SCOPE: a scorecard for osteoporosis in Europe

Archives of Osteoporosis, Sep 2013

Summary The scorecard summarises key indicators of the burden of osteoporosis and its management in each of the member states of the European Union. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. Introduction The scorecard for osteoporosis in Europe (SCOPE) is an independent project that seeks to raise awareness of osteoporosis care in Europe. The aim of this project was to develop a scorecard and background documents to draw attention to gaps and inequalities in the provision of primary and secondary prevention of fractures due to osteoporosis. Methods The SCOPE panel reviewed the information available on osteoporosis and the resulting fractures for each of the 27 countries of the European Union (EU27). The information researched covered four domains: background information (e.g. the burden of osteoporosis and fractures), policy framework, service provision and service uptake e.g. the proportion of men and women at high risk that do not receive treatment (the treatment gap). Results There was a marked difference in fracture risk among the EU27. Of concern was the marked heterogeneity in the policy framework, service provision and service uptake for osteoporotic fracture that bore little relation to the fracture burden. For example, despite the wide availability of treatments to prevent fractures, in the majority of the EU27, only a minority of patients at high risk receive treatment for osteoporosis even after their first fracture. The elements of each domain in each country were scored and coded using a traffic light system (red, orange, green) and used to synthesise a scorecard. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. Conclusions The scorecard will enable healthcare professionals and policy makers to assess their country’s general approach to the disease and provide indicators to inform future provision of healthcare.

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SCOPE: a scorecard for osteoporosis in Europe

J. A. Kanis 0 1 3 4 5 6 7 8 9 F. Borgstrm 0 1 3 4 5 6 7 8 9 J. Compston 0 1 3 4 5 6 7 8 9 K. Dreinhfer 0 1 3 4 5 6 7 8 9 E. Nolte 0 1 3 4 5 6 7 8 9 L. Jonsson 0 1 3 4 5 6 7 8 9 W. F. Lems 0 1 3 4 5 6 7 8 9 E. V. McCloskey 0 1 3 4 5 6 7 8 9 R. Rizzoli 0 1 3 4 5 6 7 8 9 J. Stenmark 0 1 3 4 5 6 7 8 9 0 F. Borgstrm LIME/MMC, Karolinska Institutet , Stockholm, Sweden 1 J. A. Kanis University of Sheffield Medical School , Sheffield, UK 2 ) WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School , Beech Hill Road, Sheffield S10 2RX, UK 3 R. Rizzoli Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine , Geneva, Switzerland 4 E. V. McCloskey University of Sheffield Academic Unit of Bone Metabolism, Metabolic Bone Centre, Northern General Hospital , Sheffield, UK 5 W. F. Lems Vrije Universiteit University Medical Center , Amsterdam, The Netherlands 6 L. Jonsson OptumInsight, Stockholm, Sweden 7 E. Nolte Health and Healthcare Policy Program , RAND Europe, Cambridge, UK 8 K. Dreinhfer CSSB, Charit Universittsmedizin Berlin and Medical Park Berlin Humboldmhle , Berlin, Germany 9 J. Compston Department of Medicine, University of Cambridge School of Clinical Medicine , Cambridge, UK Summary The scorecard summarises key indicators of the burden of osteoporosis and its management in each of the member states of the European Union. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. Introduction The scorecard for osteoporosis in Europe (SCOPE) is an independent project that seeks to raise awareness of osteoporosis care in Europe. The aim of this project was to develop a scorecard and background documents to draw attention to gaps and inequalities in the provision of primary and secondary prevention of fractures due to osteoporosis. Methods The SCOPE panel reviewed the information available on osteoporosis and the resulting fractures for each of the 27 countries of the European Union (EU27). The information researched covered four domains: background information (e.g. the burden of osteoporosis and fractures), policy framework, service provision and service uptake e.g. the proportion of men and women at high risk that do not receive treatment (the treatment gap). Results There was a marked difference in fracture risk among the EU27. Of concern was the marked heterogeneity in the policy framework, service provision and service uptake for osteoporotic fracture that bore little relation to the fracture burden. For example, despite the wide availability of treatments to prevent fractures, in the majority of the EU27, only a minority of patients at high risk receive treatment for osteoporosis even after their first fracture. The elements of each domain in each country were - scored and coded using a traffic light system (red, orange, green) and used to synthesise a scorecard. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. Conclusions The scorecard will enable healthcare professionals and policy makers to assess their countrys general approach to the disease and provide indicators to inform future provision of healthcare. SCOPE Scorecard for osteoporosis in Europe About SCOPE The ScoreCard for OsteoPorosis in Europe (SCOPE) is an independent project that seeks to raise awareness of osteoporosis care in Europe. SCOPE permits an in depth comparison of the quality of care of osteoporosis across the 27 member states of the European Union (EU27). Osteoporosis is a complex disease that can be treated and managed in a number of ways. Improvements in medication and diagnostic techniques in the past 25 years have served to reduce the risk of osteoporotic fractures. In Europe, however, research has shown significant heterogeneity in the different national approaches to the management of the disease. The scorecard summarises key indicators of the burden of osteoporosis and its management in each member state of the European Union to draw attention to the disparities in healthcare provision that can serve in the setting of benchmarks to inform patients, healthcare providers and policy makers in the EU. The aim of this scorecard is to stimulate a balanced, common and optimal approach to the management of osteoporosis throughout the EU. Table of contents Letter to all Europeans Introduction 1. Burden of disease 2. Policy framework 3. Service provision 4. Service uptake 2 3 6 Acknowledgments Abbreviations and glossary 59 61 A letter to all Europeans The statistics are startling. One in three women and at least one in six men will suffer an osteoporotic fracture in their lifetime, and it is estimated that more than ten million men and women are at high risk of osteoporotic fractures in the European Union. Osteoporosis and the 3.5 million fractures it causes cost the healthcare systems of Europe in excess of 39 billion each year based on data for 2010. But numbers dont tell the full story. For the individuals who suffer fractures as a result of the disease, the stories are personal. Pain, disability, reduced mobility and long-term disability are all too frequent. Additionally, fractures related to osteoporosis result in early death. About 43,000 deaths occur each year in Europe as a direct consequence of hip or spine fractures. The primary purpose of the scorecard for osteoporosis in Europe is to help individuals reduce their risk of osteoporosis and to ensure that all Europeans have access to the best diagnosis and treatment. Components that are critical to achieving this goal include government policy, access to assessment of risk and access to medications. This scorecard allows Europeans to measure how well their country is able to access these elements through the publicly funded healthcare systems. It also provides a benchmark to measure future progress. Our research reveals that facilities and access to testing for osteoporosis are far from adequate. Access to drug treatment that can help prevent fractures varies markedly from country to country; in some member states, individuals with osteoporosis are restricted from accessing effective treatment options. Less than half of women at high risk of fracture are treated despite the high cost of fractures and the availability of affordable medications. Action is required. The national osteoporosis societies of the International Osteoporosis Foundation are calling for a Europe-wide strategy and parallel national strategies to provide coordinated osteoporosis care and to reduce debilitating fractures and their impact on individual lives and the healthcare system. We welcome the opportunity to partner with governments at the national and European level to develop and implement these strategies. Together we can improve the bone health of all in Europe. The basis for SCOPE SCOPE comprises an independent panel of experts that have considered the information available on the burden of osteoporosis and healthcare provision and uptake in the EU27. SCOPE draws on independent research from two major sources. The first was a series of regional audits of the International Osteoporosis Foundation (IOF) [13]. This information base was broadened and updated by IOF to inform the SCOPE panel members through its outreach to over 30 national osteoporosis societies throughout Europe. The second major resource was a comprehensive report undertaken by the IOF and the Europian Federation of Pharmaceutical Industry Associations (EFPIA) on the burden of osteoporosis in the largest countries of the EU [4]. This was subsequently extended to all counties of the EU [5, 6] and made available to the panel. From the information available, the panel developed indicators of osteoporosis that could be applied to each member state, categorised as: Burden of diseaseincluding the burden of osteoporosis, fractures and forecasts for the future Policy frameworksuch as the availability of public health programmes Service provisionincluding assessment and treatments of osteoporosis Service uptakee.g. the proportion of men and women at high risk that do not receive treatment (treatment gap). Comparisons of indicators across countries are often limited by a lack of consistency of information retrieved across countries. One of the strengths of the resource documents considered by the panel is the consistency of the approach in documenting the burden of disease, wherever possible, by the use of country-specific information. The Scorecard Panel and the IOF invested substantial efforts to ensure that the European audits were updated by means of a structured questionnaire that was sent to all IOF national societies and key opinion leaders in each country. Discrepancies and ambiguities were resolved by correspondence. The panel recognised that consistency does not necessarily equal accuracy and, where information across countries is based only on opinion, this has been highlighted. The questionnaire is available on the web site of the IOF (http://www.iofbonehealth.org/). For each domain, a synthesis was summarised and tabular information provided for each member state which appears in the body of the report. For key indicators, termed scorecard elements, the information was scored and the basis for the score allocation provided. For example, the remaining lifetime risk of a hip fracture at the age of 50 years ranged from 7.0 to 25.1 % in women from the different countries of the EU. Counties were categorised by tertile of risk. High risk countries were colour coded red, intermediate risk coded orange and low-risk countries coded green. A similar traffic light approach was applied to each element in each domain. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. It will enable healthcare professionals and policy makers to assess their countrys general approach to the disease and provide indicators to inform future provision of healthcare. Some caveats are appropriate in the interpretation of scores. Green is not necessarily good and red is not necessarily bad. An example of the former is the uptake of fracture liaison services. Whereas counties coded green have up to 10 % of hospitals with such a service, the panel would consider that 50 % or more hospitals would be an appropriate target. Coding all countries red would, however, not permit the comparative performance of one country against another. Other examples are highlighted in the text. Osteoporosis is characterized by reduced bone mass and disruption of bone architecture, resulting in increased bone fragility and increased fracture risk [7]. The publication of a World Health Organization (WHO) report on the assessment of fracture risk and its application to screening for postmenopausal osteoporosis in 1994 provided diagnostic criteria for osteoporosis based on the measurement of bone mineral density (BMD) and recognised osteoporosis as an established and well-defined disease that affected more than 75 million people in the United States, Europe and Japan [8]. The diagnostic criterion for osteoporosis is based on the measurement of BMD [9]. Bone mineral density is most often described as a T score that describes the number of SDs by which the BMD in an individual differs from the mean value expected in young healthy women. The operational definition of is defined as a value for BMD 2.5 SD or more below the young female adult mean (T score less than or equal to 2.5 SD). BMD at the femoral neck is the international reference standard [10]. The consequences of low BMD reside in the fractures that arise. The relationship between BMD and fracture is continuous in that the lower the BMD, the higher the fracture risk [11]. Osteoporotic fractures The most common fractures associated with osteoporosis are those at the hip, spine, forearm and humerus but many other fractures after the age of 50 years are associated with low BMD and should be regarded as osteoporotic [12]. These include fractures of the ribs, tibia, pelvis and other femoral fractures. The causation of fractures is not solely dependent on BMD but is multifactorial. Many factors such as liability to falling, age etc. contribute to the risk of fracture. Thus, not all fragility fractures occur in individuals with a BMD T score of 2.5 SD, and the terms osteoporosis, fragility fracture and osteoporotic fractures have inherent ambiguities. For the purpose of this report, the term osteoporosis is used in a generic sense rather than a specific sense unless otherwise specified. For example the cost of osteoporosis refers to the cost of fractures at sites associated with osteoporosis irrespective of the T score. The incidence of fragility fractures increases markedly with age, though the rate of rise with age differs for different fracture outcomes. For this reason, the proportion of fractures at any site also varies with age. For example, forearm fractures account for a greater proportion at younger ages than in the elderly. Conversely, hip fractures are rare at the age of 50 years but become the predominant osteoporosis fracture from the age of 75 years. In women, the median age for distal forearm fractures is around 65 years and for hip fracture, 80 years. Thus, both the number of fractures and the type of fracture are critically dependent on the age of the populations at risk. Hip fracture is the most serious osteoporotic fracture. Hip fracture is painful and nearly always necessitates hospitalisation and surgical intervention. Up to 20 % of patients die in the first year following hip fracture, mostly as a result of serious underlying medical conditions [13], and less than half of survivors regain the level of function that they had prior to the hip fracture [14]. Thus, not all deaths associated with hip fracture are due to the hip fracture event and it is estimated that approximately 30 % of deaths are causally related. When this is taken into account, hip fracture causes more deaths than road traffic accidents in Sweden and about the same number as those caused by breast cancer [15]. Chapter 1. Burden of disease 1a Economic framework Domain Burden of diseasebackground information Background and aims Cost of illness studies provide no direct guidance on how resources should be allocated, but may provide relevant information concerning the consequences of a disease that may inform policy. Such data may aid decisions concerning societal resource allocation for research, development, and funding of new treatments. Results from cost-of-illness studies can also be utilised to assess the long-term consequences and value of medical progress. The objective of this background section is to estimate the current cost of osteoporotic fracture in the countries of the European Union set against the wealth of the nation and the healthcare spend of that wealth. A more detailed consideration of the cost is given in Chapter 1b. Direct costs of fractures in men and women from the EU27 aged 50 years or more were expressed as a proportion of total health care spending in the respective Table 1 Cost of osteoporotic fractures in relation to the population and health care spending (2010) Health care spending (000,000) Health care spending (/capita) Fracture cost (% health care spending) Fig. 1 Proportion (%) of the total direct healthcare spend in the EU27 countries allocated to osteoporotic fractures [3] country [1] and as the cost per capita of the general population [2, 3]. Health care spending varied markedly between countries, ranging from 500 million in Malta to 281 billion in Germany (Table 1). The total spend on healthcare in the European Union amounted to 1,260 billion, with the cost of osteoporotic fractures representing approximately 3 % of the healthcare spend (37.4 billion in 2010). This clearly demonstrates a substantial impact on the present healthcare budget The share of health care spending allocated to osteoporosis varied across countries, ranging from 0.7 % in Luxembourg to 5.2 % in Cyprus (Fig. 1). As might be expected there was a significant but modest relationship between the amount spent on osteoporosis, GDP and the incidence of osteoporotic fractures. The estimated cost of osteoporosis may be compared to the cost of other diseases. However, given that the EU27 is a relatively new construct, few directly comparable studies exist. Furthermore, methodological differences render some studies difficult to compare. However, a few studies are available conducted in a similar geographic area with comparable methodology. In a report issued by the European Brain Council, the yearly societal costs for a number of brain disorders in the EU27 were estimated at 105 billion for dementia, 43.5 billion for headache, 14.6 billion for multiple sclerosis, and 13.9 billion for Parkinsons disease [4]. The cost of coronary heart disease and cerebrovascular disease in the European Union (25 countries) has been estimated at approximately 45 billion and 34 billion, respectively, at 2003 prices [4]. The cost of epilepsy in the European Union (25 countries) has been estimated at 15.5 billion at 2004 prices. Healthcare costs comprised 18 % of costs, whereas direct medical costs and productivity losses represented 27 % and 55 %, respectively [5]. Thus, in relation to other common non-communicable diseases osteoporosis has major economic consequences for society. Score allocation Nonenot a score card element It should be noted that not all fracture-related costs come from the countries healthcare budgets (e.g. long-term care and variable reimbursement policies). Data on healthcare spending are for 2006. 1b Healthcare cost of osteoporotic fractures Burden of diseasebackground information Background and aims Cost of illness studies can take on a societal perspective (includes all cost carried directly or indirectly by society) or a payer perspective (usually includes all costs carried by the healthcare and social system). Both play an important role in the understanding of disease implications and may aid decisions concerning societal resource allocation for research, development, and funding of new treatments. Results from cost of illness studies can also be utilised to assess the value of medical progress. The main objective of this section is to provide detail on the current cost of osteoporotic fractures in the countries of the European Union. The cost of osteoporotic fractures was first determined without intangible costs (i.e. the monetary value of QALYs lost due to death and disability) [1]. Costs of fracture-related productivity losses were not included because they are only incurred in patients below retirement agemedian age 60 years in Europe [2]and are less than 1 % of hip fracture cost in Sweden [3]. Empirical but incomplete cost estimates were available for Austria, Belgium, Czech Republic, Denmark, Finland, Germany, Ireland, Italy, Netherlands, Portugal Slovenia, Sweden and the UK. For countries where fracture costs Table 2 Cost of osteoporosis in the EU27 in 2010 ( million, 2010) [1] were not found, the costs were imputed from the nearest country available by adjusting for differences in healthcare price levels between the relevant countries. Costs were divided into the direct cost of fractures in 2010, the ongoing cost in 2010 of fractures occurring before 2010 (long-term disability), and the cost of intervention for osteoporosis. It was conservatively assumed that fractures other than those at the hip did not incur any longer-term costs after the first year. Hip fracture costs in the second and following years after the event were based on the proportion of patients that become dependent in the long-term. The health burden of osteoporosis was additionally measured in terms QALYs lost. The QALY is a multidimensional outcome measure that incorporates both the quality (health related) and quantity (length) of life. The value of a QALY was set at value of 2 GDP per capita [4]. The direct cost of osteoporosis in the EU27 from the fractures that occurred in 2010 was 24.6 billion (Table 2). Cost per capita () QALYs lost (m) 30 29 1 12 53 37 1 10 346 336 91 40 35 361 2 3 2 2 29 76 20 7 11 7 414 29 103 2,087 To this is added the ongoing cost in 2010 incurred by fractures that occurred before 2010 which amounted to 10.7 billion (long-term disability). The cost of pharmacological intervention (assessment and treatment) was 2.1 billion. Thus, the total direct cost in the EU27 (excluding the value of QALYs lost) amounted to 37.4 billion in 2010. First year, subsequent year, and pharmacological costs accounted for 66, 29 and 5 % of the costs respectively. Whilst the proportion of costs for pharmacological intervention to total costs was low on average, some intercountry variation was observed: the lowest proportion of costs attributable to intervention was observed in Sweden (2 %) and the highest costs in Hungary (4.7 %). Hip fractures were estimated to account for 54 % of the total costs, other fractures 39 %, vertebral fractures 5 %, and forearm fractures 2 %. On average, the direct cost of osteoporotic fractures was 75 for each individual in the EU27. There was a large variation in the osteoporosis tax (cost per capita) which was highest in Denmark (188/person) and Sweden (159) and lowest in Bulgaria (6) and Romania (6). The heterogeneity of this cost is in part related to the incidence of fracture (r = 0.67, p = 0.001) and the healthcare spend per capita (r = 0.63, p = 0.004). The cost of QALYs lost in the EU27 was substantial amounting to 57.2 billion, giving a total cost of 94.6 billion in 2010. Intervention costs amounted to 2 % of the total cost (Fig. 2) and 5 % of the direct costs. Score allocation Nonenot a score card element There are few directly comparable studies in other noncommunicable diseases that exist. For coronary heart disease, healthcare costs, productivity losses, and informal care comprised 51, 34 and 15 %, respectively. Costs for pharmacological treatment accounted for 12 % of the total cost, substantially higher Fig. 2 Components (%) of the cost of osteoporosis and fractures [1] than that for osteoporosis. For cerebrovascular disease, healthcare costs, productivity losses, and informal care comprised 61, 18 and 21 %, respectively. The cost for pharmacological treatment accounted for 3 % of the total cost for cerebrovascular disease [5], somewhat lower than that for osteoporosis. 1c Men and women with osteoporosis Domain Burden of diseasebackground information Background and aims Osteoporosis is diagnosed using dual-energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD). The diagnostic reference site is the femoral neck using the NHANES III reference data [1]. Osteoporosis is diagnosed when the BMD measured at the femoral neck is more than 2.5 standard deviations below the average value of the young white female population [2]. The aim of this background information was to document the burden of osteoporosis as judged by densitometric criteria. Accurate estimates of the prevalence of osteoporosis require country-specific data on the distribution of femoral neck BMD. However, large population-based reference data are lacking in the EU27 countries. For the purposes of this report, it is assumed that the mean femoral neck BMD is similar across EU countries at the age of 50 years as is the rate of bone loss at the femoral neck with age. The same assumptions have been used elsewhere [38]. On this basis, the prevalence of osteoporosis was calculated from the ageand sex-specific BMD in the NHANES III study. These prevalence estimates were then applied to the population demography in each EU country [9]. Overall, the prevalence of osteoporosis was 6.6 and 22.1 % in men and women aged 50 years or more (Table 3). In men over the age of 50 years, the prevalence of osteoporosis varied from 5.9 (Poland) to 7.2 % (Luxembourg). In women, the prevalence ranged from 19.1 (Cyprus) to 23.5 % (France). The prevalence of osteoporosis in the entire EU27 population (i.e. all ages) was 5.5 % and ranged from 3.7 % in Cyprus and Ireland to 6.3 % in Italy (Fig. 3). In 2010, there were approximately 27.6 million men and women with osteoporosis in the EU27, of which 5,500,000 were men and 22,100,000 were women, i.e. there were four times as many women with osteoporosis as there were men. Of all member states, Germany was estimated to have the highest number of individuals with osteoporosis with approximately 1 million osteoporotic men and 4 million osteoporotic women. Score allocation Nonenot a score card element Although BMD is a strong predictor of fracture risk [10, 11], the prevalence of osteoporosis is not used as a score Table 3 Estimated number of men and women with osteoporosis, prevalence in population over 50 years, and prevalence in the total population, 2010 [9] Men with osteoporosis Women with osteoporosis Men and women with osteoporosis Prevalence in male population aged 50 or more (%) Prevalence in female population aged 50 or more (%) Prevalence in total population (%) Fig. 3 Components (%) of the cost of osteoporosis and fractures [1] card element because the relationship of osteoporosis to fracture risk varies by age and between countries [12]. For this reason, fracture risk is the preferred metric. 1d Epidemiology of hip fracture Background and aims Fracture incidence is poorly documented in the EU. The fracture incidence that has been best evaluated is hip fracture. Hip fractures account for the majority of health care expenditure, mortality and morbidity and can be used as a proxy for osteoporosis. There is a marked difference in the incidence of hip fracture worldwide and probably in other osteoporotic fractures [1]. Indeed, the difference in incidence between countries within Europe is greater than the differences in incidence between sexes within a country [2, 3]. The EU comprises countries with some of the highest hip fracture rates, but the documentation of the size of the problem and the quality of data vary between countries. The aim of this scorecard element was to summarise the information base available for the incidence of hip fracture. Studies on hip fracture risk were identified from 1950 to November 2011 by a Medline OVID search. Evaluable studies in each country were reviewed for quality and representativeness and a study (studies) chosen to represent that country. Age-specific incidence rates were age-standardised to the world population in 2010 in men and in women [1]. National data on hip fracture rates were identified in 17 member states (Table 4). No data were available for four countries (Bulgaria, Cyprus, Latvia, and Luxembourg). In the remaining six countries, regional estimates were identified. For Estonia and Slovenia data were available in women only. As expected, hip fracture rates were higher in women than in men with a female/male ratio that ranged from 1.4 Table 4 Information available on age-standardised (2010) hip fracture rates (/100,000/year) in countries of the European Union [1] (Romania) to 2.7 (Portugal). There was a nearly three-fold range of hip fracture rates throughout the EU from 198/100,000 (Romania) to 574/100,000 (Denmark). Thus, the international variation between countries was greater than the differences between men and women within countries. Table 5 Criteria for allocating scores Fig. 4 Annual incidence of hip fracture in women from countries of the EU age-standardised to the world population for 2010 [1] Score criteria The age-standardised incidence was ranked. Women were chosen since fracture rates are more robust and it permitted the inclusion of Estonia and Slovenia for which no data were available in men. The criteria for categorisation were chosen as described in Table 5. Score allocation The ranked incidence is shown in Fig. 4 and colour coded by category. On an international scale, all countries were at moderate or high risk (150250/100,000 and >250/100,000, respectively) [1]. Reasons for the large variation in fracture risk between countries are speculative, but, ecological studies have shown a weak but significant relationship between hip fracture risk and latitude and socio-economic prosperity [4]. 1e Number of fragility fractures Background and aims The most obvious and serious effect of osteoporosis is the fractures that occur as a consequence of increased bone fragility. This section determines the number of fractures associated with bone fragility in the EU27. The fractures of interest include those at the hip, spine and forearm as well as osteoporotic fractures at other vulnerable sites (humerus, ribs, tibia, pelvis and other femoral fractures) grouped as other fractures. Information on the incidence of osteoporotic fractures varies between the countries of the EU27. In general, reports on hip fracture incidence are more complete than for fractures at other sites (see Chapter 1d). The risk of hip fracture was taken from a systematic review of hip fracture incidence [1]. For the EU27 countries with incomplete information, incidence was taken from the nearest country where hip fracture incidence was available [2]. Where the incidence of fractures other than the hip was not available, the incidence was imputed from the hip fracture incidence in the relevant country, using the relationship between hip fracture incidence and incidence of fracture in other sites in Sweden [3]. The number of fractures in each country for each fracture site was computed from the age- and sex-specific estimates of incidence and population demography for 2010 [4]. Crude incidence in each country was expressed as the number of fragility fractures per 1000 of the population aged 50 years or more. There were estimated to be 3.5 million new fragility fractures in the EU in 2010equivalent to 9,556 fractures/day (or Table 6 Estimated number of incident fractures in the EU27 by site, 2010 [2] 390/h) (Table 6). Almost twice as many fractures occurred in women compared to men. Hip, vertebral, forearm and other fractures accounted for 18, 15, 16 and 51 % of all fractures, respectively. The number of incident fractures per country is shown in Table 7. Germany had the highest number of fractures for Table 7 The number of new fragility fractures in 2010 in men and women by country, the population at risk (men and women aged 50 years or more) and the crude incidence (/1000 of the population) [2] New fractures Population at risk (000) Fig. 5 The number of deaths associated with fracture events expressed per 100,000 of the population added 50 years or more in the EU27 [2] all fracture types in both men and womenapproximately 724 000 incident fractures in totalpredominately reflecting a large population size and comparatively high fracture incidence. Malta and Luxembourg had the lowest number of fractures for all types(less than 3 000 incident fractures in each country), reflecting small population sizes. When fracture numbers were expressed as a rate of the population at risk, there was a greater than two-fold range in risk that varied from 12.6/1000 in Poland to 33.1/1000 in Denmark. In addition to pain and disability, some osteoporotic fractures are associated with premature mortality. About 30 % of deaths after a hip or clinical spine fracture can be attributed to the fracture event [57]. In the EU, there were estimated to be 43,000 deaths causally related to in 2010. Approximately 50 % of fracture-related deaths in women were due to hip fractures, 28 % to clinical vertebral and 22 % to other fractures. Corresponding proportions for men were 47, 39 and 14 %, respectively. Fracture-related deaths by country are shown in Fig. 5. Note that the variability in death rates is more a reflection of the variable incidence of fractures rather than in standards of care. Score criteria The number of fragility fractures in men and women combined in 2010 expressed/1,000 of the population aged Table 8 Criteria for allocating scores Fig. 6 The annual number of fragility fractures in men and women combined expressed/1,000 of the population aged 50 years or more 50 years or more was categorised approximately by tertiles as given in Table 8. Score allocation Countries, ranked and categorised by risk, are shown in Fig. 6. The variation between countries reflects both the fracture risk and the distribution of age and sex in each country. The calculation of fracture numbers from hip fracture rates assumes that the ratios between age- and sexspecific incidence of hip fracture and fractures of other sites found in Sweden are similar in other countries. This assumption has been shown to hold true for the countries where this has been tested [3, 8]. These estimates do not include individuals who in 2010 were suffering the consequences of fractures sustained in previous years. There are important data gaps in the documentation of the fracture burden between member states which form the component of a further scorecard element (Chapter 2a). 1f Lifetime hip fracture probability Burden of diseasescorecard element Background and aims The most serious consequence of osteoporosis in terms of morbidity, mortality and health care expenditure is hip fracture. In the EU, for example, hip fractures comprise only 17 % of the total number of fragility fractures but account for 54 % of the direct costs and 49 % of deaths due to fracture [1]. The likelihood of hip fracture can be expressed as fracture probability from a given age over a given time interval (e.g. 10 years). The aim of this element is to provide estimates of the remaining lifetime probability of hip fracture in men and women at the age of 50 and 70 years. Hip fracture probability was computed taking both the risk of fracture and the risk of death into account [2]. The risk of hip fracture was taken from a systematic review of hip fracture incidence [3]. Where possible, the incidence of hip fracture was determined in men and women using 5-year age categories. Where 5-year age intervals were not available, 10 year intervals were used (intervals of greater than 10 years were an exclusion criterion). Mortality statistics of the WHO were used in 5 or 10 year age denotes no data intervals for the year 2010 [4]. The remaining lifetime probabilities were calculated in men and women from the age of 50 and 70 years. Empirical data on hip fracture rates were available for 21 of the 27 EU member states in men and women. No data were available for men from Estonia and Slovenia. Hip fracture incidence is not documented in Bulgaria, Cyprus, Latvia or Luxembourg. The average remaining lifetime probability of hip fracture in women at the age of 50 years ranged from 7.0 % (Romania) to 25.1 % (Sweden). Thus, there was approximately a three-fold range of lifetime probabilities between countries (Table 9). Table 9 Remaining lifetime probability of hip fracture (%) at the ages of 50 and 70 years in men and women by country, 2010 [3] Lifetime probability (%) At age 50 years At age 70 years Fig. 7 Remaining lifetime probability of hip fracture (%) in men and women from 21 countries in the EU from the age of 50 years [1] Probabilities of hip fracture were approximately two-fold lower in men than in women. In men, hip fracture probability at the age of 50 years ranged from 3.8 % (Romania) to 10.9 % (Sweden). There was a close correlation between hip fracture probability in men and women so that in those countries where fracture probability was high in women, so too was it high in men (Fig. 7). In Sweden, which had the highest hip fracture probabilities, the hip fracture risk in men (10.9 %) was higher than the hip fracture probability in women from Hungary, Poland or Romania. Score criteria The remaining lifetime probability of hip fracture at the age of 50 years was ranked. Women were chosen since it Table 10 Criteria for allocating scores Fig. 8 Remaining lifetime probability of hip fracture (%) in women in the EU from the age of 50 years [1] permitted the inclusion of Estonia and Slovenia for which no data were available in men. The criteria for categorisation are shown in Table 10. Score allocation The ranked incidence is shown in Fig. 8 and colour coded by category. Hip fracture probabilities from the age of 70 years were not markedly different from those from the age of 50 years. The reason for this is that increasing death and fracture hazards with age compete in the determination of probability. 1g Men and women at high fracture risk Background and aims The advent of FRAX in 2008 [1] provided a clinical tool for the calculation of fracture probability. Probability-based assessment is increasingly being incorporated into clinical guidelines in Europe [2, 3] and elsewhere. Unlike fracture incidence, the probability of fracture at any given age depends upon the hazard of death as well as the hazard of fracture over a defined interval (e.g., 10 years or lifetime). A major advantage of using fracture probability is that it standardises the output from the multiple techniques and sites used for assessment and also permits the presence or absence of risk factors other than BMD to be incorporated as a single metric. FRAX models are also calibrated to country-specific epidemiology. The ability to compute fracture probabilities in individuals permits an estimate of the prevalence of high risk individuals within a given population where the population demography and the distribution of FRAX-based probabilities are known. The aim of this score card element was to present the burden of osteoporosis in men and women in the EU27 countries expressed as the proportion of the population that has a 10 year probability of a major fracture (hip, spine, forearm or humerus) above a given threshold. There is no international standard for defining high risk based on probabilities. In Europe, intervention thresholds are commonly defined as the 10-year probability of a major fracture that equals or exceeds that of a woman with a prior fragility fracture [2, 3], termed the probability fracture threshold. In North America threshold risks have been set at probabilities of 10 and 20 % [4, 5] and these were used for this assessment. The majority of EU member states have a country-specific FRAX model. Where unavailable, a surrogate model was used. The distribution of FRAX probabilities in men and women was simulated in 5-year age intervals for each member state between the ages of 50 to 89 years [6] and applied to the demography of each country for 2010 [7]. Burden of disease was expressed as the number of men and women with a probability of major fracture above a threshold of 10 or 20 %. For comparative purposes, the burden was expressed as the proportion of the population aged 50 89 years with probabilities above these thresholds. Approximately 12.9 million men and women in the EU27 have a 10-year fracture probability that is 20 % or more. When a 10 % threshold is used the population at high risk rises to 41.3 million, representing respectively 3 and 8 % of the total EU population for 2010. The proportion of the population aged 50 years or more that in 2010 had a fracture probability of 20 % or more varied among member EU states, ranging from 2 % in Romania to 17 % in Sweden (Table 11). The proportion of Table 11 Number of men and women (000) and proportion of the population aged 5089 years (%) with a 10-year probability of a major fracture that exceeds 10 %, 20 % or the fracture threshold for women Number of men and women (000) Proportion of population aged 5089 years (%) >20 % >10 % >Fracture >20 % >10 % >Fracture threshold threshold 14 9 2 6 8 19 5 5 8 7 8 7 9 9 5 5 8 7 4 3 5 2 8 6 4 17 9 Fig. 9 Proportion of men and women (%) aged 5089 years with a 10-year probability of a major fracture that is 10 % or more and 20 % or more by member state the population aged 50 years or more that had a fracture probability of 10 % or more ranged from 12 % in Romania to 42 % in Sweden (Table 11). Figure 9 shows the rank order of population burden. For completion, the table also shows the number of men and women that lie above a fracture threshold commonly used in assessment guidelines. This is considered later in relationship to the uptake of treatments in the EU27 (Chapter 4c). Score criteria Countries were ranked by tertiles of prevalence of the population aged 5089 years above a 10 % probability threshold of a major osteoporotic fracture as given in Table 12. Score allocation The proportion of the population (%) aged 5089 years with a 10-year probability of a major fracture that is 10 % or more by member state is shown by category and rank in Fig. 10. Table 12 Criteria for allocating scores Fig. 10 The proportion of the population (%) aged 5089 years with a 10year probability of a major fracture that is 10 % or more by member state The majority of EU member states have a country-specific FRAX model. For those countries where a country-specific FRAX model was unavailable, a surrogate model was used, based on the estimate that the epidemiology of hip fracture was similar. For Bulgaria, the Romanian model was used; for Cyprus, the Maltese model was used; for Estonia and Latvia, the Lithuanian model was used; for Luxembourg, the Belgian model was used; and for Slovenia, the Hungarian model was used. 1h Population projections Domain Burden of diseasebackground information Background and aims Secular changes in life expectancy and birth rate are likely to increase the number of elderly individuals in the EU member states and thereby increase the need for resource allocation for diseases associated with ageing. The incidence of fragility fractures increases markedly with age, particularly in women. The aim of this background element is to estimate the increase in number of women aged 50 years or more in the EU member states. The age and sex distribution of the EU member states was obtained from the UN for 2010 and 2025 using the medium variant [1]. The population of women over 50 years is expected to increase by 22 % and in men by 17 % in the EU between 2010 and 2025. The number of men and women aged 50 years or more will increase in all countries except Bulgaria, Hungary and Latvia (Table 13). In the remaining countries, the increment in the population varies widely. With some exceptions, the percentage increase in number of men and women aged 75 or more years is greater than that of the population aged 5074 years. The exceptions include Belgium (women), Bulgaria (men), Greece (men), Lithuania (men), Luxembourg (women), Romania (men) and Spain (men and women). For women over the age of 75 years, the change in the population ranged from less than 10 % in Latvia (7 %) and Lithuania (9 %) to more than 40 % in Cyprus, Denmark, Finland, Ireland, Malta and the Netherlands (Fig. 11). 5074 years 75+years 5074 years 75+years Fig. 11 Projected increase by country in the female population aged 75 years or more (%) between 2010 and 2025 [1] 1i Fracture projections Background and aims As noted, the number of men and women aged 50 years or more is set to increase with time in the EU. The increase will be particularly marked in the elderly population. Since age is an important risk factor for fractures and the elderly population is projected to increase in the majority of member countries, the burden of fractures is also likely to increase. Table 14 Number of fractures in men and women in 2010 and number expected in 2025, and the percentage increase [2] Fig. 12 The relation between the percentage increase in the male and female population aged 75 years or more in EU member states. The diagonal shows the line of identity The increase in the male population aged over 75 years was generally more marked than in women. In men, the EU population aged 75 years or more is expected to increase by 33 %. In those countries with large expected changes in the proportion of the population aged 75 years or more, the increment is larger in men than in women (Fig. 12) since life expectancy, lower in men, is improving more rapidly in men than in women with time. Score criteria Nonenot a score card element UN population projections over 15 years are relatively robust in that all men and women in 2025 aged 50 years or more had already attained adulthood in 2010. The projections expressed in relative change for countries with very small populations are uncertain (e.g. Malta, Cyprus) since population numbers are given by the UN rounded to the nearest 1000. 66,066 86,094 20,028 8,678 10,208 1,530 36,292 48,939 12,647 378,082 493,031 114,949 732,137 936,461 204,324 84,256 105,284 21,028 90,011 101,544 11,533 17,947 27,372 9,425 466,475 599,034 132,559 14,284 16,204 1,920 15,084 17,484 2,400 2,684 4,015 1,331 2,618 3,744 1,125 76,691 107,671 30,980 167,033 208,591 41,558 51,329 68,448 17,119 94,240 110,099 15,858 38,363 49,508 11,145 15,471 21,795 6,323 203,794 285,453 81,659 106,857 135,029 28,172 535,724 681,956 146,231 3,487,914 4,477,152 989,238 2 0 1 12 21 2 1 1 13 0 0 0 0 3 4 2 2 1 1 8 3 15 100 Fig. 25 Score allocation based on the scope and quality of guidelines available for the assessment and treatment of osteoporosis. For the UK (star), the score for guidance provided by NICE is 8 and hat provided by the National Osteoporosis Guidelines Group has a score of 10 [IOF audit] Data were acquired by an IOF questionnaire to the EU Osteoporosis Consultation Panel undertaken in December 2012. Respondents were asked whether national guidelines were available for the assessment and/or treatment of osteoporosis. Responses were used to update an earlier audit of the IOF [1, 2]. Where guidelines were available, additional information was requested on their scope and quality. Scope of guideline: Does it relate to postmenopausal women (PMW), men or glucocorticoid-induced osteoporosis (GIOP). AGREE criteria: The quality of guidelines was judged according to the criteria developed the Appraisal of guidelines for research & evaluation (AGREE) next steps consortium [3] under 7 general domains (see footnote1). 1 AGREE criteria Systematic search. How thorough was the evidence base? Were the guidelines based on a systematic literature review conducted at the time of the guideline development (or on a previously conducted review that was updated). Recommendations: Were recommendations graded (e.g. A, B, C) according to the levels of evidence provided by the systematic review? Stakeholder involvement: Was there involvement from patient organisations, primary care physicians, national/EU societies in the consultation process for the guidelines? External review: Were the guidelines reviewed by independent experts? i.e. have they undergone a rigorous external review in addition to consultation. Procedure for update: Were the guidelines updated as and when necessary or was there explicit mention of a provision to update the guidelines in the future? Economic analysis: Were the recommendations underpinned by an economic analysis? Editorial independence: Did the guidelines explicitly state that there was editorial independence of the writing group from any funding body? Guidelines for the management of osteoporosis were available in the majority of member states (unavailable in Cyprus and Malta). All of the remaining counties had guidelines available for postmenopausal women (Table 35). 17 of 25 countries had guidelines for osteoporosis in men and 19 had guidelines for glucocorticoid-induced osteoporosis. The availability of guidelines does not necessarily improve disease management and in some countries (e.g. Italy, Spain and UK) multiple guidelines were available from different sources that are likely to confuse rather than clarify clinical practice. Score criteria A positive response in each AGREE category contributed a point to the score (maximum 7 points). Up to 3 additional points was given for the scope of the guideline (PMW, men, GIOP) to give a maximum score of 10. Where more than one guideline was available, a composite mean was used. Scores for each country were categorised as shown in Table 36. Score allocation The score allocation and grade for each country is shown in Fig. 25. There was a large variation in the extent and quality of national guidelines according to the AGREE criteria. It should be noted that a high score reflects the quality of the process, but not necessarily the quality of the content. 3f Guideline criteria for assessment and treatment Domain Service provisionsupplementary information Background and aims The aim of this section was to summarise the differences in the application of guidelines to clinical practice and, in particular, to identify where guideline recommendations conflicted with reimbursement policy. A review was undertaken of guidelines covering the assessment and treatment of osteoporosis in each EU member state that was available in English or French. Additionally, data were acquired from a structured IOF questionnaire administered to the EU Osteoporosis Consultation Panel undertaken in December 2012. Information requested included whether guidelines addressed population-based screening, the tools used for assessment, and the tools to decide eligibility for treatment. An enquiry was also made whether risk assessment or treatment recommendations were compatible with reimbursement policy. Guidelines were not available in Cyprus or Malta. In the remaining countries, guidelines were generally less than 5 years old, often related to updating, with one exception (Slovenia, 2002). Population screening was considered in guidelines from 15 of 25 countries. Although reviewed, population based screening was not recommended. In Hungary, however BMD is offered free of charge to women aged 50 years or more, though the uptake is low. Guidelines in 24 of the 25 countries covered the assessment of fracture risk (the exception was the Czech Republic). The most common tools used for fracture risk assessment were age in 22/25 countries (exceptions were Lithuania, Slovakia and Sweden) and bone mineral density (in all countries). The use of fracture risk assessment algorithms was less consistent and noted in 17 countries (Fig. 26). FRAX was the most widely used instrument though in Germany the DVO tool was recommended [1]. In the UK, both FRAX and QFracture has been approved [2]. Guidelines in all 25 countries covered eligibility for treatment with a general commonality of approach. Eligibility for treatment depended on prior fracture (except Denmark and Sweden), age (except Lithuania, Slovakia and Sweden) and BMD (all countries). As was the case for assessment (see Chapter 3d), risk assessment tools provided criteria for intervention in fewer (17/25) countries (Fig. 26). In Italy, Spain and the UK, there are several guidelines from different sources that give different recommendations. Several counties reported incompatibilities between recommendations for risk assessment or treatment with reimbursement policy (Table 37). For example, guidelines Fig. 26 The distribution of the use of risk assessment models in assessment guidelines of the EU27 countries [IOF audit] recommended the use of FRAX which was not provided for in reimbursement provision (Belgium, Poland, Romania and Slovakia), specific treatments were recommended but not reimbursed (Poland, Romania) and central DXA was recommended for risk assessment but other techniques (peripheral BMD and QCT) were reimbursed (Lithuania). In Luxembourg, the BMD thresholds for treatment differ from the criteria for reimbursement for DXA. In other instances, guidelines recommended the use of risk factors such as a prior fragility fractures but reimbursement was solely dependent on BMD (Lithuania, Romania). With regard to treatment, reimbursement was limited in time (18 months) but treatment recommended on a long-term basis (Lithuania). A problem inconsistently related to reimbursement was that multiple guidelines gave conflicting recommendations (Italy, Spain, and the UK). Another barrier to treatment is that reimbursement was only granted where the prescription was issued by a specialist (e.g. Czech Republic). Table 37 Scope of guidelines for patient assessment, treatment and consistency with reimbursement policy [IOF audit] Assessment Compatible/ Treatment Compatible/ consistent consistent na not applicable, nr not recorded Score allocation Supplementary information, no score allocation Risk assessment or treatment recommendations were compatible with reimbursement policy in approximately half of the EU member states. 3g Fracture liaison services Service provisionscorecard element Background and aims Fracture liaison services (FLS), also known as osteoporosis co-ordinator programmes and care manager programs, provide a system for the routine assessment and management of postmenopausal women and older men who have sustained a low trauma fracture [14]. Assessment includes DXA measurements, fall risk evaluation, and underlying secondary causes of osteoporosis. Although the importance of an incident fracture as a risk factor for further fracture is well recognised, the majority of patients presenting with a low trauma fracture do not receive appropriate assessment and treatment in the setting of standard hospital care. FLS address this need through a systematic approach to identifying such individuals and assessing their risk of further fractures and the need for treatment. Most FLS are based in secondary care although models in primary care have also been described. The clinical and costeffectiveness of FLS has been demonstrated in several centres [57]. Fig. 27 The proportion of hospitals (%) with FLS in the EU countries [IOF audit] The aim of this scorecard element was to document the proportion of hospitals that have a fracture liaison service in the EU27 countries. Information was acquired from a structured IOF questionnaire administered to the EU Osteoporosis Consultation Panel undertaken in December 2012. Correspondents were asked to estimate the proportion of hospitals in each member state that have a scheme in place that refers fracture patients over 50 years old to a fracture liaison service. Scoring was based on the distribution of the estimates. No estimates were provided from Malta. Of the remaining countries, no fracture liaison services were reported from Greece, Latvia, Portugal, Romania and Slovakia. The presence of FLS was acknowledged in the remaining member states, but for most countries, the proportion of hospitals that have a scheme in place was less than 10 %. Higher rates were reported from Austria, Cyprus, Czech Republic, Estonia, Finland, Hungary, Netherlands and Sweden (Fig. 27). Table 38 Criteria for allocating scores Fig. 28 Scores allocated by country on the availability of fracture liaison services in hospitals by member state [IOF audit] Score criteria The proportion of hospitals in each member state that had fracture liaison services (FLS) in place were categorised as shown in Table 38. Score allocation Figure 28 shows the scores allocated by country The information provided needs to be interpreted cautiously. It provides a perception of how many hospitals of a country has a fracture nurse working in a fracture liaison service, but is an expert opinion and not based on numerical evidence. Moreover, no account was taken of FLS in primary care. In addition, no information was available on the performance of the FLS. It is also notable that a colour code of green should not be interpreted as an endorsement since provision should, in the view of the panel, be expected in the majority of hospitals or care centres. 3h Use of quality indicators Service provisionscorecard element Background and aims The use of indicators to systematically measure the quality of care provided to people with osteoporosis or associated fractures is a relatively new discipline, with the United States perhaps having the most developed system in place [1], as shown for use of healthcare quality indicators more broadly [2]. In the UK, the Department of Health Best Practice Tariff for hip fracture care has used financial incentives since April 2010 to drive adherence with the six core benchmarks, which include an assessment of bone health and risk of falling. In the 2 years following introduction of the tariff, the proportion of patients with fragility hip fracture for whom all six standards were met rose from 24 to 55 % [3]. The aim of this scorecard element was to document the systematic approaches to enhance the quality of osteoporosis care or secondary prevention of fragility fractures in the EU. Data were acquired by an IOF questionnaire to the EU Osteoporosis Consultation Panel undertaken in December 2012. Respondents were asked whether national systems were in place that systematically collect data on the quality of care provided to people with osteoporosis or the secondary prevention of fragility fractures. Further questions were whether the systems use measures (quality indicators or standards) that are documented on a regular basis (e.g. annually) and use a set of explicit criteria to assess performance. Few countries had systems that include quality measures plus a regular audit for national health care agencies (Denmark, Germany, and UK). In the United Kingdom, osteoporosis/ secondary prevention of fragility fractures has been included in the Quality and Outcomes Framework as part of the general practitioner contract from April 2012 [4]. The Quality and Outcomes Framework is a pay for performance scheme for general practice in the UK, which awards achievement points for adhering to procedural and treatment guidelines and meeting intermediate outcome targets for over 130 quality indicators. In the UK, there is also a system of clinical audits in place, seeking to improve patient care and outcomes through systematic review of care according to explicit criteria and the implementation of change. These include the National Audit of Falls and Bone Health in Older People [5] and the continuous National Hip Table 39 Systems that provide quality indicators in the context of osteoporosis and fractures in the European Union [IOF audit] Systems in place Hip fractures Hip fractures Hip fractures Osteoporosis, fragility fracture, falls Fracture Database [3]. In Germany, selected providers and health insurance funds have, in the framework of integrated care contracts entered into agreements on coordinated osteoporosis care which may include the documentation of care standards to enable tracking of the quality of care provided. The nature and contents of these contracts vary across regions [6]. There is a systematic and nationwide collection of quality indicators for the inpatient care following hip fracture [7]; however a systematic collection of indicators that would permit assessment of care quality of those with osteoporosis and in the secondary prevention of fragility fractures is not in place. Several other counties (Bulgaria, Finland, Greece) have systems that provide quality indicators or standards that are documented on a regular basis (Table 39) but it is unclear whether criteria are developed to assess performance. In Slovakia, quality measures are in place but no provision is made for regular audit. Score criteria Score allocation The score was based on the presence of systems and their use as quality indicators as given in Table 40 Score allocation for quality indicators by country are given in Fig. 29. Given the relative novelty of using QI for the tracking of quality of care provided to people with osteoporosis or associated fractures in the European region, it should be recognised that the score is a Table 40 Criteria for allocating scores Fig. 29 Score allocation for quality indicators by country [IOF audit] proxy measure. Though audited quality measures have been introduced in some countries, the UK is far advanced in this regard. Chapter 4. Service uptake 4a Uptake of DXA Domain Service uptakebackground information Background and aims The ability to assess osteoporosis depends in part on the availability of bone mass measurements at the lumbar spine and hip with dual energy X-ray absorptiometry (DXA). The requirement for the technology will depend on the assessment guidelines in each member state and the policy with respect to the use of DXA to diagnose osteoporosis and monitor treatment. The uptake of this technology depends upon the efficiency with which the technology is used, the ease of patient access (e.g. travelling time), regulatory constraints and barriers to reimbursement. The aim of this element was to compare the access to DXA measured as a function of the requirements recommended in relevant assessment guidelines. Fig. 30 The uptake of BMD testing in men and women by age and sex in Denmark in 2005 [Data kindly provided by Bo Abrahamsen, Gentofte Hospital Copenhagen, Denmark] Ideally, uptake should be measured as the number of scans undertaken in relation to treatment guidelines in each member state. Such data are not available in the EU as a whole. Data are available by age and sex from the National Health Service of Denmark and are reported here [Abrahamsen, 2011]. The Danish National Health Service release claims data for DXA and was available most recently for 2005. The uptake of BMD testing by age and sex for 2005 is shown in Fig. 30. Although the accuracy of the claims to tests is uncertain and tests in the private sector are not captured, the uptake was very low even accounting for these errors. Thus, guidelines based on BMD testing indicate that 173 women/1,000 women aged 50 years or more qualify for BMD testing [2] whereas the corresponding figure for Denmark was 28.6 or 16 % of the desired uptake. The use of probability-based guidelines reduces the number of scans needed to 81/1000 women [2] but is still considerably higher than that attained in Denmark. The uptake in men over the age of 50 years was 4 times lower (7/1000) than in women. In men and women combined the uptake of DXA was 18.5/1000. Score allocation No score allocation More information is required from all member states on the utilisation of DXA with regard to guidelines on the assessment and monitoring of treatment. The available evidence from Denmark, a country moderately provided with DXA machines, is that service uptake is less than optimal. 4b Uptake of risk assessment algorithms Background and aims FRAX is an algorithm that determines fracture probability in individuals by integrating the weight of important clinical risk factors for fracture and mortality risk, with or without information on BMD (see Chapter 1 g). Each tool is country-specific and calibrated to the national epidemiology of fracture. They were developed by the WHO Collaborating Centre for Metabolic Bone Diseases at Sheffield, UK and launched in 2008 [1, 2]. The FRAX tools (www.shef.ac.uk/FRAX) compute the 10-year probability of hip fracture or a major osteoporotic fracture. A major osteoporotic fracture is a clinical spine, hip, forearm and humerus fracture. The use of the tool improves risk assessment compared to the use of BMD alone. FRAX is now a component of many national guidelines for the assessment of osteoporosis (see Chapter 3f) and European guidelines for postmenopausal osteoporosis and glucocorticoid-induced osteoporosis [3, 4]. The aim of this element was to determine the usage of FRAX in the EU27 countries. particularly those without a country-specific FRAX model, may use a surrogate. For example, the UK model was adopted as a surrogate in Poland before the advent of a Polish model and the Greek model is presently used in Cyprus. For this reason, we assessed the number of calculations by the source of the calculation [Google Analytics]. FRAX usage was computed as the number of calculations originating f r o m e a c h c o u n t r y a n d e x p r e s s e d a s calculations/million of the general population over a period of one year (November 2010 to December 2011). The web-based usage of the models is shown in Table 41 which shows considerable heterogeneity in uptake. Belgium, UK, Luxembourg, Sweden and Ireland have the highest usage of FRAX. Lithuania, Latvia, Germany and Bulgaria have the lowest uptake. The average uptake for the EU27 was 880 calculations/million of the general population. Country-specific models are available in 21 member states (see Chapter 3d). FRAX models are not available for Bulgaria, Cyprus, Estonia, Latvia, Luxembourg and Slovenia. There is, however, no clear relationship between the availability of a country-specific model and the use of FRAX. Score criteria Each FRAX model on the web counts the number of calculations performed for that particular country. A problem with these data is that some countries, Table 41 Uptake of FRAX in EU counties expressed as the number of calculations per million of the general population Calculations /million Calculations /million Calculations /million Table 42 Criteria for allocating scores Score allocation Countries, ranked and categorised by score, are shown in Fig. 31. These data underestimate the use of FRAX by approximately 25 % due to the availability of FRAX on bone densitometers. FRAX calculations on densitometers are not performed through the web site. In addition, hand held calculators are used in several countries, particularly in Poland. FRAX is also available as an application on the iPhone. These data underestimate the use of risk assessment in Germany. Fracture risk assessment comprises a component of the German national guidelines, but is not FRAX based. Alternative assessment algorithms are also available in the UK and the Netherlands. The caveats above indicate that the figures are conservative. Even so, there are reasons to believe that FRAX is underutilised. Fig. 31 The uptake of fracture risk assessment tools as judged by the use of FRAX from each EU country by score category. *See comment below with regard to Germany For example, the use of FRAX in Denmark (942 calculations/million per year) is much lower than the number of BMD tests/year (18,500 /million per year; see Chapter 4a). Thus, a colour code of green should not be interpreted as an endorsement of appropriate uptake. 4c Treatment uptake and treatment gap Background and aims Many surveys indicate that a minority of men and women at high fracture risk receive treatment [1, 2]. The aim of this section was to estimate the proportion of women at high risk that receives therapy for osteoporosis in the EU27. The proportion of patients eligible for treatment depends on defining an intervention threshold, i.e. the risk of fracture above which treatment can be recommended. Though treatment guidelines are available in nearly all EU member states [3] (see Chapters 3e and 3f), there is no uniform approach to intervention thresholds across the EU27. The advent of FRAX (www.shef.ac.uk/FRAX) in 2008 provided a clinical tool for the calculation of fracture probability that has been applied to the development of intervention thresholds [4]. For the purposes of this analysis, the intervention threshold set was at the 10-year fracture probability equivalent to women with a prior fragility fracture without knowledge of BMD as adopted in several European guidelines [5 7]. Thus, the intervention threshold can be likened to a fracture threshold expressed in terms of fracture probability. The proportion of women who exceed the fracture threshold was computed by simulation [8] based on the distribution of the risk-score among the cohorts used by WHO to develop FRAX and the epidemiology of fracture and death in each EU country. The number of patients treated in each country was computed from IMS Health sales data for 2010 and expressed as treatment years [3]. The use of hormone replacement treatment was excluded since the majority of women take hormone replacement treatment for menopausal symptoms rather than for osteoporosis. An adjustment factor (estimated from data from the Swedish Prescribed Drug Register) was used to correct for Table 43 Number of women eligible for treatment, treated and treatment gap in 2010 [3] suboptimal adherence. The number of women potentially treated was subtracted from the number of women exceeding the intervention threshold and expressed as a percentage. No sales data were available for Cyprus or Malta and these two countries were therefore excluded from analyses. Table 43 indicates that there is wide inter-country variation in the treatment penetration of women at high risk for osteoporotic fractures. The treatment gap varied from 25 % in Spain to 95 % in Bulgaria. Large treatment gaps were identified in countries with populations at both high and low risk of fracture. In total in the EU, it is estimated that, out of the 18.4 million women that exceed the risk level, 10.6 million are untreated. These figures are conservative since an undetermined proportion of low-risk women will have received treatment (see comments, below). Number potentially Number exceeding fracture Difference (000s) Treatment gap (%) treated (000s) risk threshold (000s) Score criteria Countries were categorised by approximate tertiles as shown in Table 44. Score allocation The score allocation and the treatment gap for each country is shown in Fig. 32. It is unlikely that 100 % of sales are captured in any country but it is difficult to define the magnitude of underestimation. IMS Health attempts to correct for under- and over-estimation, and in the absence of any additional information, there is no further adjustment of the available sales figures. Another difficulty in interpretation may arise from parallel trade. IMS Health adjusts the data for parallel trade in some countries. The countries for which adjustments have been made are Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Italy, the Netherlands, Poland, Spain, Sweden and the UK. The pattern of use within countries cannot be ascertained in this analysis, so that it is not possible to determine whether treatment is targeted appropriately to high risk individuals. There are several indicators that suggest that the targeting of treatment is heterogeneous in the EU27. Good evidence comes from the Global Longitudinal Study of Osteoporosis in Women (GLOW) which is a general practice based observational cohort study in women aged 55 years or more conducted in 10 countries, including several EU countries [1]. In the EU countries, there was heterogeneity of treatment uptake between countries with the lowest proportion of women aged 55 years or more treated in the Netherlands (7 %) and the highest in Spain (23 %) (Fig. 33). Although treatment uptake was higher in women at very high risk (a prior hip or spine fracture), a minority (45 %) were receiving treatment in these countries. Table 44 Criteria for allocating scores Fig. 32 Proportion of women of women at high risk that are untreated (treatment gap) in 2010 ranked by country and score [3] Again, there was heterogeneity in treatment uptake that ranged from 36 % in the Netherlands to 57 % in Italy. Moreover, some low-risk women were targeted in all countries. These data demonstrate that a large number of women at high risk of fractures are not receiving treatment, that a substantial number of women at low risk are prescribed treatment (1322 %) and confirm important differences in the uptake of treatment between countries. Thus, a colour code of green should not be interpreted as an optimum. Fig. 33 Proportion of women receiving treatment in six EU member states according to category of risk. All women refer to women aged 55 years or more (n=24,249). Low risk comprises women aged less than 75 years with a T score for BMD in the range of osteopenia, no prior fracture, no maternal hip fracture or osteoporosis (n=1166). High risk refers to women reported to have a BMD measurement in the range of osteoporosis (n=5258). Very high risk comprises women with a previous hip or spine fracture (n=913) [9] 4d National prescription database Service uptakeBackground information Background and aims IMS Health provides sales data that can be examined by country but give no information on who receives the agent in question or the purpose for which it was given (see Chapter 4c). Such data are not available on an EU-wide basis. However, several EU countries have a National Prescription Database that can provide more detailed information. The National Prescription Databases of Sweden was accessed to determine the number of individuals by age who had received a prescription for a bone-active medication in 2010. Exposure to oestrogens was not included. Treatment days (daily defined doses; DDD) were computed from the prescription refills in 2010 and converted to person-years of exposure to treatment (DYD). Treatment rates were expressed as a proportion of the Swedish population [1]. The numbers of individuals by age who had received boneactive medication and the DYDs are shown in Table 45. Treatment uptake is expressed as the number of individuals who were taking a bone-active medication (i.e. filled a prescription) and the number of person-years of treatment in that year. For example, there were 18,931 men and women aged 8084 years who had been prescribed a treatment in 2010. The total prescription base for that age range was equivalent to 13,888 person-years. Over all ages, 3 % of the Swedish population aged 50 years or more received treatment. Figure 34 shows the uptake of bone-active agents (oestrogens excluded) for 2010. For example, there were 77 prescriptions filled per 1,000 of the population aged 8085 years in 2010. The number of unique patients that received a prescription for that age range was 56 per 1,000 person-years. These figures are low when compared with the population at high risk. For example, the number of patients in this age range that received a treatment was approximately 13,500 representing Table 45 Population size, patients treated and patient-years of treatment by age in Sweden 2010 Patient-years of treatment Fig. 34 The number (rate/thousand) of prescriptions for bone-active medications and the number of patients filling a prescription for boneactive medications in 2010 [National Prescription Databases of Sweden] 5.6 % of the population at this age. In contrast, the number of individuals in this age range with osteoporosis is estimated at 67,800 and those with a fracture probability above a fracture threshold is estimated at 32,000 [2]. Thus, although treatments are targeted by age, the majority of high risk individuals remain untreated. Score allocation Nonesupplementary information Note that the data do not give information on persistence or compliance. Although treatments are targeted by age, the majority of high risk individuals remain untreated. 4e Treatment gap and treatment need Domain Service uptakeBackground information Background and aims Patients who sustain a prior fragility fracture are at great risk of a future fracture. The risk is increased approximately two-fold [1] and is largely independent of BMD [2]. The risk is sufficiently high that many treatment guidelines in the EU recommend that postmenopausal women with a prior fragility fracture should be offered treatment. However, the majority of such patients are untreated so that the prevalence of a prior fracture in the community provides an index of opportunity lost. This may be set against the treatment gap to provide an index of the relationship between service provision and service need. The aim of this element was to provide an index of the prevalence of a prior fracture in the EU member countries in relation to the treatment gap. For the purposes of this report, a prior fracture was defined as a hip or clinical vertebral fracture in an individual who was alive in 2010 that had occurred after the age of 50 years before 2010. The unit was the individual so that multiple fractures at the same site in one individual were only counted as one prior fracture of that site. A microsimulation model, programmed in TreeAge, was used to simulate the prevalence of prior hip and vertebral fractures from incidence data [3]. Note that the prevalence of a hip or clinical vertebral fracture will underestimate the prevalence of previous fragility fracture at other sites. More complete information on prior fractures is available for six member states (France, Germany, Italy, Spain, Sweden and the UK) using a different approach [4] and is also considered. For the treatment gap, the data from Chapter 4c were used [1]. In 2010, approximately 6.7 million men and women in the EU had sustained a prior hip or clinical spine fracture before 2010 (Table 46). As would be expected, the prevalence increased progressively with age. At the age of 95 years or more, the prevalence of a prior hip fracture was 22.5 % and for a prior vertebral fracture was 14.5 % [1]. Overall, 1.8 % of the population at the age of 50 years or more had a prior hip fracture and 1.9 % a prior clinical spine fracture. Table 46 Estimated number and percentage of men and women aged above 50 years with a prior hip or vertebral fracture by country in 2010 [3] Vertebral fracture % Population (A) % Population (B) The ranked prevalences by country are shown in Fig. 35. As would be expected, there was a close relationship between fracture risk (see Chapter 1b) and the proportion of the population with a prior hip or clinical vertebral fracture. Table 47 summarises data for the EU5+Sweden which shows the prevalence of all prior fractures in 2010 in comparator studies. The estimation of prior vertebral + prior hip fracture, shown in Fig. 35, appears to capture approximately 30 % of prior fractures. This suggests that the prevalence of a prior clinical spine or hip fracture is a reasonable surrogate for the service needs of each member state. The relationship between this service need and the treatment gap is shown in Fig. 36 for each of the EU member states and for the EU countries combined. The top right quadrant can be considered to represent countries of high need but poor provision. These included Denmark and Sweden. The other extreme (lower left quadrant) represents countries of lower need Fig. 35 The proportion (%) of the population aged 50 years or more with a prior hip or vertebral fracture in 2010 [3] Table 47 The prevalence (%) of a prior fracture at sites associated with osteoporosis in men and women aged 50 years or more compared with the prevalence of a prior vertebral or hip fracture as given in Table 46. The last column shows the proportion (%) of prior fractures accounted for by hip or clinical vertebral fracture [3] Prevalence (%) Cawston 2012 [5] Gauthier 2012 [6] Piscitelli 2012 [7] Gauthier 2012 [8] Gauthier 2011 [4] Gauthier 2011[9] but better provision. These included Estonia, Ireland Hungary and Spain. Score allocation Supplementary information, no score allocation Fig. 36 The relationship between the prevalence of a prior spine or hip fracture (service need) and the treatment gap (service provision) in the EU27 countries. The horizontal and vertical lines intersect at the EU average (weighted for population size) [3]. Country codes (ISO 31661 alpha-2); AT Austria; BE Belgium; BG Bulgaria; CY Cyprus; CZ Czech Republic; DE Germany; DK Denmark; EE Estonia; ES Spain; FI Finland; FR France; GB United Kingdom; GR Greece; HU Hungary; IE Ireland; IT Italy; LT Lithuania; LU Luxembourg; LV Latvia; MT Malta; NL Netherlands; PL Poland; PT Portugal; RO Romania; SE Sweden; SI Slovenia; SK Slovakia There is a wide variation in both (hip and spine) fractures and treatment gap between countries. This is of particular concern in countries with a high fracture burden and a high treatment gap. 4f Waiting time for hip surgery Background and aims About 5 % of people with a hip fracture die within 1 month and about one quarter within 12 months. Most deaths are due to associated conditions and not to the fracture itself [1], reflecting the high prevalence of comorbidity. In the EU27, hip fractures were estimated to result in approximately 11,000 premature deaths in women that were directly attributable to the fracture event in 2010. The corresponding numbers for men were estimated at approximately 9,000 [2]. A determinant of peri-operative morbidity and mortality is the time a patient takes to get to surgery which, in turn, is an early marker of a patients progress following a hip fracture. Early surgery (<48 h) is associated with a statistically and clinically significant reduction in mortality at 1 year and an increase in the proportion of patients returning to their original residence [3]. The aim of this scorecard element was to determine average waiting times for hip surgery in the EU member states. Data were acquired by an IOF questionnaire to the EU Osteoporosis Consultation Panel undertaken in December 2012. Respondents were asked to provide information on the average waiting time for hip surgery after hip fracture. Countries were categorised according to average waiting times between hospital admission and surgical intervention. An additional indicator of management that was sought was the proportion of hip fracture cases that were managed surgically. Waiting times between admission to hospital and surgical intervention were on average 1 day or less in 7 countries, 12 days in 13 countries and greater than 2 days in 6 countries (Table 48). Information was not recorded for Malta. More than 90 % of hip fracture cases received surgery in the majority of countries. Exceptions included Bulgaria, Czech Republic, Hungary and Italy where 7590 % of cases received a surgical intervention. Score criteria and allocation Uptake was categorised by average waiting time for hip surgery (Table 49) Score allocation Score results are given in Table 48 and colour coded in Fig. 37. Table 48 Average waiting times between hospital admission and surgical intervention and the proportion of hip fracture cases managed surgically [IOF audit] nr, not recorded Note that average waiting times give no index of the dispersion around the mean Table 49 Criteria for allocating scores Fig. 37 Countries categorised by the average waiting time for surgical intervention for hip fracture [IOF audit] References The scorecard SCOPE. The Scorecard for Osteoporosis in Europe, is an innovative tool that allows health and policy professionals to assess key indicators on the healthcare provision for osteoporosis in countries and between counties within the EU. Scorecard key Competing interests The panel has received speaker fees, advisory board fees and/or unrestricted research grants from governmental and non-governmental sources. A full list of disclosures is available from the International Osteoporosis Foundation upon request. Acknowledgments SCOPE was supported by an unrestricted grant from Amgen and GlaxoSmithKline (GSK). Neither company was involved in the design or writing of the report. We are grateful to Carey Kyer of the International Osteoporosis Foundation for the administration of the IOF questionnaire for her help with formatting and editing the report and to Gilberto Lontro of the International Osteoporosis Foundation for designing the scorecard. We thank Robert McGruer, Simone Boselli of Hill & Knowlton for their support services. Prof F Hooven, University of Massachusetts Medical School and B Abrahamsen, University of Southern Denmark kindly supplied previously unpublished data for use in this report. We are grateful to H Sundseth (European Institute of Women's Health) for her help in the early phase of this project. We are grateful for the help provided by the National Societies of the IOF based in the EU, listed below for updating the information base of the European audit Osteoporosis in the European Union in 2008: Ten years of progress and ongoing challenges. Finally, we thank the Committee of Scientific Advisors of the IOF their review and endorsement of this report. Austrian Society for Bone and Mineral Research (AUSBMR) Action for Healthy Bones Austrian Menopause Society National Osteoporosis Patient Society Austria The Royal Belgian Rheumatology Society Belgian Bone Club Bulgarian Society for Clinical Densitometry Association Women without Osteoporosis Bulgarian League for the Prevention of Osteoporosis-blpo Bulgarian Medical Society of Osteoporosis and Osteoathrosis Cyprus Society for Osteoporosis Osteologic Academy zlin Czech Osteoporosis League National Osteoporosis Foundation Denmark Cyprus Society against Osteoporosis and Myoskeletal Diseases Czech Society for Metabolic Skeletal Diseases (SMOS) Danish Bone Society Estonian Osteoporosis Society Finnish Bone Society Finnish Osteoporosis Association French League Against Rheumatism (AFLAR) French Society of Orthopaedic And Trauma Surgery (SOFCOT) French Society For Clinical Densitometry (SO.F.O.C.) Research And Information Group On Osteoporosis (GRIO) Hungarian Osteoporosis Patients Association (HOPA) Romanian Society Of Rheumatology Slovak Union Against Osteoporosis German Osteoporosis Patient Society (BFO) Osteoporose Selbsthilfegruppen Dachverband E.V (OSD) Slovene Bone Society Netzwerk-osteoporose e.v German Society For Endocrinology (DGE) Slovene Osteoporosis Patients Society Spanish Society for Rheumatology Committee For Healthy Bones Kuratorium Knochengesundheit Orthopdische Gesellschaft Fr Osteologie (OGO) Hellenic Foundation Of Osteoporosis Hellenic Society Of Osteoporosis Patient Support Hellenic Endocrine Society - Panhellenic Association Of Endocrinologists Hungarian Society For Osteoporosis And Osteoarthrology Irish Osteoporosis Society (IOS) Italian Association Of Osteoporosis Patients Italian Foundation For Research On Osteoporosis And Musculoskeletal Diseases - FIROMMS Italian COPD Patient Association Osteoporosis Italian Association - Osteo Stop Italian Society For Osteoporosis Mineral Metabolism And Skeletal Diseases (SIOMMMS) Italian Federation Of Osteoporosis And Diseases Of The Skeleton (FEDIOS) Italian Osteoporosis League (LIOS) Italian Society Of Rheumatology Latvian Osteoporosis And Bone Metabolism Diseases Association Lithuanian Association Of Metabolic Bone Diseases Incorporated In Lithuanian Endocrine Society Association luxembourgeoise dtude du mtabolisme osseux et de lostoporose (ALEMO) Hellenic Society For The Study Of Bone Metabolism Portuguese Society Of Osteoporosis And Other Metabolic Bone Diseases (SPODOM) National Association Against Osteoporosis (APOROS) Association For Prevention Of Osteoporosis In Romania (ASPOR) Romanian Society Of Osteoporosis And Musculoskeletal Diseases Romanian Foundation Of Osteoarthrology (OSART) Slovak Society Osteoporosis & Metabolic Bone Diseases Latvia Osteoporosis Patient And Invalid Association Lithuanian Osteoporosis Foundation Malta Osteoporosis Society Osteoporose Vereniging Osteoporose Stichting - Dutch Osteoporosis Foundation Healthy Bone Enthusiasts Society (STENKO) Polish Foundation of Osteoporosis Polish Osteoarthrology Society Multidisciplinary Osteoporotic Forum Portuguese Osteoporosis Association (APO) Spanish Society for Research on Bone and Mineral Metabolism (SEIOMM) Hispanic Foundation Of Osteoporosis And Metabolic Bone Diseases (FHOEMO) Spanish Association Against Osteoporosis (AECOS) Spanish Society of Osteoporotic Fractures Sweden 1.6 million club Swedish Osteoporosis Patient Society (ROP) Swedish Rheumatism Association Swedish Osteoporosis Society UK The Bone Research Society National Osteoporosis Society (NOS) Multinational International Osteoporosis Foundation (IOF) Umbrella organisation of German speaking osteoporosis patient societies (DOP) Umbrella organisation of German speaking societies of osteology (DVO) European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) Deustche Gesellschaft fur Osteologie International Society For Fracture Repair (ISFR) Mediterranean Society For Osteoporosis And Other Skeletal Diseases (MSOSD) Ibero American Society of Osteology and Mineral Metabolism (SIBOMM) European Union Geriatrics Medicine (EUGMS) European Calcified Tissue Society (ECTS) Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited. Abbreviations and glossary Bone mineral density, usually measured as the amount of calcium in bone per unit area. Body mass index, an index of leanness or obesity measured from height and weight Confidence interval Clinical risk factor, in this context for fracture Disability-adjusted life year, a product of years of life lost and the remaining years of life disabled (i.e., disutility). Defined daily dosage Used in health technology assessment to describe direct healthcare costs (e.g., hospital admissions, medical examinations, drug therapy, etc.), the indirect costs (e.g., losses in productivity resulting from absence NOGG Prevalence to work) and intangible costs (e.g. pain and suffering, poor quality of life). Dual-energy X-ray absorptiometry, a method for measuring BMD European Federation of Pharmaceutical Industries Association The 27 member states of the European Union Fracture risk assessment tool developed by the WHO Collaborating Centre, University of Sheffield Medical School, UK. FRAX calculates the 10-year probability of a major osteoporotic fracture and hip fracture in individuals from clinical risk factors and BMD Gross domestic product, the total value of goods produced and services provided in a country in 1 year Global Longitudinal Study of Osteoporosis in Women International classification of diseases Intercontinental Marketing Services The frequency of an event, usually expressed as a rate e.g. 10 per 1000 of the population/year. International Osteoporosis Foundation Milligram Medication possession ratio National Health and Nutrition Examination Survey National Institute of Health and Clinical Excellence National Osteoporosis Guideline Group The number of cases of disease (e.g. osteoporosis) for a given area or at a given time The likelihood of an event, e.g. fracture. Fracture probability depends on two hazardsthe incidence of fracture and the incidence of death The QALY is a multi-dimensional outcome measure that incorporates both the quality (health related) and quantity (length) of life. The value of a QALY was set at value of 2 GDP per capita Quantitative computed tomography Quality of life Quantitative ultrasound Scorecard for osteoporosis in Europe Standard deviation Describes the number of standard deviations (SD) by which the BMD in an individual differs from the mean value expected in young healthy Willingness to pay, used in Health Technology assessment to describe the value that society or a health care payer is prepared to pay to gain a QALY. The value of a QALY was set at value of 2 GDP per capita.


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J. A. Kanis, F. Borgström, J. Compston, K. Dreinhöfer, E. Nolte, L. Jonsson, W. F. Lems, E. V. McCloskey, R. Rizzoli, J. Stenmark. SCOPE: a scorecard for osteoporosis in Europe, Archives of Osteoporosis, 2013, 144, DOI: 10.1007/s11657-013-0144-1