Osteoporosis in Europe: a compendium of country-specific reports

Summary This report describes epidemiology, burden, and treatment of osteoporosis in each of the 27 countries of the European Union plus Switzerland and the UK (EU 27+2). Introduction The aim of this report was to characterize the burden of osteoporosis in each of the countries of the European Union plus Switzerland and the UK in 2019 and beyond. Methods The data on fracture incidence and costs of fractures in the EU27+2 was taken from a concurrent publication in this journal (SCOPE 2021: a new scorecard for osteoporosis in Europe) and country-specific information extracted. The information extracted covered four domains: burden of osteoporosis and fractures; policy framework; service provision; and service uptake. Results The clinical and economic burden of osteoporotic fractures in 2019 is given for each of the 27 countries of the EU plus Switzerland and the UK. Each domain was ranked and the country performance set against the scorecard for all nations studied. Data were also compared with the first SCOPE undertaken in 2010. Fifteen of the 16 score card metrics on healthcare provision were used in the two surveys. Scores had improved or markedly improved in 15 countries, remained constant in 8 countries and worsened in 3 countries. The average treatment gap increased from 55% in 2010 to 71% in 2019. Overall, 10.6 million women who were eligible for treatment were untreated in 2010. In 2019, this number had risen to 14.0 million. 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.

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. Over the past three 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 "SCOPE 2021: a new scorecard for osteoporosis in Europe" describes the current burden of osteoporosis in the EU in 2019 [1]. In 2019, 25.5 million women and 6.5 million men were estimated to have osteoporosis in the European Union plus Switzerland and the United Kingdom; and 4.3 million new fragility fractures were sustained, comprising 827,000 hip fractures, 663,000 vertebral fractures, 637,000 forearm fractures and 2,150,000 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 in 2019 was estimated at € 57 billion. In the EU27+2, there were estimated to be 248,487 causally related deaths in 2019. The number of fracture-related deaths are comparable to or exceed some of the most common causes of death such as lung cancer, diabetes, chronic lower respiratory diseases. The population age 50 years or more is projected to increase by 11.4% in men and women between 2019 and 2034 and the annual number of osteoporotic fractures in the EU27+2 will increase by 25%. The majority of individuals who have sustained an osteoporosis-related fracture or who are at high risk of fracture are untreated and the proportion of high risk 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 plus Switzerland and the UK. Epidemiological and health economic aspects of osteoporosis and osteoporotic fractures are summarised for 2019 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 also provides information on the policy framework together with service provision and service uptake within each country. 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.

Introduction
The scorecard summarises key indicators of the burden of osteoporosis and its management in the 27 member states of the European Union, as well as the UK and Switzerland (termed EU27+2) [1]. This country-specific report summarises the principal results for Greece.

Methods
The information obtained covers four domains: burden of osteoporosis and fractures; policy framework; service provision; and service uptake. Data were collected from numerous sources including previous research and IOF reports, and available registers which were used for additional analysis of resource utilization, costing and HRQoL data. Furthermore, country-specific information on osteoporosis management was obtained from each IOF member state via a questionnaire.

Burden of disease
The direct cost of incident fractures in Greece in 2019 was €694.7 million. Added to this was the ongoing cost in 2019 from fractures that occurred before 2019, which amounted to €203.5 million (long-term disability). The cost of pharmacological intervention (assessment and treatment) was €80.5 million. Thus, the total direct cost (excluding the value of QALYs lost) amounted to €0.98 billion in 2019. Key metrics are presented in Table 1.
In 2019, the average direct cost of osteoporotic fractures in Greece was €91.2 per individual in the population, while in 2010 the average was €66.2 (after adjusting for inflation), representing an increase of 38% (€91.2 versus €66.2) and put Greece in 13th place in terms of highest cost of osteoporotic fractures per capita in the EU27+2.
The cost of osteoporotic fractures in Greece accounted for approximately 6.2% of healthcare spending (i.e. €0.98 billion out of €14.60 billion in 2019), which was significantly higher than the EU27+2 average of 3.5%. Indeed, Greece was ranked first across the EU27+2 countries. These numbers indicate a substantial impact of fragility fractures on the healthcare budget.
Using World Health Organization diagnostic criteria for osteoporosis based on the measurement of bone mineral density (BMD) [2], there were approximately 684,000 individuals with osteoporosis in Greece in 2019, of whom almost 80% were women. The prevalence of osteoporosis in the total Greek population amounted to 5.5%, on par with the EU27+ 2 average (5.6%). There were estimated to be 99,000 new fragility fractures in Greece in 2019, equivalent to 272 fractures/day (or 11 per hour). This was a slight increase compared to 2010, equivalent to an increment of 1.8 fractures/1000 individuals, totalling 22.0 fractures/ 1000 individuals in 2019.
Some osteoporotic fractures are associated with premature mortality [3]. In Greece, the annual number of deaths associated with a fracture event was estimated to be 130 per 100,000 individuals of the population aged 50 years or more, compared to the EU27+2 average of 116/ 100,000. The number of fracture-related deaths is comparable to or exceeds that for some of the most common causes of death such as lung cancer, diabetes, chronic lower respiratory diseases.
The remaining lifetime probability of hip fracture (%) at the ages of 50 years in men and women was 8.0% and 15.8%, respectively, placing Greece in the upper tertile of risk for men and the mid tertile for women.
The population in men and women age 50 years or more is projected to increase by 11.9% between 2019 and 2034, close to the EU27+2 average of 11.4%. The increases in men and women aged 75 years or more are even more marked and amount to 23.7% and 21.0%, respectively. The annual number of osteoporotic fractures in Greece is expected to increase by 22,000 to 121,000 in 2034.
Policy framework (Table 2) Documentation of the burden of disease is an essential prerequisite to determine the resources that should be allocated to the diagnosis and treatment of the disorder. High quality national data on hip fracture rates have been identified in 18 of 29 countries, of which Greece was not deemed as one. No data are collected on a national basis and the latest report dates from 2007 [4].
Given that osteoporosis and fragility fractures are common and that effective treatments are widely available, the vast majority of patients with osteoporosis are preferably managed at the primary health care level by general practitioners (GPs), with specialist referral reserved for difficult complex cases. Primary care was the principal provider of the medical care for osteoporosis in 13 of the 28 countries where data were available.
Osteoporosis and metabolic bone disease is not a recognised specialty in most countries including Greece. For Greece, orthopaedics was the lead specialty for osteoporosis management. Specialty care of osteoporosis in Greece is also managed via other specialties including endocrinology, and rheumatology. Osteoporosis is also recognized as a component of specialty training. Although it is possible that these specialties educate their trainees adequately, the wide variation may reflect inconsistencies in patient care, training of primary care physicians and a suboptimal voice to "defend" the interests of those who work within the field of osteoporosis. The role of national patient organisations is to improve the care of patients and increase awareness and prevention of osteoporosis and related fractures among the general public. Advocacy by patient organisations can fall into four categories: policy, capacity building and education, peer support, research and development. For Greece, three of these advocacy areas were covered by a patient organisation. All four advocacy areas were covered for only 10 out of the 26 countries with at least one patient organisation. (Table 3) A wide variety of approved drug treatments is available for the management of osteoporosis [5]. Potential limitations of their use in member states relate to reimbursement policies which may impair the delivery of health care. 12 out of 27 countries offered full reimbursement, of which Greece was not one.

Service provision
The assessment of bone mineral density forms a key component for the general management of osteoporosis, being used for diagnosis, risk prediction, selection of patients for treatment and monitoring of patients on treatment. In Greece, the number of DXA units expressed per million of the general population amounted to 51.4 which puts the country in 1 st place among the EU27+2.
The average waiting time for DXA ranged from 0 to 180 days across countries, and there was no clear relation between waiting times and the availability of DXA. In Greece, the estimated average waiting time for DXA amounted to five days. Only two countries reported shorter average waiting times. Reimbursement for DXA scans varied between member states both in terms of the criteria required and level of reimbursement awarded. In Greece, the reimbursement was conditional and varied depending on the patient's condition.
The effective targeting of treatment to those at highest risk of fracture requires an assessment of fracture risk. Risk assessment models for fractures, most usually based on FRAX, were available in 24 out of 29 countries, of which Greece was one. For Greece, guidance on the use of risk assessment within national guidelines was available, as in only 14 of the other countries.
Guidelines for the management of osteoporosis were available in Greece (as in 27 out of 29 countries). The guidelines in Greece included postmenopausal women specifically, as well as osteoporosis in men.
Fracture liaison services (FLS), also known as osteoporosis coordinator programmes and care manager programmes, provide a system for the routine assessment and management of postmenopausal women and older men who have sustained a low trauma fracture. Fracture liaison services were reported for 1-10% of hospitals in Greece. The use of indicators to systematically measure the quality of care provided to people with osteoporosis or associated fractures has expanded as a discipline within the past decade [6]. No use of national quality indicators was reported for Greece.
Service uptake (Table 4) The web-based usage of FRAX showed considerable heterogeneity in uptake between the countries. The average uptake for the EU27+2 was 1,555 sessions/million/ year of the general population with an enormous range of 49 to 41,874 sessions/million. The usage for Greece amounted to 4,566 sessions/million in 2019, with an eight-fold increase since 2011.
Many studies have demonstrated that a significant proportion of men and women at high fracture risk do not receive therapy for osteoporosis (the treatment gap) [7]. In the EU27+2 the average treatment gap was 71% but ranged from 32% to 87%. For Greece, the treatment gap amongst women amounted to 43% or 211,000 out of 485,000 characterised at risk and had increased compared to 2010. The average treatment gap among EU27+2 increased from 55% in 2010 to 71% in 2019. About 5% of people with a hip fracture die within 1 month of their fracture [8]. A determinant of peri-operative morbidity and mortality is the time a patient takes to get to surgery [9]. For Greece, the average waiting time for hip fracture surgery after hospital admission was reported to be 2-3 days. The proportion of surgically managed hip fractures was reported to be over 90%.

Scores and scorecard
Scores were developed for Burden of disease and the healthcare provision (Policy framework, Service provision and Service uptake) in the EU27+2 countries. Greece scores resulted in a 9th place regarding Burden of disease. The combined healthcare provision scorecard resulted in a 18th place for Greece. Thus, Greece presents as one of the eight highburden low-provision countries among the EU27+2.
The first SCOPE was undertaken in 2010, almost 10 years previously. Fifteen of the 16 score card metrics on healthcare provision were used in the two surveys. Scores had improved or markedly improved in 15 countries, remained constant in 8 countries and worsened in 3 countries. For Greece the scores were unchanged.  1 Scores by country for metrics related to policy framework, service provision and service uptake. The mean score for each of the 3 domains is given. An asterisk denotes that there was one or more missing metric which decreases the overall score The second edition of the Scorecard for Osteoporosis in Europe (SCOPE 2021) allows health and policy professionals to assess key indicators on the healthcare provision for osteoporosis within countries and between countries within the EU 27+2. The scorecard is not intended as a prescriptive template. Thus, it does not set performance targets but may serve as a guide to the performance targets at which to aim in order to deliver the outcomes required.