Osteoporosis International

, Volume 24, Issue 3, pp 835–847 | Cite as

The health burden and costs of incident fractures attributable to osteoporosis from 2010 to 2050 in Germany—a demographic simulation model

  • F. Bleibler
  • A. Konnopka
  • P. Benzinger
  • K. Rapp
  • H.-H. König
Original Article



To predict the burden of incident osteoporosis attributable fractures (OAF) in Germany, an economic simulation model was built. The burden of OAF will sharply increase until 2050. Future demand for hospital and long-term care can be expected to substantially rise and should be considered in future healthcare planning.


The aim of this study was to develop an innovative simulation model to predict the burden of incident OAF occurring in the German population, aged >50, in the time period of 2010 to 2050.


A Markov state transition model based on five fracture states was developed to estimate costs and loss of quality adjusted life years (QALYs). Demographic change was modelled using individual generation life tables. Direct (inpatient, outpatient, long-term care) and indirect fracture costs attributable to osteoporosis were estimated by comparing Markov cohorts with and without osteoporosis.


The number of OAF will rise from 115,248 in 2010 to 273,794 in 2050, cumulating to approximately 8.1 million fractures (78 % women, 22 % men) during the period between 2010 and 2050. Total undiscounted incident OAF costs will increase from around 1.0 billion Euros in 2010 to 6.1 billion Euros in 2050. Discounted (3 %) cumulated costs from 2010 to 2050 will amount to 88.5 billion Euros (168.5 undiscounted), with 76 % being direct and 24 % indirect costs. The discounted (undiscounted) cumulated loss of QALYs will amount to 2.5 (4.9) million.


We found that incident OAF costs will sharply increase until the year 2050. As a consequence, a growing demand for long-term care as well as hospital care can be expected and should be considered in future healthcare planning. To support decision makers in managing the future burden of OAF, our model allows to economically evaluate population- and risk group-based interventions for fracture prevention in Germany.


Cost-of-illness Demographic change Germany Healthcare planning Markov model Osteoporosis attributable fractures 

Supplementary material

198_2012_2020_MOESM1_ESM.doc (310 kb)
ESM 1(DOC 309 kb)


  1. 1.
    Statistisches Bundesamt (2009) Bevölkerung Deutschland bis 2060. 12. koordinierte Bevölkerungsvorausberechnung [Population in Germany up to the year 2060. Results of the 12th coordinated projection of population]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  2. 2.
    Kanis JA, Johnell O, Oden A, Jonsson B, De Laet C, Dawson A (2000) Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 27:585–590PubMedCrossRefGoogle Scholar
  3. 3.
    World Health Organisation (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group. World Health Organ Tech Rep Ser 843:1–129Google Scholar
  4. 4.
    Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA, Fujiwara S, Kroger H, Mellstrom D, Meunier PJ, Melton LJ 3rd, O’Neill T, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20:1185–1194PubMedCrossRefGoogle Scholar
  5. 5.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312:1254–1259PubMedCrossRefGoogle Scholar
  6. 6.
    Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, Nevitt MC, Cummings SR (2003) BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res 18:1947–1954PubMedCrossRefGoogle Scholar
  7. 7.
    Osnes EK, Lofthus CM, Meyer HE, Falch JA, Nordsletten L, Cappelen I, Kristiansen IS (2004) Consequences of hip fracture on activities of daily life and residential needs. Osteoporos Int 15:567–574PubMedCrossRefGoogle Scholar
  8. 8.
    Hiligsmann M, Ethgen O, Richy F, Reginster JY (2008) Utility values associated with osteoporotic fracture: a systematic review of the literature. Calcif Tissue Int 82:288–292PubMedCrossRefGoogle Scholar
  9. 9.
    Morin S, Lix LM, Azimaee M, Metge C, Caetano P, Leslie WD (2011) Mortality rates after incident non-traumatic fractures in older men and women. Osteoporos Int 22:2439–2448PubMedCrossRefGoogle Scholar
  10. 10.
    Budhia S, Mikyas Y, Tang M, Badamgarav E (2012) Osteoporotic fractures: a systematic review of US healthcare costs and resource utilization. Pharmacoeconomics 30:147–170PubMedCrossRefGoogle Scholar
  11. 11.
    Konnopka A, Jerusel N, Konig HH (2009) The health and economic consequences of osteopenia- and osteoporosis-attributable hip fractures in Germany: estimation for 2002 and projection until 2050. Osteoporos Int 20:1117–1129PubMedCrossRefGoogle Scholar
  12. 12.
    Häussler B, Gothe H, Gol D, Glaeske G, Pientka L, Felsenberg D (2007) Epidemiology, treatment and costs of osteoporosis in Germany—the BoneEVA Study. Osteoporos Int 18:77–84PubMedCrossRefGoogle Scholar
  13. 13.
    Schwenkglenks M, Lippuner K, Hauselmann HJ, Szucs TD (2005) A model of osteoporosis impact in Switzerland 2000–2020. Osteoporos Int 16:659–667PubMedCrossRefGoogle Scholar
  14. 14.
    Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A (2007) Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 22:465–475PubMedCrossRefGoogle Scholar
  15. 15.
    Burge RT, Worley D, Johansen A, Bhattacharyya S, Bose U (2001) The cost of osteoporotic fractures in the UK: projections for 2000–2020. J Med Econ 4:51–62CrossRefGoogle Scholar
  16. 16.
    Tosteson AN, Jonsson B, Grima DT, O’Brien BJ, Black DM, Adachi JD (2001) Challenges for model-based economic evaluations of postmenopausal osteoporosis interventions. Osteoporos Int 12:849–857PubMedCrossRefGoogle Scholar
  17. 17.
    Statistisches Bundesamt (2006) Generationensterbetafeln für Deutschland. Modellrechnungen für die Geburtsjahrgänge 1871–2004 [Generation life tables for Germany. A model calculation for the birth cohorts 1871–2004]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  18. 18.
    Jerusel N (2009) Analyse und Prognose der Krankheitslast Osteoporose—attributabler proximaler Femurfrakturen in Deutschland [Analysis and Prognosis of the health burden of osteoporosis attributable proximal femur fractures in Germany]. University of Leipzig, DissertationGoogle Scholar
  19. 19.
    Wildner M (2001) Osteoporose [Osteoporosis]. Dtsch med Wochenschr 126:A1170–A1172Google Scholar
  20. 20.
    Konig HH, Barry JC (2004) Cost–utility analysis of orthoptic screening in kindergarten: a Markov model based on data from Germany. Pediatrics 113:e95–e108PubMedCrossRefGoogle Scholar
  21. 21.
    Paggiosi M, Glueer C, Roux C, Reid D, Felsenberg D, Barkmann R, Eastell R (2011) International variation in proximal femur bone mineral density. Osteoporos Int 22:721–729PubMedCrossRefGoogle Scholar
  22. 22.
    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 8:468–489PubMedCrossRefGoogle Scholar
  23. 23.
    Statistisches Bundesamt (2011) Tiefgegliederte Diagnosedaten der Krankenhauspatientinnen und -patienten 2009 [Deep stratified diagnosis—data from female and male inpatients 2009]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  24. 24.
    Gedeborg R, Engquist H, Berglund L, Michaelsson K (2008) Identification of incident injuries in hospital discharge registers. Epidemiology 19:860–867PubMedCrossRefGoogle Scholar
  25. 25.
    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 19:1139–1145PubMedCrossRefGoogle Scholar
  26. 26.
    Finnern HW, Sykes DP (2003) The hospital cost of vertebral fractures in the EU: estimates using national datasets. Osteoporos Int 14:429–436PubMedCrossRefGoogle Scholar
  27. 27.
    Oleksik A, Lips P, Dawson A, Minshall ME, Shen W, Cooper C, Kanis J (2000) Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures. J Bone Miner Res 15:1384–1392PubMedCrossRefGoogle Scholar
  28. 28.
    Einsiedel T, Becker C, Stengel D, Schmelz A, Kramer M, Daxle M, Lechner F, Kinzl L, Gebhard F (2006) Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65. Z Gerontol Geriatr 39:451–461PubMedCrossRefGoogle Scholar
  29. 29.
    Boufous S, Finch C, Close J, Day L, Lord S (2007) Hospital admissions following presentations to emergency departments for a fracture in older people. Inj Prev 13:211–214PubMedCrossRefGoogle Scholar
  30. 30.
    Van Staa TP, Leufkens HG, Cooper C (2002) Does a fracture at one site predict later fractures at other sites? A British cohort study. Osteoporos Int 13:624–629PubMedCrossRefGoogle Scholar
  31. 31.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739PubMedCrossRefGoogle Scholar
  32. 32.
    Kanis JA, Borgstrom F, Johnell O, Jonsson B (2004) Cost-effectiveness of risedronate for the treatment of osteoporosis and prevention of fractures in postmenopausal women. Osteoporos Int 15:862–871PubMedCrossRefGoogle Scholar
  33. 33.
    Johnell O, Kanis JA, Oden A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jonsson B (2004) Mortality after osteoporotic fractures. Osteoporos Int 15:38–42PubMedCrossRefGoogle Scholar
  34. 34.
    Konig HH, Bernert S, Angermeyer MC (2005) Health Status of the German population: results of a representative survey using the EuroQol questionnaire. Gesundheitswesen 67:173–182PubMedCrossRefGoogle Scholar
  35. 35.
    Dolan P (1997) Modeling valuations for EuroQol health states. Med Care 35:1095–1108PubMedCrossRefGoogle Scholar
  36. 36.
    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 15:20–26PubMedCrossRefGoogle Scholar
  37. 37.
    Institut für das Entgeltsystem im Krankenhaus (INEK) (2011) G-DRG V2010 Browser. Institut für das Entgeltsystem im Krankenhaus, SiegburgGoogle Scholar
  38. 38.
    Deutsche Krankenhausgesellschaft (2011) Landesbasisfallwerte der Bundesländer 2005–2011 [Base rates of the German Federal States 2005–2011]. http://www.dkgev.de/media/file/7827.LBFW_2005_2010_Stand_160610.pdf. Accessed 18 Feb 2012
  39. 39.
    Krauth C, Hessel F, Hansmeier T, Wasem J, Seitz R, Schweikert B (2005) Empirical standard costs for health economic evaluation in Germany—a proposal by the working group methods in health economic evaluation. Gesundheitswesen 67:736–746PubMedCrossRefGoogle Scholar
  40. 40.
    Kreck S, Klaus J, Leidl R, von Tirpitz C, Konnopka A, Matschinger H, Konig HH (2008) Cost effectiveness of ibandronate for the prevention of fractures in inflammatory bowel disease-related osteoporosis: cost-utility analysis using a Markov model. Pharmacoeconomics 26:311–328PubMedCrossRefGoogle Scholar
  41. 41.
    Kassenärztliche Bundesvereinigung (KBV) (2010) Einheitlicher Bewertungsmaßstab (EBM) 2010. http://www.kbv.de/ebm2012/EBMGesamt.htm. Accessed 18 Feb 2012
  42. 42.
    Rote Liste Service GmbH (2009) Rote Liste 2009 [Red List 2009]. Rote Liste Service GmbH, Frankfurt am MainGoogle Scholar
  43. 43.
    Statistisches Bundesamt (2011) Pflegestatistik 2009. Pflege im Rahmen der Pflegeversicherung. Deutschlandergebnisse [Statistics on care 2009—care in the context of the care insurance results from Germany]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  44. 44.
    Bundesverband AOK (2009) Krankheitsartenstatistik 2008 [Disease statistic 2008]. AOK Bundesverband, BerlinGoogle Scholar
  45. 45.
    Deutsche Rentenversicherung (2010) Statistik der Deutschen Rentenversicherung. Rehabilitation 2009 Band 179 [Statistic of the German pension insurance fund—rehabilitation 2009 volume 179]. Deutsche Rentenversicherung, BerlinGoogle Scholar
  46. 46.
    Statistisches Bundesamt (2011) Verdienste und Arbeitskosten, Jahr 2010, Fachserie 16 Reihe 2.3 [Earning and labour cost 2010, Series 16(2.3)]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  47. 47.
    Statistisches Bundesamt (2009) Mikrozenus 2009, Fachserie 1 Reihe 4.1.1 [Microcensus 2009, Series 1(4.1.1)]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  48. 48.
    Statistisches Bundesamt (2003) Wo bleibt die Zeit? Die Zeitverwendung der Bevölkerung in Deutschland 2001/02 [Where has the time gone? The time use of the German population in 2001/02]. Statistisches Bundesamt, WiesbadenGoogle Scholar
  49. 49.
    Briggs A, Claxton K, Sculpher M (2007) Decision modelling for health economic evaluation. Oxford University, OxfordGoogle Scholar
  50. 50.
    Statistisches Bundesamt (2012) Die Gesundheitsberichterstattung des Bundes: Ausgaben, Kosten, Finanzierung [Federal health monitoring: expenditures, costs and financing].https://www.gbebund.de/gbe10/abrechnung.prc_abr_test_logon?p_uid=gast&p_aid=51115479&p_sprache=E&p_knoten=TR19200. Accessed 15 April 2012
  51. 51.
    Nguyen ND, Center JR, Eisman JA, Nguyen TV (2007) Bone loss, weight loss, and weight fluctuation predict mortality risk in elderly men and women. J Bone Miner Res 22:1147–1154PubMedCrossRefGoogle Scholar
  52. 52.
    Melton LJ 3rd, Thamer M, Ray NF, Chan JK, Chesnut CH 3rd, Einhorn TA, Johnston CC, Raisz LG, Silverman SL, Siris ES (1997) Fractures attributable to osteoporosis: report from the National Osteoporosis Foundation. J Bone Miner Res 12:16–23PubMedCrossRefGoogle Scholar
  53. 53.
    Mackey DC (2011) Determining which fractures are osteoporotic: empirical associations would provide better evidence than expert opinion. J Clin Epidemiol 64:45PubMedCrossRefGoogle Scholar
  54. 54.
    Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, Melton LJ, Cummings SR, Kanis JA (2011) Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int 22:1277–1288PubMedCrossRefGoogle Scholar
  55. 55.
    Oxford Centre of Evidence-Based Medicine (2009) Levels of evidence (March 2009). http://www.cebm.net/index.aspx?o=1025. Accessed 18 Feb 2012
  56. 56.
    Mueller D, Gandjour A (2009) Cost-effectiveness of using clinical risk factors with and without DXA for osteoporosis screening in postmenopausal women. Value Health 12:1106–1117PubMedCrossRefGoogle Scholar
  57. 57.
    Kennedy CC, Papaioannou A, Adachi JD (2006) Treating osteoporosis: economic aspects of bisphosphonate therapy. Expert Opin Pharmacother 7:1457–1467PubMedCrossRefGoogle Scholar
  58. 58.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767PubMedCrossRefGoogle Scholar
  59. 59.
    Becker C, Cameron ID, Klenk J, Lindemann U, Heinrich S, Konig HH, Rapp K (2011) Reduction of femoral fractures in long-term care facilities: the Bavarian fracture prevention study. PLoS One 6:e24311PubMedCrossRefGoogle Scholar
  60. 60.
    Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, Kerse N (2010) Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 20:CD005465Google Scholar
  61. 61.
    Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH (2009) Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev CD007146Google Scholar
  62. 62.
    Davis JC, Robertson MC, Ashe MC, Liu-Ambrose T, Khan KM, Marra CA (2009) Does a home-based strength and balance programme in people aged > or =80 years provide the best value for money to prevent falls? A systematic review of economic evaluations of falls prevention interventions. Br J Sports Med 44:80–89CrossRefGoogle Scholar
  63. 63.
    Church J, Goodall S, Norman R, Haas M (2011) An economic evaluation of community and residential aged care falls prevention strategies in NSW. N S W Public Health Bull 22:60–68PubMedCrossRefGoogle Scholar
  64. 64.
    Gandjour A, Weyler EJ (2008) Cost-effectiveness of preventing hip fractures by hip protectors in elderly institutionalized residents in Germany. Value Health 11:1088–1095PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2012

Authors and Affiliations

  • F. Bleibler
    • 1
  • A. Konnopka
    • 1
  • P. Benzinger
    • 2
  • K. Rapp
    • 2
  • H.-H. König
    • 1
  1. 1.Department for Medical Sociology and Health Economics, Hamburg Center for Health EconomicsUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Department of Clinical GerontologyRobert-Bosch-HospitalStuttgartGermany

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