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Moving Toward Healthier Diets

Osteoporosis-Related Hip
Fractures Cost $13 Billion
to $18 Billion Yearly
Eric Barefield
(404) 880-6289

steoporosisa bone disor- and costs associated with lost pro- the skeleton is replaced each year in
der associated with in- ductivity. adults.
creased susceptibility to Hip fractures are the most serious Bone grows in length at first, then
fracture of the hip, spine, wrist, consequence of osteoporosis. About during adolescence there is a dra-
shoulder, and ribsafflicts an esti- 20 percent result in death, and those matic increase in bone mass or den-
mated 25 million people in the who survive often have disability sity. Peak bone mass is the maxi-
United States. Osteoporosis accounts and loss of independence. Osteo- mum skeletal mineral content
for approximately 1.5 million new porosis-related hip fractures result achieved by a person. During the
fractures each year, with associated in estimated costs of $12.8 billion to first three decades of life more bone
medical charges (including rehabili- $17.8 billion per year for medical is formed than lost, and peak bone
tation and extended treatment facili- care, extended treatment facilities, mass is achieved. After that time the
ties) costing an estimated $10 billion, and the value of lost productivity. body removes old bone faster than
according to the National Osteo- Rehabilitation and institutionaliza- new bone forms, leading to a loss of
porosis Foundation. Because osteo- tion costs, at about $5.1 billion to bone mass. If bone loss is excessive,
porosis affects primarily the elderly, $7.1 billion, account for 40 percent of bones become fragile and more sus-
the National Osteoporosis Founda- the estimated total economic cost of ceptible to fracture.
tion estimates that these costs will osteoporosis-related hip fractures.
increase to $60 billion by the year The value of lost productivity due to Half of All Women Over
2000 and to $200 billion by the year missed work is less than 1 percent of
2040, as the number of Americans total economic costs, while value of
Age 50 Are Affected
over the age of 65 years grows. premature death accounts for 35.3 Bone loss is a natural part of the
But medical charges are not the percent. Initial medical costs for hos- aging process. Two factors make
only costs to consider. Lost produc- pitalization and outpatient care, at women more susceptible to osteo-
tivity (from missing work due to about $3.1 billion to $4.3 billion, ac- porosis than men. First, women are
disability and premature death) count for 24.4 percent of the total susceptible to greater bone losses
from osteoporosis-related fractures economic cost of osteoporosis-re- than men. Starting around the
pose additional costs. This article is lated hip fractures. fourth or fifth decade of life, both
based on research funded by USDAs men and women lose bone mass at a
Economic Research Service (ERS) to Bone Is Constantly rate of 0.3 to 0.5 percent per year.
estimate economic costs of osteo- After the onset of menopause, the
porosis-related hip fractures. Eco-
Being Renewed rate of bone loss in women can in-
nomic costs include medical charges Many people think of bone as a crease as much as 10-fold due to the
hard, permanent substance that does reduced production of estrogen, a
not change after childhood. How- female hormone that plays an im-
ever, bone is alive and dynamic, portant role in maintaining bone
constantly renewed through a mass. Women can lose up to 20 per-
The author is a research specialist at Clark process of removal or reabsorption cent of their total bone mass in the
Atlanta University. This research was conducted
under a cooperative agreement with the Food and of old bone and formation or laying
Consumer Economics Division, Economic Research down of new bone. Through this re-
Service, USDA.
modeling process, about one-fifth of

January-April 1996
Moving Toward Healthier Diets

first 5 to 7 years following meno- Calcium is the most abundant a half cup of broccoli contains 6 per-
pause. By age 70 or 80, women have mineral in the body, accounting for cent of the RDA. Canned sardines
typically lost about 30 to 50 percent about 2 percent of total body and salmon provide 41 and 23 per-
of their bone mass, compared with a weight. The bones and teeth contain cent, respectively, of the calcium
loss of only 20 to 30 percent among about 99 percent of the calcium in RDA per 3-ounce serving.
men. the human body, with the remaining Dairy products are the major
Second, women achieve peak 1 percent circulating in the blood. source of calcium in the U.S. food
bone mass earlier than men. Conse- Without calcium, the body cannot supply, contributing 75 percent in
quently, men have more years to maintain strong, healthy bones. 1990. Fluid milk provided 37 percent
build up bone mass and fewer years Calcium requirements are greatest of the calcium in 1990, while cheese
to lose bone mass. A related factor is during the periods of rapid growth provided 23 percent and other dairy
that men also tend to have larger during childhood and adolescence, products provided 15 percent. Meat,
bones than women. during pregnancy and lactation, and eggs, and legumes together pro-
The National Osteoporosis Foun- in later adult years to compensate vided 9 percent of the calcium in
dation estimates that half of all for age-related bone loss. Increased 1990, and vegetables provided 6 per-
women over the age of 50 are af- calcium intake during the first three cent.
fected by osteoporosis, compared decades of life may allow for attain- Most American men get the rec-
with one in every five men. By age ment of genetic peak bone mass. In- ommended calcium intake, but most
75, 90 percent of women will experi- creasing the level of bone mass from women do not consume enough cal-
ence an osteoporosis-related frac- which loss occurs reduces a persons cium. USDA consumption surveys
ture, as opposed to only 33 percent risk of hip fracture. indicate that mens calcium intake
of men. from dietary sources increases with
age, peaks during late adolescence
...But Women Often Do at 1,145 milligrams, and then de-
Higher Intake of Calcium Not Consume Enough clines. The pattern is similar for
May Prevent/Delay Hip Calcium women, although the peak occurs at
age 11 with 916 milligrams per day.
Fractures... The Recommended Dietary Al- Average calcium intake among boys
Genetics is a major determinant of lowance (RDA) for calcium is 800 ages 12 to 19 is 95 percent of the
osteoporosis. Women account for 80 milligrams per day for children age RDA, but only 66 percent for girls in
percent of the 25 million Americans 10 years and under and for most the same age groupmaking it un-
affected by osteoporosis. National adults age 25 years and over (not likely that many of them will fully
incidence rates of hip fractures in including pregnant and lactating reach their genetic potential for peak
the United States are highest for women) and is 1,200 milligrams per bone mass. In fact, after age 11, most
White women, about 2 to 2.4 times day for those ages 11-24 years. How- American girls never get their cal-
the rates for White men and Blacks. ever, experts at the National Insti- cium consumption up to recom-
Blacks have about 10 percent more tute of Healths 1994 Consensus De- mended levels.
bone mass than Whites. velopment Conference on Optimal Men 20 years and older consume
There is interest in learning more Calcium Intake recommended in- an average of 101 percent of the
about the factors within an individ- creasing these levels to between RDA for calcium, while women of
uals control, such as exercise and 1,000 and 1,500 milligrams and be- the same age consume an average of
diet, that might reduce the risk of tween 1,200 and 1,500 milligrams, only 75 percent of the RDA for cal-
suffering an osteoporosis-related respectively, per day. cium. Calcium intake for women
fracture. Research suggests that Dairy products are good sources ages 20 and over is typically 632
among the dietary factors, calcium of calcium, with 1 cup of lowfat milligrams per day, 25 percent lower
may play an important role in pre- milk and plain yogurt providing 37 than among men 20 and over. Cal-
venting or delaying the onset of os- and 52 percent, respectively, of the cium intake for women generally in-
teoporosis and that higher intakes of RDA for most adults 25 years of age creases during pregnancy and lacta-
calcium could prevent 40 to 60 per- and older. Leafy green vegetables, tion.
cent of osteoporosis-related hip frac- canned sardines and salmon, and
tures. fortified fruit juices are other easily
accessible sources. Collard greens
provide 22 percent of the calcium
RDA in each half-cup serving, while

Moving Toward Healthier Diets

Hip Fractures Are the tient and outpatient care costs are habilitation and personal care for
based on Medicare cost data and are daily activities.
Most Serious conservative estimates of actual In this analysis, about 96 percent
Consequence of costs, because Medicare reimburses of the patients were assumed to be
Osteoporosis approximately 80 percent of the discharged from the hospital after
market value of medical services. the initial care, and 4 percent were
Although hip fractures are not as Room and board in the hospital assumed to die. Of those discharged
numerous as fractures of the wrist after surgery accounts for 73 percent from the hospital, 32 percent go
or spine, they are by far the most se- of the estimated $11,582 cost per pa- home and 68 percent are sent to
rious consequence of osteoporosis. tient associated with inpatient and some type of facility for rehabilita-
Often times, spinal fractures will go outpatient care for hip fractures. tion or extended care. Half of this 68
untreated. However, osteoporosis- Multiplying this cost by the 270,000 percent go to an intermediate-care
related hip fractures typically re- to 375,000 cases of osteoporosis-re- facility to recuperate. The other half
quire surgery, hospitalization, and lated hip fractures in the United require more intensive medical care
an extended period of rehabilitation. States each year results in total ini- and are discharged to a skilled nurs-
Hip fractures also lead to premature tial medical costs of between $3.1 ing facility.
death, with an estimated 20 percent billion and $4.3 billion. Due to the late stage in life in
of people who fracture their hip which hip fractures tend to occur,
dying within 1 year. this study assumes that in the first
The Older Womens League esti-
High Costs for Longer
year after the fracture only about 23
mates that hip fractures account for Term Care percent of all people who fracture
18 percent of the annual 1.5 million The criteria for developing the their hips fully recover to their pre-
osteoporosis-related fractures, while cost estimates for longer term care fracture status, 32 percent regain
the National Osteoporosis Founda- were taken from studies reported in near normal functioning with mini-
tion estimates that hip fractures ac- various medical journals. These mal assistance, and 25 percent are
count for 25 percent. This range of studies used medical records and injured more severely and require
270,000 to 375,000 osteoporosis- observations of fracture patients dependent care in a facility for at
related hip fractures each year is over time. Depending on the sever- least 1 year. The remaining 20 per-
used as the basis for the medical and ity of the fracture, patients require cent are assumed to die within 1
lost productivity cost estimates in varying degrees of assistance in re- year. Figure 1 shows the various dis-
this article.
The annual costs of osteoporosis-
related hip fractures were estimated Table 1
by using the traditional cost-of-ill- Initial Medical Costs of Hip Fractures
ness method. This method catego-
rizes disease cases by the level of Initial medical costs Cost per patient
severity, then calculates the costs of
medical treatment and lost produc- Dollars
tivity for each severity category, and
sums up the categories for an esti- Inpatient costs 11,508
mate of the total economic cost. Ambulance 290
Emergency room doctor fee 53
Nonmedical emergency room services 554
Hospitalization and Room and board 8,500
Outpatient Care Cost Initial doctor visit 107
Surgery 1,312
$3.1 Billion to $4.3 Billion Anesthesia 270
a Year Daily doctor visits 360
Hospital discharge visit 62
The initial medical costs of hip
fractures include hospitalization and Outpatient costs 74
outpatient care (table 1). Because hip Office followup visit 36
fractures are generally associated X-ray 38
with an accidental fall, all patients
are assumed to arrive at the hospital Total initial medical cost per patient 11,582
in an ambulance and to be admitted Source: Chrischilles, E., T. Shireman, and R. Wallace. Costs and Health Effects of Osteo-
through the emergency room. Inpa- porotic Fractures, Bone, Vol. 15, No. 4, 1994, pp. 377-86. Updated to 1995 dollars.

January-April 1996
Moving Toward Healthier Diets

charge destinations and health out- verely handicapped and to require value of a statistical life. This value
comes within 1 year of the fracture. care for at least 1 year. Among the provides a conservative estimate of
Table 2 shows the estimated per patients discharged to a skilled the value of a statistical life, because
patient cost associated with the vari- nursing facility, 51 percent are as- it does not account for the value of
ous levels of rehabilitation and long- sumed to require institutional care lost leisure time of patients or for
term care. The patients discharged for at least 1 year, 10 percent are as- their pain and suffering. This study
to their homes are assumed to re- sumed to die within 6 months, and assumes that the average patient
quire a minimum amount of care 39 percent are assumed to die within suffers an osteoporosis-related hip
after being discharged from the hos- 6 to 12 months. Total costs associ- fracture at age 75, about 20 percent
pital. This study conservatively as- ated with rehabilitation and institu- of whom die within the year. Based
sumes that these patients require a tional care are estimated at $5.1 bil- on $83,632 as the value of a statisti-
minimum of 6 weeks of rehabilita- lion to $7.1 billion each year. cal life at age 76 and the two earlier
tion, regardless of whether they estimates of annual cases, osteo-
fully recover to their prefracture sta- porosis-related hip fractures result
tus or to a near normal level. Three- Lost Productivity in losses from premature death of
fourths of the patients discharged to Increases the Annual $4.5 billion to $6.3 billion.
an intermediate-care facility are as- The study assumes that individu-
sumed to recover to a near normal
Cost of Hip Fractures als in the laborforce miss work for
level of functioning and return The estimate of lost productivity the duration of their rehabilitation
home after spending an average of due to osteoporosis-related hip frac- following osteoporosis-related hip
90 days in the facility. tures uses average weekly earnings fractures. The laborforce participa-
The remaining patients dis- to value lost wages for those who tion rate is the percentage of the
charged to an intermediate-care fa- miss work and, for those who die total population (or a subgroup of
cility are assumed to remain se- within a year, the Landefeld-Seskin the population) that is in the labor-

Figure 1
Almost Half of Those Hospitalized With Osteoporosis-Related Hip Fractures
Never Fully Recover

Patient status Discharge destination Outcome after 1 year Final outcome

at end of
hospital stay 75% fully recover
23% of total
fully recover
32% go home

25% recover to near normal

32% of total
96% live and recover to near
are discharged 74% recover to near normal normal
50% go to an
care facility
68% go to
an extended- 26% remain severely
care facility handicapped
Total entering
25% of total
hospital with remain severely
51% remain
osteoporosis- severely handicapped handicapped
related 50% go to a
skilled nursing
hip fractures facility

49% die
20% of total
die within
4% die in hospital 1 year

Moving Toward Healthier Diets

Table 2
Although the Majority of Patients Recover From Osteoporosis-Related Hip Fractures,
Two-Thirds Require Institutional Care

Discharge Outcome Share of Days Daily Total cost

destination after patients in care rate Low High
discharge facility1 range2 range3

Percent Number Dollars Million dollars

Home Fully recover 23.0 42 8 20.87 28.98

Home Near normal 7.7 42 8 6.99 9.70
Intermediate care facility Near normal 24.1 90 73 427.50 593.76
Intermediate care facility Severely handicapped 8.5 360 73 603.12 837.68
Skilled nursing facility Severely handicapped 16.6 360 135 2,178.25 3,025.35
Skilled nursing facility Die within 3 months 1.3 90 135 42.64 59.23
Skilled nursing facility Die within 3-6 months 2.0 180 135 131.22 182.25
Skilled nursing facility Die within 6-12 months 12.7 360 135 1,666.49 2,314.57

Total N/A 95.94 N/A N/A 5,077.08 7,051.52

Notes: Costs are in 1995 dollars. N/A = Not applicable. 1Assumes that patients discharged to the home still require an average of 6
weeks of rehabilitation regardless of their final outcome. Patients discharged to an intermediate care facility and who recover stay an
average of 3 months in the facility; others stay 1 year. Patients discharged to a skilled nursing facility stay at least 1 year, unless they die.
2Based on the Older Womens League estimate that 18 percent of the 1.5 million fractures each year are osteoporosis-related hip frac-

tures (270,000 hip fractures per year). 3Based on the National Osteoporosis Foundation estimate that 25 percent of the 1.5 million frac-
tures each year are osteoporosis-related hip fractures (375,000 hip fractures per year). 4The remaining 4 percent of patients die in the
hospital before being discharged.

force. For the 80 percent of patients Table 3

who survive, osteoporosis-related Largest Cost of Osteoporosis-Related Hip Fractures Due to Rehabilita-
hip fractures result in $75 million to tion and Extended Care
$104 million in lost productivity due
to missed work (using a 4.6-percent Item Cost
laborforce participation rate for peo- Low range1 High range2
ple 75 years and older and an aver-
age daily wage rate of $48.14 for Million dollars
those working at the time of the hip
fracture) (table 3). Initial medical costs 3,127.14 4,343.25
This study estimates that the total Rehabilitation and institutional costs 5,077.08 7,051.52
economic cost of osteoporosis-re- Value of missed work 74.72 103.79
lated hip fractures is $12.8 billion to Value of premature death 4,516.13 6,272.4
$17.8 billion each year. The costs of
Total cost 12,795.07 17,770.96
hospitalization and outpatient care
Costs attributed to diet3 5,118.03 10,662.58
are $3.1 billion to $4.3 billion per
year. Further, because hip fractures
Notes: Costs are in 1995 dollars. 1The low range is based on the Older Womens
tend to occur among the elderly, the League estimate that 18 percent of the 1.5 million fractures each year are osteoporo-
value of lost productivity due to sis-related hip fractures (270,000 hip fractures per year). 2The high range is based on
missed work is a smaller component the National Osteoporosis Foundation estimate that 25 percent of the 1.5 million frac-
of the total cost than is the value of tures each year are osteoporosis-related hip fractures (375,000 hip fractures per year).
3Studies suggest that 40 to 60 percent of osteoporosis-related hip fractures could be
premature death or the costs of re-
prevented by increasing calcium intake.
habilitation and institutionalization.
Rehabilitation and institutionaliza-
tion costs of $5.1 billion to $7.1 bil-
lion account for 40 percent of the es-

January-April 1996
Moving Toward Healthier Diets

timated total economic cost of osteo- until the process begins to start pre- Chrischilles, E., T. Shireman, and
porosis-related hip fractures. ventive action. Consuming adequate R. Wallace. Costs and Health Ef-
Since there is no known cure for dietary calcium should be a lifelong fects of Osteoporotic Fractures,
osteoporosis, preventive measures process, especially for women be- Bone, Vol. 15, No. 4, 1994, pp. 377-86.
are important. Increasing evidence cause of their increased risk.
indicates that inadequate calcium in- Holbrook, Troy, Elizabeth Barrett-
take is at least partly responsible for Connor, and Deborah Wingard. Di-
the risk of osteoporosis-related hip etary Calcium Intake and Risk of
fractures. Medical research suggests Bowen, Otis. Osteoporosis: Pre- Hip Fracture: 14 Year Prospective
that increased consumption of cal- vention and the Quality of Life for Population Study, The Lancet, Nov.
cium could prevent 40 to 60 percent Older Americans, Public Health Re- 5, 1988, pp. 1046-48.
of osteoporosis-related hip fractures. ports, U.S. Department of Health
This study estimates that these diet- and Human Services, Sept.-Oct. 1989 Landefeld, Steven J., and Eugene
related fractures result in costs of (suppl.) pp. 11-13. Seskin. The Economic Value of Life:
$5.1 billion to $10.7 billion per year Linking Theory to Practice, Ameri-
for medical care, extended-treatment Chapuy, Marie, Monique Arlot, can Journal of Public Health, Vol. 72,
facilities, and the value of lost pro- and Francois Duboeuf. Vitamin D3 No. 6, pp. 555-66.
ductivity. Since bone loss begins in and Calcium to Prevent Hip Frac-
the mid-thirties, it is best not to wait tures in Elderly Women, The New McBean, Lois D., Tab Forgac, and
England Journal of Medicine, Vol. 327, Susan Calvert Finn. Osteoporosis:
No. 23, Dec. 3, 1992, pp. 1637-42. Visions for Care and PreventionA
Conference Report, Journal of the
American Dietetic Association, Vol. 94,
No. 6, June 1994, pp. 668-71.