Blame, compassion and science

On August 14^th, mainstream media was reporting that osteoporosis-linked fractures have dramatically increased over the past decade. Among 723 news stories, not one questioned the study behind the news. The public not only lost an opportunity to learn the facts, but a valuable take-home lesson.

According to a syndicated Reuters Health story, the number of Americans hospitalized for osteoporosis-related fractures and other injuries have increased 55 percent since 1995, accounting for 254,000 hospitalizations in 2006. According to a study by the Agency for Healthcare Research and Quality (AHRQ), such hospitalization rates had been 55/100,000 people in 1995 and 85/100,000 in 2006. "This is a fairly alarming increase," Anne Elixhauser, Ph.D., a social science analyst with the AHRQ, was quoted saying.

Most of the osteoporosis-related hospitalizations were among older women, with 89 percent of the patients women and 90 percent over age 65. The news article negated aging of the population as fully accounting for the increase, however, and instead suggested that lack of exercise and inadequate calcium and vitamin D intake, as well as medications to treat high blood pressure, such as diuretics, were the “culprits.”

Professor Elixhauser said everyone should start thinking about osteoporosis prevention and adopt healthy lifestyles, eating more calcium and vitamin D in foods, and using supplements as necessary, exercising, not smoking and drinking only in moderation. “Doing so may also make a difference in terms of healthcare dollars,” the story said, adding that osteoporosis-related injuries carried a price tag of $2.4 billion in hospital costs in 2006.

Notice how readers were led to view the elderly victims as being to blame for costing society billions of dollars and to believe that, had the women adopted healthy diets and lifestyles, they could have prevented their problems?

This type of subtle messaging, couched as research, is everywhere today and can lead us to come away believing that popular beliefs are supported by science, when there is no science at all. The only way to prevent being misled is to think questionably about everything, go to the original source and look for the solid evidence.

This story gave us every reason to question it, too. Notice the leaps. There was no attempt to see if there was even a connection between diet and exercise and the osteoporosis-related hospitalizations; no effort to see if there was a link between bone density or calcium levels and osteoporosis-related hospitalizations; and, certainly no attempt to look at medication usage. Readers were left to assume that this study validated the popular beliefs about osteoporosis.

The explanations for the “alarming trend” and the recommendations being given didn’t add up, based on the evidence already in the medical literature:

● Osteoporosis risk is primarily determined by advancing age and by genes. Hip fractures increase with age, with rates doubling every decade after age 50 years.

● Yet, low bone mineral densities don’t predict who will develop fractures. More than half of women who have hip fractures don’t have osteoporosis.

● Despite common beliefs that lifestyle factors — exercise, calcium intake, protein, salt, etc. — hold critical roles in bone density, none of the risk factors used to predict osteoporosis have been shown to make much difference. Even the AHRQ 2002 Evidence Report found no evidence that screening for risk factors or bone mineral density predicts fractures or improves actual clinical outcomes. Nor is there credible support for claims that older women are less active today than they were a decade ago. And NHANES “What We Eat in America” data shows that calcium intake among women of all ages has even been slightly increasing — from a mean of 746 mg/day in 2001 to 858 mg in 2006, for example.

● Repeated studies [reviewed here], including the Women’s Health Initiative which followed 36,000 women for seven years, have also found no evidence that calcium supplements prevent fractures. As the Australian Fracture Prevention Summit’s summary of randomized controlled clinical trial evidence concluded, there remains no evidence that calcium or vitamin D supplementation can reduce osteoporotic fractures among the population.

● It’s widely recognized in the medical literature that osteoporosis rates among fat people are about half that of the general population, with osteoporosis exceedingly rare among obese women who’ve not had bariatric surgeries, and that bone fractures are highest among thin elderly people. But those facts wouldn’t support the government’s healthy diet and lifestyle policies and are rarely mentioned.

● Why was no attempt made to investigate a possible iatrogenic link due to prescription drugs, even though prescription records are readily available in more than 80 percent of hospitalization records, according to the AHRQ authors? According to the CDC’s Health US 2007 [covered here], the number of prescription drugs taken by Americans has increased by 71 percent just since 1996, with the greatest usage among women and rising with age.

Antidepressants make up the largest percentages of drugs prescribed for Americans, for example, tripling just between 1988-97 and 1999-2002. Medco Health Solutions, Inc, the nation’s leading pharmacy benefit manager (PBM), reported that since 2001, nearly half of all women are taking prescription drugs with one in five on anti-depressants [covered here]. Yet the most-used antidepressants, known as selective serotonin reuptake inhibitors (SSRIs, such as Lexapro, Prozac and Zoloft), are known to be associated with increased fractures and osteoporosis, doubling the risk for fractures in older adults in the Canadian Multicentre Osteoporosis Study, for instance.

Going to the study

The source of the news story was a Statistical Brief #76 published in July by the AHRQ as part of is Healthcare Cost and Utilization Project (HCUP). It was authored by professor Elixhauser and colleagues at the AHRQ. These briefs have used the HCUP Nationwide Inpatient Sample database — hospital discharge records on a sampling of 1,000 civilian hospitals, using ICD-9 billing codes (International Classification of Diseases, Ninth Revision, Clinical Modification)* — along with U.S. Census data. Specifically, the authors looked at hospitalizations in 2006, where the condition of “osteoporosis” and “injury” or “fracture” had been checked on the billing claims.

How many readers thought the study had shown there to be more hospitalizations for bone fractures due to osteoporosis? Those who read the actual report would have learned that, in truth, among the hospitalized patients who also reportedly had osteoporosis, the paper had included all sorts of “injuries” that were unrelated to fractures, including superficial injuries and bruises (10%), external caused conditions and injuries (8.2%), sprains and strains, open wounds of extremities, etc. All together, one-fourth (25.1%) of the hospital stays were unrelated to fractures at all.

More telling, while the news reported the patients had been hospitalized for osteoporosis-related fractures, the report reveals that the patients had been hospitalized and received treatment for all sorts of things, including 8.1% for hip replacements. Only 21.9% of the hospitalized patients had received any treatment for fractures or dislocation of hips or extremities.

The AHRQ report also claimed that osteoporosis is a “preventable condition” and that a diet rich in calcium and vitamin D, regular exercise and bone mineral density screenings and treatment “can prevent, improve and slow the progression of the condition.” It said barriers to care, such limitations in insurance coverage for screening tests, could reduce early detection and create a “substantial strain on the healthcare system.”

The footnoted support for this claim was legislation (HR 1894: Medicare Fracture Prevention and Osteoporosis Testing Act of 2009) that had been introduced, and a reference from the National Osteoporosis Foundation about Medicare laws to pay for bone density screenings. This foundation lobbies public policy on behalf of its corporate contributors, and whose corporate partners sell calcium supplements.

This example reminds us of the new role of the AHRQ and its U.S. Preventive Services Task Force — away from its founding purpose as a leading source for objective, systematic reviews of the medical research to its new political role redirected by Congress to build consensus between government health agencies and outside stakeholder partners and to produce information that will support preventive wellness guidelines and pay-for-performance measures.

Going to the original source

The raw HCUP statistics are available directly, so next, we go to the original source: the “HCUP Facts and Figures, 2006” report on hospital stays for 2006 and trends from 1993. HCUP reports have specifically tracked the principle diagnoses and procedures for hospital stays in the United States. Fractures and dislocations of the hip and femur don’t even appear as a frequent diagnosis for hospitalizations until the 85+ age group. This type of fracture is also the most significant type of fracture that medical professionals hope to avoid among adults reaching advancing ages because it is so strongly associated with death and long-term disability.

In fact, just this week, another study was published showing just how significant the connection is between fractures and mortality. The 5-year Canadian Multicenter Osteoporosis Study of a randomly selected cross section of the Canadian population found that hip and vertebral fractures more than tripled the risk for death.

But an interesting fact appears on page 24 of the HCUP report: hip fractures are the only principle diagnosis among the oldest ages that has decreased since 1997, with a nominal drop of 5 percent. The actual HCUP data negates the AHRQ claims. The HCUP report states: “Hospital stays for hip fractures, a common diagnosis among adults 85 and over, changed very little between 1997 and 2006.”

Exhibit 2.2 in the report, which gives the most frequent principle diagnosis by age for all hospital stays shows hip fractures among the 85+ age group were 12.5% of discharges in 1997 and 11.9% of discharges in 2006. Looking at Exhibit 3.2, which lists medical procedures by age, the HCUP statistics reveal that among this age group, 8.7% of hospital patients were treated for fractures or dislocations of hip and femur in 1997 and 2005, and 8.45% in 2006.

Body of evidence

The fact that rates of fractures have been relatively unchanged and have even slightly dropped over the past decade — not experiencing the “alarming increase” as the AHRQ claims — is not a surprise. In fact, that’s been the case for decades across North America.

Health US 2007 and Health US 2008, issued by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, are our government’s reports of the health of the population. They show that rates of hospitalizations for all types of fractures for every age group have dropped, but most significantly among older women.

● Among men 65-74 years of age, rates were 0.45% in 1990; 0.45% in 2005 and 0.41% in 2006.

● Among men aged 75+, rates were 1.37% of hospitalizations in 1990 and 1.34% in 2005.

● Among women 65-74 years of age, rates were 0.84% in 1990; 0.80% in 2005 and 0.76% in 2006.

● Among women 75+, rates were 3.15% of hospitalizations in 1990 and 1.49% in 2005.

● Among the oldest of all adults, those 85 years and over, fracture rates were 4.39% in 1990 and by 2006 had dropped to 4.03%.

Canadian health statistics, from the Canadian Institute for Health Information database, also show age-adjusted hip fracture rates have steadily declined since 1985 and most rapidly since 1996. The figures compiled by the Osteoporosis Surveillance Expert Working Group were published in last week’s Journal of the American Medical Association. They reported a drop in age-adjusted hip fracture rates of 31.8% in women and 25% in men.

Lost lesson

Because no one thought to question this news story, investigate the original sources, and think about the evidence, the myth was perpetuated that chronic diseases of aging and heredity are largely preventable if everyone followed the government’s recommended healthy diets and lifestyles.

Because no one thought to question this news story, investigate the original sources, and think about the evidence, the belief was reinforced that elderly people who develop age-related conditions are to blame for their conditions.

Because no one thought to question, go to the original sources, and to think about the evidence, viewing seniors needing medical care as unnecessarily raising healthcare costs for everyone else was encouraged.

Information that comes from the government or seems to confirm what we believe to be true, does not make it factual. Marketing rarely comes in the form of an obvious advertisement. Yet, whether it’s to move us to think a certain way, to believe certain things or to act in certain ways, it is still selling us.

To help prevent ourselves from being misled, it’s never been more important to question things we hear, go to the original sources and look for the sound evidence, and to think.

Think about the consequences of a populace that fails to question or think. Think about why the re-emergence of the preventive wellness and healthism movement, and its anti-science, is so important to understand.

© 2009 Sandy Szwarc

* ICD-9. As reviewed previously, the ICD-9 released in 1984, is an enormous, complex system that gives a number to every disease and medical procedure. The medical literature is filled with documentations of its inaccuracy in reflecting actual patient disease rates. Over recent years, healthcare providers have also been encouraged to check off these codes in order to receive reimbursement from third party payers, and the use of ICD-9 codes has increased. Caution is warranted in extrapolating more billing codes to mean that there were actually more cases of any condition.