Osteoporosis International

, Volume 16, Issue 3, pp 229–238 | Cite as

Requirements for DXA for the management of osteoporosis in Europe

  • J. A. Kanis
  • O. Johnell
Position Paper


The availability of dual energy X-ray absorptiometry (DXA) varies markedly in different countries. There is, however, little information to indicate the optimal requirements for this technology. The principal aim of this study was to estimate the requirements for DXA in Europe for the assessment and treatment of osteoporosis. Three assessment scenarios were chosen. The first envisaged screening of all women with DXA at the age of 65 years. A second scenario comprised a screening programme based on the identification of clinical risk factors with the selective addition of BMD tests in those close to an intervention threshold. The third scenario envisaged a case finding strategy where women aged 65 years were identified on the basis of risk factors and referred for DXA. Requirements for women aged more than 65 years were amortised over a 10-year period. A secondary aim was to estimate the number and cost of osteoporotic fractures in Europe. The requirements for DXA in assessment ranged from 4.21 to 11.21 units/million of the population. The most efficient assessment scenario was the use of clinical risk factors with the selective use of BMD. With this scenario, an additional 6.39 units/million would be required to monitor treatment giving a total requirement of 10.6 units/million. In 2000, the number of osteoporotic fractures was estimated at 3.79 million, of which 0.89 million were hip fractures (179,000 hip fractures in men and 711,000 in women). The total direct costs were estimated at €31.7 billion (£21.165 billion), which were expected to increase to €76.7 billion (£51.1 billion) in 2050 based on the expected changes in the demography of Europe.


Dual energy X-ray absorptiometry Europe Fracture probability Hip fracture Osteoporotic fracture Risk assessment Screening 



The work was supported by a grant from the International Osteoporosis Foundation. Information on DXA units was kindly provided by K. Faulkner, GE-Lunar.


  1. 1.
    Kanis JA, Johnell O, De Laet C et al. (2002b) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17:1237–1244PubMedGoogle Scholar
  2. 2.
    European Commission (1998) Report on osteoporosis in the European Community—action on prevention. Luxembourg Office for Official Publications of the European Communities, 1998, pp 112Google Scholar
  3. 3.
    Kanis JA, Johnell O, Oden A et al. (2000) Long term risk of osteoporotic fracture in Malmo. Osteoporosis Int 11:669–674CrossRefGoogle Scholar
  4. 4.
    Johnell O, Kanis JA, Jonsson B, Oden A, Johansson H, De Laet C (2005) The burden of hospitalised fractures in Sweden. Osteoporos Int DOI 10.1007/s00198-004-1686-2Google Scholar
  5. 5.
    Delmas PD (2002) Treatment of postmenopausal osteoporosis. Lancet 359:2018–2026CrossRefPubMedGoogle Scholar
  6. 6.
    Cuddily MT, Gabriel SE, Crowson CS, Atkinson E (2000) Osteoporosis management in postmenopausal women after low impact distal forearm fracture: a missed opportunity. J Bone Miner Res 15 (suppl 1):187 (abstract)Google Scholar
  7. 7.
    Kamel HK, Hussain MS, Tariq S, Perry MM, Maely JE (2000) Failure to diagnose and treat osteoporosis in elderly patients hospitalised with hip fracture. Am J Med 109:338–339CrossRefPubMedGoogle Scholar
  8. 8.
    Torgerson DJ, Dolan P (1998) Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis 57:378–379PubMedGoogle Scholar
  9. 9.
    Briancon D, de Gaudemar J-B, Forestier R (2004) Management of osteoporosis in women with peripheral osteoporotic fractures after 50 years of age: a study of practices. Joint Bone Spine 71:128–130CrossRefPubMedGoogle Scholar
  10. 10.
    Panneman MJM, Lips P, Sen SS, Herings RMC (2004) Undertreatment with anti-osteoporotic drugs after hospitalisation for fracture. Osteoporos Int 15:120–124CrossRefGoogle Scholar
  11. 11.
    Kanis JA, Gluer CC, for the Committee of Scientific Advisors, International Osteoporosis Foundation (2000) An update on the diagnosis and assessment of osteoporosis with densitometry. Osteoporos Int 11:192–202CrossRefPubMedGoogle Scholar
  12. 12.
    National Osteoporosis Foundation (1998) Physician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington D.C., pp 1–38Google Scholar
  13. 13.
    US Preventive Services Task Force (2003) Screening for osteoporosis in postmenopausal women. Office of Disease Prevention and Health Promotion, Washington D.C.Google Scholar
  14. 14.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936CrossRefPubMedGoogle Scholar
  15. 15.
    Johansson H, Oden A, Johnell O, Jonsson B, De Laet C, Oglesby A, McCloskey EV, Kayan K, Jalava T, Kanis JA 2004 Optimisation of BMD measurements to identify high risk groups for treatment—a test analysis. J Bone Miner Res 19:906–913Google Scholar
  16. 16.
    Kanis JA, Johansson H, Oden A, Johnell O, De Laet C, Melton LJ, Tenenhouse A, Reeve J, Silman AJ, Pols HAP, Eisman JA, McCloskey EV, Mellstrom D (2004) A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 19:893–899PubMedGoogle Scholar
  17. 17.
    Kanis JA, Johnell O, Oden A, Borgstrom F, Johansson H, De Laet C, Jonsson B (2005) Intervention thresholds for osteoporosis in men and women. A study based on data from Sweden. Osteoporos Int 16:6–14Google Scholar
  18. 18.
    Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D on behalf of the EFFO (1997) Guidelines for the diagnosis and management of osteoporosis. Osteoporos Int 7:390–406PubMedGoogle Scholar
  19. 19.
    Royal College of Physicians (1999) Osteoporosis: clinical guidelines for prevention and treatment. RCP, LondonGoogle Scholar
  20. 20.
    Royal College of Physicians (2000) Osteoporosis: clinical guidelines for prevention and treatment. Update on pharmacological interventions and an algorithm for management. RCP, LondonGoogle Scholar
  21. 21.
    United Nations Population Division (2003) World population prospects: the 2002 revision and world urban prospects. Population Division of the Department of Economic and Social Affairs of the UN SecretariatGoogle Scholar
  22. 22.
    Seeley DG, Browner WS, Nevitt MC, Genant HK, Scott JC, Cummings SR for the Study of Osteoporotic Fractures Research Group (1991) Which fractures are associated with low appendicular bone mass in elderly women? Ann Int Med 115:837–842Google Scholar
  23. 23.
    Kanis JA, Oden A, Johnell O, Jonsson B, De Laet C, Dawson A (2002) The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int 12:417–424CrossRefGoogle Scholar
  24. 24.
    Baron JA, Barrett J, Malenka D et al. (1994) Racial differences in fracture risk. Epidemiology 5:42–47PubMedGoogle Scholar
  25. 25.
    Melton LJ, Crawson CS, O’Fallon WM (1999) Fracture incidence in Olmsted County, Minnesota: comparison of urban and with rural rates and changes in urban rates over time. Osteoporos Int 9:29–37CrossRefPubMedGoogle Scholar
  26. 26.
    Sanders KM, Nicholson GC, Ugoni AM, Pasco JA, Seeman E, Kotowicz MA (1999) Health burden of hip and other fractures in Australia beyond 2000. Projections based on the Geelong Osteoporosis study. Med J Aust 170:467–470PubMedGoogle Scholar
  27. 27.
    Singer BR, McLauchlan CJ, Robinson CM, Christie J (1998) Epidemiology of fracture in 15,000 adults. The influence of age and gender. J Bone Joint Surg 80B:234–238Google Scholar
  28. 28.
    Felsenberg D, Silman AJ, Lunt M, Ambrecht G, Ismail AA, Finn JD, Cockerill WC, Banzer D, Benevolenskaya LI, Bhalla A, Bruges Armas J, Cannata JB, Cooper C, Dequeker J, Eastell R, Ershova O, Felsch B, Gowin W, Havelka S, Hoszowski K, Jajic I, Janot J, Johnell O, Kanis JA, Kragl G, Lopez Vaz A, Lorenc R, Lyritis G, Masaryk P, Matthis C, Miazgowski T, Parisi G, Pols HAP, Poor G, Raspe HH, Reid DM, Reisinger W, Scheidt-Nave C, Stepan J, Todd C, Weber K, Woolf AD, Reeve J, O’Neill TW (2002) Incidence of vertebral fracture in Europe: results from the European Prospective Osteoporosis Study EPOS. J Bone Miner Res 17:716–724PubMedGoogle Scholar
  29. 29.
    Elffors L, Allander E, Kanis JA, Gullberg B, Johnell O, Dequeker J, Dilzen G, Gennari C, Lopez-Vaz AA, Lyritis G, Mazzuoli GF, Miravet L, Passeri M, Perez Cano R, Rapado A, Ribot C (1994) The variable incidence of hip fracture in Southern Europe. The MEDOS Study. Osteoporos Int 4:253–263PubMedGoogle Scholar
  30. 30.
    Johnell O, Gullberg B, Kanis JA (1997) The hospital burden of vertebral fracture in Europe: a study of national register sources. Osteoporos Int 7:138–144Google Scholar
  31. 31.
    Dolan P, Torgerson DJ (1998) The cost of treating osteoporosis in the United Kingdom female population. Osteoporos Int 8:611–617CrossRefPubMedGoogle Scholar
  32. 32.
    Kanis JA, Brazier JE, Stevenson M et al. (2002a) Treatment of established osteoporosis: a systematic review and cost utility analysis. Health Technology Assessment 6:1–146Google Scholar
  33. 33.
    Melton LJ, Gabriel SE, Crowson CS, Tosteson ANA, Johnell O, Kanis JA (2003) Cost equivalence of different osteoporotic fractures. Osteoporos Int 14:383–388CrossRefPubMedGoogle Scholar
  34. 34.
    Borgstrom F, Johnell O, Kanis JA, Jonsson B (2004) Hip fracture probability and ability to pay for treatment: a worldwide perspective. Osteoporos Int 15:S12CrossRefGoogle Scholar
  35. 35.
    Johnell O, Gullberg B, Allander E, Kanis JA, the MEDOS study group (1992) The apparent incidence of hip fracture in Europe: a study of national register sources. Osteoporos Int 2:298–302PubMedGoogle Scholar
  36. 36.
    O’Neill TW, Felsenberg D, Varlow J, Cooper C, Kanis JA, Silman AJ 1996 The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 11:1010–1017Google Scholar
  37. 37.
    Lindsay RL, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, Licata A, Benhamou L, Geusens P, Flowers K, Stracke H, Seeman E (2001) Risk for new vertebral fracture in the year following a fracture. JAMA 285:320–323CrossRefPubMedGoogle Scholar
  38. 38.
    Kanis JA, Johnell O, Oden A, Borgstrom F, Zethraeus N, De Laet C, Jonsson B (2004) The risk and burden of vertebral fractures in Sweden. Osteoporos Int 15:20–26CrossRefPubMedGoogle Scholar
  39. 39.
    Finnern HW, Sykes DP (2003) The hospital cost of vertebral fractures in the EU: estimates using natural data sets. Osteoporos Int 14:429–436CrossRefPubMedGoogle Scholar
  40. 40.
    Gullberg B, Johnell O, Kanis JA (1997) World wide projections for hip fracture. Osteoporosis Int 7:407–413Google Scholar
  41. 41.
    Kayan K, De Takats D, Ashford R, Kanis JA, McCloskey EV (2003) Performance of clinical referral criteria for bone densitometry in patients under 65 years of age assessed by spine bone mineral density. Postgrad Med J 79:581–584CrossRefGoogle Scholar
  42. 42.
    Cummings SR, Palermo L, Browner W, Marcus R, Wallace R, Pearson J, Blackwell T, Eckert S, Black D for the Fracture Intervention Trial Research Group (2000) Monitoring osteoporosis therapy with bone densitometry. Misleading changes and regression to the mean. JAMA 283:1318–1321CrossRefPubMedGoogle Scholar
  43. 43.
    Compston J (2004) Action plan for the prevention of osteoporotic fractures in the European Community. Osteoporos Int 15:259–262CrossRefGoogle Scholar
  44. 44.
    De Laet C, Oden A, Johnell O, Jonsson B, Kanis JA (2005) The impact of the use of multiple risk factors on case finding strategies: a mathematical framework. Osteoporos Int DOI 10.1007/s00198-004-1689-zGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2004

Authors and Affiliations

  1. 1.WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffieldUK
  2. 2.Department of OrthopaedicsMalmo General HospitalMalmoSweden

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