Osteoporosis 2016 | Scope Of The Problem: Prof. Elaine Dennison #osteo2016
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Transcript of Osteoporosis 2016 | Scope Of The Problem: Prof. Elaine Dennison #osteo2016
Osteoporosis: Scope of the Problem
Elaine DennisonMRC Lifecourse Epidemiology Unit, University of Southampton
Outline
• Public and personal burden of osteopotic fracture
• Geographic trends • Temporal trends• Strategies to reduce burden
0 1000 AD 2000 AD1000 BC
400 BCHippocrates
of Kos
700 ADSaxon
tomb, Wells
1825 ADSir AstleyCooper
1850 ADOsteoporosis
1950 2016199019801970
1948Albright
1963SPA
1976HRT
1987DXA
1990–2016 WHOCalcium, fluoridebisphosphonatesSERMs, PTH, Sr,Dmab, Scl-ab, ODN, FRAX
1940 1960
Osteoporosis: Three Millennia
Normal Bone Osteoporosis
WHO Definition of Osteoporosis; 1994
A disorder characterised by low bone mass and microarchitectural deterioration of bone tissue
leading to an increased risk of fracture
Osteoporosis in Europe
Impact of Osteoporosis-Related Fractures in Europe
Hip Spine Wrist
Lifetime risk (%)Women 14 11 13Men 3 4 2
Cases/yr 615k 516m 560k
Hospitalisation (%) 100 1-2 5
Relative survival 0.83 0.82 1.00
All sites combined: n=3.5m; cost ~ 39 billion Euros
Hernlund E et al Arch Osteop 2013; 8(1-2): 136
400 -
300 -
200 -
100 -
0 -
Men Women
= Hip fracture
= Radiographic vertebral fracture
= Clinical vertebral fracture
Inci
denc
e pe
r 10,
000/
year
Age group Age group
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
400 -
300 -
200 -
100 -
0 -50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
= Forearm fracture
Sambrook P, Cooper C. Lancet 2006; 367: 2010-18
Incidence of Osteoporotic Fractures
Fracture frequency in clinical practice POSSIBLE, EU study
Freemantle N et al Arch Osteop 2010; 5: 61-72
Number of days in hospital, rehabilitation centre or nursing home for patients with a fracture of the spine, hip
or non-spine/non-hip
617392
120
1306 1252
398
38054083
1103
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Hospital Rehabilitation centre Nursing home
No
of d
ays
Spine fracture Hip fracture Non-spine, non-hip fracture
Ioannidis G et al Osteoporosis Int 2013; 24: 59-67GLOW cohort
Survival after osteoporotic fracture
Cooper et al, Am J Epidemiol 1993; 137: 1001-5
0.6
0.7
0.8
0.9
1
1.1
0 1 2 3 4 5
Time since fracture (years)
Survival (%) Vertebral
HipWrist
• Monetary burden:– Direct costs of treating incident fracture
• 26 billion Euros– Long-term fracture care
• 11 billion Euros– Prevention
• 2 billion Euros
• Costs by fracture site:– Hip 55%– Vertebral 5%– Wrist 1%– Other fractures 38%
Costs of Fracture: EU27, 2010
Hernlund E et al. Arch Osteop 2013; 8 (1-2): 136Kanis JA et al. Arch Osteop 2013; 8 (1-2): 137
Treatment gap (%)
0
20
40
60
80
100
Spain
IrelandH
ungaryG
reeceP
ortugalFranceLuxem
bourgS
loveniaB
elgiumS
lovakiaA
ustriaD
enmark
UK
ItalyN
etherlandsFinlandS
weden
Czech R
epublicG
ermany
Poland
Rom
aniaLatviaE
stoniaLithuaniaB
ulgariaE
U27
Moderate
High
Very high
Proportion of women at high risk that are untreated (treatment gap) in 2010 ranked by country and score
Hernlund E et al. Arch Osteop 2013; 8 (1-2): 136Kanis JA et al. Arch Osteop 2013; 8 (1-2): 137
Worldwide variation in hip fracture incidenceMen and Women
Low (<150/100,000)Moderate (150-250)High (>250) Kanis JA et al. Osteop Int 2012; 23: 2239-56
Geographic variation in hip fracture incidence: Europe
Arden N et al (2000)
Correlates:
• Latitude
• Sunlight
• Activity
• BMI
• Height
• Fall risk
• Not BMD
Geographic variation in hip fracture incidenceUSA; 1984-87
Jacobsen SJ et al JAMA 1990; 264: 500-502
Ecological correlates of hip fractureUSA
• Significant relationship:– Latitude (higher in South)– Water hardness (-ve)– Sunlight hours in January (-ve)– Poverty level– Rural land use– Fluoridated water
• Non-significant relationship:– Activity level, cigarette smoking, alcohol consumption,
Scandinavian heritage, obesity
Jacobsen SJ et al JAMA 1990; 264: 500-502
Regional variation in fragility fracture (spine, hip, wrist, rib, pelvis, and humerus) incidence in men and women aged 50+ years within UK
CPRD; 1988-2012. Relative rates of fracture are displayed in comparison to London.
Curtis E et al. Bone 2016; 87: 19-26
Fragility fracture incidence and index of multiple deprivation (IMD); UK, 1988-2012
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1 2 3 4 5
Rela
tive
rate
of f
ract
ure
Index of Multiple Deprivation Category
Fragility
Men
Women
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1 2 3 4 5
Rela
tive
rate
of f
ract
ure
Index of Multiple Deprivation Category
Hip
Men
Women
0.90.920.940.960.98
11.021.041.061.08
1.1
1 2 3 4 5
Rela
tive
rate
of f
ract
ure
Index of Multiple Deprivation Category
Radius/Ulna
Men
Women
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1 2 3 4 5
Rela
tive
rate
of f
ract
ure
Index of Multiple Deprivation Category
Vertebral
Men
Women
Curtis E et al. Bone 2016; 87: 19-26
Regional variation in childhood fracture incidence within UK. Relative rate of fractures for each sex compared to that observed in Greater London
BOYS GIRLS
Referent
Low <1.50
Medium 1.50-1.64
High ≥ 1.65
Relative Rate
Moon R et al. Bone 2016; 85: 9-14
Childhood fracture incidence and ethnicityUK: 1988-2012
Moon R et al. Bone 2016; 85: 9-14
Prevalence of Vertebral Deformity EVOS
25
20
15
10
5
0
Pre
vale
nce
(%)
Age (years)
O'Neill et al, J Bone Min Res 1996; 11: 1010-18
50 55 60 65 70 75
MenWomen
Grade 1 ~ 20-25%
Shape
Normal Endplate Wedge Crush
% change in shape
These changes in shape are often combined
Vertebral fracture: Semi-quantitative grading
Genant HK, et al. J Bone Miner Res. 1996;11(7):984–96.
Grade 2 ~ 25-40%
Grade 3 40%+
Distribution of Vertebral Fractures
0102030405060708090
100
T4 T5 T6 T7 T8 T9T10 T11 T1
2 L1 L2 L3 L4
Ismail et al, J Bone Min Res (1999)
Incidence of Vertebral Fracture
Age (years)
MEN WOMEN
Morphometric
<50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+0
1000
2000
3000
4000
5000
Frac
ture
/100
,000
p-y
EPOS (morph) EPOS (sq) Roch, MN (est) Japan Roch, MN (morph)
<50 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+0
1000
2000
3000
4000
5000
Cooper C et al. ASBMR Primer (2006)
Outcome of Vertebral Fracture
Incidentvertebralfractures
Clinical attention
Hospitalization1-3%
40%
100%
Cooper et al J Bone Min Res 1992; 7: 221-7
Global projections for hip fracture
Adapted from Cooper C, et al. Osteoporosis Int 1992;2:285-289
Estimated no of hip fractures: (1000s)
Projected to reach 3.250 million in Asia by 2050
1990 2050
600
3250
1990 2050
668
400
1990 205074
2
378
1990 2050
100
629Total number of
hip fractures:1990 = 1.66 million 2050 = 6.26 million
Age-adjusted incidence rate for hip fracture Rochester, MN; 1928-2006
Melton LJ et al Osteop Int 2009; 20: 687-694
HR per 10yr interval = 0.8 [0.6 -0.9]
Segments Annual Change, % (95% CI)
Both sexes 1985-1996 -1.2 (-1.3 to -1.0)1996-2005 -2.4 (-2.6 to -2.1)
Males 1985-1996 -0.8 (-1.1 to -0.5)1996-2005 -2.0 (-2.4 to -1.6)
Females 1985-1996 -1.3 (-1.5 to -1.1)1996-2005 -2.4 (-2.6 to -2.2)
Leslie WD et al JAMA 2009; 302: 883-9
Trends in hip fracture incidence: Canada, 1985-2005
Trends in hip fracture incidence in CanadaAge-period-cohort analysis
• Hip fracture incidence 1985-2005
• Age-period-cohort model
• Declining rates in each 5-yr period• -12% women; -7% men
• Significant birth cohort effects• men and women (p<0.0001)
Jean S et al J Bone Min Res 2013; 28: 1283-9
Reversal of the hip fracture secular trend in Belgian women
-
-
-
-
-
-
Hiligsmann et al. Arthritis Care Res 2012; Jan 11 [epub]
Reginster et al. Bull World Health Organ 2001; 79: 942-6
+2.1%
-1.1%
1984-1996 2000-2007
Ave
rage
yea
rly c
hang
e in
the
inci
denc
e of
hip
frac
ture
s
Age- and gender-specific incidence of cervical and trochanteric fractures in Tottori, Japan; 1986-2006
Hagino H et al. Osteoporos Int 2009; 20: 543-8
Change in age-specific incidence of hip fracture in Beijing, China from 1990-1992 to 2002-2006
*
Xia W et al. J Bone Min Res 2012; 27: 125-9
Japan 02-06Japan 86-01
Singapore 92-98 Singapore 60-91Hong Kong 85-01Hong Kong 66-85
New Zealand 89-98 New Zealand 79-89Australia 89-00
Canada 92-01 Canada 76-85
Spain 88-02Hungary 93-03
Switzerland 91-00Austria 94-06Germany 95-04
Netherlands 93-02 Netherlands 86-93UK 92-98 UK 78-85
UK 68-78Finland 92-03
Finland 70-97Denmark 87-97
Sweden 92-95Sweden 50-92
Norway 79-99
-10 -5 0 5 10% Annual Change
Secular Trends in Hip Fracture Worldwide
Europe
N. America
Oceania
Asia
USA (Rochester) 28-72USA (Rochester) 72-92USA (Rochester) 80-06 USA (Framingham) 48-96
Cooper C et al Osteop Int 2011; 22: 1277-87
Secular trends in hip fracture
Effects of:
• Age
• Period
• Birth-cohort
Risk factors during adult life
Bone mass(g/Ca)
Age (yr)
1500 -
1000 -
500 -
0 -
0 20 40 60 80 100
Risk factors during adult life
• Potential contribution• Obesity• Physical inactivity• Vitamin D insufficiency• Increasingly frail elderly population• Risk assessment by DXA and pharmacotherapy
• Less likely contribution• Dietary calcium intake• Cigarette smoking• Alcohol consumption• Estrogen use
Risk factors during development, childhood and adolescence
Bone mass(g/Ca)
Age (yr)
1500 -
1000 -
500 -
0 -
0 20 40 60 80 100
Peak bone mass
Bone massTarget those with a low
bone density
Bone massMove entire distribution by
intervening in everyone
Mean-1SD +1SD
Preventive strategies: High-risk approach
Cooper C, et al. Trends Endocrinol Metab 1992;3:224–9.
Fracture risk after hip fracture decreases with time
Ryg J et al. J Bone Miner Res 2009; 24: 1299-1307.
Relative risk for a second hip fracture increases
one month after a hip fracture11.8x
Rel
ativ
e ris
k
Relative risk for a second hip fracture increases
one year after a hip fracture2.2x
“CAPTURE THE FRACTURE” IOF Campaign www.iofbonehealth.org
A global campaign facilitating the implementation of coordinator-based, post-fracture models of care for
secondary fracture prevention
1 STANDARD LEVEL 1 BRONZE LEVEL 2 SILVER LEVEL 3 GOLD
Patient Identification
Standard
Fracture patients within the scope of the institution (inpatient and/or outpatient facility) are identified to enable delivery of secondary fracture prevention.
Clinical fracture patients are being identified but no patient tracking system exists to evaluate percentage of patients that are identified versus those that are not.
Clinical fracture patients are being identified and a patient tracking system exists to evaluate percentage of patients that are identified versus those that are not.
Clinical fracture patients are being identified and a patient tracking system exists to evaluate percentage of patients that are identified versus those that are not. The quality of data capture has been subject to independent review.
• Best Practice Framework• 14 standards (Identification; follow-up;
risk assessment; treatment decision)• 3 levels of achievement
Akesson K et al Osteoporosis Int 2013; 24: 2135-52
Conclusions• Increasing recognition of burden from non-hip, non-vertebral fractures
• Geographic variation and incidence trends in hip fracture evaluated between 1928 and the present day
• Wide geographic variation in age-adjusted incidence persists for hip (but not vertebral) fracture in most recent studies
• Age-adjusted rates appear to be reaching a plateau, or have even begun to decline, in North America, northern Europe and Oceania, but rates continue to rise in Oriental populations
• Age, period and cohort effects point at determinants throughout the life-course eg. maternal vitamin D status
• Secondary prevention of fracture an urgent priority
With thanks to all at Southampton