.l ... -
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 II 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 Iife-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 isa 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,
'1(~/~);J~
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. OSTEOPOR08]S AND ITS EFFECT ON THE PEOPLE OF ARlWNA
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 programming 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: forearIn: or wrist
• Fractures significantly decrease quality oflife and increase health care costs
• Also known as the "Silent Disease"
• This disease is tbougbt to be preventable for most people. Wbile tbere are
treatments for osteoporosis, there is currently no cure
• Four important steps in the prevention of osteoporosis: diet, activity, lifestyle:
bone density testing
1
Pathology:
First step in prevention is to determine 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 gradual10ss 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 of the population that has the disease
2002 Prevalence Data for Arizona
Totals: Total Women with Total Men with Grand Total for
Osteoporosis and Osteoporosis and Men and Women
Low Bone Mass Low Bone Mass
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
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 ofosteoporosis
incidence data.
2
II. COSTS
Arizona Projections 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 lCD-9
coding for hosp admission
• $97 million in charges
• 31,000 hospital days
• 51% discharge to long tenn care
Total medical costs (2000)
• Inpatient - $136 million (acute care, physician costs, acute rehab)
• Outpatient - $18.4 million (home care, physician visits, out patient therapy
and services)
• Long tenn care - $83 million
• Total: $237 million for all fracture types, both male and female
Projections
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 10/02 - American College ofRheumatology)
• 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 BMD 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 HeatTh
System, Mercy Care, Pacificare
• All offer BMD screening, 1 limited to specific age group (over 60)
• Initial referral and frequency of repeat 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 % ofwomen 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 discretio~ 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-formulary and failed trials of formulary
equivalents.
Ill. 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 BMDtesting
• 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 ofAging
o Office ofWomen~s Health
o Department ofPublic Health
4
.'.\
o Department of Agriculture
• Other panners integrating osteoporosis programs
o Worksite wellness programs
o Cooperative extension networks
o Fall prevention programs
o State Medical Association and other heahhprofessions 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 curriculum
o Older adult exercise classes
o Surveillance systems - BRFSS
N. ARIZONA OSTEOPOROSIS PROGRAMS
Maricopa County Office of Nutrition Ser"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: Depr~ssion, 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-yearcontract (7/99-6/01)
with the Arizona Department of Health Services. Through this work, AzOC established
the following resources and programs:
• Through a partnership with the Maricopa County Cooperative Extension, 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
disciplines
• The first data monograph about osteoporosis in Arizona
• A public awareness message and plan for a campaign including a professional
brochure in both Spanish and English, 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.orl;!)
• 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 ofNutntion 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
campaigIl; distribution ofbrochures and written infonnation, additional Bone'Builders
volunteer training and additional opportunities to present osteoporosis education to health
care providers across Arizona.
V. WEB SITE RESOURCES
1. Vv"WW.nof.org (National Osteoporosis Foundation)
2. www.fitbones.org (Arizona Osteoporosis Coalition)
3. www.bonebuilders.org
4. www.fore.ori2 (Foundation for Osteoporosis Research & Educ)
5. www.4women.QOV
6. Vv"WW.obQyn.net/osteoporosis
7. www.endocrineweb.com
8. VlWW.osteorec.com
9. www.osteo.orQ (Nlli osteoporosis and related bone diseases)
10. naviQator.tufts.edu (nutrition information)
11. nutritiononestop.com (nutrition information)
12. www.asbmr.org (Am Society ofBone and Mineral Research)
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JanetNapolitano
Governor
Office of the Governor
* OSTEOPOROSIS AWARENESS MONTH *
WHEREAS, Osteoporosis is the most common disease of postmenopausal women; and
WHEREAS, in 2004 the U.S. Surgeon General estimated that by 2020, one in two Americans over the
age 50 will be at Risk for Fracture from Osteoporosis or Low Bone Mass; and
WHEREAS, The estimated lifetime risk of developing a spine, hip, or wrist fracture after age 50 is 50%
for women and 13% in men; and
WHEREAS, in Arizona there are an estimated 810,000 cases of osteoporosis and low bone mass, and
the costs for medical care for osteoporosis-related fractures in Arizona is $236 million annually; and
WHEREAS, about half of the women in Arizona aged 50 and older report that they have never had a
bone density test; and
WHEREAS, the Arizona Osteoporosis Coalition, and the University of Arizona Cooperative Extension
Bone Builders program have been educating women and health professionals that osteoporosis is a
preventable and treatable disease, and fracture protection is needed to help prevent or reduce fractures
in postmenopausal women; and
WHEREAS, Osteoporosis Awareness Month helps raise awareness about maximizing your bone
strength, appropriate calcium and vitamin 0 consumption, understanding the treatment options, and
most importantly, knowing your risk for fracture.
NOW, THEREFORE, I, Janet Napolitano, Governor of the State of Arizona, do hereby proclaim Mayas
* OSTEOPOROSIS AWARENESS MONTH *
IN WITNESS WHEREOF, I have hereunto set my hand and
caused to be alliXen::;a,,/'bLArizona
V4
G OVE:lOR
DONE at the Capitol in Phoenix on this 22nd day of March in
the year Two Thousand and Five and of the Independence
of the United States of America the Two Hundred and
Twenty-ninth.
ATTEST:
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
03/08/2005
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, 725 ofthe
729 patient charts with ICD-9 diagnostic codes for fractures have been reviewed. 208 of
the 725 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. 208 medical charts have been screened. The collected
information has been entered into a database.
Ofthe 208 screened patient charts, 152 (73.1%) are female subjects and 56
(26.9%) are male subjects. The mean age of the patients is 73.7 years old. There are 10
(4.8%) American Indians, 3 (1.4%) Asians, 3 (1.4%) African American and 191 (91.8%)
Caucasians. There are 24 (11.5%) patients ofHispanic ethnicity. 161 (77.4%) ofthe
patients are retired. There are 91 (43.8%) married subjects and 68 (32.7%) widowed
subjects. There are 73 (35.1%) admissions for fractured hips and 127 (61.1%) admissions
for vertebral fractures. 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, 3.4% of patients had a trochanter fracture, 8.6 % of patients had at least one
femoral neck fracture, 39.4% of patients had at least one prior vertebral fracture, 4.3% of
patients had a wrist fracture and 23.2% ofpatients had other fractures. 78.9% ofpatients
had at least one other (vertebral, hip or other) fragility fracture before the indexed
fracture date. 21.1% had no prior fragility fracture of any kind. Prior to their indexed
fracture, 22.1% of patients had DXA (the accepted way to diagnose osteoporosis)
examinations. After their indexed fracture, 3.9% of patients had DXA examinations.
Ofthe 208 screened patient charts, 35.6% ofthe patients were taking at least one
anti-osteoporosis medication prior to their indexed fracture. 43.3% ofthe patients were
recommended (either told to continue their osteoporosis medicine regiment or to start
taking osteoporosis medication) to use at least one anti-osteoporosis medication. After
their fracture, 61.1% ofthe patients were taking at least one anti-osteoporosis medication.
This data is derived only from the hospital charts. It is possible that these patients
had other studies performed by other physicians as outpatients.