SECTION CONTENTS:

A Call to Action by the US Surgeon General

The incidence and effects of osteoporosis have reached such epidemic proportions worldwide that the US has joined an international effort to commit resources to accelerate progress in musculoskeletal health issues. In support of this international collaboration, President George W. Bush declared 2002–2011 as the Decade of the Bone and Joint in the US.

In October 2004, at the request of Congress, the first-ever report on the nation’s bone health was issued by the US Surgeon General, Richard H. Carmona, MD, MPH, FACS. The overriding message of Bone Health and Osteoporosis: A Report of the Surgeon General is that the prevalence and socioeconomic impact of poor bone health in the US is staggering, and with the graying of America, osteoporosis is likely to increase at such an astounding rate that by 2020 half of all Americans over 50 will be at risk for fracture if no immediate action is taken.

Bone fractures from osteoporosis are so common that they have been considered a “normal” part of aging. This myth has worked against the understanding that this is a disease that is both treatable and preventable. The report serves as a call to action – a new emphasis on prevention, lifestyle changes, early diagnosis and appropriate treatment to help stem the tide of this epidemic.

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Why Bone Health Is Important

A healthy skeletal system with strong bones is essential to overall health and quality of life for every human being. Healthy bones provide the framework for the body’s muscles and mobility. Strong bones protect the heart, lungs, brain, and other organs. Bones are also a repository for minerals that the body needs to function. Unhealthy bones not only cause debilitating fractures, but can also impede the proper functioning of the body’s systems.

Osteoporosis–the most common chronic bone disease–is a reduction in the amount of bone mass leading to fractures after minimal trauma. Osteoporosis—sometimes referred to as a “silent disease”—can lead to major declines in physical and mental health, quality of life, and premature death. Unlike other chronic diseases such as asthma or diabetes, declining bone mass exhibits no signs or symptoms, and is very often not recognized until a fracture takes place. With osteoporosis, fractures can occur from normal lifting and bending as well as from falls.

It is a myth to view osteoporosis as an “old women’s” disease since osteoporosis can strike at any age. Further, bone disease is a risk for both men and women—four times as many men and nearly three times as many women have osteoporosis than report having the disease. It is higher in white and Asian women, but still occurs in black, Hispanic, American Indian and Alaskan native women.

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Magnitude of the Problem

Fractures due to bone disease are common, costly, and often become a chronic burden on individuals and society. Hip fractures have the greatest morbidity and socioeconomic impact. The US Surgeon General reports that more than 44 million Americans over the age of 50 suffer from osteoporosis (10 million) and/or low bone mass (34 million). These individuals are fragile, at risk for fracture, and as a group surpass those who suffer from diabetes, heart disease or asthma.

Osteoporosis is responsible for more than 1.5 million fractures annually, including approximately:

• 300,000 hip fractures
• 700,000 vertebral fractures
• 250,000 wrist fractures
• 300,000 fractures at other sites

Social Impact: Quality of Life & Independence

Fractures have a tremendous impact on quality of life. According to one study, 80 percent of women older than 75 years preferred death to a bad hip fracture that resulted in nursing home placement. (NIH, 2001) Not surprisingly, fracture can have a negative impact on self-esteem, body image, and mood, which may lead to psychological consequences. Fear, anxiety, and depression are frequently reported in women with established osteoporosis.

Other quality-of-life issues include increased difficulty in activities of daily life, including losing the ability to walk, stand up, or dress. People who have had a fracture may become immobilized by a fear of falling and suffering. Fifty percent of those people experiencing a hip fracture will be unable to walk without assistance, only one-third of hip-fracture patients regain their full pre-fracture abilities and another one-third require nursing home placement.

Many people are forced to move - sometimes temporarily, but often permanently - from independent living to assisted care or a nursing home as a result of the fracture. Because an individual’s functional status can be significantly compromised, resulting in loss of independence, financial instability and negative emotional consequences, family caregivers bear a great deal of burden assisting individuals in need.

Medical Impact: Morbidity & Mortality

Individuals who have fractured are at risk for medical complications such as pressure sores, pneumonia and urinary tract infections. Osteoporosis often causes very painful fractures, which can take many months to heal. Often the pain starts to go away as the fracture heals. Pain that continues after that is generally considered chronic pain. Chronic pain lasts beyond the expected time for healing and interferes with normal life. The pain may be triggered by muscle tension, stiffness, weakness or spasms. Chronic pain can affect all areas of life and should be taken seriously.

Bone diseases can lead to a downward spiral in physical health and quality of life and in the worst-case scenario, premature death. Hip fractures have the greatest mortality of all osteoporotic fractures. The risk of death from a hip fracture is especially high during the first year after the fracture--one in five patients dies within one year of the fracture.

Economic Impact

The cost for direct care of osteoporosis-related fractures was conservatively estimated to be between $12 billion and $18 billion a year in 2002, and indirect costs add billions more. Inpatient hospitalization accounts for the bulk of these costs and does not include the indirect costs of lost wages or productivity of either the patient or the caregiver. As a result, these figures underestimate the true costs of osteoporosis. With the aging of the population, these costs could double or triple in the coming decades.

Resource Utilization

In addition to resources such as medication, physical therapy sessions, diagnostic radiology, psychiatric care, transportation and meals-on-wheels, the following resource utilization is related to fracture:

Future Impact

According to the US Surgeon General, by 2020 half of all Americans over 50 will have or be at high risk for osteoporosis and fracture. The good news is that fracture is preventable--with the proper intervention, low bone mass is detectable and correctable for most people. In just a few simple steps, we can reduce fracture rates. The alert health care professional can detect declining bone mass early through easy assessments and can implement simple preventive measures before the onset of osteoporosis and fracture.

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Closing the “Gap” Between What Is Known and What Is Done

In an effort to reduce the impact of osteoporosis and fracture, the US Department of Health and Human Services, Office of the Surgeon General, challenges doctors, policymakers, the nation’s health care system, and Americans themselves to change the way they think and act about bone health. Heightening awareness of the problem and solutions is crucial, as is closing the gap between what is known and what is done by all—insurers and health plans, health care professionals, and the general public. A collaborative effort will bring us closer to eradicating this painful, yet detectable and correctable problem.

The US Surgeon General calls on health care professionals to help Americans maintain healthy bones by evaluating risks for patients of all ages. The Report encourages health care professionals to look for “red flags” that may indicate that someone is at risk and to recommend bone density tests for women over the age of 65 and for any man or woman who suffers even a minor fracture after the age of 50. In addition, the Report recommends including people under age 50 who have had multiple fractures, or patients who take medications or have a disease that can lead to bone loss.

Lack of awareness is the single largest impediment to improving the bone health of Americans. Great improvements in the bone health status of Americans can be made “simply” by applying in a timely manner that which is already known about prevention, assessment, detection, diagnosis, and treatment of bone disease. Unfortunately, there is a large gap between what is known and what is practiced by both health care providers and the public.

The US Surgeon General calls for a coordinated approach that brings together a variety of public and private sector stakeholders in a collaborative effort to improve the bone health of Americans.

Insurers and health plans are in a unique position to heed the call to action because of their broad-scale abilities to increase awareness and promote standardized health initiatives.

• 90.8 percent of physicians contract with managed care (HSC, 2002)
• 1,300 health benefit companies provide coverage to approximately 200 million Americans (AHIP)
• Medicare Modernization Act encourages a collaborative effort between the public and private sectors to enhance health care delivery (CMS)

Health care professionals can be encouraged to do more to proactively assess, diagnose and treat those patients with declining bone mass, while at the same time be reminded to help themselves maintain good bone health in their everyday lives. Americans need to understand that with appropriate nutrition, including adequate calcium and vitamin D, and physical activity throughout their lives, they can significantly reduce their risk of bone disease and fractures.

By utilizing infrastructures that are already in place, commercial providers can help put into practice bone health and preventive strategies available to and suitable for younger people as well as provide early fracture risk assessment and appropriate treatment for older individuals under their care.

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