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Abstract
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.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Mary McKillop Research Institute, Australian Catholic University, Melbourne, Australia.
| | - Helena Johansson
- Mary McKillop Research Institute, Australian Catholic University, Melbourne, Australia
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Eugene V McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
- Mellanby Centre for Bone Research, Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
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Sànchez-Riera L, Wilson N. Fragility Fractures & Their Impact on Older People. Best Pract Res Clin Rheumatol 2017; 31:169-191. [PMID: 29224695 DOI: 10.1016/j.berh.2017.10.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/05/2017] [Accepted: 09/14/2017] [Indexed: 01/31/2023]
Abstract
Osteoporotic fractures, in particular hip and vertebral, are a major health burden worldwide. The majority of these fractures occur in the elderly population, resulting in one of the most important causes of mortality and disability in older ages. Their cost for societies is enormous and is forecast to steadily increase over the coming decades globally. Low bone mineral density (BMD) remains a key preventable risk factor for fractures. Screening and treatment of individuals with high risk of fracture is cost-effective. Predictive tools including clinical risk factors, minimisation of falls risk and public authorities' support to create Fracture Liaison Services are paramount strategies.
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Affiliation(s)
- Lídia Sànchez-Riera
- University Hospital Bristol NHS Foundation Trust, Bristol, UK; Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, St Leonards, NSW, Australia.
| | - Nicholas Wilson
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, St Leonards, NSW, Australia
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Leslie WD, Lix LM, Finlayson GS, Metge CJ, Morin SN, Majumdar SR. Direct healthcare costs for 5 years post-fracture in Canada: a long-term population-based assessment. Osteoporos Int 2013; 24:1697-705. [PMID: 23340947 DOI: 10.1007/s00198-012-2232-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/23/2012] [Indexed: 11/24/2022]
Abstract
UNLABELLED High direct incremental healthcare costs post-fracture are seen in the first year, but total costs from a third-party healthcare payer perspective eventually fall below pre-fracture levels. We attribute this to higher mortality among fracture cases who are already the heaviest users of healthcare ("healthy survivor bias"). Economic analyses that do not account for the possibility of a long-term reduction in direct healthcare costs in the post-fracture population may systematically overestimate the total economic burden of fracture. INTRODUCTION High healthcare costs in the first 1-2 years after an osteoporotic fracture are well recognized, but long-term costs are uncertain. We evaluated incremental costs of non-traumatic fractures up to 5 years from a third-party healthcare payer perspective. METHODS A total of 16,198 incident fracture cases and 48,594 matched non-fracture controls were identified in the province of Manitoba, Canada (1997-2002). We calculated the difference in median direct healthcare costs for the year pre-fracture and 5 years post-fracture expressed in 2009 Canadian dollars with adjustment for expected age-related healthcare cost increases. RESULTS Incremental median costs for a hip fracture were highest in the first year ($25,306 in women, $21,396 in men), remaining above pre-fracture baseline to 5 years in women but falling below pre-fracture costs by 5 years in men. In those who survived 5 years following a hip fracture, incremental costs remained above pre-fracture costs at 5 years ($12,670 in women, $7,933 in men). Incremental costs were consistently increased for 5 years after spine fracture in women. Total incremental healthcare costs for all incident fractures combined showed a large increase over pre-fracture costs in the first year ($137 million in women, $57 million in men), but fell below pre-fracture costs within 3-4 years. Elevated total healthcare costs were seen at year 5 in women after wrist, humerus and spine fractures, but these were somewhat offset by decreases in total healthcare costs for other fractures. CONCLUSIONS High direct healthcare costs post-fracture are seen in the first year, but total costs eventually fall below pre-fracture levels. Among those who survive 5 years following a fracture, healthcare costs remain above pre-fracture levels.
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Affiliation(s)
- W D Leslie
- Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba, Canada.
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Diel P, Freiburghaus L, Röder C, Benneker LM, Popp A, Perler G, Heini PF. Safety, effectiveness and predictors for early reoperation in therapeutic and prophylactic vertebroplasty: short-term results of a prospective case series of patients with osteoporotic vertebral fractures. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 21 Suppl 6:S792-9. [PMID: 21877131 DOI: 10.1007/s00586-011-1989-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 08/14/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vertebroplasty (VP) is a cost-efficient alternative to kyphoplasty; however, regarding safety and vertebral body (VB) height restoration, it is considered inferior. We assessed the safety and efficacy of VP in alleviating pain, improving quality of life (QoL) and restoring alignment. METHODS In a prospective monocenter case series from May 2007 until July 2008, there were 1,408 vertebroplasties performed during 319 interventions in 306 patients with traumatic, lytic and osteoporotic fractures. The 249 interventions in 233 patients performed because of osteoporotic vertebral fractures were analyzed regarding demographics, treatment and radiographic details, pain alleviation (VAS), QoL improvement (NASS and EQ-5D), complications and predictors for new fractures requiring a reoperation. RESULTS The osteoporotic patient sample consisted of 76.7% (179) females with a median age of 80 years. A total of 54 males had a median age of 77 years. On average, there were 1.8 VBs fractured and 5 VBs treated. The preoperative pain was assessed by the visual analog scale (VAS) and decreased from 54.9 to 40.4 pts after 2 months and 31.2 pts after 6 months. Accordingly, the QoL on the EQ-5D measure (-0.6 to 1) improved from 0.35 pts before surgery to 0.56 pts after 2 and to 0.68 pts after 6 months. The preoperative Beck Index (anterior height/posterior height) improved from a mean of 0.64 preoperative to 0.76 postoperative, remained stable at 2 months and slightly deteriorated to 0.72 at 6 months postoperatively. There were cement leakages in 26% of the fractured VBs and in 1.4% of the prophylactically cemented VBs; there were symptoms in 4.3%, and most of them were temporary hypotension and one pulmonary cement embolism that remained asymptomatic. The univariate regression model revealed a tendency for a reduced risk for new or refractures on radiographs (OR = 2.61, 95% CI 0.92-7.38, p = 0.12) and reoperations (OR = 2.9, 95% CI 0.94-8.949, p = 0.1) when prophylactic augmentation was performed. The final multivariate regression model revealed male patients to have an about three times higher refracture risk (radiographic) (OR = 2.78, p = 0.02) at 6 months after surgery. Patients with a lumbar index fracture had an about three to five times higher refracture/reoperation risk than patients with a thoracic (OR = 0.33/0.35, p = 0.009/0.01) or thoracolumbar (OR = 0.32/0.22, p = 0.099/0.01) index fracture. CONCLUSION If routinely used, VP is a safe and efficacious treatment option for osteoporotic vertebral fractures with regard to pain relief and improvement of the QoL. Even segmental realignment can be partially achieved with proper patient positioning. Certain patient or fracture characteristics increase the risk for early radiographic refractures or new fractures, or a reoperation; a consequent prophylactic augmentation showed protective tendencies, but the study was underpowered for a final conclusion.
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Affiliation(s)
- Peter Diel
- Spine Service Inselspital, University Hospital, University of Bern, Bern, Switzerland
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Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CK, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 2011; 57:1404-23. [PMID: 21388771 PMCID: PMC3124072 DOI: 10.1016/j.jacc.2011.02.005] [Citation(s) in RCA: 570] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, Newby LK, Piña IL, Roger VL, Shaw LJ, Zhao D, Beckie TM, Bushnell C, D'Armiento J, Kris-Etherton PM, Fang J, Ganiats TG, Gomes AS, Gracia CR, Haan CK, Jackson EA, Judelson DR, Kelepouris E, Lavie CJ, Moore A, Nussmeier NA, Ofili E, Oparil S, Ouyang P, Pinn VW, Sherif K, Smith SC, Sopko G, Chandra-Strobos N, Urbina EM, Vaccarino V, Wenger NK. Effectiveness-based guidelines for the prevention of cardiovascular disease in women--2011 update: a guideline from the american heart association. Circulation 2011; 123:1243-62. [PMID: 21325087 PMCID: PMC3182143 DOI: 10.1161/cir.0b013e31820faaf8] [Citation(s) in RCA: 1215] [Impact Index Per Article: 93.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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An evaluation of the NICE guidance for the prevention of osteoporotic fragility fractures in postmenopausal women. Arch Osteoporos 2010. [DOI: 10.1007/s11657-010-0045-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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SWISSspine-a nationwide health technology assessment registry for balloon kyphoplasty: methodology and first results. Spine J 2010; 10:961-71. [PMID: 19819192 DOI: 10.1016/j.spinee.2009.08.452] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 07/14/2009] [Accepted: 08/26/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The Swiss Federal Office of Public Health demanded a nationwide health technology assessment registry for cervical and lumbar total disc arthroplasty and for balloon kyphoplasty (BKP) to make a decision about reimbursement of these interventions. PURPOSE The goal of the SWISSspine registry is to generate evidence about the safety and effectiveness of these technologies. We report on results of patients with balloon kyphoplasty. STUDY DESIGN/SETTING Prospective, multicenter, observational case series. PATIENT SAMPLE From March 2005 until June 2008, 331 interventions with 391 treated levels in 320 patients have been documented. 75.6% of patients were females with mean age of 74 years (range 43-95.2 years); mean age of males was 72.6 years (range 41.4-93 years). OUTCOME MEASURES Surgeon-administered outcome instruments were primary intervention form for BKP, implant, and follow-up form; patient self-reported measures were Euroqol-5D, North American Spine Society, and a comorbidity questionnaire. METHODS Data were recorded perioperative, at 3 months, 1 year, and annually thereafter. Wilcoxon signed-rank test was used for comparison of preoperative to postoperative measurements. Multivariate regression was used for identifying factors with a significant influence on the outcome. RESULTS Significant and clinically relevant reduction of back pain, improvement of quality of life (QoL), and reduction of pain killer consumption were seen in the 1-year follow-up. Improvement of preoperative segmental kyphosis was achieved in the majority of cases. There were three symptomatic cement extrusions with radiculopathy documented. CONCLUSIONS Balloon kyphoplasty is a safe and effective treatment concerning pain reduction, QoL improvement, and pain killer consumption. The SWISSspine registry proved to be an excellent tool for evaluation of this new technology, and its results, in combination with an elaborate health technology assessment report, led to a permanent coverage of BKP by the basic health insurance.
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Seeman E, Boonen S, Borgström F, Vellas B, Aquino JP, Semler J, Benhamou CL, Kaufman JM, Reginster JY. Five years treatment with strontium ranelate reduces vertebral and nonvertebral fractures and increases the number and quality of remaining life-years in women over 80 years of age. Bone 2010; 46:1038-42. [PMID: 20026265 DOI: 10.1016/j.bone.2009.12.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 12/04/2009] [Accepted: 12/09/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Longevity has resulted in a greater proportion of the population entering a time of life when increasing bone fragility and falls predispose to fractures, particularly nonvertebral fractures. Women over 80 years of age constitute 10% of the population but contribute 30% of all fractures and 60% of all nonvertebral fractures. Despite this, few studies have examined antifracture efficacy of treatments in this high-risk group and none has provided evidence for benefits beyond 3 years. MATERIALS AND METHODS To determine whether strontium ranelate reduces the risk of vertebral and nonvertebral fractures during 5 years, we analyzed a subgroup of 1489 female patients over 80 years of age (mean 83.5+/-3.0 years) with osteoporosis from the SOTI (spinal osteoporosis therapeutic intervention) and TROPOS (treatment of peripheral osteoporosis) studies randomized to strontium ranelate 2 g/d or placebo. All received a supplement of calcium plus vitamin D. RESULTS By intention to treat, vertebral fracture risk was reduced by 31% (relative risk, RR=0.69; 95% confidence interval, CI 0.52-0.92), nonvertebral fracture risk by 27% (RR=0.73; 95% CI 0.57-0.95), major nonvertebral fracture risk by 33% (RR=0.67; 95% CI 0.50-0.89) and hip fracture risk by 24% (RR=0.76; 95% CI 0.50-1.15, not significant). Treatment was cost-saving as it decreased cost and increased QALYs and life-years. DISCUSSION Strontium ranelate safely produced a significant reduction in vertebral and nonvertebral fracture risk during 5 years in postmenopausal women over 80 years of age and was cost saving.
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Affiliation(s)
- Ego Seeman
- Austin Health, University of Melbourne, Melbourne, Australia.
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Bartl R, Gradinger R. [Current diagnosis and therapy of osteoporosis on the basis of "European guidance 2008"]. DER ORTHOPADE 2009; 38:365-79; quiz 380. [PMID: 19305966 DOI: 10.1007/s00132-008-1404-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Osteoporosis is one of the 10 most important and widespread global diseases. In Germany alone the cost of osteoporosis runs into many billions of Euros. However, it should be noted that in the past 15 years great progress has been made both in diagnosis and in the development of new medications, and this has changed the general perception of and attitude to osteoporosis. It is now taken very seriously and recognised as a national and global disorder which is both preventable and treatable. In spite of this progress, in Europe and especially in Germany, osteoporosis remains an underdiagnosed and undertreated disease. In Germany, only about 10%-15% of patients with manifest osteoporosis are properly treated. However, in addition to national guidelines, there is now a new edition of the "European Position Paper for the Diagnosis and Management of Osteoporosis". This provides physicians treating osteoporosis patients with additional information and therefore more confidence.
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Affiliation(s)
- R Bartl
- Bayerisches Osteoporosezentrum, Universität München-Grosshadern, München, Deutschland.
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Diel P, Merky D, Röder C, Popp A, Perler M, Heini PF. Safety and efficacy of vertebroplasty: Early results of a prospective one-year case series of osteoporosis patients in an academic high-volume center. Indian J Orthop 2009; 43:228-33. [PMID: 19838343 PMCID: PMC2762175 DOI: 10.4103/0019-5413.53452] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Vertebroplasty (VP) is a cost-efficient alternative to kyphoplasty. However, it is considered inferior when it comes to maintaining safety and in vertebral body (VB) height restoration. We assess the safety and efficacy of VP in alleviating pain, improving quality of life (QoL), and restoring alignment. MATERIALS AND METHODS In a prospective monocenter case series, from April 2007 until July 2008, 1,422 vertebroplasties were performed, during 307 interventions, in 279 patients with traumatic, lytic, and osteoporotic fractures with 28 repeat interventions, for new fractures after the primary surgery, in 28 patients. The 226 interventions (n=203 patients) done for osteoporotic fractures were analyzed for demographics, treatment and radiographic details, pain alleviation, QoL improvement [NASS and Euroqol (EQ-5D)] and complications. RESULTS Osteoporotic patient sample consisted of 77.8% (n=158) females with a median age of 78 years and 45 males who had the same median age. Around 69% of these patients were ASA (American Society of Anesthesiologists) grade 3 and above. On an average there were 1.8 VBs fractured and five VBs treated,whereas the most frequently performed cementations were in six (35.6%, n=80) or five (19.6%, n=44) levels. About 36.5%, (n=414) of the interventions were localized at the thoraco-lumbar junction (Th12-L2). On applying the Genant classification, there was a slight height reduction in 13.1% (n=29), a medium loss in 34.3% (n=78), and a severe loss of height in 52.6% (n=119). The pre-operative pain was assessed by the visual analog scale (VAS) and decreased from 56.7 to 41.4 pts after two months. Accordingly, the QoL on the EQ-5D measure (0.6 to 1) improved from 0.32 pts before surgery to 0.58 pts after two months. The pre-operative Beck index (anterior height/posterior height) improved from a mean of 0.66 preoperative to 0.80 post-operative and remained stable at two months post-operatively. There were cement leakages in 33% of the fractured VBs and in 0.8% of the prophylactically cemented VBs; there were symptoms in 7.1%, and most of them were temporary hypotension and one pulmonary cement embolism that remained asymptomatic. CONCLUSION If routinely used, VP is a safe and efficient treatment option for osteoporotic vertebral fractures with regard to pain relief and improvement of the QoL. Even segmental re-alignment can be achieved to a certain extent with proper patient positioning.
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Affiliation(s)
- Peter Diel
- Spine Service, Inselspital Bern, Switzerland,Institute for Evaluative Research in Orthopedic Surgery, University of Bern, Bern, Switzerland
| | | | - Christoph Röder
- Spine Service, Inselspital Bern, Switzerland,Institute for Evaluative Research in Orthopedic Surgery, University of Bern, Bern, Switzerland,Address for correspondence: Dr. Christoph Röder, Spine Service, Inselspital Bern, Freiburgstrasse, CH-3010 Bern, Switzerland. E-mail:
| | - Albrecht Popp
- Osteoporosis Policlinic, University Hospital, University of Bern, Switzerland
| | - Malgorzata Perler
- Institute for Evaluative Research in Orthopedic Surgery, University of Bern, Bern, Switzerland
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[Treatment of osteoporosis according to the "European Guidance 2008". Fracture-oriented--economical--cost-effective]. Internist (Berl) 2008; 49:1126-36. [PMID: 18704350 DOI: 10.1007/s00108-008-2192-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Osteoporosis is one of the ten most important and widespread global diseases. In Germany alone the costs of osteoporosis run into billions of Euros. However, during the past 15 years great progress has been made both in diagnosis and in the development of new medications. Osteoporosis is now taken very seriously and recognized as a national and global disorder which is now both preventable and treatable. Nevertheless, at a practical level, both in Europe and especially in Germany, osteoporosis remains an underdiagnosed and undertreated disease. In Germany, only about 10-15% of patients with manifest osteoporosis are properly treated. The consequences of such inadequate care are high additional costs-not to mention the unnecessary suffering of the patients involved. However, in support of national guidelines, a new edition of the "European Position Paper for the Diagnosis and Management of Osteoporosis" provides the doctors who treat patients with osteoporosis with additional information and therefore more confidence. In this paper several aspects are emphasized: improvements in diagnostic evaluation, assessment of the efficacy of fracture-oriented medications, and cost-effectiveness of the treatment of patients with osteoporosis.
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Kanis JA, Compston JE. NICE continues to muddy the waters of osteoporosis. Osteoporos Int 2008; 19:1105-7. [PMID: 18528723 DOI: 10.1007/s00198-008-0649-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 05/06/2008] [Indexed: 11/28/2022]
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