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Variations in osteoporosis medication utilization. A population-based ecological cross-sectional study in the region of Valencia, Spain

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      Abstract

      Little is known about the contextual variability in osteoporosis medication utilization. Our aims were 1) to describe variations in utilization and spending on osteoporotic medication between the Primary Care Health Zones (PHZ) of the Valencia region, Spain, 2) to analyze observed variations using Small Area Variation Analysis methods, and 3) to quantify the influence of the specialized care level on variations in utilization. We conducted a population-based cross-sectional ecological study of expenditure and utilization of five therapeutic groups marketed as osteoporosis treatments in Spain in 2009. The unit of analysis was the PHZ (in total 240) nested in the 23 Hospital Healthcare Departments (HHD) of the region of Valencia, covering a population of about 4.9 million inhabitants. Drug utilization was measured by dispensed Defined Daily Dose per 1000 women aged 50 years old and over and day (DID) per PHZ and cost was measured by the annual osteoporosis drug cost per woman aged 50 and older as well as the average price of DDD (Defined Daily Dose) in each PHZ. We calculated Indirect Standardized Drug Utilization Ratios (ISR) and we used Spearman’s correlation to analyze associations between the ISRs of the different therapies. The average osteoporosis drug consumption was 119.1 DID, ranging from 77.6 to 171.3 DID (2.2 times higher) between PHZs in the 5th and 95th percentiles. Annual expenditure also showed a two-fold variation among PHZs. Average prices of the DDD by therapeutic group showed very low or no variation, although they differed substantially among therapeutic groups. Regarding the standardized consumption of osteoporotic drugs, HHDs explained a substantial part (39%) of the variance among PHZs. In conclusion, there is considerable variability in the volume and choice of anti-osteoporotic treatments between PHZs. with HHDs explaining an important proportion of the variation in utilization. Interventions aimed at reducing variation to improve appropriate care should take into account both the PHZ and HHD levels of care.

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      Most cited references 27

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      An estimate of the worldwide prevalence and disability associated with osteoporotic fractures.

       O. Johnell,  J Kanis (2006)
      The aim of this study was to quantify the global burden of osteoporotic fracture worldwide. The incidence of hip fractures was identified by systematic review and the incidence of osteoporotic fractures was imputed from the incidence of hip fractures in different regions of the world. Excess mortality and disability weights used age- and sex-specific data from Sweden to calculate the Disability Adjusted Life Years (DALYs) lost due to osteoporotic fracture. In the year 2000 there were an estimated 9.0 million osteoporotic fractures of which 1.6 million were at the hip, 1.7 million at the forearm and 1.4 million were clinical vertebral fractures. The greatest number of osteoporotic fractures occurred in Europe (34.8%). The total DALYs lost was 5.8 million of which 51% were accounted for by fractures that occurred in Europe and the Americas. World-wide, osteoporotic fractures accounted for 0.83% of the global burden of non-communicable disease and was 1.75% of the global burden in Europe. In Europe, osteoporotic fractures accounted for more DALYs lost than common cancers with the exception of lung cancer. For chronic musculo-skeletal disorders the DALYs lost in Europe due to osteoporosis (2.0 million) were less than for osteoarthrosis (3.1 million) but greater than for rheumatoid arthritis (1.0 million). We conclude that osteoporotic fractures are a significant cause of morbidity and mortality, particularly in the developed countries.
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        Osteoporosis in the European Union: medical management, epidemiology and economic burden

        Summary This report describes the epidemiology, burden, and treatment of osteoporosis in the 27 countries of the European Union (EU27). Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risk of fragility fractures which represent the main clinical consequence of the disease. Fragility fractures are associated with substantial pain and suffering, disability and even death for affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in the EU27 in 2010 and beyond. Methods The literature on fracture incidence and costs of fractures in the EU27 was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Results Twenty-two million women and 5.5 million men were estimated to have osteoporosis; and 3.5 million new fragility fractures were sustained, comprising 610,000 hip fractures, 520,000 vertebral fractures, 560,000 forearm fractures and 1,800,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures). The economic burden of incident and prior fragility fractures was estimated at € 37 billion. Incident fractures represented 66 % of this cost, long-term fracture care 29 % and pharmacological prevention 5 %. Previous and incident fractures also accounted for 1,180,000 quality-adjusted life years lost during 2010. The costs are expected to increase by 25 % in 2025. The majority of individuals who have sustained an osteoporosis-related fracture or who are at high risk of fracture are untreated and the number of patients on treatment is declining. Conclusions In spite of the high social and economic cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by the aging populations, the use of pharmacological interventions to prevent fractures has decreased in recent years, suggesting that a change in healthcare policy is warranted.
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          The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care.

          The health implications of regional differences in Medicare spending are unknown. To determine whether regions with higher Medicare spending provide better care. Cohort study. National study of Medicare beneficiaries. Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). Content of care (for example, frequency and type of services received), quality of care (for example, use of aspirin after acute myocardial infarction, influenza immunization), and access to care (for example, having a usual source of care). Average baseline health status of cohort members was similar across regions of differing spending levels, but patients in higher-spending regions received approximately 60% more care. The increased utilization was explained by more frequent physician visits, especially in the inpatient setting (rate ratios in the highest vs. the lowest quintile of hospital referral regions were 2.13 [95% CI, 2.12 to 2.14] for inpatient visits and 2.36 [CI, 2.33 to 2.39] for new inpatient consultations), more frequent tests and minor (but not major) procedures, and increased use of specialists and hospitals (rate ratio in the highest vs. the lowest quintile was 1.52 [CI, 1.50 to 1.54] for inpatient days and 1.55 [CI, 1.50 to 1.60] for intensive care unit days). Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures. Access to care in higher-spending regions was also no better or worse. Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.
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            Author and article information

            Affiliations
            [1 ] Center for Public Health Research (CSISP-FISABIO), Valencia, Spain
            [2 ] Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
            [3 ] Navarrabiomed, Navarra Biomedical Centre, Pamplona, Navarra, Spain
            UiT The Arctic University of Norway, NORWAY
            Author notes

            Competing Interests: The authors have declared that no competing interests exist.

            Contributors
            ORCID: http://orcid.org/0000-0001-7098-4576, Role: Conceptualization, Role: Formal analysis, Role: Funding acquisition, Role: Methodology, Role: Supervision, Role: Validation, Role: Writing – original draft, Role: Writing – review & editing
            Role: Data curation, Role: Formal analysis, Role: Methodology, Role: Validation, Role: Writing – review & editing
            Role: Conceptualization, Role: Data curation, Role: Formal analysis, Role: Methodology, Role: Validation
            Role: Conceptualization, Role: Formal analysis, Role: Funding acquisition, Role: Methodology, Role: Validation
            ORCID: http://orcid.org/0000-0002-4313-3976, Role: Methodology, Role: Validation, Role: Writing – original draft, Role: Writing – review & editing
            Role: Editor
            Journal
            PLoS One
            PLoS ONE
            plos
            plosone
            PLoS ONE
            Public Library of Science (San Francisco, CA USA )
            1932-6203
            21 June 2018
            2018
            : 13
            : 6
            29927952
            6013112
            10.1371/journal.pone.0199086
            PONE-D-17-22089
            (Editor)
            © 2018 Sanfélix-Gimeno et al

            This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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            Figures: 0, Tables: 4, Pages: 12
            Product
            Funding
            Funded by: Department of Health of the Autonomous Government of Valencia
            Award ID: 047/2010
            Award Recipient :
            Funded by: funder-id http://dx.doi.org/10.13039/501100004587, Instituto de Salud Carlos III;
            Award ID: PI09/90882
            Funded by: funder-id http://dx.doi.org/10.13039/501100004587, Instituto de Salud Carlos III;
            Award ID: PI13/01721
            This project was partially funded by the Department of Health of the Autonomous Government of Valencia (Project 047/2010, www.san.gva.es) and the Instituto de Salud Carlos III from the Spanish Ministry of Health (Project PI09/90882 and PI13/01721, www.isciii.es). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
            Categories
            Research Article
            Medicine and Health Sciences
            Rheumatology
            Connective Tissue Diseases
            Osteoporosis
            Medicine and Health Sciences
            Women's Health
            People and places
            Geographical locations
            Europe
            European Union
            Spain
            Biology and Life Sciences
            Biochemistry
            Hormones
            Parathyroid Hormone
            Medicine and Health Sciences
            Pharmaceutics
            Drug Therapy
            Medicine and Health Sciences
            Health Care
            Health Care Policy
            Drug Policy
            Medicine and Health Sciences
            Public and Occupational Health
            Drug Policy
            Medicine and Health Sciences
            Pharmacology
            Drugs
            Physical Sciences
            Chemistry
            Chemical Elements
            Strontium
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            All relevant data are within the paper and its Supporting Information files.

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