Medical care costs of Paget's disease of bone in a privately insured population

Paget's Disease in Primary Total Hip Arthroplasty Is Associated With Greater In-Hospital Lengths of Stay, Costs, and Complications

BACKGROUND

There are few well-powered studies investigating the association of Paget's disease of bone on patients undergoing primary total hip arthroplasty (THA). This study utilized a nationwide database to determine whether Paget's patients undergoing primary THA are associated with higher rates of (1) lengths of stay (LOS); (2) costs; and (3) complications (medical/surgical and implant-related).

METHODS

Using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes, Paget's patients undergoing primary THA were identified and matched to non-Paget's patients in a 1:5 ratio by age, sex, and comorbidities utilizing the PearlDiver database. This resulted in 21,714 patients in Paget's (n = 3619) and non-Paget's (n = 18,095) cohorts. Outcomes assessed included LOS, episode-of-care costs, medical/surgical complications, and implant-related complications. A P value less than .003 was considered statistically significant.

RESULTS

Compared to the matched cohort, Paget's patients undergoing primary THA had significantly longer LOS (P < .0001), higher 90-day total global episode-of-care costs (P < .0001), higher 90-day medical and surgical complications (P < .0001), and higher implant-related complications (P < .0001).

CONCLUSION

We found that Paget's was associated with higher rates of LOS, costs, and complications. Although there was an association found, the risk appears reasonably low compared to the matched cohort. The study can be utilized by orthopedic professionals to counsel and educate these patients of potential complications which may occur following their procedure.

Neurologic complications of Paget disease of bone

OBJECTIVE

To review the epidemiology, evaluation, and management of the neurologic complications associated with Paget disease of bone (PDB).

METHODS

We reviewed the English-language medical literature using MEDLINE data sources from 1950 to August 2008 and manually searched cross-references from original articles and reviews. Search terms included "Paget* disease of bone" and "neurologic* complications," "cranial nerve," "spinal cord," or "peripheral nerve."

RESULTS

Several neurologic problems in the central and peripheral nervous systems may complicate PDB. Up to 76% of patients may have some form of neurologic involvement. Neurologic complications can occur in patients with a long history of PDB as well as in patients with previously unrecognized disease. The primary mechanisms of nerve damage in PDB involving the spine are ischemic myelitis and compression due to bone hypertrophy. Evaluation includes determining the serum alkaline phosphatase level and imaging by radiography, bone scintigraphy, computed tomographic scanning, and, for lesions of the central nervous system, magnetic resonance imaging. If a soft-tissue mass is found, biopsy should be considered to exclude the presence of sarcoma. Treatment strategies include calcium, vitamin D, bisphosphonates, and possibly surgical intervention for refractory cases.

CONCLUSION

Neurologic sequelae of PDB may be underappreciated. Despite the paucity of data guiding treatment, zoledronic acid is a reasonable first-line therapy. Lack of response to treatment or relapse should prompt diagnostic reevaluation with a heightened suspicion for tumor.

Morbidity and mortality associated with Paget's disease of bone: a population-based study

INTRODUCTION

Limited information is available about the clinical features of Paget's disease of bone among unselected patients in the community. We examined morbidity and mortality associated with this condition in a large inception cohort of Olmsted County, MN, residents with a new diagnosis of Paget's disease from 1950 through 1994.

MATERIALS AND METHODS

Survival was estimated using the Kaplan-Meier method. Cox proportional hazards models were used to assess the impact of various covariates on death.

RESULTS

Paget's disease of bone was diagnosed in 236 Olmsted County residents (mean age at diagnosis, 69.6 yr; 55% men). The majority were symptomatic at diagnosis (58%), and the proportion with symptoms did not change from the prescreening era (1950 to June 1974) to the postscreening era (July 1974-1994). Most patients had polyostotic disease (72%), and the pelvis (67%), vertebra (41%), and femur (31%) were the most common sites of involvement. Skeletal complications attributable to Paget's disease included bowing deformities (7.6%), fracture of pagetic bone (9.7%), and osteosarcoma (0.4%). Osteoarthritis was observed in 73% of patients, and 11% had a hip or knee replacement. Nonskeletal complications related to Paget's disease included cranial nerve (0.4%), peripheral nerve (1.7%), and nerve root (3.8%) compression, basilar invagination (2.1%), hypercalcemia (5.2%), and congestive heart failure (3.0%). Hearing loss, noted in 61%, was significantly higher than previously reported.

CONCLUSIONS

Compared with white Minnesota residents, overall survival was slightly better than expected (p = 0.010). No clinical risk factors were identified that were associated with an increased risk of death.

A review of Paget's disease of bone with a focus on the efficacy and safety of zoledronic acid 5 mg

BACKGROUND

Paget's disease of bone, the second most common metabolic bone disease in the United States, is characterized by localized areas of excessive bone resorption coupled with accelerated bone formation, resulting in new bone that is less structurally organized and is weaker than normal bone. Complications of Paget's disease can include bone pain, osteoarthritis, skeletal deformity, hearing loss, and fractures. The objective of this review is to provide a comprehensive overview of current standards of treatment in Paget's disease.

SCOPE

A review of literature from 1974 to 2007 was performed on topics such as epidemiology, etiology, treatment of Paget's disease of bone, and bisphosphonates.

FINDINGS

Paget's disease affects an estimated 2-7% of persons of age 55 years or older in North America and western Europe. Antiresorptive treatment with bisphosphonates is the standard treatment, but there may be limitations to oral therapy. Intravenous pamidronate is efficacious and has long been available, but its use is hindered by an impractical recommended dosing regimen of 30 mg IV over 4 h for three consecutive days. In two identical, double-blind, 6-month trials, 96% of patients treated with a one-time intravenous treatment of zoledronic acid 5 mg achieved therapeutic response, compared with 74% treated with 60 days of daily oral treatment with risedronate 30 mg (p < 0.001). One limitation of this review is that historical data are not reviewed in the same level of detail as newer treatments, because recent advances in pharmacotherapy of Paget's disease have reduced the clinical utility of the older drugs.

CONCLUSION

The etiology of Paget's disease is unclear, but some evidence suggests genetic and viral components. Bisphosphonates restore normal bone turnover and relieve bone pain, but oral formulations may be limited by complicated dosing regimens and poor gastrointestinal absorption. The bisphosphonate, zoledronic acid is administered as a single intravenous infusion and offers antiresorptive efficacy and longer-lasting remission.

Consequences of poor compliance with bisphosphonates

BACKGROUND

Prior research on the ability of bisphosphonates to prevent fractures and related health care utilization has been based on high levels of compliance achievable in clinical trial settings. This study was undertaken to assess rates of osteoporotic fractures and health care utilization as a function of bisphosphonate compliance in usual clinical practice.

METHODS

This retrospective cohort study used 2000-2004 pharmacy and medical claims data from 45 large U.S. employers. Our sample included persons diagnosed with osteoporosis, aged 40 years or older, and who initiated use of either alendronate or risedronate. Main outcome measures were medication compliance, rates of osteoporotic fracture, and costs for inpatient care, outpatient services, and prescription drugs.

RESULTS

We identified 17,988 new users of bisphosphonate therapy. After 1 to 3 years of follow-up, only 30.6% to 42.9% of patients could achieve high compliance (80%-100%), 17.4%-23.0% moderate compliance (79%-40%), and 33.8%-52.0% had low compliance (0%-39%). Multivariate models of fracture risk showed benefits (p<10) with compliance levels of at least 60%, after which no risk benefit could be detected. Multivariate models of health care costs showed statistically significant (p<.05) total costs savings of $859 to $366 per year with high to moderate compliance levels. However, individuals achieving less than 40% compliance had no detectable decrease in inpatient or outpatient costs to offset the increase in drug costs.

CONCLUSIONS

Reductions in fracture risk and overall health costs can be detected in individuals achieving as little as 60% to 40% compliance with bisphosphonates. However, as many as 34% of patients in the first year of therapy and 52% by the third year will not reach even the minimal compliance levels required to receive benefits.

Nonmalignant complications of Paget's disease

Paget's disease of bone is a focal or multifocal disorder characterized by intense disorderly remodeling activity at sites of involvement, producing dramatic alterations of local bone architecture. These functional and structural alterations, interacting with the specific characteristics of the site of involvement, account for most of the complications of the disease. This presentation will focus on selected nonneoplastic complications of particular current interest.