Open Access
Original Article

Archives of Osteoporosis

, 8:137

Osteoporosis in the European Union: a compendium of country-specific reports

Authors

  • A. Svedbom
    • OptumInsight
  • E. Hernlund
    • OptumInsight
  • M. Ivergård
    • OptumInsight
  • J. Compston
    • Department of Medicine, Addenbrooke’s HospitalCambridge University
  • C. Cooper
    • MRC Lifecourse Epidemiology UnitUniversity of Southampton
    • NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal SciencesUniversity of Oxford
  • J. Stenmark
    • International Osteoporosis Foundation
  • E. V. McCloskey
    • Academic Unit of Bone Metabolism, Northern General Hospital
    • WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield
  • B. Jönsson
    • Stockholm School of Economics
  • J. A. Kanis
    • WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield
    • WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical School
  • the EU review panel of the IOF

DOI: 10.1007/s11657-013-0137-0

Abstract

Summary

This report describes epidemiology, burden, and treatment of osteoporosis in each of the 27 countries of the European Union (EU27).

Introduction

In 2010, 22 million women and 5.5 million men were estimated to have osteoporosis in the EU; and 3.5 million new fragility fractures were sustained, comprising 620,000 hip fractures, 520,000 vertebral fractures, 560,000 forearm fractures and 1,800,000 other fractures. The economic burden of incident and prior fragility fractures was estimated at € 37 billion. 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. The aim of this report was to characterize the burden of osteoporosis in each of the EU27 countries in 2010 and beyond.

Methods

The data on fracture incidence and costs of fractures in the EU27 were taken from a concurrent publication in this journal (Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden) and country specific information extracted.

Results

The clinical and economic burden of osteoporotic fractures in 2010 is given for each of the 27 countries of the EU. The costs are expected to increase on average 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 cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis has decreased in recent years, suggesting that a change in healthcare policy concerning the disease is warranted.

Keywords

Epidemiology Fracture Economic burden European Union Treatment Health Technology Assessment

Table of Contents

Introduction

Epidemiology and economic burden of osteoporosis in
  1. 1

    Austria

     
  2. 2

    Belgium

     
  3. 3

    Bulgaria

     
  4. 4

    Cyprus

     
  5. 5

    Czech Republic

     
  6. 6

    Denmark

     
  7. 7

    Estonia

     
  8. 8

    Finland

     
  9. 9

    France

     
  10. 10

    Germany

     
  11. 11

    Greece

     
  12. 12

    Hungary

     
  13. 13

    Ireland

     
  14. 14

    Italy

     
  15. 15

    Latvia

     
  16. 16

    Lithuania

     
  17. 17

    Luxembourg

     
  18. 18

    Malta

     
  19. 19

    Netherlands

     
  20. 20

    Poland

     
  21. 21

    Portugal

     
  22. 22

    Romania

     
  23. 23

    Slovakia

     
  24. 24

    Slovenia

     
  25. 25

    Spain

     
  26. 26

    Sweden

     
  27. 27

    United Kingdom

     

Acknowledgements

List of abbreviations
DDD

Defined daily dosage

DXA

Dual-energy X-ray absorptiometry

EU27

Refers to the 27 countries of the European Union

FRAX®

WHO fracture risk assessment tool

GDP

Gross domestic product

QALY

Quality-adjusted life year

SD

Standard deviation

T-score

number of SDs by which BMD in an individual differs from the mean value expected in young healthy women

Introduction

Osteoporosis, literally “porous bone”, is a disease characterized by weak bone. It is a major public health problem, affecting hundreds of millions of people worldwide, predominantly postmenopausal women. The main clinical consequence of the disease is bone fractures. It is estimated that one in three women and one in five men over the age of fifty worldwide will sustain an osteoporotic fracture. Hip and spine fractures are the two most serious fracture types, associated with substantial pain and suffering, disability, and even death. As a result, osteoporosis imposes a significant burden on both the individual and society. During the past two decades, a range of medications has become available for the treatment and prevention of osteoporosis. The primary aim of pharmacological therapy is to reduce the risk of osteoporotic fractures.

A recent report ‘Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden’ published concurrently with this report described the current burden of osteoporosis in the EU in 2010. Twenty two million women and 5.5 million men were estimated to have osteoporosis; and 3.5 million new fragility fractures were sustained, comprising 620,000 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.

The objective of this report is to review and describe the current burden of osteoporosis in each of the EU member states. Epidemiological and health economic aspects of osteoporosis and osteoporotic fractures are summarised for 2010 with projections of the future prevalence of osteoporosis, the number of incident fractures, the direct and total cost of the disease including the value of QALYs lost. The report may serve as a basis for the formulation of healthcare policy concerning osteoporosis in general and the treatment and prevention of osteoporosis in particular. It may also provide guidance regarding the overall healthcare priority of the disease in each member state.

Epidemiology and Economic Burden of Osteoporosis in Austria

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, HP Dimai and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Hans Peter Dimai, Medical University of Graz, Department of Internal Medicine, Division of Endocrinology and Metabolism, Graz, Austria

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Austria

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Austria.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Austria, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Austria was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 87,000 new fragility fractures were sustained in Austria, comprising 16,000 hip fractures, 13,000 vertebral fractures, 13,000 forearm fractures and 44,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 799 million for the same year. Incident fractures represented 68 % of this cost, long-term fracture care 29 % and pharmacological prevention 4 %. Previous and incident fractures also accounted for 27,900 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 116,000 in 2025, representing an increase of 30,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 5,700, 4,400, 3,700 and 15,900, respectively. The burden of fractures in Austria in 2025 was estimated to increase by 28 % to € 1,025 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Austria in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Austria was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Austria

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 1,381,000 and 1,660,000 respectively in Austria in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Austria, 2010 [1]

Age

Women

Men

All

50–59

556,000

545,000

1,101,000

60–69

477,000

435,000

912,000

70–79

351,000

275,000

626,000

80–89

238,000

116,000

354,000

90+

38,000

10,000

48,000

50+

1,660,000

1,381,000

3,041,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 460,000 (Table 2). There were 28.7 DXA scan machines per million inhabitants [2] and guidelines for the assessment and treatment of osteoporosis are available [3, 4]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Austria by age using female-derived reference ranges at the femoral neck, 2010 [5]

Age group

Women

Men

50–54

19,026

7,525

55–59

24,384

8,540

60–64

34,320

12,992

65–69

47,874

15,614

70–74

54,684

12,636

75–79

58,125

11,639

80+

130,272

20,916

50+

368,685

89,862

Data on hip fracture incidence are available for Austria [6]. Given that country specific incidences of vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 322.9 and 757.2 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Austria by age

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabc_HTML.gif
The number of incident fractures in 2010 was estimated at 87,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 16,000, 13,000, 13,000 and 44,000 respectively. 66 % of fractures occurred in women. These estimates are in close agreement with recently published data for 2008 [7].
Table 4

Estimated number of incident fractures in Austria, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 2.44 % for hip and 2.75 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Austria, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 74,000 and 84,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Austria with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 1,018 (Table 8). Hip, vertebral and “other” fractures accounted for 505, 317 and 195 deaths respectively. Overall, approximately 55 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Austria within the first year after fracture (adjusted for comorbidities), 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabg_HTML.gif
Table 8

The number of deaths in men and women in Austria in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Austria including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

For Austria, only inpatient costs the first year after hip fracture had been reported at the cut off date [8]. Total first year costs after fracture were imputed by applying the inpatient cost for Austria to the ratio of inpatient cost to total first year costs observed in Sweden, resulting in an estimated total first year hip fracture cost of € 13,527. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report. A recent publication provides similar estimates [7].

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 33,317 [9]) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Cost of pharmacological fracture prevention including its administration were based on treatment uptake reported by IMS Health [10]. Annual drug cost for individual treatments is shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 30 [11] and a DXA scan costing € 30 every second year to monitor treatment [11].
Table 9

One year costs for relevant pharmaceuticals in Austria, 2010 [11]

 

Annual drug cost (€)

Alendronate

174

Risedronate

173

Etidronate

337

Ibandronate

266

Zoledronic acid

368

Raloxifene

463

Strontium ranelate

602

Parathyroid hormone

4,881

Teriparatide

5,033

The cost of osteoporosis in 2010 was estimated at € 799 million (Table 10). These costs are close to recently published estimates for 2008 [7]. First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 540 million, € 229 million and € 30 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 3.8 % of the total cost.
Table 10

Cost of osteoporosis (€) in Austria by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 421 million) followed by “other” (€ 300 million), spine (€ 36 million) and forearm fractures (€ 11 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites. The results are generally consistent with a recent cost of illness study undertaken for the year 2008 [7].
Table 11

Total cost (€) in 2010 by fracture site in men and women in Austria. Note that costs for fracture prevention therapy and monitoring are not included.

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabk_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figa_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Austria. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 27,900 (Table 12). 66 % of the total QALY loss was incurred in women. Prior fractures accounted for 53 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 1.90 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Austria according to age

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Table 13

Value of lost QALYs (€) in men and women in Austria in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

121,258,606

242,517,213

363,775,819

Incident vertebral fractures

139,325,710

278,651,420

417,977,130

Incident forearm fractures

15,209,448

30,418,897

45,628,345

Incident other fractures

167,398,442

334,796,883

502,195,325

Prior hip fractures

360,280,447

720,560,893

1,080,841,340

Prior vertebral fractures

147,816,230

295,632,461

443,448,691

Total

951,288,883

1,902,577,766

2,853,866,649

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 2.70 billion in Austria in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 20 %, 8 %, 1 %, 70 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 3.0 million in 2010 to 3.8 million in 2025, corresponding to an increase of 26 % (Table 14).
Table 14

Population projections in Austria by age and sex [12]

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The total number of fractures was estimated to rise from 87,000 in 2010 to 116,000 in 2025 (Table 15), corresponding to an increase of 34 %. Hip, clinical spine, forearm and other fractures increased by 5,700, 4,400, 3,700 and 15,900 respectively. The increase in the number of fractures ranged from 28 % to 36 %, depending on fracture site. The increase was estimated to be particularly marked in men (49 %) compared to women (27 %). Note that the calculations assume no change in the age- and sex-specific incidence of fracture. In the case of hip fracture, there is evidence that age specific rates have been decreasing in recent years [13].
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Austria

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The cost of osteoporosis (excluding values of QALYs lost) was estimated to rise from € 799 million in 2010 to € 1,025 million in 2025, corresponding to an increase of 28 % (Table 16). Costs incurred in women and men increased by 21 % and 43 % respectively.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding values of QALYs lost) by age and calendar year in men and women in Austria

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabp_HTML.gif
The total number of QALYs lost due to fracture was estimated to rise from 27,900 in 2010 to 34,600 in 2025, corresponding to an increase of 24 % (Table 17). The increase was estimated to be particularly marked in men (38 %) compared to women (17 %). Incident and prior fractures accounted for 67 % and 33 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Austria

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabq_HTML.gif
The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 2.7 billion in 2010 to € 3.4 billion in 2025. The increase was estimated to be particularly marked in men (+39 %) compared to women (+18 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Austria assuming the uptake of treatment remains unchanged

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabr_HTML.gif

Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figb_HTML.gif

Fig. 2 Treatment uptake in Austria (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 3.06 % in 2001 to 6.1 % in 2006 but subsequently decreased to 5.17 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Austria were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 52 % and 51 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

21

43

22

52

Women

139

282

143

51

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

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Epidemiology and Economic Burden of Osteoporosis in Belgium

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, M Hiligsmann, S Goemaere, J-Y Reginster and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Mickaël Hiligsmann, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium AND Department of Health Service Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands

Stefan Goemaere, Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium.

Jean-Yves Reginster, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis ✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Belgium

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Belgium.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Belgium, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Belgium were reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 80,000 new fragility fractures were sustained in Belgium, comprising 15,000 hip fractures, 12,000 vertebral fractures, 12,000 forearm fractures and 41,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 606 million for the same year. Incident fractures represented 69 % of this cost, long-term fracture care 26 % and pharmacological prevention 5 %. Previous and incident fractures also accounted for 26,800 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 99,000 in 2025, representing an increase of 19,000 fractures. Hip, clinical spine, forearm and other fractures was estimated to increase by 3,900, 2,900, 2,300 and 10,300, respectively. The burden of fractures in Belgium in 2025 was estimated to increase by 21 % to € 733 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. A substantial proportion of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Belgium in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Belgium was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Belgium

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 1,829,000 and 2,130,000 respectively in Belgium in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Belgium, 2010 [1]

Age

Women

Men

All

50–59

727,000

728,000

1,455,000

60–69

568,000

540,000

1,108,000

70–79

480,000

379,000

859,000

80–89

308,000

168,000

476,000

90+

47,000

14,000

61,000

50+

2,130,000

1,829,000

3,959,000

The number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 600,000 (Table 2), similar to an earlier estimate in 2008 [2]. There are 53 DXA scan machines per million inhabitants [3], and guidelines for the assessment and treatment of osteoporosis are available [4–8]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤-2.5 SD) in Belgium by age using female-derived reference ranges at the femoral neck, 2010 [9]

Age group

Women

Men

50–54

23,940

9,550

55–59

33,312

12,110

60–64

46,189

18,212

65–69

49,490

16,724

70–74

68,634

16,068

75–79

87,750

17,819

80+

167,560

30,212

50+

476,875

120,695

Data on hip fracture incidence are available for Belgium and we used a mean estimate for 2005–7 [10]. The incidence of hip fractures was determined using the national hospital database, which fully covers the annual hospital stays in Belgium (source: INAMI-RIZIV [Institut National d’Assurance Maladie Invalidité–Rijksinstituut voor Ziekte en Invaliditeitsverzekering] and SPF Public Health). Given that country specific incidence of vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 228.5 and 538.7 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Belgium by age

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabv_HTML.gif
The number of incident fractures in 2010 was estimated at 80,000 (Table 4). Incident hip, clinical vertebral, forearm and “other” fractures were estimated at 15,000, 12,000, 12,000 and 41,000 respectively. 66 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Belgium, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.88 % for hip and 2.04 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Belgium, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 74,000 and 81,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Belgium with a prior hip or clinical vertebral fracture fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. These comprise approximately 30 % of deaths associated with fracture [11]. The number of causally related deaths in 2010 was estimated at 979 (Table 8). Hip, vertebral and “other” fractures accounted for 492, 310 and 177 deaths respectively. Overall, approximately 51 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Belgium within the first year after fracture (adjusted for comorbidities), 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabz_HTML.gif
Table 8

The number of deaths in men and women in Belgium in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Belgium including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 11,426 in Belgium [12] comparable to a more recent estimate [13]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 22,608 [14]) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 19 and a DXA scan at € 34 every second year to monitor treatment [15].
Table 9

One year costs for relevant pharmaceuticals in Belgium, 2010 [15]

 

Annual drug cost (€)

Alendronate

123

Risedronate

131

Etidronate

93

Ibandronate

160

Zoledronic acid

324

Raloxifene

395

Strontium ranelate

464

Parathyroid hormone

-

Teriparatide

3,656

The cost of osteoporosis in 2010 was estimated at € 606 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 419 million, € 157 million and € 29 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 4.8 % of the total cost. This cost is very likely overinflated since reimbursement for DXA only came into effect in August of 2010 and repeat DXA is only reimbursed at 5 years.
Table 10

Cost of osteoporosis (€) in Belgium by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 308 million) followed by “other” (€ 232 million), spine (€ 28 million) and forearm fractures (€ 9 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Belgium. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabad_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figc_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Belgium. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 26,800 (Table 12). 67 % of the total QALY loss was incurred in women. Prior fractures accounted for 55 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 1.73 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Belgium according to age

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Table 13

Value of lost QALYs (€) in men and women in Belgium in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

107,584,970

215,169,940

322,754,911

Incident vertebral fractures

121,830,873

243,661,747

365,492,620

Incident forearm fractures

13,312,751

26,625,503

39,938,254

Incident other fractures

146,788,449

293,576,898

440,365,347

Prior hip fractures

342,179,611

684,359,221

1,026,538,832

Prior vertebral fractures

135,438,142

270,876,285

406,314,427

Total

867,134,797

1,734,269,594

2,601,404,391

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 2.34 billion in Belgium in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 18 %, 7 %, 1 %, 74 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 4.0 million in 2010 to 4.6 million in 2025, corresponding to an increase of 17 % (Table 14).
Table 14

Population projections in Belgium by age and sex [16]

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The total number of fractures was estimated to rise from 80,000 in 2010 to 99,000 in 2025 (Table 15), corresponding to an increase of 24 %. Hip, clinical vertebral, forearm and other fractures increased by 3,900, 2,900, 2,300 and 10,300 respectively. The increase in the number of fractures ranged from 19 % to 26 %, depending on fracture site. The increase was estimated to be particularly marked in men (32 %) compared to women (20 %). Note that no change in the age and sex specific incidence was assumed over this period.
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Belgium

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The cost of osteoporosis (excluding values of QALYs lost) was estimated to rise from € 606 million in 2010 to € 733 million in 2025, corresponding to an increase of 21 % (Table 16). Costs incurred in women and men increased by 17 % and 29 % respectively.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Belgium

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The total number of QALYs lost due to fracture was estimated to rise from 26,800 in 2010 to 31,300 in 2025, corresponding to an increase of 17 % (Table 17). The increase was estimated to be particularly marked in men (25 %) compared to women (13 %). Incident and prior fractures accounted for 65 % and 35 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Belgium

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 2.3 billion in 2010 to € 2.8 billion in 2025. The increase was estimated to be particularly marked in men (+26 %) compared to women (+14 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Belgium assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figd_HTML.gif

Fig. 2 Treatment uptake in Belgium (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 2 % in 2001 to 6.3 % in 2011 and thereafter decreased.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Belgium were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 45 % and 47 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk. Not all individuals at high risk as assessed by FRAX are eligible for reimbursement with the present reimbursement criteria.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

32

58

26

45

Women

214

402

188

47

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Hiligsmann M (2010) Economic evaluation of osteoporosis management. PhD Thesis, University of Liège 2010.

3. Kanis JA (2011) Personal communication.

4. International Osteoporosis Foundation (2011) Osteoporosis in the European Union in 2008 - Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

5. Boonen S, Body JJ, Boutsen Y et al. (2005) Evidence-based guidelines for the treatment of postmenopausal osteoporosis: a consensus document of the Belgian Bone Club. Osteoporos Int 16: 239–254.

6. Devogelaer JP, Gomaere S, Boonen S et al. (2006) Evidence-based guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis: a consensus document of the Belgian Bone Club. Osteoporos Int 17: 8–19.

7. Body J-J, Bergmann P Boonen S et al. (2010) Evidence-based guidelines for the pharmacological treatment. of postmenopausal osteoporosis: a consensus document by the Belgian Bone Club. Osteoporos Int 21: 1657–1680.

8. Body JJ, Bergmann P, Boonen S et al. (2011) Non-pharmacological management of osteoporosis: a consensus of the Belgian Bone Club. Osteoporos Int 22: 2769–2788.

9. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

10. Hiligsmann M, Bruyère O, Roberfroid D et al. (2012) Trends in Hip Fracture Incidence and in the Prescription of Antiosteoporosis Medications During the Same Time Period in Belgium (2000–2007). Arthritis Care & Research 64:744–50.

11. Kanis JA, Oden A, Johnell O, Laet CD, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture Bone. 30:468–73.

12. Bouee S, Lafuma A, Fagnani F, Meunier PJ, Reginster JY (2006) Estimation of direct unit costs associated with non-vertebral osteoporotic fractures in five European countries. Rheumatol Int 26: 1063–72

13. Hiligsmann M, Gathon HJ, Bruyère O, Daubie M, Dercq JP, Parmentier Y, Reginster JY. Hospitalisation costs of hip fractures in Belgium. Osteoporosis Int 2011, 22 S1, S332. (abstract)

14. Autier P, Haentjens P, Bentin J, Baillon JM, Grivegnee AR, Closon MC, Boonen S (2000) Costs induced by hip fractures: a prospective controlled study in Belgium. Belgian Hip Fracture Study Group. Osteoporos Int 11: 373–80

15. INAMI-RIZIV Institute national d’assurance maladie-invalidité (2011). Accessed June: http://​www.​inami.​fgov.​be/​insurer/​fr/​rate/​pdf/​last/​doctors/​rx20110601fr.​pdf

16. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Bulgaria

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, A-M Borissova, R Kovacheva, A Shinkov, M Boyanov, R Rachkov, P Popivanov, Z Kolarov, and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Anna-Maria Borissova,, Department of Thyroid and Metabolic Bone Diseases, University Hospital of Endocrinology, Medical University of Sofia, Sofia, Bulgaria

Russanka Kovacheva, Department of Thyroid and Metabolic Bone Diseases, University Hospital of Endocrinology, Medical University of Sofia, Sofia, Bulgaria

Alexander Shinkov,, Department of Thyroid and Metabolic Bone Diseases, University Hospital of Endocrinology, Medical University of Sofia, Sofia, Bulgaria

Mihail Boyanov, Department of Internal Medicine, Clinic of Endocrinology and Metabolism, University Hospital Alexandrovska, Medical University of Sofia, Sofia, Bulgaria

Racho Rachkov, Department of Internal Medicine, Clinic of Rheumatology, University Hospital Ivan Rilski, Medical University of Sofia, Sofia, Bulgaria

Plamen Popivanov, Department of Internal Medicine, Bone Metabolic Unit, University Hospital Alexandrovska, Medical University of Sofia, Sofia, Bulgaria

Zlatimir Kolarov, Department of Internal Medicine, Clinic of Endocrinology and Metabolism, University Hospital Alexandrovska, Medical University of Sofia, Sofia, Bulgaria

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Bulgaria

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Bulgaria.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Bulgaria, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Bulgaria was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 38,000 new fragility fractures were sustained in Bulgaria, comprising 5,900 hip fractures, 6,400 vertebral fractures, 6,500 forearm fractures and 19,400 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 42 million for the same year. Incident fractures represented 71 % of this cost, long-term fracture care 25 % and pharmacological prevention 3 %. Previous and incident fractures also accounted for 12,300 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 40,000 in 2025, representing an increase of 1,400 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 400, 200, 100 and 600, respectively. The burden of fractures in Bulgaria in 2025 was estimated to increase by 5 % to € 45 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment remained at very low levels in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Bulgaria in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Bulgaria was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Bulgaria

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 1,270,000 and 1,606,000 respectively in Bulgaria in 2010 (Table 1). A more recent census in 2011 indicates a small decrease in the population aged 50 years or more from 2.88 million to 2.84 million [2].
Table 1

Population at risk: men and women over the age of 50 in Bulgaria, 2010 [2]

Age

Women

Men

All

50–59

545,000

503,000

1,048,000

60–69

503,000

407,000

910,000

70–79

376,000

257,000

633,000

80–89

170,000

97,000

267,000

90+

12,000

6,000

18,000

50+

1,606,000

1,270,000

2,876,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 420,000 (Table 2). Allowing for differences in the calculation of T-scores the estimate for women is similar to previously published data [3]. There are 1.2 DXA scan machines per million inhabitants [4], and guidelines for the assessment and treatment of osteoporosis are available [5]. A country specific FRAX model for the assessment of fracture risk is not available for Bulgaria.
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Bulgaria by age using female-derived reference ranges at the femoral neck, 2010 [6]

Age group

Women

Men

50–54

16,947

6,375

55–59

26,496

8,680

60–64

40,040

13,630

65–69

45,046

12,728

70–74

55,242

10,920

75–79

66,750

12,051

80+

85,904

17,098

50+

336,425

81,482

Incidence data were not available for Bulgaria; therefore data for hip fractures was imputed from Romanian age-standardized incidence rates [7]. Fracture incidence is presented in Table 3. Standardized to the EU27 population, this hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 170.3 and 282.3 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Bulgaria by age

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The number of incident fractures in 2010 was estimated at 38,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 6,000, 6,000, 6,000 and 19,000 respectively. 56 % of fractures occurred in women. The number of hip fractures is consistent with Government sources when accounting for multiple admissions [8].
Table 4

Estimated number of incident fractures in Bulgaria, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.09 % for hip and 1.14 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age, presented in Table 5, are consistent with an earlier report of a survey in Bulgarian women [9].
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Bulgaria, 2010

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In the population over 50 years of age, the number of individuals with hip and clinical vertebral fractures that occurred before 2010 was estimated at 31,000 and 33,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Bulgaria with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 647 (Table 8). Hip, vertebral and “other” fractures accounted for 294, 283 and 71 deaths respectively. Overall, approximately 47 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Bulgaria within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Bulgaria in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Bulgaria including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 1,826 in Bulgaria based on hip fracture costs in Slovenia [10]. The costs are consistent with the information available from the Romanian National Health Insurance Fund [11]. No other fracture costs were available. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 4,044 [12]) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 2 [13] and a DXA scan costing € 59 [14] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Bulgaria, 2010 [15]

 

Annual drug cost (€)

Alendronate

80

Risedronate

147

Etidronate

-

Ibandronate

142

Zoledronic acid

309

Raloxifene

279

Strontium ranelate

389

Parathyroid hormone

-

Teriparatide

3,198

The cost of osteoporosis in 2010 was estimated at € 42 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 30 million, € 11 million and € 1 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 3.1 % of the total cost.
Table 10

Cost of osteoporosis (€) in Bulgaria by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 20 million) followed by “other” (€ 18 million), spine (€ 2 million) and forearm fractures (€ 1 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Bulgaria. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Fige_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Bulgaria. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 12,300 (Table 12). 58 % of the total QALY loss was incurred in women. Prior fractures accounted for 52 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 118 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Bulgaria according to age

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Table 13

Value of lost QALYs (€) in men and women in Bulgaria in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

6,692,022

13,384,044

20,076,066

Incident vertebral fractures

10,017,949

20,035,897

30,053,846

Incident forearm fractures

1,062,140

2,124,279

3,186,419

Incident other fractures

10,804,803

21,609,606

32,414,408

Prior hip fractures

22,118,181

44,236,361

66,354,542

Prior vertebral fractures

8,402,614

16,805,229

25,207,843

Total

59,097,708

118,195,416

177,293,124

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 160 million in Bulgaria in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 19 %, 7 %, 1 %, and 74 %, respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to be approximately constant at 2.9 million between 2010 and 2025 (Table 14).
Table 14

Population projections in Bulgaria by age and sex [16]

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The total number of fractures was estimated to rise from 38,000 in 2010 to 40,000 in 2025 (Table 15), corresponding to an increase of 4 %. Hip, clinical spine, forearm and other fractures increased by 400, 200, 100 and 600 respectively. The increase in the number of fractures ranged from 2 % to 8 %, depending on fracture site. The increase in women was estimated at 7 % while a decrease is expected in men.
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Bulgaria

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The cost of osteoporosis (excluding values of QALYs lost) was estimated to rise from € 42 million in 2010 to € 45 million in 2025, corresponding to an increase of 5 % (Table 16). Costs incurred in women and men increased by 9 % and 1 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding values of QALYs lost) by age and calendar year in men and women in Bulgaria

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The total number of QALYs lost due to fracture was estimated to rise only from 12,300 in 2010 to 12,800 in 2025, corresponding to an increase of 4 % (Table 17). The increase in men was estimated to be 1 % and the increase in women was estimated at 6 %. Incident and prior fractures accounted for 46 % and 54 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Bulgaria

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 160 million in 2010 to € 168 million in 2025. The increase was estimated to be 1 % in men and 7 % in women (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women from Bulgaria assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figf_HTML.gif

Fig. 2 Treatment uptake in Bulgaria (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.01 % in 2001 to 0.53 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Bulgaria were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 98 % and 95 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

2

92

90

98

Women

13

240

227

95

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. National Statistical Institute (NSI) (2011) 2011 census final results. Accessed January 2013. http://​censusresults.​nsi.​bg/​Census/​Reports/​2/​2/​R1.​aspx

2. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

3. Borissova A-M, Rashkov R, Boyanov M, Shinkov A, Popivanov P, Temelkova N, Vlahov J, Gavrailova M (2011) Femoral neck bone mineral density and 10-year absolute fracture risk in a national representative sample of Bulgarian women aged 50 years and older. Arch Osteoporosis 6:189–195

4. Kanis J (2011) personal communication, data on file.

5. The International Osteoporosis Foundation (IOF) (2011) Eastern European & Central Asian Regional Audit—Individual Country Reports. www.​iofbonehealth.​org/​publications/​eastern-european-central-asian-audit-2010.​html;

6. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

7. Grigorie D, Sucaliuc A, Johansson H, Kanis JA, McCloskey E (2012) Incidence of hip fracture in Romania and the development of a Romanian FRAX model. Calcif Tiss Intl 92: 429–36

8. Boyanov MA (2006) Prevalence of Low Central Bone Mineral Density in a Bulgarian Female Referral Population: a Pilot Study. Rheumatol Int 26:523–9

9. Lesnyak O, Nauroy L (2010) The Eastern European and central Asian regional audit. Epidemiology, cost and burden of osteoporosis in 2010. International Osteoporosis Foundation, Nyon. Available at http://​www.​iofbonehealth.​org/​eastern-european-central-asian-audit

10. Dzajkovska B, Wertheimer AI, Mrhar A (2007) The burden-of-illness study on osteoporosis in the Slovenian female population. Pharm World Sci 29: 404–11

11. Borissova A-M, personal communication, December 2012.

12. Nursing homes (2011) Personal communication—average of three Bulgarian nursing homes (750, 650, and 550 lev/month).

13. Vatkova J (2011) National Health Insurance Fund in Bulgaria. Personal communication.

14. International Osteoporosis Foundation (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges. IOF, Nyon

15. Ministry of Health Bulgaria (2011). Accessed December 2011. www.​mh.​government.​bg/​Articles.​aspx?​lang=​bg-BG&​pageid=​383&​categoryid=​3999.

16. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Cyprus

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, GL Georgiades, C Kaisis and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

George L Georgiades, Cyprus Association for Musculoskeletal Diseases, Larnaca, Cyprus

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Cyprus

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Cyprus.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Cyprus, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Cyprus was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 5,000 new fragility fractures were sustained in Cyprus, comprising 800 hip fractures, 800 vertebral fractures, 1,000 forearm fractures and 2,600 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 52 million for the same year. Incident fractures represented 65 % of this cost, long-term fracture care 13 % and pharmacological prevention 22 %. Previous and incident fractures also accounted for 1,800 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 7,700 in 2025, representing an increase of 2,600 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 440, 390, 420 and 1,300, respectively. The burden of fractures in Cyprus in 2025 was estimated to increase with 47 % to € 76 million.

Conclusions There is a high cost of osteoporosis with a substantial projected increase of the economic burden driven by an aging population, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Cyprus in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Cyprus was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Cyprus

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 150,000 and 161,000 respectively in Cyprus in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Cyprus, 2010 [1]

Age (years)

Women

Men

All

50–59

65,000

66,000

131,000

60–69

49,000

45,000

94,000

70–79

30,000

27,000

57,000

80–89

15,000

11,000

26,000

90+

2,000

1,000

3,000

50+

161,000

150,000

311,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 40,000 (Table 2). There are 23.9 DXA scan machines per million (m) inhabitants [2], and there are no guidelines for osteoporosis treatment [3]. A country specific FRAX model for the assessment of fracture risk is not available for Cyprus.
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Cyprus by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

2,205

875

55–59

2,880

1,085

60–64

3,861

1,450

65–69

4,444

1,480

70–74

4,743

1,248

75–79

4,875

1,133

80+

8,024

1,992

50+

31,032

9,263

Incidence data was not available for Cyprus, therefore data for hip fractures was imputed from Greek age-standardized incidence rates [5]. Fracture incidence is presented in Table 3. Standardized to the EU27 population, this hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 212.7 and 494.0 respectively. The incidence of vertebral, forearm and “other” fractures was imputed using the methods described in Chapter 3 of the main report.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Cyprus by age

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The number of incident fractures in 2010 was estimated at approximately 5,000 (Table 4). Incident hip, clinical spine, forearm fractures were estimated at approximately 1,000 each and “other” fractures were estimated at 3,000. 61 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Cyprus, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.58 % for hip and 1.98 % for vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Cyprus, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 5,000 and 6,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Cyprus with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 53 (Table 8). Hip, vertebral and “other” fractures accounted for 27, 19 and 8 deaths respectively. Overall, approximately 46 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Cyprus within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Cyprus in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Cyprus including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 14,821 in Cyprus based on cost estimates in Italy [6]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 15,261 [7,8], approximated by adjusting the Bulgarian cost for health adjusted price levels) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 14 [9] and a DXA scan costing € 75 [10] every second year to monitor treatment.

Table 9

One year costs for relevant pharmaceuticals in Cyprus, 2010 [9]

 

Annual drug cost (€)

Alendronate

327

Risedronate

508

Etidronate

-

Ibandronate

489

Zoledronic acid

481

Raloxifene

1,037

Strontium ranelate

655

Parathyroid hormone

-

Teriparatide

7,179

The cost of osteoporosis in 2010 was estimated at € 52 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 34 million, € 7 million and € 12 million, respectively. It is notable that pharmacological fracture prevention costs accounted for only 22.4 % of the total cost.
Table 10

Cost of osteoporosis (€) in Cyprus by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, “other” fractures were most costly (€ 20 million) followed by hip (€ 17 million), spine (€ 2 million) and forearm fractures (€ 1 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Cyprus. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabbp_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figg_HTML.gif

Fig. 1. Share (%) of fracture cost by fracture site in Cyprus. Note that costs for fracture prevention therapy and monitoring are not included.

The number of QALYs lost due to osteoporosis in 2010 was estimated at 1,800 (Table 12). Prior fractures accounted for 58 % of the total loss and 63 % of the loss occurred in women. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 78 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Cyprus according to age

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Table 13

Value of lost QALYs (€) in men and women in Cyprus in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

3,878,655

7,757,311

11,635,966

Incident vertebral fractures

5,369,465

10,738,931

16,108,396

Incident forearm fractures

704,293

1,408,586

2,112,879

Incident other fractures

6,555,346

13,110,692

19,666,038

Prior hip fractures

15,557,915

31,115,830

46,673,745

Prior vertebral fractures

7,059,402

14,118,803

21,178,205

Total

39,125,076

78,250,153

117,375,229

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 130 million in Cyprus in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 26 %, 5 %, 9 % and 60 %, respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 311,000 in 2010 to 430,000 in 2025, corresponding to an increase of 38 % (Table 14).
Table 14

Population projections in Cyprus by age and sex [11]

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The total number of fractures was estimated to rise from 5,000 in 2010 to 8,000 in 2025 (Table 15), corresponding to an increase of 50 %. Hip, clinical spine, forearm and other fractures increased by 400, 400, 400 and 1,300 respectively. The increase in the number of fractures ranged from 44 % to 57 %, depending on fracture site. The increase was estimated to be particularly marked in men (49 %) compared to women (51 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Cyprus

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 52 million in 2010 to € 76 million in 2025, corresponding to an increase of 47 % (Table 16). Costs incurred in women and men increased by 47 % and 48 % respectively.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Cyprus

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The total number of QALYs lost due to fracture was estimated to rise from 1,800 in 2010 to 2,300 in 2025, corresponding to an increase of 29 % (Table 17). The increase was estimated to be particularly marked in men (38 %) compared to women (24 %). Incident and prior fractures accounted for 73 % and 27 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Cyprus

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 130 million in 2010 to € 177 million in 2025. The increase was estimated to be particularly marked in men (+42 %) compared to women (+33 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Cyprus assuming the uptake of treatment remains unchanged

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabbw_HTML.gif

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. International Osteoporosis Foundation (2011) Osteoporosis in the European Union in 2008—Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

5. Paspati I, Galanos A, Lyritis GP (1998) Hip fracture epidemiology in Greece during 1977–1992. Calcif Tissue Int 62: 542–47

6. Visentin P, Ciravegna R, Fabris F (1997) Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy. Maturitas 26: 185–92

7. Nursing homes (2011) Personal communication—average of three Bulgarian nursing homes (750, 650, and 550 lev/month).

8. International Bank for Reconstruction and Development/The World Bank (2008) 2005 International Comparison Program, Tables of final results.

9. Ministry of Health Cyprus (2011). Accessed June: www.​moh.​gov.​cy

10. International Osteoporosis Foundation, IOF (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges.

11. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in the Czech Republic

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, M Bayer and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Milan Bayer, Charles University Prague, Medical Faculty in Hradec Králové, Hradec Králové, Czech Republic

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Czech Republic

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in the Czech Republic.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in the Czech Republic, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in the Czech Republic was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 72,000 new fragility fractures were sustained in the Czech Republic, comprising 12,000 hip fractures, 11,000 vertebral fractures, 12,000 forearm fractures and 37,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 273 million for the same year. Incident fractures represented 60 % of this cost, long-term fracture care 20 % and pharmacological prevention 19 %. Previous and incident fractures also accounted for 22,800 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 94,000 in 2025, representing an increase of 21,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 4,700, 3,400, 2,400 and 11,000, respectively. The burden of fractures in the Czech Republic in 2025 was estimated to increase by 29 % to € 352 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment remained at very low levels in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by an aging population, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in the Czech Republic in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in the Czech Republic was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in the Czech Republic

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 1,710,000 and 2,092,000 respectively in the Czech Republic in 2010 (Table 1).
Table 2

Population at risk: men and women over the age of 50 in the Czech Republic, 2010 [1]

Age (years)

Women

Men

All

50–59

768,000

746,000

1,514,000

60–69

662,000

573,000

1,235,000

70–79

406,000

276,000

682,000

80–89

235,000

109,000

344,000

90+

21,000

6,000

27,000

50+

2,092,000

1,710,000

3,802,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 530,000 (Table 2). There are 5.2 DXA scan machines per million inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in the Czech Republic by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

23,310

9,200

55–59

38,208

13,230

60–64

55,484

20,068

65–69

55,348

16,798

70–74

56,637

11,544

75–79

76,125

13,184

80+

120,832

19,090

50+

425,944

103,114

Data on hip fracture incidence are available for the Czech Republic [5]. Given that country specific incidence of vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 277.1 and 566.6 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in the Czech Republic by age

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The number of incident fractures in 2010 was estimated at 72,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 12,000, 11,000, 12,000 and 37,000 respectively. 61 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in the Czech Republic, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.55 % for hip and 1.69 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in the Czech Republic, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 59,000 and 64,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in the Czech Republic with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 1,034 (Table 8). Hip, vertebral and “other” fractures accounted for 501, 380 and 154 deaths respectively. Overall, approximately 50 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in the Czech Republic within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in the Czech Republic in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in the Czech Republic including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 5,169 in the Czech Republic [6]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 10,614 [6]) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 18 (approximated by adjusting Polish cost for health adjusted price levels [7]) and a DXA scan costing € 32 [8] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in the Czech Republic, 2010 [9]

 

Annual drug cost (€)

Alendronate

187

Risedronate

231

Etidronate

-

Ibandronate

328

Zoledronic acid

355

Raloxifene

454

Strontium ranelate

478

Parathyroid hormone

4,485

Teriparatide

4,753

The cost of osteoporosis in 2010 was estimated at € 273 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 165 million, € 56 million and € 53 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 19.2 % of the total cost.
Table 10

Cost of osteoporosis (€) in the Czech Republic by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 110 million) followed by “other” (€ 96 million), spine (€ 11 million) and forearm fractures (€ 4 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in the Czech Republic. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabch_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figh_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in the Czech Republic. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 22,800 (Table 12). Prior fractures accounted for 52 % of the total loss and 63 % of the loss occurred in women. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 630 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in the Czech Republic according to age

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Table 13

Value of lost QALYs (€) in men and women in the Czech Republic in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

38,084,562

76,169,123

114,253,685

Incident vertebral fractures

48,705,018

97,410,035

146,115,053

Incident forearm fractures

5,531,867

11,063,733

16,595,600

Incident other fractures

58,403,810

116,807,619

175,211,429

Prior hip fractures

117,570,796

235,141,592

352,712,388

Prior vertebral fractures

46,747,054

93,494,108

140,241,161

Total

315,043,105

630,086,211

945,129,316

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 900 million in Czech Republic in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 18 %, 6 %, 6 %, and 70 %, respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 3.8 million in 2010 to 4.3 million in 2025, corresponding to an increase of 13 % (Table 14).
Table 14

Population projections in the Czech Republic by age and sex [10]

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The total number of fractures was estimated to rise from 72,000 in 2010 to 94,000 in 2025 (Table 15), corresponding to an increase of 31 %. Hip, clinical spine, forearm and other fractures increased by 4,700, 3,400, 2,400 and 11,000 respectively. The increase in the number of fractures ranged from 20 % to 39 %, depending on fracture site. The increase was estimated to be similar in men (29 %) and women (30 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in the Czech Republic

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 273 million in 2010 to € 352 million in 2025, corresponding to an increase of 29 % (Table 16). Costs incurred in women and men increased by 27 % and 33 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in the Czech Republic

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabcm_HTML.gif
The total number of QALYs lost due to fracture was estimated to rise from 22,800 in 2010 to 27,900 in 2025, corresponding to an increase of 22 % (Table 17). The increase was estimated to be particularly marked in men (27 %) compared to women (19 %). Incident and prior fractures accounted for 67 % and 33 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in the Czech Republic

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabcn_HTML.gif
The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 900 million in 2010 to € 1.1 billion in 2025. The increase was estimated to be particularly marked in men (+28 %) compared to women (+22 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in the Czech Republic assuming the uptake of treatment remains unchanged

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabco_HTML.gif

Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figi_HTML.gif

Fig.2 Treatment uptake in the Czech Republic (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.64 % in 2001 to 2.29 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in the Czech Republic were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 88 % and 76 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

12

102

90

88

Women

79

330

251

76

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis J (2011) personal communication, data on file.

3. The International Osteoporosis Foundation (IOF) (2011) Eastern European & Central Asian Regional Audit—Individual Country Reports. www.​iofbonehealth.​org/​publications/​eastern-european-central-asian-audit-2010.​html;

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

5. Stepan J (2010) Personal communication.

6. Kudrna K, Krska Z (2005) Expense analysis of the proximal femoral fractures treatment. [Rozbor nákladů na léčbu zlomenin horního konce stehenní kosti]. Rozhl Chir 84: 631–34

7. International Bank for Reconstruction and Development/The World Bank (2008) 2005 International Comparison Program, Tables of final results.

8. International Osteoporosis Foundation, IOF (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges.

9. SÚKL State Institute for Drug Control in Czech Republic (2011). Accessed in June: www.​sukl.​eu/​

10. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Denmark

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, B Abrahamsen and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Bo Abrahamsen, Department of Medicine F, Gentofte Hospital, Hellerup, Denmark.

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Denmark

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Denmark.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Denmark, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Denmark was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 66,000 new fragility fractures were sustained in Denmark, comprising 12,000 hip fractures, 10,000 vertebral fractures, 10,000 forearm fractures and 34,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 1,055 million for the same year. Incident fractures represented 68 % of this cost, long-term fracture care 28 % and pharmacological prevention 4 %. Previous and incident fractures also accounted for 20,200 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 86,000 in 2025, representing an increase of 20,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 4,300, 3,200, 2,400 and 10,300, respectively. The burden of fractures in Denmark in 2025 was estimated to increase by 27 % to € 1,344 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment remained at very low levels in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Denmark in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Denmark was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis. Where possible, country-specific data were used (see below).

Epidemiology of osteoporosis in Denmark

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 950,000 and 1,053,000 respectively in Denmark in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Denmark, 2010 [1]

Age (years)

Women

Men

All

50–59

355,000

357,000

712,000

60–69

346,000

337,000

683,000

70–79

205,000

175,000

380,000

80–89

119,000

72,000

191,000

90+

28,000

9,000

37,000

50+

1,053,000

950,000

2,003,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 280,000 (Table 2). Note that the numbers do not include patients with vertebral osteoporosis (spine T-score <−2.5) in whom femoral neck BMD lies in the normal or osteopenic range. There are 14.6 DXA scan machines per million inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Denmark by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

11,403

4,600

55–59

16,704

6,055

60–64

27,170

10,904

65–69

31,512

11,026

70–74

32,364

8,112

75–79

33,375

7,313

80+

69,384

13,446

50+

221,912

61,456

Epidemiology of fracture in Denmark

Data on hip fracture incidence are available for Denmark [5], based on admission statistics from the Danish National Board of Health. These rates also included repeat admissions which overestimate somewhat the hip fracture incidence. Given that country specific incidence of the vertebral, forearm and, “other” fractures were not available, these were imputed using the methods described in Chapter 3 of the main report. Briefly, it was assumed for each age and sex that the ratio of the incidence of non-hip fracture to hip fractures in Sweden would be comparable to the ratio of vertebral fracture incidence to hip fracture incidence in Denmark. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 386.0 and 853.0 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Denmark by age

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The number of incident fractures in 2010 was estimated at 66,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 12,000, 10,000, 10,000 and 34,000 respectively. 63 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Denmark, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 2.48 % for hip and 2.92 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Denmark, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 50,000 and 59,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Denmark with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 879 (Table 8). Hip, vertebral and “other” fractures accounted for 427, 293 and 158 deaths respectively. Overall, approximately 52 % of deaths occurred in women.
Table 7

Estimated incidence (per 100,000) of causally related deaths [6] in Denmark within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Denmark in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Denmark including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 25,117 in Denmark [7, 8]. No other fracture costs were available. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 64,831 [9]) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 160 [10] and a DXA scan costing € 187 [10] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Denmark, 2010 [11]

 

Annual drug cost (€)

Alendronate

126

Risedronate

50

Etidrontate

103

Ibandronate

400

Zoledronic acid

468

Raloxifene

430

Strontium ranelate

721

Parathyroid hormone

6,874

Teriparatide

6,902

The cost of osteoporosis in 2010 was estimated at € 1,055 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 718 million, € 300 million and € 37 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 3.5 % of the total cost.
Table 10

Cost of osteoporosis (€) in Denmark by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 564 million) followed by “other” (€ 431 million), spine (€ 12 million) and forearm fractures (€ 12 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Denmark. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figj_HTML.gif

Fig. 1. Share (%) of fracture cost by fracture site in Denmark. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 20,200 (Table 12). Prior fractures accounted for 50 % of the total loss and 63 % of the loss occurred in women. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 1.7 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Denmark according to age

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Table 13

Value of lost QALYs (€) in men and women in Denmark in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

113,232,433

226,464,867

339,697,300

Incident vertebral fractures

135,875,793

271,751,585

407,627,378

Incident forearm fractures

14,518,357

29,036,714

43,555,071

Incident other fractures

159,969,903

319,939,806

479,909,708

Prior hip fractures

299,757,795

599,515,589

899,273,384

Prior vertebral fractures

128,584,668

257,169,335

385,754,003

Total

851,938,948

1,703,877,896

2,555,816,844

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 2.76 billion in Denmark in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 26 %, 11 %, 1 %, 62 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 2.0 million in 2010 to 2.4 million in 2025, corresponding to an increase of 18 % (Table 14).
Table 14

Population projections in Denmark by age and sex [12]

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The total number of fractures was estimated to rise from 66,000 in 2010 to 86,000 in 2025 (Table 15), corresponding to an increase of 30 %, assuming that age-specific fracture rates remain unchanged over time. At present, hip fracture rates are falling in Denmark [13], so that if this trend continues, the present analysis may be an overestimate. Hip, spine, forearm and other fractures increased by 4,300, 3,200, 2,400 and 10,300, respectively. The increase in the number of fractures ranged from 23 % to 35 %, depending on fracture site. The increase was estimated to be particularly marked in men (35 %) compared to women (28 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Denmark

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 1055 million in 2010 to € 1344 million in 2025, corresponding to an increase of 27 % (Table 16). Costs incurred in women and men increased by 23 % and 34 % respectively.
Table 16

Current and future cost of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Denmark

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The total number of QALYs lost due to fracture was estimated to rise from 20,200 in 2010 to 24,900 in 2025, corresponding to an increase of 23 % (Table 17). The increase was estimated to be particularly marked in men (30 %) compared to women (19 %). Incident and prior fractures accounted for 67 % and 33 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Denmark

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 2.8 billion in 2010 to € 3.4 billion in 2025. The increase was estimated to be particularly marked in men (+32 %) compared to women (+21 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Denmark assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figk_HTML.gif

Fig. 2 Treatment uptake in Denmark (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.79 % in 2001 to 5.71 % in 2011. This is near the European average but high by North European standards.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in each country were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 50 % and 54 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

13

26

13

50

Women

87

190

103

54

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis J (2011) personal communication, data on file.

3. The International Osteoporosis Foundation (IOF) (2011) Osteoporosis in the European Union in 2008—Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468-89

5. Abrahamsen B (2011) Personal communication.

6. Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32; 468–473.

7. Strom O, Borgstrom F, Sen SS, Boonen S, Haentjens P, Johnell O, Kanis JA (2007) Cost-effectiveness of alendronate in the treatment of postmenopausal women in 9 European countries—an economic evaluation based on the fracture intervention trial. Osteoporos Int 18: 1047–61

8. Kronborg C, Vass M, Lauridsen J, Avlund K (2006) Cost effectiveness of preventive home visits to the elderly: economic evaluation alongside randomized controlled study. Eur J Health Econ 7: 238–46

9. Nurmi I, Narinen A, Luthje P, Tanninen S (2003) Cost analysis of hip fracture treatment among the elderly for the public health services: a 1-year prospective study in 106 consecutive patients. Arch Orthop Trauma Surg 123:551-554

10. The Danish Ministry of Health (2000). Takstsystem 2011 ISBN 978-87-7601304-2:

11. Danish Medicines Agency (2011). Accessed July: http://​www.​medicinpriser.​dk

12. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

13. Abrahamsen B, Vestergaard P (2010) Declining incidence of hip fractures and the extent of use of anti-osteoporotic therapy in Denmark 1997–2006. Osteoporos Int 21: 373–380.

Epidemiology and Economic Burden of Osteoporosis in Estonia

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, K Maasalu and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Katre Maasalu, Department of Traumatology and Orthopaedics, University of Tartu, Estonia

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Estonia

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Estonia.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Estonia, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Estonia was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 9,000 new fragility fractures were sustained in Estonia, comprising 1,600 hip fractures, 1,400 vertebral fractures, 1,400 forearm fractures and 4,300 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 30 million for the same year. Incident fractures represented 73 % of this cost, long-term fracture care 23 % and pharmacological prevention 3 %. Previous and incident fractures also accounted for 2,800 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 10,000 in 2025, representing an increase of 1,500 fractures. Hip, clinical spine (vertebral), forearm and other fractures were estimated to increase by 400, 200, 100 and 800, respectively. The burden of fractures in Estonia in 2025 was estimated to increase by 18 % to € 35 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above whom received treatment remained at very low levels in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Estonia in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Estonia was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Estonia

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 188,000 and 297,000 respectively in Estonia in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Estonia, 2010 [1]

Age (years)

Women

Men

All

50–59

99,000

81,000

180,000

60–69

81,000

55,000

136,000

70–79

74,000

38,000

112,000

80–89

38,000

13,000

51,000

90+

5,000

1,000

6,000

50+

297,000

188,000

485,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 80,000 (Table 2). There are 8.9 DXA scan machines per million (m) inhabitants, and guidelines for the assessment and treatment of osteoporosis are available [2]. A country specific FRAX model for the assessment of fracture risk is not available for Estonia. Based on the likelihood that the fracture rate and mortality in Lithuania was equal to Estonia, the FRAX model for Lithuania was used as a surrogate,
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Estonia by age using female-derived reference ranges at the femoral neck, 2010 [3]

Age (years)

Women

Men

50–54

3,150

1,075

55–59

4,704

1,330

60–64

6,149

1,798

65–69

7,676

1,776

70–74

11,439

1,794

75–79

12,375

1,545

80+

20,296

2,324

50+

65,789

11,642

There are limited data on fracture rates in Estonia and no specific information on hip fracture incidence [4] Data for hip fractures were imputed from Finnish age-standardized incidence rates [5]. Fracture incidence is presented in Table 3. Standardized to the EU27 population, this hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 238 and 440 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Estonia by age

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The number of incident fractures in 2010 was estimated at 8,700 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 1,600, 1,400, 1,400 and 4,300 respectively. 69 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Estonia, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 1.52 % for hip and 1.54 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Estonia, 2010

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In the population over 50 years of age, the number of both men and women with hip or vertebral fractures that occurred before 2010 was estimated at 7,000 (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Estonia with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 134 (Table 8). Hip, vertebral and “other” fractures accounted for 65, 50 and 19 deaths respectively. Overall, approximately 54 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Estonia within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Estonia in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Estonia including and excluding value of QALYs Lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

In Estonia, the cost of a hip fracture has been estimated at € 5,580 using the fracture cost in Finland [6]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 10,483 [7,8], based on Finnish cost of nursing home that was PPP adjusted) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 12 [9] and a DXA scan costing € 187 [9] every second year to monitor treatment. The cost is conservative in that monitoring is usually conducted annually.
Table 9

One year costs for relevant pharmaceuticals in Estonia, 2010 [10]

 

Annual drug cost (€)

Alendronate

171

Risedronate

143

Etidronate

-

Ibandronate

283

Zoledronic acid

202

Raloxifene

-

Strontium ranelate

446

Parathyroid hormone

-

Teriparatide

-

The cost of osteoporosis in 2010 was estimated at € 30 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 22 million, € 7 million and € 1 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 3.3 % of the total cost.
Table 10

Cost of osteoporosis (€) in Estonia by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 15 million) followed by “other” (€ 12 million), spine (€ 1.5 million) and forearm fractures (€ 0.5 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women from Estonia. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figl_HTML.gif

Fig. 1. Share (%) of fracture cost by fracture site in Estonia. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 2,800 (Table 12). 72 % of the total QALY loss was incurred in women. Prior fractures accounted for 52 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 60 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Estonia according to age

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Table 13

Value of lost QALYs (€) in men and women in Estonia in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

3,899,777

7,799,554

11,699,331

Incident vertebral fractures

4,735,018

9,470,037

14,205,055

Incident forearm fractures

503,032

1,006,063

1,509,095

Incident other fractures

5,159,726

10,319,452

15,479,178

Prior hip fractures

11,216,129

22,432,259

33,648,388

Prior vertebral fractures

4,170,935

8,341,869

12,512,804

Total

29,684,617

59,369,234

89,053,851

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 90 million in Estonia in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 25 %, 8 %, 1 %, 66 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 485,000 in 2010 to 511,000 in 2025, corresponding to an increase of 5 % (Table 14).
Table 14

Population projections in Estonia by age and sex [11]

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The total number of fractures was estimated to rise from 9,000 in 2010 to 10,000 in 2025 (Table 15), corresponding to an increase of 11 %. Hip, clinical spine, forearm and other fractures increased by 400, 200, 100 and 800 respectively. The increase in the number of fractures ranged from 9 % to 23 %, depending on fracture site. The increase was estimated to be 19 % in men and 17 % in women.
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women from Estonia

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 30 million in 2010 to € 35 million in 2025, corresponding to an increase of 18 % (Table 16). Costs incurred in both women and men increased by 18 %.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Estonia

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The total number of QALYs lost due to fracture was estimated to rise from 2,800 in 2010 to 3,200 in 2025, corresponding to an increase of 15 % (Table 17). The increase was estimated to be particularly marked in men (17 %) compared to women (15 %). Incident and prior fractures accounted for 53 % and 47 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Estonia

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 89 million in 2010 to € 104 million in 2025. The increase was estimated to be 17 % in men and 16 % in women (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Estonia assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
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Fig. 1 Treatment uptake in Estonia (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.13 % in 2001 to 1.66 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Estonia were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 93 % and 86 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

1

14

13

93

Women

7

48

41

86

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. The International Osteoporosis Foundation (IOF) (2011) Eastern European & Central Asian Regional Audit—Individual Country Reports. www.​iofbonehealth.​org/​publications/​eastern-european-central-asian-audit-2010.​html;

3. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

4. National Institute for Health Development, Estonia. Accessed January 2013 http://​pxweb.​tai.​ee/​esf/​pxweb2008/​Database_​en/​Morbidity/​databasetree.​asp

5. Kroger H (2011) Personal communication.

6. Nurmi I, Narinen A, Luthje P, Tanninen S (2003) Cost analysis of hip fracture treatment among the elderly for the public health services: a 1-year prospective study in 106 consecutive patients. Arch Orthop Trauma Surg 123: 551–54

7. Hujanen T, Kapiainen S, Tuominen U, Pekurinen M (2008) Terveydenhuollon yksikkökustannukset Suomessa vuonna 2006.

8. International Bank for Reconstruction and Development/The World Bank (2008) 2005 International Comparison Program, Tables of final results.

9. Estonian Health Insurance Fund (2011). Available at Riigi Teataja: www.​riigiteataja.​ee/​akt/​121062011024#para17

10. Estonian Medicine Information (Raviminfo) (2011). Accessed August: http://​www.​raviminfo.​ee/​otsing.​php

11. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Finland

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, H Kröger and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Heikki Kröger, Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Finland

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Finland.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Finland, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Finland was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 36,000 new fragility fractures were sustained in Finland, comprising 7,000 hip fractures, 6,000 vertebral fractures, 6,000 forearm fractures and 19,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 383 million for the same year. Incident fractures represented 70 % of this cost, long-term fracture care 27 % and pharmacological prevention 3 %. Previous and incident fractures also accounted for 12,300 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 49,000 in 2025, representing an increase of 13,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 2,900, 2,000, 1,200 and 6,600, respectively. The burden of fractures in Finland in 2025 was estimated to increase by 34 % to € 514 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Finland in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Finland was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Finland

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 960,000 and 1,130,000 respectively in Finland in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Finland, 2010 [1]

Age (years)

Women

Men

All

50–59

383,000

379,000

762,000

60–69

348,000

327,000

675,000

70–79

227,000

175,000

402,000

80–89

147,000

72,000

219,000

90+

25,000

7,000

32,000

50+

1,130,000

960,000

2,090,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 300,000 (Table 2). There are 16.8 DXA scan machines per million (m) inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk ( http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Finland by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

11,844

4,700

55–59

18,720

6,685

60–64

29,458

11,484

65–69

28,684

9,546

70–74

33,759

7,800

75–79

39,750

7,725

80+

81,184

13,114

50+

243,399

61,054

Data on the incidence of hip fractures are available for Finland [5–7] and that used to build the FRAX model was chosen for this study [7]. Given that country specific incidence of the vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Empirical data are expected in the near future [8]. Fracture incidence is presented in Table 3. Standardized to the EU27 population for 2010, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 238.0 and 440.0 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Finland by age

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The number of incident fractures in 2010 was estimated at 36,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 7,000, 6,000, 6,000 and 19,000 respectively. 60 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Finland, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 1.64 % for hip and 1.78 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Estimated proportion of men and women (in %) with a prior hip or clinical fracture in Finland, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 34,000 and 37,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Estimated number of men and women in Finland with a prior hip or clinical fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 425 (Table 8). Hip, vertebral and “other” fractures accounted for 209, 144 and 72 deaths respectively. Overall, approximately 47 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths [9] in Finland within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Finland in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Finland including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

In Finland, the cost of a hip fracture has been estimated at € 16,066 [10] No other fracture costs were available. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 32,930 [11]) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 17 [12] and a DXA scan costing € 146 [12] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Finland, 2010 [12]

 

Annual drug cost (€)

Alendronate

40

Risedronate

40

Etidronate

1,072

Ibandronate

456

Zoledronic acid

394

Raloxifene

488

Strontium ranelate

527

Parathyroid hormone

5,593

Teriparatide

5,933

The cost of osteoporosis in 2010 was estimated at € 383 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 269 million, € 104 million and € 10 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 2.6 % of the total cost.
Table 10

Cost of osteoporosis (€) in Finland by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 198 million) followed by “other” (€ 151 million), spine (€ 18 million) and forearm fractures (€ 5 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Finland. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Fign_HTML.gif

Fig. 1. Share (%) of fracture cost by fracture site in Finland. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 12,300 (Table 12). 62 % of the total QALY loss was incurred in women. Prior fractures accounted for 55 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 830 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Finland according to age

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Table 13

Value of lost QALYs (€) in men and women in Finland in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

49,153,821

98,307,641

147,461,462

Incident vertebral fractures

59,720,352

119,440,704

179,161,056

Incident forearm fractures

6,212,943

12,425,886

18,638,829

Incident other fractures

70,640,403

141,280,807

211,921,210

Prior hip fractures

163,554,941

327,109,882

490,664,823

Prior vertebral fractures

65,017,379

130,034,757

195,052,136

Total

414,299,839

828,599,677

1,242,899,516

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 1.21 billion in Finland in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 22 %, 9 %, 1 %, 68 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 2.1 million in 2010 to 2.3 million in 2025, corresponding to an increase of 12 % (Table 14).
Table 14

Population projections in Finland by age and sex [13]

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The total number of fractures was estimated to rise from 36,000 in 2010 to 49,000 in 2025 (Table 15), corresponding to an increase of 36 %. Hip, clinical spine, forearm and other fractures increased by 2,900, 2,000, 1,200 and 6,600 respectively. The increase in the number of fractures ranged from 21 % to 44 %, depending on fracture site. The increase was estimated to be particularly marked in men (42 %) compared to women (30 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women from Finland

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 383 million in 2010 to € 514 million in 2025, corresponding to an increase of 34 % (Table 16). Costs incurred in women and men increased by 28 % and 44 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Finland

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The total number of QALYs lost due to fracture was estimated to rise from 12,300 in 2010 to 15,800 in 2025, corresponding to an increase of 28 % (Table 17). The increase was estimated to be particularly marked in men (38 %) compared to women (22 %). Incident and prior fractures accounted for 59 % and 41 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Finland

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 1.2 billion in 2010 to € 1.6 billion in 2025. The increase was estimated to be particularly marked in men (+40 %) compared to women (+24 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Finland assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figo_HTML.gif

Fig. 2 Treatment uptake in Finland (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 1.38 % in 2001 to 4.22 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Finland were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the numberof individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 84 % and 69 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

8

51

43

84

Women

53

172

119

69

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis J (2011) personal communication, data on file.

3. The International Osteoporosis Foundation (IOF) (2011) Osteoporosis in the European Union in 2008—Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468-89

5. Sund R (2007) Utilization of routinely collected administrative data in monitoring the incidence of aging dependent hip fracture. Epidemiol Perspect Innov. 4:2

6. Huusko T, Arnala I, Aro H, Impivaara O, Jäntti P, Laukkanen P, Piirtola M, Sipilä R, Sund R, Tarkkila P, Varis T, Välimäki VV: Hip fracture—Current Care Summary. Duodecim 2011;127:1508–9. http://​www.​kaypahoito.​fi/​web/​kh/​suositukset/​naytaartikkeli/​…/​ccs00092

7. Kroger H and Sund R (2011) Personal communication.

8. Koski AM, Patala A, Patala E, Sund R (2013) Incidence of osteoporotic fractures in elderly women and men in Finland during 2005–2006—a population-based study. Scandinavian Journal of Surgery, in press.

9. Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003) The components of excess mortality after hip fracture. Bone 32; 468–473.

10. Nurmi I, Narinen A, Luthje P, Tanninen S (2003) Cost analysis of hip fracture treatment among the elderly for the public health services: a 1-year prospective study in 106 consecutive patients. Arch Orthop Trauma Surg 123: 551–54

11. Hujanen T, Kapiainen S, Tuominen U, Pekurinen M (2008) Terveydenhuollon yksikkökustannukset Suomessa vuonna 2006.

12. The Social Insurance Institution of Finland (2011). Accessed July: http://​kela.​fi/​

13. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in France

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Local author—to be determined

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in France

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in France.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in France, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in France was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 377,000 new fragility fractures were sustained in France, comprising 74,000 hip fractures, 56,000 vertebral fractures, 56,000 forearm fractures and 191,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 4,853 million for the same year. Incident fractures represented 66 % of this cost, long-term fracture care 27 % and pharmacological prevention 7 %. Previous and incident fractures also accounted for 139,400 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 491,000 in 2025, representing an increase of 115,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 24,500, 17,200, 12,900 and 60,000, respectively. The burden of fractures in France in 2025 was estimated to increase by 26 % to € 6,111 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. A substantial minority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in France in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in France was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in France

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 10,287,000 and 12,358,000 respectively in France in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in France, 2010 [1]

Age (years)

Women

Men

All

50–59

4,222,000

4,006,000

8,228,000

60–69

3,330,000

3,122,000

6,452,000

70–79

2,578,000

2,015,000

4,593,000

80–89

1,877,000

1,034,000

2,911,000

90+

351,000

110,000

461,000

50+

12,358,000

10,287,000

22,645,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 3,480,000 (Table 2). There are 29.1 DXA scan machines per million (m) inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in France by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

134,757

50,850

55–59

199,968

69,020

60–64

284,141

109,330

65–69

271,286

91,538

70–74

361,305

84,474

75–79

481,125

95,996

80+

1,051,616

189,904

50+

2,784,198

691,112

Data on hip fracture incidence are available for France [5]. Given that country specific incidence of vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 168 and 443 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in France by age

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabex_HTML.gif
The number of incident fractures in 2010 was estimated at 377,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 74,000, 56,000, 56,000 and 191,000 respectively. 68 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in France, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabey_HTML.gif
A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 1.92 % for hip and 1.92 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in France, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabez_HTML.gif
In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 435,000 and 436,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in France with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfa_HTML.gif
The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 4,233 (Table 8). Hip, vertebral and “other” fractures accounted for 2,098, 1,256 and 880 deaths respectively. Overall, approximately 51 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in France within the first year after fracture (adjusted for comorbidities), 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfb_HTML.gif
Table 8

The number of deaths in men and women in France in the first year after fracture attributable to the fracture event (causally related), 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfc_HTML.gif

Cost of osteoporosis in France including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture in France was not available. Therefore, it was imputed from the UK cost of a hip fracture by adjusting for differences in health care price levels and estimated at € 12,030 [6,7]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 31,512 [6], imputed from the UK long term care cost adjusting for differences in the health care price levels) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug cost (€) for individual treatments is shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 50 [8] and a DXA scan costing € 41 [9] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in France, 2010 [10]

 

Annual drug cost (€)

Alendronate

209

Risedronate

380

Etidrontate

99

Ibandronate

327

Zoledronic acid

410

Raloxifene

365

Strontium ranelate

579

Parathyroid hormone

-

Teriparatide

4,829

The cost of osteoporosis in 2010 was estimated at € 4,853 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 3,179 million, € 1,329 million and € 346 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 7.1 % of the total cost.
Table 10

Cost of osteoporosis (€) in France by age in men and women, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfe_HTML.gif
When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 2,588 million) followed by “other” (€ 1,689 million), spine (€ 153 million) and forearm fractures (€ 77 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in France. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabff_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figp_HTML.gif

Fig. 1. Share (%) of fracture cost by fracture site in France. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 139,400 (Table 12). 70 % of the total QALY loss was incurred in women. Prior fractures accounted for 60 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 8.31 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in France according to age

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfg_HTML.gif
Table 13

Value of lost QALYs (€) in men and women in France in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

478,803,425

957,606,851

1,436,410,276

Incident vertebral fractures

510,715,979

1,021,431,958

1,532,147,937

Incident forearm fractures

55,054,072

110,108,144

165,162,216

Incident other fractures

630,485,223

1,260,970,447

1,891,455,670

Prior hip fractures

1,814,820,821

3,629,641,642

5,444,462,463

Prior vertebral fractures

664,773,990

1,329,547,980

1,994,321,969

Total

4,154,653,510

8,309,307,021

12,463,960,531

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 13.16 billion in France in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 24 %, 10 %, 3 %, and 63 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 22.6 million in 2010 to 27.1 million in 2025, corresponding to an increase of 20 % (Table 14).
Table 14

Population projections in France by age and sex [11]

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfi_HTML.gif
The total number of fractures was estimated to rise from 377,000 in 2010 to 491,000 in 2025 (Table 15), corresponding to an increase of 30 %. Hip, clinical spine, forearm and other fractures increased by 24,500, 17,200, 12,900 and 60,000 respectively. The increase in the number of fractures ranged from 23 % to 33 %, depending on fracture site. The increase was estimated to be particularly marked in men (36 %) compared to women (28 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in France

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfj_HTML.gif
The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 4.9 billion in 2010 to € 6.1 billion in 2025, corresponding to an increase of 26 % (Table 16). Costs incurred in women and men increased by 23 % and 35 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in France

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfk_HTML.gif
The total number of QALYs lost due to fracture was estimated to rise from 139,400 in 2010 to 167,900 in 2025, corresponding to an increase of 20 % (Table 17). The increase was estimated to be particularly marked in men (29 %) compared to women (17 %). Incident and prior fractures accounted for 61 % and 39 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in France

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfl_HTML.gif
The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 13.2 billion in 2010 to € 16.1 billion in 2025. The increase was estimated to be particularly marked in men (+31 %) compared to women (+19 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in France assuming the uptake of treatment remains unchanged

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabfm_HTML.gif

Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figq_HTML.gif

Fig. 2 Treatment uptake in France (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 1.21 % in 2001 to 7.18 % in 2008, but fell back to 6.30 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in France were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 26 % and 43 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

208

282

74

26

Women

1,390

2,437

1,047

43

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. The International Osteoporosis Foundation (IOF) (2011) Osteoporosis in the European Union in 2008—Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468-89

5. Delmas PD (2006) Personal Communication.

6. Stevenson M, Davis S (2006) Analyses of the cost-effectiveness of pooled alendronate and risedronate, compared with strontium ranelate, raloxifene, etidronate and teriparatide. ScHARR: School of Health and Related Research.

7. Stevenson M, Davis S, Kanis J (2006) The hospitalization costs and outpatient costs of fragility fractures. Women’s Health Medicine 3: 149–51

8. Saraux A, Brun-Strang C, Mimaud V, Vigneron AM, Lafuma A (2007) Epidemiology, impact, management, and cost of Paget’s disease of bone in France. Joint Bone Spine 74: 90–95

9. International Osteoporosis Foundation, IOF (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges.

10. Vidal-pro (L’information de référence sur le médicament) (2011). www.​vidal.​fr/​

11. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Germany

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, K Dreinhoefer and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Karsten Dreinhoefer, Department of Muskuloskeletal Rehabilitation, Prevention and Health Service Research, Center for Sport Science and Sport Medicine (CSSB), Center for Musculoskeletal Surgery (CMSC), Charité Universitätsmedizin, Berlin; Department of Orthopedics and Traumatology, Medical Park Berlin Humboldtmühle, Berlin, Germany

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Germany

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Germany.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Germany, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Germany was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 725,000 new fragility fractures were sustained in Germany, comprising 130,000 hip fractures, 114,000 vertebral fractures, 118,000 forearm fractures and 363,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 9,008 million for the same year. Incident fractures represented 73 % of this cost, long-term fracture care 23 % and pharmacological prevention 4 %. Previous and incident fractures also accounted for 246,300 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 928,000 in 2025, representing an increase of 203,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 42,900, 28,000, 23,200 and 108,800, respectively. The burden of fractures in Germany in 2025 was estimated to increase by 25 % to € 11,261 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment remained at very low levels in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Germany in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Germany was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Germany

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 15,246,000 and 17,764,000 respectively in Germany in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Germany, 2010 [1]

Age (years)

Women

Men

All

50–59

5,799,000

5,813,000

11,612,000

60–69

4,641,000

4,405,000

9,046,000

70–79

4,485,000

3,677,000

8,162,000

80–89

2,455,000

1,247,000

3,702,000

90+

384,000

104,000

488,000

50+

17,764,000

15,246,000

33,010,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 5,020,000 (Table 2). There are 29.1 DXA scan machines per million (m) inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Germany by age using female-derived reference ranges at the femoral neck, 2010 [3]

Age (years)

Women

Men

50–54

192,528

78,050

55–59

263,328

94,185

60–64

335,621

131,950

65–69

463,388

157,620

70–74

754,137

181,428

75–79

668,250

139,153

80+

1,340,008

224,266

50+

4,017,260

1,006,652

Data on hip fracture incidence are available for Germany [4] and are in the process of being updated [5]. Given that country specific incidence of vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 218 and 522 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Germany by age

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The number of incident fractures in 2010 was estimated at 725,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 130,000, 114,000, 118,000 and 363,000 respectively. 67 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Germany, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 2.03 % for hip and 2.35 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Germany, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 670,000 and 776,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Germany with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 8,777 (Table 8). Hip, vertebral and “other” fractures accounted for 4,285, 2,965 and 1,527 deaths respectively. Overall, approximately 57 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Germany within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Germany in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Germany including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long–term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

In Germany, the cost of a hip fracture and the cost of a vertebral fracture has been estimated at € 19,218 [6] and €5,585 [7], respectively. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 34,534 [8], an average of 4 long term care facilities) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug cost (€) for individual treatments is shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 38 [9] and a DXA scan costing € 36 [10] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Germany, 2010 [11]

 

Annual drug cost (€)

Alendronate

245

Risedronate

509

Etidronate

475

Ibandronate

576

Zoledronic acid

562

Raloxifene

540

Strontium ranelate

611

Parathyroid hormone

7,853

Teriparatide

7,700

The cost of osteoporosis in 2010 was estimated at € 9,008 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 6,617 million, € 2,055 million and € 336 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 3.7 % of the total cost.
Table 10

Cost of osteoporosis (€) in Germany by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 4,251 million) followed by “other” (€ 3,625 million), spine (€ 657 million) and forearm fractures (€ 139 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Germany. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figr_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Germany. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 246,300 (Table 12). 68 % of the total QALY loss was incurred in women. Prior fractures accounted for 55 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 14.93 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Germany according to age

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Table 13

Value of lost QALYs (€) in men and women in Germany in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

881,109,143

1,762,218,285

2,643,327,428

Incident vertebral fractures

1,085,336,609

2,170,673,218

3,256,009,827

Incident forearm fractures

120,265,846

240,531,692

360,797,537

Incident other fractures

1,240,870,037

2,481,740,073

3,722,610,110

Prior hip fractures

2,909,128,253

5,818,256,507

8,727,384,760

Prior vertebral fractures

1,227,012,854

2,454,025,708

3,681,038,562

Total

7,463,722,741

14,927,445,482

22,391,168,223

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 23.94 billion in Germany in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 28 %, 9 %, 1 % and 62 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 33 million in 2010 to 38.5 million in 2025, corresponding to an increase of 17 % (Table 14).
Table 14

Population projections in Germany by age and sex [12]

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The total number of fractures was estimated to rise from 725,000 in 2010 to 928,000 in 2025 (Table 15), corresponding to an increase of 28 %. Hip, clinical spine, forearm and other fractures increased by 42,900, 28,000, 23,200 and 108,800 respectively. The increase in the number of fractures ranged from 20 % to 33 %, depending on fracture site. The increase was estimated to be particularly marked in men (37 %) compared to women (24 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Germany

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 9 billion in 2010 to € 11 billion in 2025, corresponding to an increase of 25 % (Table 16). Costs incurred in women and men increased by 21 % and 34 % respectively.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Germany

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The total number of QALYs lost due to fracture was estimated to rise from 246,300 in 2010 to 296,800 in 2025, corresponding to an increase of 20 % (Table 17). The increase was estimated to be particularly marked in men (31 %) compared to women (16 %). Incident and prior fractures accounted for 60 % and 40 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Germany

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 23.9 billion in 2010 to € 29.2 billion in 2025. The increase was estimated to be particularly marked in men (+32 %) compared to women (+17 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Germany assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
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Fig. 2 Treatment uptake in Germany (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 1.59 % in 2001 to 2.67 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Germany were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 80 % and 77 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.

Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

109

540

431

80

Women

730

3,231

2,501

77

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

4. Icks A, Haastert B, Wildner M, Becker C, Meyer G (2008) Trend of hip fracture incidence in Germany 1995–2004: a population-based study. Osteoporos Int 19: 1139–45

5. Linder R, Klein S, Hadji P, Gothe H, Verheyen F, Häussler B (2012) Bone Evaluation Study (BEST): Epidemiologie der Osteoporose in Deutschland sowie Analysen zur Inanspruchnahme von Diagnostik und Therapie. German Medical Science. Accessed January 2013 http://​www.​egms.​de/​static/​en/​meetings/​gmds2012/​12gmds165.​shtml

6. Brecht JG, Kruse HP, Mohrke W, Oestreich A, Huppertz E (2004) Health-economic comparison of three recommended drugs for the treatment of osteoporosis. Int J Clin Pharmacol Res 24: 1–10

7. Brecht JG, Kruse HP, Felsenberg D, Mohrke W, Oestreich A, Huppertz E (2003) Pharmacoeconomic analysis of osteoporosis treatment with risedronate. Int J Clin Pharmacol Res 23:93–105

8. Seniorenpartner Elisabeth Schulz (2011) Alten-und Pflegeheim Wiblingen. SeniorenCentrum. Domicil. www.​pflegeheim-haus-am-see.​de, www.​aphw.​telebus.​de, www.​hausstiftstrasse​.​de, www.​domicil-seniorenresidenz​en.​de:

9. Lordick F, Ehlken B, Ihbe-Heffinger A, Berger K, Krobot KJ, Pellissier J, Davies G, Deuson R (2007) Health outcomes and cost-effectiveness of aprepitant in outpatients receiving antiemetic prophylaxis for highly emetogenic chemotherapy in Germany. Eur J Cancer 43: 299–307

10. International Osteoporosis Foundation, IOF (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges.

11. Rote Liste (2011). www.​rote-liste.​de

12. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Greece

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, GP Lyritis, P Makras and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

George P Lyritis, Hellenic Osteoporosis Foundation, Athens, Greece

Polyzois Makras, Department of Endocrinology and Diabetes, 251 Hellenic Air Force General Hospital, Athens, Greece

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Greece

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Greece.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Greece, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Greece was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 86,000 new fragility fractures were sustained in Greece, comprising 15,000 hip fractures, 13,000 vertebral fractures, 15,000 forearm fractures and 43,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 680 million for the same year. Incident fractures represented 72 % of this cost, long-term fracture care 15 % and pharmacological prevention 13 %. Previous and incident fractures also accounted for 31,000 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 107,000 in 2025, representing an increase of 21,000 fractures. Hip, clinical spine, forearm and other fractures were estimated to increase by 4,100, 3,000, 2,800 and 11,300, respectively. The burden of fractures in Greece in 2025 was estimated to increase by 20 % to € 814 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. A substantial minority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap in women and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Greece in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Greece was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Greece

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 1,959,000 and 2,277,000 respectively in Greece in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Greece, 2010 [1]

Age (years)

Women

Men

All

50–59

749,000

725,000

1,474,000

60–69

615,000

555,000

1,170,000

70–79

583,000

459,000

1,042,000

80–89

288,000

199,000

487,000

90+

42,000

21,000

63,000

50+

2,277,000

1,959,000

4,236,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at c. 640,000 (Table 2). There are 37.5 DXA scan machines per million (m) inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3] and have been recently updated [4]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Greece by age using female-derived reference ranges at the femoral neck, 2010 [5]

Age (years)

Women

Men

50–54

24,822

9,500

55–59

34,080

12,075

60–64

48,620

18,270

65–69

55,550

17,760

70–74

87,048

19,344

75–79

101,625

21,733

80+

155,760

36,520

50+

507,505

135,202

Data on hip fracture incidence are available for Greece [6] which has very recently been updated [7]. We used the earlier report which was available at the time of writing [6]. Given that country specific incidence of the vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 213 and 494 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Greece by age

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The number of incident fractures in 2010 was estimated at 86,000 (Table 4). Incident hip, clinical vertebral, forearm and “other” fractures were estimated at 15,000, 13,000, 15,000 and 43,000 respectively. 64 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Greece, 2010

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In the population aged 50 years or more, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 2.06 % for hip and 2.40 % for vertebral fractures. The estimated proportions of men and women with prior hip and clinical vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (%) with a prior hip or clinical vertebral fracture in Greece, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 87,000 and 102,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Greece with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 1,128 (Table 8). Hip, vertebral and “other” fractures accounted for 566, 352 and 210 deaths respectively. Overall, approximately 54 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Greece within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Greece in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Greece including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

As from March 2012 the Greek National Health System reimburses € 470 (2 days admission) for a hip fracture treated with osteosynthesis and € 1,463 (7 days admission) for a hip fracture treated by hemiarthroplasty. More than 90 % of all hip fractures are treated surgically, usually by hemiarthroplasty. Specific data for the cost of a hip fracture was not available for Greece before 2012, and the cost of hip fracture was estimated at € 12,550 using information from Italy [8]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 13,271 [9, 10], based on Bulgarian cost of nursing home, purchasing power parity adjusted) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, since patients can be followed either in a private or in a public setting, it was assumed that patients on treatment made an annual physician visit costing € 8 [11] and a DXA scan at two sites costing € 115 [12] every second year to monitor treatment.
Table 9

One year costs for relevant pharamceuticals in Greece, 2010 [13]

 

Annual drug cost (€)

Alendronate

239

Risedronate

286

Etidrontae

79

Ibandronate

235

Zoledronic acid

357

Raloxifene

332

Strontium ranelate

494

Parathyroid hormone

3,630

Teriparatide

5,289

The cost of osteoporosis in 2010 was estimated at € 680 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 488 million, € 102 million and € 91 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 13.4 % of the total cost.
Table 10

Cost of osteoporosis (€) in Greece by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 260 million) followed by “other” (€ 284 million), spine (€ 34 million) and forearm fractures (€ 11 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Greece. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figt_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Greece. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 31,000 (Table 12). 66 % of the total QALY loss was incurred in women. Prior fractures accounted for 58 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 1.26 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Greece according to age

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Table 13

Value of lost QALYs (€) in men and women in Greece in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

68,416,328

136,832,656

205,248,984

Incident vertebral fractures

86,072,643

172,145,287

258,217,930

Incident forearm fractures

10,008,139

20,016,278

30,024,417

Incident other fractures

99,760,468

199,520,936

299,281,404

Prior hip fractures

258,272,433

516,544,867

774,817,300

Prior vertebral fractures

108,891,599

217,783,198

326,674,797

Total

631,421,611

1,262,843,222

1,894,264,833

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 1.94 billion in Greece in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 25 %, 5 %, 5 % and 65 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 4.2 million in 2010 to 5.1 million in 2025, corresponding to an increase of 20 % (Table 14).
Table 14

Population projections in Greece by age and sex [14]

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The total number of fractures was estimated to rise from 86,000 in 2010 to 107,000 in 2025 (Table 15), corresponding to an increase of 24 %. Hip, clinical spine, forearm and other fractures increased by 4,100, 3,000, 2,800 and 11,300 respectively. The increase in the number of fractures ranged from 19 % to 28 %, depending on fracture site. The increase was estimated to be particularly marked in men (28 %) compared to women (23 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Greece

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 680 million in 2010 to € 814 million in 2025, corresponding to an increase of 20 % (Table 16). Costs incurred in women and men increased by 18 % and 24 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Greece

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The total number of QALYs lost due to fracture was estimated to rise from 31,000 in 2010 to 35,200 in 2025, corresponding to an increase of 14 % (Table 17). The increase was estimated to be particularly marked in men (21 %) compared to women (10 %). Incident and prior fractures accounted for about 67 % and 33 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Greece

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 1.9 billion in 2010 to € 2.2 billion in 2025. The increase was estimated to be particularly marked in men (+22 %) compared to women (+13 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Greece assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
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Fig. 2 Treatment uptake in Greece (defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 1.67 % in 2001 to 9.1 % in 2009 but subsequently decreased to 8.2 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Greece were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. For men, the data indicate that the volume of sold osteoporosis drugs would be sufficient to cover treatment for more patients than the number that fall above the fracture threshold. It should be noted, however, that the results from this analysis should be interpreted with some caution since it has been assumed that the distribution of drug use between genders observed in Sweden is valid for all countries. The treatment gap in men and women were estimated at −25 % and 31 % respectively (Table 19). Also note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

50

40

−10

−25

Women

333

482

149

31

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis J (2011) personal communication, data on file.

3. The International Osteoporosis Foundation (IOF) (2011) Osteoporosis in the European Union in 2008—Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

4. Makras P, Vaiopoulos G, Lyritis GP; Greek National Medicine Agency (2012) 2011 guidelines for the diagnosis and treatment of osteoporosis in Greece. J Musculoskelet Neuronal Interact. 12(1):38–42.

5. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

6. Paspati I, Galanos A, Lyritis GP (1998) Hip fracture epidemiology in Greece during 1977–1992. Calcif Tissue Int 62: 542–47

7. Lyritis GP, Rizou S, Galanos A, Makras P (2013) Incidence of hip fractures in Greece during a 30-year period: 1977–2007. Osteoporos Int 24: 1579–85

8. Visentin P, Ciravegna R, Fabris F (1997) Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy. Maturitas 26: 185–92

9. Nursing homes (2011) Personal communication—average of three Bulgarian nursing homes (750, 650, and 550 lev/month).

10. International Bank for Reconstruction and Development/The World Bank (2008) 2005 International Comparison Program, Tables of final results.

11. IKA Social Insurance Instiute G (2011). Accessed July: http://​www.​ika.​gr/​

12. International Osteoporosis Foundation, IOF (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges.

13. (2011) Hellenic Association of Pharmaceutical Companies, SFEE. Accessed July: www.​sfee.​gr

14. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retreived in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Hungary

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson P Lakatos, L Szekeres, I Marton, K Zalatnai and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Peter Lakatos, 1st Department of Medicine, Semmelweis University Medical School, Budapest, Hungary

Laszlo Szekeres, Országos Reumatológiai és Fizioterápiás Intézet (ORFI), Budapest, Hungary

Istvan Marton, Rozsakert Medical Center and Hungarian Society for Osteoporosis and Osteoarthrology, Budapest, Hungary

Klára Zalatnai, Hungarian Osteoporosis Patient Association, Budapest, Hungary.

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Hungary

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Hungary.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Hungary, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Hungary was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 102,000 new fragility fractures were sustained in Hungary, comprising 13,000 hip fractures, 11,000 vertebral fractures, 39,000 forearm fractures and 38,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 197 million for the same year. Incident fractures represented 64 % of this cost, long-term fracture care 15 % and pharmacological prevention 20 %. Previous and incident fractures also accounted for 23,700 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 116,000 in 2025, representing an increase of 13,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 2,900, 1,700, 2,700 and 6,000, respectively. The burden of fractures in Hungary in 2025 was estimated to increase by 15 % to € 226 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. A substantial minority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Hungary in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Hungary was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Hungary

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 1,540,000 and 2,143,000 respectively in Hungary in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Hungary, 2010 [1]

Age (years)

Women

Men

All

50–59

762,000

671,000

1,433,000

60–69

633,000

481,000

1,114,000

70–79

472,000

272,000

744,000

80–89

246,000

106,000

352,000

90+

30,000

10,000

40,000

50+

2,143,000

1,540,000

3,683,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 550,000 (Table 2). There are 6 DXA scan machines per million inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Hungary by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

22,806

8,200

55–59

38,400

12,005

60–64

47,762

15,486

65–69

60,398

15,836

70–74

71,145

12,012

75–79

81,375

12,154

80+

130,272

19,256

50+

452,158

94,949

Data on hip fracture incidence and forearm incidence are available for Hungary [5]. Given that country specific incidence of the vertebral and “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 274.1 and 560.6 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Hungary by age

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The number of incident fractures in 2010 was estimated at 102,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 13,000, 11,000, 39,000 and 38,000 respectively. 67 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Hungary, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.55 % for hip and 1.65 % for vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Hungary, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 57,000 and 61,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Hungary with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 1,241 (Table 8). Hip, vertebral and “other” fractures accounted for 592, 460 and 189 deaths respectively. Overall, approximately 51 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Hungary within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Hungary in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Hungary including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture was not available specifically for Hungary, therefore the hip fracture cost was estimated at € 3,594 based on the cost in Slovenia [6]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 5,789 [7]) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 43 (approximated by adjusting Romanian cost for health adjusted price levels [8]) and a DXA scan costing € 7 [7] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Hungary, 2010 [9]

 

Annual drug cost (€)

Alendronate

115

Risedronate

247

Etidronate

-

Ibandronate

329

Zoledronic acid

254

Raloxifene

383

Strontium ranelate

449

Parathyroid hormone

-

Teriparatide

4,663

The cost of osteoporosis in 2010 was estimated at € 197 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 127 million, € 30 million and € 40 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 20.3 % of the total cost.
Table 10

Cost of osteoporosis (€) in Hungary by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 71 million) followed by “other” (€ 69 million), forearm (€ 9 million) and spine fractures (€ 8 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Hungary. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figv_HTML.gif

Fig. 1 Share (%) of fracture cost (%) by fracture site in Hungary. Note that costs for fracture prevention therapy and monitoring are not included

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 23,700 (Table 12). 68 % of the total QALY loss was incurred in women. Prior fractures accounted for 48 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 460 million.

Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Hungary according to age

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Table 13

Value of lost QALYs (€) in men and women in Hungary in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

29,729,410

59,458,819

89,188,229

Incident vertebral fractures

35,535,859

71,071,717

106,607,576

Incident forearm fractures

12,972,073

25,944,146

38,916,219

Incident other fractures

42,596,507

85,193,013

127,789,520

Prior hip fractures

80,158,522

160,317,044

240,475,567

Prior vertebral fractures

30,940,008

61,880,016

92,820,023

Total

231,932,378

463,864,756

695,797,134

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 660 million in Hungary in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 19 %, 5 %, 6 % and 70 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 3.7 million in 2010 to 3.9 million in 2025, corresponding to an increase of 5 % (Table 14).
Table 14

Population projections in Hungary by age and sex [10]

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The total number of fractures was estimated to rise from 102,000 in 2010 to 116,000 in 2025 (Table 15), corresponding to an increase of 13 %. Hip, clinical spine, forearm and other fractures increased by 2,900, 1,700, 2,700 and 6,000 respectively. The increase in the number of fractures ranged from 7 % to 22 %, depending on fracture site. The increase was estimated to be 11 % in men and 14 % in women.
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Hungary

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 197 million in 2010 to € 226 million in 2025, corresponding to an increase of 15 % (Table 16). Costs incurred in women and men increased by 15 % and 14 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Hungary

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The total number of QALYs lost due to fracture was estimated to rise from 23,700 in 2010 to 26,200 in 2025, corresponding to an increase of 11 % (Table 17). The increase was estimated to be 12 % in men and 11 % in women. Incident and prior fractures accounted for 71 % and 29 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Hungary

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhq_HTML.gif
The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 660 million in 2010 to € 740 million in 2025. The increase was estimated to be 12 % in both men and women (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Hungary assuming the uptake of treatment remains unchanged

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhr_HTML.gif

Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figw_HTML.gif

Fig. 2 Treatment uptake in Hungary (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.97 % in 2001 to 7.6 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Hungary were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 41 % and 28 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk. Notwithstanding, there is some evidence that hip fracture rates are declining in Hungary, a phenomenon attributed to pharmaceutical treatment [11].
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

36

60

24

41

Women

238

332

94

28

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. The International Osteoporosis Foundation (IOF) (2011) Eastern European & Central Asian Regional Audit—Individual Country Reports. www.​iofbonehealth.​org/​publications/​eastern-european-central-asian-audit-2010.​html;

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468-89

5. Pentek M, Horvath C, Boncz I, Falusi Z, Toth E, Sebestyen A, Majer I, Brodszky V, Gulacsi L (2008) Epidemiology of osteoporosis related fractures in Hungary from the nationwide health insurance database, 1999–2003. Osteoporos Int 19: 243–49

6. Dzajkovska B, Wertheimer AI, Mrhar A (2007) The burden-of-illness study on osteoporosis in the Slovenian female population. Pharm World Sci 29: 404–11

7. Freyler P, Hungarian National Health Insurance Fund OEP (2011) Personal communication.

8. International Bank for Reconstruction and Development/The World Bank (2008) 2005 International Comparison Program, Tables of final results.

9. Common European Drug Database (2011). Accessed June 2012: www.​cedd.​oep.​hu,

10. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

11. Lakatos P, Tóth E, Szekeres L, Poór Gy, Héjj G, Takács I (2012) A csontritkulás kezelésének hatékonysága Magyarországon. Az Országos Egészségbiztosítási Pénztár adatainak elemzése [Efficiency of osteoporosis treatment in Hungary—An analysis of the Hungarian Insurance Company’s data] Lam Kid 2: 5–12.

Epidemiology and Economic Burden of Osteoporosis in Ireland

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, M OBrien and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Michele O'Brien, The Irish Osteoporosis Society, Dublin, Ireland

John A Kanis,WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Ireland

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Ireland.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Ireland, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Ireland was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 18,000 new fragility fractures were sustained in Ireland, comprising 3,200 hip fractures, 2,700 vertebral fractures, 3,000 forearm fractures and 9,200 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 223 million for the same year. Incident fractures represented 56 % of this cost, long-term fracture care 28 % and pharmacological prevention 16 %. Previous and incident fractures also accounted for 6,100 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 28,000 in 2025, representing an increase of 9,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 1,800, 1,400, 1,400 and 4,900, respectively. The burden of fractures in Ireland in 2025 was estimated to increase by 44 % to € 320 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. A substantial minority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Ireland in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Ireland was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Ireland

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 599,000 and 647,000 respectively in Ireland in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Ireland, 2010 [1]

Age (years)

Women

Men

All

50–59

254,000

255,000

509,000

60–69

191,000

190,000

381,000

70–79

122,000

108,000

230,000

80–89

67,000

41,000

108,000

90+

13,000

5,000

18,000

50+

647,000

599,000

1,246,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 170,000 (Table 2). There are 10 DXA scan machines per million inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Ireland by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

8,442

3,350

55–59

11,520

4,235

60–64

15,301

6,264

65–69

16,968

6,068

70–74

18,693

4,836

75–79

20,625

4,738

80+

37,760

7,636

50+

129,309

37,127

Data on hip fracture incidence are available for Ireland [5]. Given that country specific incidence of vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 167 and 488 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Ireland by age

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhv_HTML.gif
The number of incident fractures in 2010 was estimated at 18,000 (Table 4). Incident hip, clinical spine and forearm fractures were each estimated at 3 000, and “other” fractures were estimated at 9,000. 66 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Ireland, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhw_HTML.gif
A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 1.38 % for hip and 1.50 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Ireland, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhx_HTML.gif
In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 17,000 and 19,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Ireland with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhy_HTML.gif
The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 209 (Table 8). Hip, vertebral and “other” fractures accounted for 104, 68 and 38 deaths respectively. Overall, approximately 53 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Ireland within the first year after fracture (adjusted for comorbidities), 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabhz_HTML.gif
Table 8

The number of deaths in men and women in Ireland in the first year after fracture attributable to the fracture event (causally related), 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabia_HTML.gif

Cost of osteoporosis in Ireland including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 15,230 in Ireland based on first year hospital costs [6]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 39,073 [7,8], based on purchasing power parity adjusted UK cost of public nursing home) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 46 [9] and a DXA scan costing € 99 [10] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Ireland, 2010 [11]

 

Annual drug cost (€)

Alendronate

240

Risedronate

514

Etidronate

138

Ibandronate

432

Zoledronic acid

433

Raloxifene

420

Strontium ranelate

631

Parathyroid hormone

6,519

Teriparatide

7,111

The cost of osteoporosis in 2010 was estimated at € 223 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 125 million, € 62 million and € 35 million, respectively. It is notable that pharmacological fracture prevention costs amounted to only 15.8 % of the total cost.
Table 10

Cost of osteoporosis (€) in Ireland by age in men and women, 2010

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabic_HTML.gif
When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 105 million) followed by “other” (€ 72 million), spine (€ 8 million) and forearm fractures (€ 3 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Ireland. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabid_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figx_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Ireland. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 6,100 (Table 12). 68 % of the total QALY loss was incurred in women. Prior fractures accounted for 56 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 430 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Ireland according to age

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabie_HTML.gif
Table 13

Value of lost QALYs (€) in men and women in Ireland in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

24,752,860

49,505,719

74,258,579

Incident vertebral fractures

29,289,392

58,578,785

87,868,177

Incident forearm fractures

3,500,853

7,001,707

10,502,560

Incident other fractures

36,108,044

72,216,088

108,324,133

Prior hip fractures

85,284,615

170,569,230

255,853,844

Prior vertebral fractures

33,866,552

67,733,103

101,599,655

Total

212,802,316

425,604,632

638,406,948

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 650 million in Ireland in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 19 %, 10 %, 5 % and 66 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 1.2 million in 2010 to 1.8 million in 2025, corresponding to an increase of 42 % (Table 14).
Table 14

Population projections in Ireland by age and sex [12]

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabig_HTML.gif
The total number of fractures was estimated to rise from 18,000 in 2010 to 28,000 in 2025 (Table 15), corresponding to an increase of 53 %. Hip, clinical spine, forearm and other fractures increased by 1,800, 1,400, 1,400 and 4,900 respectively. The increase in the number of fractures ranged from 47 % to 56 %, depending on fracture site. The increase was estimated to be 57 % in men and 50 % in women.
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Ireland

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabih_HTML.gif
The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 223 million in 2010 to € 320 million in 2025, corresponding to an increase of 44 % (Table 16). Costs incurred in women and men increased by 40 % and 52 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Ireland

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabii_HTML.gif
The total number of QALYs lost due to fracture was estimated to rise from 6,100 in 2010 to 8,200 in 2025, corresponding to an increase of 34 % (Table 17). The increase was estimated to be particularly marked in men (46 %) compared to women (29 %). Incident and prior fractures accounted for 68 % and 32 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Ireland

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabij_HTML.gif
The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 650 million in 2010 to € 890 million in 2025. The increase was estimated to be particularly marked in men (+48 %) compared to women (+33 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Ireland assuming the uptake of treatment remains unchanged

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabik_HTML.gif

Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figy_HTML.gif

Fig. 2 Treatment uptake in Ireland (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 1.57 % in 2001 to 8.56 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Ireland were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 20 % and 26 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

14

17

3

20

Women

91

124

33

26

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. Irish Osteoporosis Society (2011) Guidelines. www.​irishosteoporosi​s.​ie/​images/​uploads/​Osteoporosis-Guidelines.​pdf

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

5. Dodds MK, Codd MB, Looney A, Mulhall KJ (2009) Incidence of hip fracture in the Republic of Ireland and future projections: a population-based study. Osteoporos Int 20: 2105–10

6. Azhar A, Lim C, Kelly E, O’Rourke K, Dudeney S, Hurson B, Quinlan W (2008) Cost induced by hip fractures. Ir Med J 101: 213–15

7. Stevenson M, Davis S (2006) Analyses of the cost-effectiveness of pooled alendronate and risedronate, compared with strontium ranelate, raloxifene, etidronate and teriparatide. School of Health and Related Research, University of Sheffield. Sheffield

8. International Bank for Reconstruction and Development/The World Bank (2008) 2005 International Comparison Program, Tables of final results.

9. Gillespie P, O’Shea E, Murphy AW, Byrne MC, Byrne M, Smith SM, Cupples ME (2010) The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease. Int J Technol Assess Health Care 26: 263–71

10. Irish Osteoporosis Society (2011). Communication with Michele O’Brien in August 2011: www.​irishosteoporosi​s.​ie

11. Common European Drug Database (2011). Accessed June 2011: www.​cedd.​oep.​hu,

12. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Italy

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

A Svedbom, E Hernlund, M Ivergård, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, M L Brandi, F Silveri, M Rossini and JA Kanis

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Moa Ivergård, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Maria Luisa Brandi, Department of Internal Medicine, University of Florence, Florence Italy

Ferdinando Silveri, Department of Rheumatology, Università Politecnica delle Marche, Ancona, Italy; Italian Federation of Osteoporosis and Diseases of the Skeleton (FEDIOS)

Maurizio Rossini, Department of Rheumatology, Università di Verona, Verona, Italy; Italian Federation of Osteoporosis and Diseases of the Skeleton (FEDIOS)

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Italy

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Italy.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Italy, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Italy was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 465,000 new fragility fractures were sustained in Italy, comprising 91,000 hip fractures, 71,000 clinical vertebral fractures, 72,000 forearm fractures and 232,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 7,032 million for the same year. Incident fractures represented 61 % of this cost, long-term fracture care 34 % and pharmacological prevention 5 %. Previous and incident fractures also accounted for 171,300 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 598,000 in 2025, representing an increase of 132,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 27,900, 18,800, 15,400 and 70,300, respectively. The burden of fractures in Italy in 2025 was estimated to increase by 23 % to € 8,644 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment remained at very low levels in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Italy in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Italy was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Italy

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 10,791,000 and 12,997,000 respectively in Italy in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Italy, 2010 [1]

Age

Women

Men

All

50–59

3,928,000

3,799,000

7,727,000

60–69

3,595,000

3,307,000

6,902,000

70–79

3,134,000

2,478,000

5,612,000

80–89

1,997,000

1,092,000

3,089,000

90+

343,000

115,000

458,000

50+

12,997,000

10,791,000

23,788,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 3,790,000 (Table 2). There are 18.6 DXA scan machines per million (m) inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Italy by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age group

Women

Men

50–54

128,709

49,800

55–59

180,960

63,245

60–64

274,703

105,386

65–69

338,148

110,260

70–74

463,419

109,356

75–79

552,375

110,828

80+

1,104,480

200,362

50+

3,042,794

749,237

Data on hip fracture incidence are available for Italy [5]. Given that country specific incidence of the vertebral, forearm and, “other” fractures were not found, these were imputed using the methods described in Chapter 3 of the main report. Fracture incidence is presented in Table 3. Standardized to the EU27 population, hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 189.5 and 498.4 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Italy by age

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The number of incident fractures in 2010 was estimated at 465,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 91,000, 71,000, 72,000 and 232,000 respectively. 69 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Italy, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportion of individuals who had suffered a fracture prior to 2010 was estimated at 2.17 % for hip and 2.27 % for vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Italy, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 517,000 and 539,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Italy with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 5,476 (Table 8). Hip, vertebral and “other” fractures accounted for 2,778, 1,659 and 1,039 deaths respectively. Overall, approximately 53 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Italy within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Italy in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Italy including and excluding value of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”), and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

Total first year costs after fracture were imputed by applying the inpatient cost for Italy to the ratio of inpatient cost to total first year costs observed in Sweden, resulting in an estimated total first year hip fracture cost of € 19,602. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 50,202 [6]) with the simulated number of individuals with prior fractures that had been transferred to nursing home due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 50 [7] and a DXA scan costing € 81 [8] every second year to monitor treatment.
Table 9

One year costs for relevant pharamceuticals in Italy, 2010 [9]

 

Annual drug cost (€)

Alendronate

294

Risedronate

474

Etidrontae

97

Ibandronate

524

Zoledronic acid

529

Raloxifene

452

Strontium ranelate

665

Parathyroid hormone

6,528

Teriparatide

7,445

The cost of osteoporosis in 2010 was estimated at € 7,032 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 4,269 million, € 2,402 million and € 361 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 5.1 % of the total cost.
Table 10

Cost of osteoporosis (€) in Italy by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 3,977 million) followed by “other” (€ 2,324 million), spine (€ 284 million) and forearm fractures (€ 86 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Italy. Note that costs for fracture prevention therapy and monitoring are not included

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https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figz_HTML.gif

Fig. 1. Share of fracture cost by fracture site in Italy. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 171,300 (Table 12). 70 % of the total QALY loss was incurred in women. Prior fractures accounted for 59 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 8.77 billion.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Italy according to age

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Table 13

Value of lost QALYs (€) in men and women in Italy in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

512,093,317

1,024,186,634

1,536,279,952

Incident vertebral fractures

567,207,399

1,134,414,797

1,701,622,196

Incident forearm fractures

60,693,357

121,386,713

182,080,070

Incident other fractures

659,775,142

1,319,550,284

1,979,325,426

Prior hip fractures

1,872,214,580

3,744,429,160

5,616,643,740

Prior vertebral fractures

713,370,642

1,426,741,285

2,140,111,927

Total

4,385,354,437

8,770,708,874

13,156,063,310

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 15.8 billion in Italy in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 27 %, 15 %, 2 % and 56 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 23.8 million in 2010 to 29.2 million in 2025, corresponding to an increase of 23 % (Table 14).
Table 14

Population projections in Italy by age and sex [10]

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The total number of fractures was estimated to rise from 465,000 in 2010 to 598,000 in 2025 (Table 15), corresponding to an increase of 28 %. Hip, clinical spine, forearm and other fractures increased by 27,900, 18,800, 15,400 and 70,300 respectively. The increase in the number of fractures ranged from 21 % to 31 %, depending on fracture site. The increase was estimated to be particularly marked in men (37 %) compared to women (24 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Italy

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The cost of osteoporosis (excluding value of QALYs lost) was estimated to rise from € 7 billion in 2010 to € 8.6 billion in 2025, corresponding to an increase of 23 % (Table 16). Costs incurred in women and men increased by 20 % and 31 % respectively.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Italy

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The total number of QALYs lost due to fracture was estimated to rise from 171,300 in 2010 to 205,100 in 2025, corresponding to an increase of 20 % (Table 17). The increase was estimated to be particularly marked in men (28 %) compared to women (16 %). Incident and prior fractures accounted for 59 % and 41 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Italy

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 15.8 billion in 2010 to € 19.1 billion in 2025. The increase was estimated to be particularly marked in men (+29 %) compared to women (+18 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Italy assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
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Fig. 2 Treatment uptake in Italy (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 1.03 % in 2001 to 5.2 % in 2010 but subsequently decreased to 5.14 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Italy were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number of individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 30 % and 59 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

160

228

68

30

Women

1,069

2,635

1,566

59

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. The International Osteoporosis Foundation (IOF) (2011) Osteoporosis in the European Union in 2008—Country reports. www.​iofbonehealth.​org/​policy-advocacy/​europe/​eu-osteoporosis-consultation-panel/​country-reports-08.​html

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

5. Piscitelli P, Brandi ML, Chitano G, Johannson H, Kanis JA, Black DM (2013) Updated fracture incidence rates for the Italian version of FRAX®. Osteoporos Int 24:859–66

6. Visentin P, Ciravegna R, Fabris F (1997) Estimating the cost per avoided hip fracture by osteoporosis treatment in Italy. Maturitas 26: 185–92

7. Capri S, Perlini S (2005) Cost-effectiveness in Italy of preventive treatment with ramipril in patients at high risk of cardiovascular events. Curr Med Res Opin 21: 913–21

8. International Osteoporosis Foundation, IOF (2011) Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges.

9. Agenzia Italiana del Farmco (2011). www.​agenziafarmaco.​it

10. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Latvia

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

M Ivergård, A Svedbom, E Hernlund, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson I Rasa, I Pavlina, S Berza and JA Kanis

Moa Ivergård, OptumInsight, Stockholm, Sweden

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Ingvars Rasa, Latvian Osteoporosis and Bone Metabolic Diseases Association, Rīga Stradiņš University, Riga East Clinical University Hospital, Riga, Latvia

Inese Pavliņa, Latvian Osteoporosis and Bone Metabolic Diseases Association, Riga East Clinical University Hospital, Riga, Latvia

Santa Berza, Riga Business School, Riga Technical University, Riga, Latvia

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Latvia

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Latvia.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Latvia, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Latvia was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 14,000 new fragility fractures were sustained in Latvia, comprising 3,000 hip fractures, 2,000 vertebral fractures, 2,000 forearm fractures and 7,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 38 million for the same year. Incident fractures represented 78 % of this cost, long-term fracture care 17 % and pharmacological prevention 5 %. Previous and incident fractures also accounted for 4,500 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 16,000 in 2025, representing an increase of 2,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 500, 300, 100 and 1,100, respectively. The burden of fractures in Latvia in 2025 was estimated to increase by 13 % to € 43 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Latvia in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Latvia was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Latvia

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 313,000 and 499,000 respectively in Latvia in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Latvia, 2010 [1]

Age (years)

Women

Men

All

50–59

163,000

136,000

299,000

60–69

139,000

93,000

232,000

70–79

125,000

63,000

188,000

80–89

64,000

20,000

84,000

90+

8,000

1,000

9,000

50+

499,000

313,000

812,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 130,000 (Table 2). There are 4.9 DXA scan machines per million inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model for the assessment of fracture risk is not available for Latvia.
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Latvia by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

All

50–54

5,292

1,825

7,117

55–59

7,584

2,205

9,789

60–64

9,581

2,726

12,307

65–69

14,544

3,404

17,948

70–74

19,251

2,886

22,137

75–79

21,000

2,678

23,678

80+

33,984

3,486

37,470

50+

111,236

19,210

130,446

Incidence data was not available for Latvia, therefore data for hip fractures was imputed from Finnish age-standardized incidence rates [5]. Fracture incidence is presented in Table 3. Standardized to the EU27 population, this hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 238.0 and 440.0 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and other fractures in Latvia by age

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The number of incident fractures in 2010 was estimated at 14,300 (Table 4). Incident hip, clinical spine, forearm and other fractures were estimated at 2,600, 2,300, 2,400 and 7,000 respectively. 69 % of fractures occurred in women. The number of hip fractures is close to recent but unpublished estimates [6].
Table 4

Estimated number of incident fractures in Latvia, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.46 % for hip and 1.43 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Latvia, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 12,000 and 12,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Latvia with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 241 (Table 8). Hip, vertebral and other fractures accounted for 116, 92 and 33 deaths respectively. Overall, approximately 56 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Latvia within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Latvia in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Latvia including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

As the cost of a hip fracture was not available in Latvia, the cost of a hip fracture has been estimated at € 4,522 in Latvia based on the cost in Finland [7]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 6,169 [8], average for all municipalities and other organizations administering adult social care centers) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug cost for individual treatments is shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing at € 9 [9] and a DXA scan at € 18 [9] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Latvia, 2010 [10]

 

Annual drug cost (€)

Alendronate

85

Risedronate

186

Etidronate

-

Ibandronate

315

Zoledronic acid

420

Raloxifene

-

Strontium ranelate

431

Parathyroid hormone

-

Teriparatide

5,101

The cost of osteoporosis in 2010 was estimated at € 38 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 29 million, € 7 million and € 2 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 5.0 % of the total cost.
Table 10

Cost of osteoporosis (€) in Latvia by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 17 million) followed by other (€ 17 million), spine (€ 2 million) and forearm fractures (€ 1 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Latvia. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabjp_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figab_HTML.gif

Fig.1 Share (%) of fracture cost by fracture site in Latvia. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 4,500 (Table 12). 73 % of the total QALY loss was incurred in women. Prior fractures accounted for 51 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 72 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Latvia according to age

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Table 13

Value of lost QALYs (€) in men and women in Latvia in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

4,790,861

9,581,722

14,372,583

Incident vertebral fractures

5,840,330

11,680,661

17,520,991

Incident forearm fractures

628,292

1,256,584

1,884,876

Incident other fractures

6,360,827

12,721,653

19,082,480

Prior hip fractures

13,553,267

27,106,534

40,659,801

Prior vertebral fractures

4,809,703

9,619,406

14,429,109

Total

35,983,280

71,966,559

107,949,839

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 110 million in Latvia in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 27 %, 6 %, 2 % and 66 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase modestly from 0.81 million in 2010 to 0.84 million in 2025, corresponding to an increase of 4 % (Table 14).
Table 14

Population projections in Latvia by age and sex [11]

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The total number of fractures was estimated to rise from 14,000 in 2010 to 16,000 in 2025 (Table 15), corresponding to an increase of 13 %. Hip, clinical spine, forearm and other fractures increased by 500, 300, 100 and 1,100 respectively. The increase in the number of fractures ranged from 5 % to 18 %, depending on fracture site. The increase was estimated to be particularly marked in men (20 %) compared to women (10 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site, age and sex in men and women in Latvia

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The cost of osteoporosis (excluding values of QALYs lost) was estimated to rise from € 38 million in 2010 to € 43 million in 2025, corresponding to an increase of 13 % (Table 16). Costs incurred in women and men increased by 10 % and 18 % respectively.
Table 16

Current and future cost (€ 000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Latvia

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The total number of QALYs lost due to fracture was estimated to rise from 4,500 in 2010 to 5,000 in 2025, corresponding to an increase of 11 % (Table 17). The increase was estimated to be particularly marked in men (17 %) compared to women (9 %). Incident and prior fractures accounted for 58 % and 42 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Latvia

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 110 million in 2010 to € 123 million in 2025. The increase was estimated to be particularly marked in men (+17 %) compared to women (+9 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Latvia assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figac_HTML.gif

Fig. 2 Treatment uptake in Latvia (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.06 % in 2001 to 2.12 % in 2008 but subsequently decreased to 1.5 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Latvia were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 93 % and 85 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

2

24

22

93

Women

12

80

68

85

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. Latvian Osteoporosis and Metabolic Diseases Association (2012) Osteporosis Clinical Guidelines [Osteoporozes klīniskās vadlīnijas]. Nacionālais veselības dienests. Accessed Jan 2013 http://​www.​vmnvd.​gov.​lv/​lv/​420-kliniskas-vadlinijas/​klinisko-vadliniju-datu-baze/​registretas-2012gada

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

5. Kroger H (2011) Personal communication.

6. Rasa I (2012) Personal communication.

7. Nurmi I, Narinen A, Luthje P, Tanninen S (2003) Cost analysis of hip fracture treatment among the elderly for the public health services: a 1-year prospective study in 106 consecutive patients. Arch Orthop Trauma Surg 123: 551–54

8. Latvia Ministry (2011) Latvijas Republikas—Labklajibas Ministrija. www.​lm.​gov.​lv/​index.​php

9. Health Payment Center in Latvia (VNC) (2011) communication with Toms Noviks August, 2011. http://​www.​vnc.​gov.​lv/​

10. Common European Drug Database (2011). Accessed June: www.​cedd.​oep.​hu,

11. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Lithuania

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

M Ivergård, A Svedbom, E Hernlund, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, V Alekna, M Tamulaitiene, and JA Kanis

Moa Ivergård, OptumInsight, Stockholm, Sweden

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Vidmantas Alekna, Lithuanian Osteoporosis Foundation, Vilnius, Lithuania and Vilnius University, Vilnius, Lithuania

Marija Tamulaitiene, Lithuanian Osteoporosis Foundation, Vilnius, Lithuania and Vilnius University, Vilnius, Lithuania

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Lithuania

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Lithuania.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Lithuania, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Lithuania was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 15,000 new fragility fractures were sustained in Lithuania, comprising 3,000 hip fractures, 2,000 vertebral fractures, 3,000 forearm fractures and 7,000 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 47 million for the same year. Incident fractures represented 68 % of this cost, long-term fracture care 26 % and pharmacological prevention 6 %. Previous and incident fractures also accounted for 4,900 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 17,000 in 2025, representing an increase of 2,000 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 500, 300, 300 and 1,300, respectively. The burden of fractures in Lithuania in 2025 was estimated to increase by 14 % to € 54 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. The majority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Lithuania in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Lithuania was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Lithuania

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 442,000 and 685,000 respectively in Lithuania in 2010 (Table 1).
Table 1

Population at risk: men and women over the age of 50 in Lithuania, 2010 [1]

Age (years)

Women

Men

All

50–59

236,000

195,000

431,000

60–69

189,000

127,000

316,000

70–79

169,000

88,000

257,000

80–89

83,000

30,000

113,000

90+

8,000

2,000

10,000

50+

685,000

442,000

1,127,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 180,000 (Table 2). There are 2.4 DXA scan machines per million (m) inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model is also available for the assessment of fracture risk (http://​www.​shef.​ac.​uk/​FRAX/​).
Table 2

2 Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in the UK by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

8,190

2,750

55–59

10,176

2,975

60–64

13,728

3,944

65–69

18,786

4,366

70–74

25,668

3,978

75–79

28,875

3,811

80+

42,952

5,312

50+

148,375

27,136

At the time of writing the report, national data on the incidence of fracture was not available for Lithuania, therefore data for hip fractures was imputed from Polish age–standardized incidence rates [5]. Since then, data have become available from Vilnius [6]. Fracture incidence is presented in Table 3. Standardized to the EU27 population, this hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 166.5 and 333.2 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Lithuania by age

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The number of incident fractures in 2010 was estimated at 15,000 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 2,600, 2,400, 2,500 and 7,500 respectively. 67 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Lithuania, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.16 % for hip and 1.13 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and clinical vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Lithuania, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 13,000 and 13,000 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Lithuania with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 244 (Table 8). Hip, vertebral and “other” fractures accounted for 114, 98 and 32 deaths respectively. Overall, approximately 52 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Lithuania within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Lithuania in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Lithuania including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture has been estimated at € 4,810 based on Finnish costs [7]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 10,691 [8]) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug costs (€) for individual treatments are shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 3 [9] and a DXA scan costing € 28 [9] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Lithuania, 2010 [10]

 

Annual drug cost (€)

Alendronate

146

Risedronate

321

Etidronate

-

Ibandronate

402

Zoledronic acid

-

Raloxifene

516

Strontium ranelate

512

Parathyroid hormone

5,428

Teriparatide

5,758

The cost of osteoporosis in 2010 was estimated at € 47 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 32 million, € 12 million and € 3 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 5.5 % of the total cost.
Table 10

Cost of osteoporosis (€) in Lithuania by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 23 million) followed by “other” (€ 18 million), spine (€ 2 million) and forearm fractures (€ 1 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Lithuania. Note that costs for fracture prevention therapy and monitoring are not included

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tabki_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figad_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Lithuania. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 4,900 (Table 12). 70 % of the total QALY loss was incurred in women. Prior fractures accounted for 52 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 80 m.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Lithuania according to age

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Table 13

Value of lost QALYs (€) in men and women in Lithuania in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

4,991,011

9,982,021

14,973,032

Incident vertebral fractures

6,463,375

12,926,749

19,390,124

Incident forearm fractures

710,674

1,421,348

2,132,022

Incident other fractures

7,073,665

14,147,329

21,220,994

Prior hip fractures

15,623,405

31,246,811

46,870,216

Prior vertebral fractures

5,574,601

11,149,202

16,723,803

Total

40,436,730

80,873,461

121,310,191

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 130 million in Lithuania in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 25 %, 9 %, 2 % and 63 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 1.1 million in 2010 to 1.2 million in 2025, corresponding to an increase of 8 % (Table 14).
Table 14

Population projections in Lithuania by age and sex [11]

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The total number of fractures was estimated to rise from 15,000 in 2010 to 17,000 in 2025 (Table 15), corresponding to an increase of 16 %. Hip, clinical spine, forearm and other fractures increased by 500, 300, 300 and 1,300 respectively. The increase in the number of fractures ranged from 11 % to 19 %, depending on fracture site. The increase was estimated to be 16 % in both men and women.
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Lithuania

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The cost of osteoporosis (excluding values of QALYs lost) was estimated to rise from € 47 million in 2010 to € 54 million in 2025, corresponding to an increase of 15 % (Table 16). Costs incurred in women and men increased by 15 % and 13 % respectively.
Table 16

Current and future cost (€ 000, 000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Lithuania

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The total number of QALYs lost due to fracture was estimated to rise from 4,900 in 2010 to 5,500 in 2025, corresponding to an increase of 13 % (Table 17). The increase was estimated to be 12 % in men and 13 % in women. Incident and prior fractures accounted for 57 % and 43 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Lithuania

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 128 million in 2010 to € 145 million in 2025. The increase was estimated to be 12 % in men and 14 % in women (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Lithuania assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figae_HTML.gif

Fig. 2 Treatment uptake in Lithuania (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 0.4 % in 2001 to 1.38 % in 2008 but subsequently decreased to 1.21 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Lithuania were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. The treatment gaps in men and women were estimated at 95 % and 90 % respectively (Table 19). Note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk.
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010

 

Number potentially treated (1000 s)

Number eligible for treatment (1000 s)

Difference (1000 s)

Treatment gap (%)

Men

2

31

29

95

Women

11

109

98

90

Acknowledgements This report has been sponsored by an unrestricted educational grant from the European Federation of Pharmaceutical Industry Associations (EFPIA) and the International Osteoporosis Foundation (IOF). The data in this report have been used to populate a more detailed report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden. We acknowledge the help of Helena Johansson and Prof Anders Odén for their help in the calculations of fracture probability. We thank Oskar Ström and Fredrik Borgström who were prominent authors of an earlier report covering a similar topic in a sample of EU countries and provided the template for the present report. We also thank Dr Dominique Pierroz, Carey Kyer and Ageeth Van Leersum of the IOF for their help in editing the report. The report has been reviewed by the members of the IOF EU Osteoporosis Consultation Panel and the IOF European Parliament Osteoporosis Interest Group, and we are grateful for their local insights on the management of osteoporosis in each country.

References

1. Eurostat (2011) Statistics database. Data retrieved in November, 2011: http://​epp.​eurostat.​ec.​europa.​eu

2. Kanis JA (2011) Personal communication.

3. The International Osteoporosis Foundation (IOF) (2011) Eastern European & Central Asian Regional Audit—Individual Country Reports. www.​iofbonehealth.​org/​publications/​eastern-european-central-asian-audit-2010.​html;

4. Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC, Jr., Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8: 468–89

5. Czerwinski E, Lorenc R (2011) Personal communication.

6. Tamulaitiene M and Alekna V (2012) Incidence and direct hospitalisation costs of hipfractures in Vilnius, capital of Lithuania, in 2010. BMC Public Health 12: 495–503

7. Nurmi I, Narinen A, Luthje P, Tanninen S (2003) Cost analysis of hip fracture treatment among the elderly for the public health services: a 1-year prospective study in 106 consecutive patients. Arch Orthop Trauma Surg 123: 551–54

8. Republic of Lithuania—Ministry of Health (2011) Kauno Territorial Health Insurance Fund. Accessed June 2011 www.​sam.​lt/​index.​php?​3474664842

9. Republic of Lithuania—Ministry of Health (2011) Lithuanian National Health Insurance Fund under the Ministry of Health. www.​vlk.​lt

10. Common European Drug Database (2011). Accessed June: www.​cedd.​oep.​hu,

11. United Nations Department of Economic and Social Affairs—Population Division (2011) World Population Prospects test. Data retrieved in November, 2011: http://​esa.​un.​org/​unpd/​wpp/​unpp/​p2k0data.​asp

Epidemiology and Economic Burden of Osteoporosis in Luxembourg

A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

M Ivergård, A Svedbom, E Hernlund, J Compston, C Cooper, J Stenmark, EV McCloskey, B Jönsson, M Hirsch and JA Kanis

Moa Ivergård, OptumInsight, Stockholm, Sweden

Axel Svedbom, OptumInsight, Stockholm, Sweden

Emma Hernlund, OptumInsight, Stockholm, Sweden

Juliet Compston, Department of Medicine, Addenbrooke’s Hospital, Cambridge University, Cambridge, UK

Cyrus Cooper, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton and NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK

Judy Stenmark, International Osteoporosis Foundation, Nyon, Switzerland

Eugene V McCloskey, Academic Unit of Bone Metabolism, Northern General Hospital, Sheffield, UK and WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Bengt Jönsson, Stockholm School of Economics, Stockholm, Sweden

Marco Hirsch, Department of Rheumatology, Zithaklinik, Luxembourg

John A Kanis, WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK

Author for correspondence

Prof John A Kanis (✉) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,

Beech Hill Road, Sheffield S10 2RX, UK;

Tel: +44 114 285 1109;

Fax: +44 114 285 1813;

w.j.pontefract@shef.ac.uk

Running title: Burden of osteoporosis in Luxembourg

Abstract

Summary This report describes epidemiology, burden, and treatment of osteoporosis in Luxembourg.

Introduction Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this study is to describe the epidemiology and economic burden of fragility fractures as a consequence of osteoporosis in Luxembourg, as a further detailed addition to the report for the entire European Union (EU27): Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden.

Methods The literature on fracture incidence and costs of fractures in Luxembourg was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Furthermore, data on sales of osteoporosis treatments and the population at high risk were used to estimate treatment uptake and treatment gap.

Results It was estimated that approximately 2,700 new fragility fractures were sustained in Luxembourg, comprising 470 hip fractures, 410 vertebral fractures, 460 forearm fractures and 1,400 other fractures (i.e. fractures of the pelvis, rib, humerus, tibia, fibula, clavicle, scapula, sternum and other femoral fractures) in 2010. The economic burden of incident and previous fragility fractures was estimated at € 22 million for the same year. Incident fractures represented 71 % of this cost, long-term fracture care 20 % and pharmacological prevention 9 %. Previous and incident fractures also accounted for 900 quality-adjusted life years (QALYs) lost during 2010. When accounting for the demographic projections for 2025, the number of incident fractures was estimated at 4,000 in 2025, representing an increase of 1,300 fractures. Hip, clinical vertebral (spine), forearm and other fractures were estimated to increase by 240, 200, 180 and 700, respectively. The burden of fractures in Luxembourg in 2025 was estimated to increase by 41 % to € 31 million. Though the uptake of osteoporosis treatments increased from 2001, the proportion of patients aged 50 or above who received treatment declined in the past few years. A substantial minority of women at high fracture risk did not receive active treatment.

Conclusions In spite of the high cost of osteoporosis, a substantial treatment gap in women and projected increase of the economic burden driven by aging populations, the use of pharmacological prevention of osteoporosis is significantly less than optimal, suggesting that a change in healthcare policy concerning the disease is warranted.

Introduction

Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased risks 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 the affected patients and substantial costs to society. The aim of this report was to characterize the burden of osteoporosis in Luxembourg in 2010 and beyond.

Methods

The literature on fracture incidence and costs of fractures in Luxembourg was reviewed and incorporated into a model estimating the clinical and economic burden of osteoporotic fractures in 2010. Details of the methods used are found in Chapters 3 and 4 of the report Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden, published concurrently in Archives of Osteoporosis.

Epidemiology of osteoporosis in Luxembourg

For the purpose of this report, the population at risk of osteoporosis was considered to include men and women ≥50 years. The number of men and women ≥50 years of age amounted to 75,000 and 83,000 respectively in Luxembourg in 2010 (Table 1). It should be noted that this includes a substantial proportion of French, Belgian and German nationals.
Table 1

Population at risk: men and women over the age of 50 in Luxembourg, 2010 [1]

Age (years)

Women

Men

All

50–59

32,000

33,000

65,000

60–69

22,000

23,000

45,000

70–79

17,000

14,000

31,000

80–89

11,000

5,000

16,000

90+

1,000

0

1,000

50+

83,000

75,000

158,000

In the population at risk, the number of individuals with osteoporosis—as defined by the WHO diagnostic criteria—was estimated at 22,000 (Table 2). There are 2 DXA scan machines per million inhabitants [2], and guidelines for the assessment and treatment of osteoporosis are available [3]. A country specific FRAX model for the assessment of fracture risk is not available for Luxembourg.
Table 2

Estimated number of women and men with osteoporosis (defined as a T-score ≤−2.5 SD) in Luxembourg by age using female-derived reference ranges at the femoral neck, 2010 [4]

Age (years)

Women

Men

50–54

1,071

450

55–59

1,440

525

60–64

1,716

754

65–69

2,020

740

70–74

2,511

624

75–79

3,000

618

80+

5,664

830

50+

17,422

4,541

Incidence data was not available for Luxembourg, therefore data for hip fractures was imputed from Belgian age-standardized incidence rates [5]. Fracture incidence is presented in Table 3. Standardized to the EU27 population, this hip fracture incidence (per 100,000 person years) in men and women ≥50 years of age was estimated at 228.5 and 538.7 respectively.
Table 3

Incidence per 100,000 person years of hip, clinical vertebral, forearm, and “other” fractures in Luxembourg by age

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The number of incident fractures in 2010 was estimated at 2,700 (Table 4). Incident hip, clinical spine, forearm and “other” fractures were estimated at 470, 400, 460 and 1,400 respectively. 66 % of fractures occurred in women.
Table 4

Estimated number of incident fractures in Luxembourg, 2010

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A prior fracture was defined as a fracture in an individual who was alive during the index year (i.e. 2010) which had occurred after the age of 50 years and before 2010. In the population ≥50 years of age, the proportions of individuals who had suffered a fracture prior to 2010 were estimated at 1.55 % for hip and 1.77 % for clinical vertebral fractures. The estimated proportions of men and women with prior hip and vertebral fractures by age are presented in Table 5.
Table 5

Proportion of men and women (in %) with a prior hip or clinical vertebral fracture in Luxembourg, 2010

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In the population over 50 years of age, the number of individuals with hip and vertebral fractures that occurred before 2010 was estimated at 2,400 and 2,800 respectively (Table 6). Note that fractures sustained in 2010 were not included in the estimate.
Table 6

Number of men and women in Luxembourg with a prior hip or clinical vertebral fracture after the age of 50 years, 2010

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The incidence of causally related deaths (per 100,000) in the first year after fracture by age is presented in Table 7. The number of causally related deaths in 2010 was estimated at 28 (Table 8). Hip, vertebral and “other” fractures accounted for 14, 10 and 4 deaths respectively. Overall, approximately 56 % of deaths occurred in women.
Table 7

Incidence (per 100,000) of causally related deaths in Luxembourg within the first year after fracture (adjusted for comorbidities), 2010

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Table 8

The number of deaths in men and women in Luxembourg in the first year after fracture attributable to the fracture event (causally related), 2010

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Cost of osteoporosis in Luxembourg including and excluding values of QALYs lost

For the purpose of this report, the cost of osteoporosis in 2010 (excluding value of QALYs lost) was considered to consist of three components: (i) cost of fractures that occurred in 2010 (“first year costs”); (ii) cost of fractures sustained prior to year 2010 but which still incurred costs in 2010 (“long-term disability cost”); and (iii) cost of pharmacological fracture prevention including administration and monitoring costs (“pharmacological fracture prevention costs”). See Chapter 4 of the main report for further details.

The cost of a hip fracture was not available specifically for Luxembourg, therefore hip fracture costs has been estimated at € 12,616 based on Belgian costs [6]. Given that no cost data for the other fracture sites were found, these were imputed as described in Chapter 4 of the main report.

Long-term disability costs were estimated by multiplying the yearly cost of residing in nursing home (€ 19,787 [7,8], based on Belgian cost of public nursing home) with the simulated number of individuals with prior fractures that had been transferred to nursing homes due to the fracture.

Annual drug cost for individual treatments is shown in Table 9. In addition, it was assumed that patients on treatment made an annual physician visit costing € 30 [9] and a DXA scan at € 59 [9] every second year to monitor treatment.
Table 9

One year costs for relevant pharmaceuticals in Luxembourg, 2010 [9]

 

Annual drug cost (€)

Alendronate

109

Risedronate

226

Etidronate

223

Ibandronate

379

Zoledronic acid

355

Raloxifene

446

Strontium ranelate

375

Parathyroid hormone

-

Teriparatide

4,666

The cost of osteoporosis in 2010 was estimated at € 22 million (Table 10). First year costs, subsequent year costs and pharmacological fracture prevention costs amounted to € 15 million, € 4 million and € 2 million respectively. It is notable that pharmacological fracture prevention costs amounted to only 9.1 % of the total cost.
Table 10

Cost of osteoporosis (€) in Luxembourg by age in men and women, 2010

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When stratifying costs of osteoporosis by fracture type, hip fractures were most costly (€ 10 million) followed by “other” (€ 9 million), spine (€ 1 million) and forearm fractures (€ 0.4 million) (Table 11 and Fig. 1). Please note that costs for pharmacological fracture prevention were not included given that they cannot be allocated to specific fracture sites.
Table 11

Total cost (€) in 2010 by fracture site in men and women in Luxembourg. Note that costs for fracture prevention therapy and monitoring are not included.

https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Tablb_HTML.gif
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figaf_HTML.gif

Fig. 1 Share (%) of fracture cost by fracture site in Luxembourg. Note that costs for fracture prevention therapy and monitoring are not included.

The number of quality adjusted life years (QALYs) lost due to osteoporosis in 2010 was estimated at 900 (Table 12). 67 % of the total QALY loss was incurred in women. Prior fractures accounted for 55 % of the total QALY loss. The monetary value of a QALY was varied between 1 to 3 times the gross domestic product (GDP) per capita (Table 13). Assuming a QALY is valued at 2 times GDP/capita, the total cost of the QALYs lost was estimated at € 150 million.
Table 12

Number of QALYs lost due to fractures during 2010 in men and women in Luxembourg according to age

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Table 13

Value of lost QALYs (€) in men and women in Luxembourg in 2010

 

1 × GDP/capita

2 × GDP/capita

3 × GDP/capita

Incident hip fractures

8,583,304

17,166,608

25,749,911

Incident vertebral fractures

10,492,614

20,985,228

31,477,842

Incident forearm fractures

1,260,591

2,521,181

3,781,772

Incident other fractures

12,706,581

25,413,161

38,119,742

Prior hip fractures

28,851,341

57,702,681

86,554,022

Prior vertebral fractures

12,004,972

24,009,944

36,014,916

Total

73,899,402

147,798,804

221,698,206

When the cost of osteoporosis was combined with the value for QALYs lost (valued at 2 × GDP), the cost of osteoporosis amounted to € 170 million in Luxembourg in 2010. Incident fracture, prior fracture, pharmacological fracture prevention, and value of QALYs lost accounted for 9 %, 3 %, 1 % and 87 % respectively.

Burden of osteoporosis up to 2025

The population above 50 years of age is expected to increase from 158,000 in 2010 to 220,000 in 2025, corresponding to an increase of 39 % (Table 14).
Table 14

Population projections in Luxembourg by age and sex [10]

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The total number of fractures was estimated to rise from approximately 2,700 in 2010 to 4,000 in 2025 (Table 15), corresponding to an increase of 49 %. Hip, clinical spine, forearm and other fractures increased by 200, 200, 200 and 700 respectively. The increase in the number of fractures ranged from 40 % to 52 %, depending on fracture site. The increase was estimated to be particularly marked in men (66 %) compared to women (41 %).
Table 15

Projected annual number of incident fractures in 2010 and 2025 by fracture site and age in men and women in Luxembourg

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The cost of osteoporosis (excluding values of QALYs lost) was estimated to rise from € 22 million in 2010 to € 31 million in 2025, corresponding to an increase of 41 % (Table 16). Costs incurred in women and men increased by 33 % and 59 % respectively.
Table 16

Current and future cost (€000,000) of osteoporosis (excluding value of QALYs lost) by age and calendar year in men and women in Luxembourg

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The total number of QALYs lost due to fracture was estimated to rise from 900 in 2010 to 1,200 in 2025, corresponding to an increase of 30 % (Table 17). The increase was estimated to be particularly marked in men (48 %) compared to women (21 %). Incident and prior fractures accounted for 75 % and 25 % of the increase respectively.
Table 17

Projected QALYs lost due to incident and prior fractures for the years 2010 and 2025 by age in men and women in Luxembourg

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The cost of osteoporosis including value of QALYs lost was estimated to increase from approximately € 170 million in 2010 to € 220 million in 2025. The increase was estimated to be particularly marked in men (+49 %) compared to women (+23 %) (Table 18).
Table 18

Present and future cost (€ 000,000) of fracture (direct cost and cost of QALYs) by age and calendar year in men and women in Luxembourg assuming the uptake of treatment remains unchanged

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Treatment uptake

To estimate uptake of individual osteoporosis treatments, sales data from IMS Health (2001–2011) were used to derive the number of defined daily doses (DDDs) sold per 100,000 persons aged 50 years or above (Fig. 2).
https://static-content.springer.com/image/art%3A10.1007%2Fs11657-013-0137-0/MediaObjects/11657_2013_137_Figag_HTML.gif

Fig. 2 Treatment uptake in Luxembourg (Defined daily doses [DDDs] per 100,000 persons aged 50 years or above)

Adjusting the sales data for compliance allowed for an estimation of the proportion of population aged 50 years or above who received any osteoporosis treatment (see Chapter 5 of the report on Osteoporosis in the European Union: Medical Management, Epidemiology and Economic Burden for further details). The proportion of persons over the age of 50 years who were treated increased from 4.65 % in 2001 to 8.25 % in 2006 but subsequently decreased to 5.78 % in 2011.

Treatment gap

In order to assess the potential treatment gap, the numbers of men and women eligible for treatment in Luxembourg were defined as individuals with a 10-year fracture probability exceeding that of a woman with a prior fragility fracture derived from FRAX®, equivalent to a ‘fracture threshold’ (See Chapter 5 of the main report for further details). Subsequently, these estimates were compared to the number individuals who received osteoporosis treatment obtained from the analysis of IMS Health data. For men, the data indicate that the volume of sold osteoporosis drugs would be sufficient to cover treatment for more patients than the number that fall above the fracture threshold. It should be noted, however, that the results from this analysis should be interpreted with some caution since it has been assumed that the distribution of drug use between genders observed in Sweden is valid for all countries. The treatment gaps in men and women were estimated at −35 % and 43 % respectively (Table 19). Also note that the estimate of the treatment gap is conservative given that it assumes that current use of osteoporosis treatments are only directed to men and women at high risk. This has been shown not to be the case [11].
Table 19

Number of men and women eligible for treatment, treated and treatment gap in 2010