Hip fracture incidence from 1981 to 2009 in the Czech Republic as a basis of the country-specific FRAX model

Epidemiology of osteoporotic fracture in Kazakhstan and development of a country specific FRAX model

Retrospective and prospective population-based survey in a region of the Republic of Kazakhstan determined the incidence of fractures at the hip, proximal humerus and distal forearm. The hip fracture rates were used to create a FRAX® model to enhance fracture risk assessment in Kazakhstan.

OBJECTIVE

This paper describes the epidemiology of osteoporotic fractures in the Republic of Kazakhstan that was used to develop a country specific FRAX® tool for fracture prediction.

METHODS

We carried out a retrospective population-based survey in Taldykorgan in the Republic of Kazakhstan representing approximately 1% of the country's population. Hip, forearm and humerus fractures were identified retrospectively in 2015 and 2016 from hospital registers and the trauma centre. Hip fractures were prospectively identified in 2017 from the same sources and additionally from primary care data. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Kazakhstan. Fracture probabilities were compared with those from neighbouring countries having FRAX models.

RESULTS

The difference in hip fracture incidence between the retrospective and prospective survey indicated that approximately 25% of hip fracture cases did not come to hospital attention. The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 11,690 and is predicted to increase by 140% to 28,000 in 2050. Hip fracture incidence was a good predictor of forearm and humeral fractures in men but not in women.

CONCLUSION

The FRAX model should enhance accuracy of determining fracture probability among the Kazakh population and help guide decisions about treatment.

A brief history of FRAX

This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008.

INTRODUCTION

Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments.

METHODS

The method used in this paper is literature review.

RESULTS

FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population.

CONCLUSION

FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.

Frequency and Associated Factors of Bone Fractures in Russians: The Ural Eye and Medical Study

With information about frequency of bone fractures in Russia mostly missing, we assessed the frequency of previous bone fractures in a Russian population. The population-based study Ural Eye and Medical Study included 5899 (80.5%) out of 7328 eligible individuals (mean age: 59.0 ± 10.7 years; range: 40–94 years). The history of previous bone fractures was assessed in a standardized interview for 5397 (91.5%) individuals. Mean frequency of any previous bone fracture was 1650/5397 (30.6%; 95% confidence interval (CI): 29, 3, 31.8). In multivariate analysis, higher frequency of bone fractures was associated with male sex (P < 0.001; odds ratio (OR): 1.67; 95% CI: 1.41, 2.00), urban region (P < 0.001; OR: 1.45; 95% CI: 1.23, 1.72), higher prevalence of vigorous activity during leisure (P < 0.001; OR: 1.42; 95% CI: 1.20, 1.68), current smoking (P = 0.001; OR: 1.46; 95% CI: 1.16, 1.82) and higher prevalence of cardiovascular disease (P = 0.007; OR: 1.29; 95% CI: 1.07, 1.56), low blood pressure episodes with hospital admission (P = 0.001; OR: 2.08; 95% CI: 1.37, 3.16), tumbling (P < 0.001; OR: 2.58; 95% CI: 1.37, 3.16) and thoracic spine pain (P < 0.001; OR: 1.43; 95% CI: 1.18, 1.73). In women, menopause (P < 0.001; OR: 2.17; 95% CI: 1.47, 3.22) was additionally associated. The most common single-bone fractures involved leg and knee (229/5397; 4.2%), hand in general (n = 169; 3.1%) or hand wrist only (n = 97; 1.8%), arm (n = 94; 1.7%) and ankle (n = 67; 1.2%). Severe fractures included spine (n = 35; 0.6%), os sacrum (n = 10; 0.2%), skull (n = 6; 0.1%), pelvis (n = 5; 0.1%) and hip (n = 22; 0.4%). Most frequent combined fractures included as most important part the leg (n = 90; 1.7%), spine (n = 18; 0.3%), and hip (n = 18; 0.3). These data give hints on the epidemiology of bone fractures in Russia.

Unparallel gender-specific changes in the incidence of hip fractures in Tangshan, China

This study, which measured the incidence of hip fractures in Tangshan, China, in 2015, shows that compared to data we reported in Tangshan in 2010, the crude incidence of hip fractures in 2015 increased in females and slightly decreased in males. However, the incidences of age-specific hip fracture in females aged over 65 and males aged over 75 are both increasing.

INTRODUCTION

The purpose of this study was to assess the incidence of hip fractures in 2015 in Tangshan, China, and to compare this incidence with that previously reported in Tangshan in 2010.

METHODS

Data were obtained from 15 hospitals within Tangshan that had an orthopedic department, and the medical records and radiographs of all patients who sustained such fractures in 2015 were reviewed. The absolute number of admissions was described, and the incidence rates per 100,000 individuals adjusted by age (-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, and ≥85 years) and gender were calculated based on the data of the Tangshan population. The 2015 population of Tangshan was determined to be 3,134,239 (1,573,118 males and 1,561,121 females).

RESULTS

The population over 65 years of age represented 15.43% of the total population and included 477,021 individuals (236,140 males and 240,881 females). In 2015, there were 1645 cervical and trochanteric fractures in 714 males and 931 females, with a male-to-female ratio of 1:1.30. The overall incidence or rate of the hip fractures was 45.39 fractures per 100,000 men per year and 59.64 fractures per 100,000 women per year. Females showed a significantly higher incidence of hip fractures than males in the over 60-and-older groups, but in the youngest group, males had a markedly higher incidence than females. Compared to the incidence measured in 2010 in Tangshan, the crude incidence of hip fractures decreased by 5.04% in males and increased by 18.33% in females. The age-specific incidence increased in the male 75-and-older age groups, and the age-specific incidence increased in the female 65-and-older age groups but decreased in those younger than 65 years.

CONCLUSION

Compared to the results in 2010, the crude incidence of hip fractures in 2015 in Tangshan increased in females but slightly decreased in males. However, the age-specific incidences of hip fracture in females aged over 65 and males aged over 75 are still increasing.

Secondary fracture prevention in hip fracture patients requires cooperation from general practitioners

Despite individual recommendations on osteoporosis management in patients after hip fracture surgery, addressed by orthopedic surgeons to Czech general practitioners, the patients remained undiagnosed and untreated because of provider-level barriers to post-fracture secondary prevention.

PURPOSE

The goal of the study was to assess whether an individual recommendation on osteoporosis treatment addressed to a hip fracture patient's GP would lead to better osteoporosis management.

METHODS

Two groups of patients who suffered hip fractures and were treated at the Orthopedic Department were evaluated. In 111 patients, general recommendations on osteoporosis treatment and fracture prevention were provided in a discharge report addressed to the GP. In the second group, 96 patients were provided individually with a detailed written set of recommendations on osteoporosis examination, treatment, and fracture prevention, which was also provided in the discharge report. A questionnaire to assess the provided care was mailed to the patients 5.3 ± 1.2 months of discharge. Those patients who did not return the questionnaires were contacted by phone.

RESULTS

The questionnaires were received from 44% and 49% of patients from the general and detailed recommendation groups, respectively. Along with the phone call, we were able to contact 78 (70.3%) and 68 (70.8%) patients from the general and detailed recommendation groups, respectively. GPs secured osteoporosis evaluation in 14.6% of the patients. Calcium supplementation and vitamin D supplementation were newly provided in 42.7 and 36.4% of the patients, respectively. Anti-resorptive therapy was newly provided in 8.3% of the patients. No significant differences between the groups were observed in osteoporosis evaluation, calcium and vitamin D supplementation, and anti-osteoporosis treatments. Out of 207 patients, further examination or treatment was requested by 45 patients (21.7%); 75 patients (36.2%) declared no interest in further care.

CONCLUSION

Recommendations on osteoporosis management addressed to Czech GPs after surgical fracture management had little effect on treatment. As the anti-osteoporotic preparations can only be prescribed by specialists, the availability of necessary examinations and treatment is limited by the motivation of GPs. Consequently, the implementation of Fracture Liaison Services to help close the care gap may be limited in the absence of participation by Czech GPs.

How General Practitioners and Their Patients Adhere to Osteoporosis Management: A Follow-Up Survey among Czech General Practitioners

Introduction: General practitioners (GPs) are key participants in osteoporosis (OP) management. The aim was to evaluate their adherence to lege artis management of the disease, potential barriers, and to discuss differences observed in comparison with the baseline survey carried out in 2007; the focus was on secondary prevention.

Methods: On behalf of two professional associations, 2-round postal survey among randomly selected GPs (>1/4 of all Czech GPs) was performed in 2014. The questionnaire covered areas concerning GP's role in the fight against OP, knowledge about OP, management of OP-related fractures, barriers to the management of OP, system- and patient-related in particular, and availability and use of information sources.

Results: The overall questionnaire return rate was 37% (551 respondents); mean age of the respondents was 53 year (37% men). The GP's role in the treatment of OP was rated as essential in 28 and 37% of men and women, respectively (P = 0.012). The guideline for diagnosis and treatment of OP for GPs was considered accessible by 92% of respondents. As much as 60% of the respondents were adherent to the guideline, i.e., used it repeatedly. The knowledge of several risk factors was very good, however, recommended daily intake of calcium was stated correctly by only 41% of respondents, and daily intake of vitamin D by only 40%. Three quarters reported active steps after a fracture: referral to a specialist, life-style recommendations, prescription of calcium/vitamin D supplements. Half of the respondents focus on fall prevention. System-related barriers, such as lack of possibility to prescribe selected drugs (61%) and financial limits set by health insurance company (44%) were most frequently reported. Patient-related barriers were also common, patient's non-adherence (reported by 29%) and patient's reluctance to go to a specialist (18%).

Conclusion: GPs adhered to OP management more than in 2007. Knowledge of risk factors and involvement in post-fracture care was relatively high. Compared to baseline survey, patient-related barriers, patient non-adherence in particular, were more common. Prescribing conditions are still an important issue. Among GPs, education should be focused on calcium and vitamin D intake, doses, sources, and supplements.

Adherence to denosumab in the treatment of osteoporosis and its utilization in the Czech Republic

OBJECTIVES

The objective was to analyze adherence and current trends in utilization and prescription practice patterns of the anti-RANKL monoclonal antibody denosumab in the treatment of postmenopausal osteoporosis (OP).

METHODS

The prescription-based database of the General Health Insurance Company of the Czech Republic that covers approximately 60% of the Czech population (6 million) was used as the data source. Medication possession ratio (MPR) and persistence were calculated for all patients (both OP medication-naïve and medication-experienced) with postmenopausal OP from the start of their therapy with denosumab 60 mg per ml subcutaneous injection within a period between September 2011, i.e. first denosumab availability, and May 2014. Clinical data such as fractures, co-morbidities and co-medication were not analyzed.

RESULTS

A total of 7904 women treated with denosumab were analyzed; 93.8% of patients were identified as compliant (MPR ≥0.8) while 6.2% were non-compliant (MPR < 0.8). Persistence (base case, i.e. refill gap ≤30 days) was 59.1% after 12 months and 34.8% after 24 months. By 2013, i.e. within 2 years, denosumab became the second most utilized and most costly drug after oral bisphosphonates.

CONCLUSIONS

Despite relatively high MPR and persistence rate observed in denosumab treatment, adherence enhancing strategies, focused on persistence in particular, are still needed. The uptake of denosumab has been rapid, its utilization keeps rising swiftly, and denosumab already represents a significant part of the osteoporosis therapy budget.

The incidence of hip fractures in Estonia, 2005-2012

The incidence of hip fractures among individuals aged over 50 in Estonia and trends over time were assessed for 2005-2012. The incidence among women is relatively low, with the declining trend, but the rate among men is among the highest in Eastern and Central Europe.

INTRODUCTION

The aim of this study was to assess the incidence and trends of hip fractures among individuals over 50 years in Estonia in 2005-2012 and to increase understanding of the incidence of hip fractures in Eastern Europe.

METHODS

We identified all patients aged 50 years or older with hip fracture (ICD-10 codes S72.0, S72.1 and S72.2) in 2005-2012 using medical claims data from the Estonian Health Insurance Fund. Crude and age-specific incidence rates were calculated for men and women using the population of Estonia in 2005-2012. To adjust for age differences in the population, standardized incidence rates (SIR) were estimated.

RESULTS

The SIR per 100,000 for the entire observation period was 209.2 (95% CI 204.2 to 214.2) in women and 215.6 (95%CI 208.2 to 223.1) in men, resulting in a female to male rate ratio of 0.97 (95% CI 0.84 to 1.11). Over the period of 2005-2012 the estimated SIR/100,000 ranged from 211.5 (95% CI 196.8-226.3) in 2005 to 183.7 (95% CI 170.8-196.7) in 2012 in women, and from 238.5 (95% CI 215.4-261.7) in 2005 to 187.9 (95% CI 169.0-206.8) in 2012, in men. For women, the decrease in SIR for the study period approached statistical significance (p = 0.058), and for the period of 2009-2012, we observed an accelerated 16% decrease (p = 0.008).

CONCLUSIONS

The incidence of hip fractures among Estonian women is relatively low, whereas the rate among men is among the highest in Eastern and Central Europe. In line with many countries, we found a recent decline in incidence among women.

Geographic and ethnic disparities in osteoporotic fractures

Osteoporotic fractures are a major worldwide epidemic. Here, we review global variability, ethnic differences and secular changes in osteoporotic fractures. Worldwide, age-standardized incidence rates of hip fracture vary >200-fold in women and >140-fold in men when comparing the country in which incidence rates are the highest with that in which they are the lowest. Median age-standardized rates are highest in North America and Europe, followed by Asia, Middle East, Oceania, Latin America and Africa. Globally, rates of hip fracture are greater in women than in men, with an average ratio of ∼2:1. The incidence of radiographic vertebral fractures is much higher than that of hip fractures, whereas the incidence rates of clinical vertebral fractures mirror hip fracture rates in most countries. Methodological challenges of defining and ascertaining vertebral fractures limit the interpretation of these data. Secular declines in hip fracture rates have been reported in populations from North America, Europe and Oceania. These declines are especially notable in women, suggesting that reproductive factors might contribute to this reduction. By contrast, hip fracture rates are increasing in parts of Asia and Latin America. Global indicators of health, education and socioeconomic status are positively correlated with fracture rates suggesting that lifestyles in developed countries might contribute to hip fracture. Improvements in fracture assessment, in particular for nonhip fractures, and identification of factors that contribute to this variability might substantially influence our understanding of osteoporotic fracture aetiology and provide new avenues for prevention.

Incidence of hip fractures in Greece during a 30-year period: 1977-2007

The incidence of hip fractures doubled in Greece from 1977 to 2007 among people aged 50 and over. A mild decrease was observed after 2002, although the future trend cannot be safely anticipated at the moment. Half of all hip fractures in 2007 were derived from the age group of 80 and over.

INTRODUCTION

The purpose of this study was to determine the incidence of hip fractures during a 30-year period in Greece among people aged 50 and over and to document possible alterations in secular trends.

METHODS

We studied hip fractures during 2007 and compared them with those of previous years starting from 1977 with an in-between 5-year interval (1977, 1982, 1987, 1992, 1997, 2002). Age- and sex-specific incidence was calculated, and secular trends were recorded. The relative risk of hip fracture in every age group was estimated according to the corresponding incidence of 1977.

RESULTS

The adjusted incidence of hip fractures increased approximately 100 % throughout the study; it progressively increased from 1977 to 2002 and exhibited a mild significant decrease thereafter. The relative risk of hip fractures among subjects aged 60-69 in 2007 has declined compared with 1977 [0.85, 95 % confidence intervals (CI) 0.79-0.92, p < 0.0005]. Among people aged 70-79, an increased relative fracture risk (1.53, 95 % CI 1.45-1.61, p < 0.0005) was estimated in 2007 compared with 1977. People ≥80 years old were responsible for half of the hip fractures in 2007 but only for the 22.5 % of fractures in 1977. The relative fracture risk in people aged ≥80 was 2.81 times higher (95 % CI 2.64-2.98, p < 0.0005) in 2007 than in 1977.

CONCLUSIONS

The incidence of hip fractures doubled during the last 30 years among people aged ≥50 years, although a mild decrease was observed in almost all age groups after 2002. The most affected group is 80 and over.

Updated fracture incidence rates for the Italian version of FRAX®

In order to update data underlying the Italian version of FRAX, we computed the national hip fracture incidence in Italy from hospitalization records for the year 2008. Mortality data and 10-year probabilities of major osteoporotic fractures were also updated. This revision will improve FRAX accuracy and reliability.

INTRODUCTION

The original Italian version of FRAX® was based on five regional estimates of hip fracture risk undertaken up to 20 years previously. Our objective was to update hip fracture rates for the model with more recently derived data from the whole Italian population and more recent data on mortality.

METHODS

We analyzed the Italian national hospitalization database for the year 2008 in order to compute age- and sex-specific hip fracture incidence rates. Re-hospitalisations of the same patients within 1 year were excluded from the analysis. Hip fracture incidence rates were computed for the age range of 40-100 years, whereas the original FRAX model lacked data on the youngest and oldest age groups. In addition, we used the national mortality data for the same year 2008 to update the model. Ten-year fracture probabilities were re-calculated on the basis of the new fracture incidence rates.

RESULTS

The new hip fracture age- and sex-specific incidence rates were close to those used in the original FRAX tool, although some significant differences (not exceeding 25-30 %) were found for men aged 65-75 years and women under 55 years of age. In general, the revision resulted in decreased estimated 10-year probabilities in the younger age groups, whilst those in the older age groups were slightly increased.

CONCLUSIONS

The Italian version of FRAX has been updated using the new fracture incidence rates. The impact of these revisions on FRAX is likely to increase the accuracy and reliability of FRAX in estimating 10-year fracture probabilities.