Cost-effective osteoporosis treatment thresholds in Greece

Assessment for bone health in patients with differentiated thyroid carcinoma after postoperative thyroid-stimulating hormone suppression therapy: a new fracture risk assessment algorithm

Purpose

The fracture risk assessment tool (FRAX) is used to assess the 10-year risk of major site and hip fractures; however, whether this tool can be applied to patients receiving levothyroxine-based thyroid-stimulating hormone (TSH) suppressive therapy for postoperative differentiated thyroid cancer (DTC) patients is yet to be clarified.

Methods and design

A total of 64 patients with DTC following thyroidectomy and oral levothyroxine for TSH suppression therapy and 30 gender- and age-matched controls were collected. The fracture risk was compared between the affected groups with different TSH levels. FRAX was used to calculate the fracture risk with and without bone mineral density (BMD). The TSH level was converted to an age-weighted score to estimate the fracture risk of postoperatively differentiated thyroid cancer patients. The sensitivity, specificity, and area under the AUC curve of the traditional FRAX and the new algorithm for osteoporosis diagnosis were compared. The dual-energy X-ray bone mineral density measurement T score was used as the gold standard to diagnose osteoporosis.

Results

There were 24 patients in the T ≥ -1-2.5 group, 23 in the -2.5 < T < -1 group, and 17 in the T ≤ -2.5 group. The T score of BMD in the disease group was significantly lower than that in the control group (p < 0.05). The risk of MOF and hip fracture without a T score were significantly different under various TSH levels (p < 0.05). The area under the curve (AUC) of FRAX without BMD for predicting major osteoporotic fractures (PMOF) and major hip fractures (PHF) was 0.694 and 0.683, respectively. The cutoff values were 2.15% and 0.25%, respectively. The AUC of FRAX with BMD for PMOF and PHF was 0.976 and 0.989, respectively, and the cutoff values were 4.15% and 1.1%, respectively. The AUC of FRAX without BMD for PMOF and PHF was 0.708 and 0.72, respectively, and the cutoff values were 5.5% and 1.55%, respectively.

Conclusions

FRAX is suitable for postoperative DTC patients after TSH suppressive therapy. In the absence of BMD, TSH weighted by age can improve the specificity of FRAX in the diagnosis of osteoporosis in this population.

Cost Effectiveness Analyses of Interventions for Osteoporosis in Men: A Systematic Literature Review

BACKGROUND

Osteoporosis is often considered to be a disease of women. Over the last few years, owing to the increasing clinical and economic burden, the awareness and imperative for identifying and managing osteoporosis in men have increased substantially. With the approval of agents to treat men with osteoporosis, more economic evaluations have been conducted to assess the potential economic benefits of these interventions. Despite this concern, there is no specific overview of cost-effectiveness analyses for the treatment of osteoporosis in men.

OBJECTIVES

This study aims (1) to systematically review economic evaluations of interventions for osteoporosis in men; (2) to critically appraise the quality of included studies and the source of model input data; and (3) to investigate the comparability of results for studies including both men and women.

METHODS

A literature search mainly using MEDLINE (via Ovid) and Embase databases was undertaken to identify original articles published between 1 January, 2000 and 30 June, 2022. Studies that assessed the cost effectiveness of interventions for osteoporosis in men were included. The Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases and the International Osteoporosis Foundation osteoporosis-specific guideline was used to assess the quality of design, conduct, and reporting of included studies.

RESULTS

Of 2973 articles identified, 25 studies fulfilled the inclusion criteria, classified into economic evaluations of active drugs (n = 8) or nutritional supplements (n = 4), intervention thresholds (n = 5), screening strategies (n = 6), and post-fracture care programs (n = 2). Most studies were conducted in European countries (n = 15), followed by North America (n = 9). Bisphosphonates (namely alendronate) and nutritional supplements were shown to be generally cost effective compared with no treatment in men over 60 years of age with osteoporosis or prior fractures. Two other studies suggested that denosumab was cost effective in men aged 75 years and older with osteoporosis compared with bisphosphates and teriparatide. Intervention thresholds at which bisphosphonates were found to be cost effective varied among studies with a 10-year probability of a major osteoporotic fracture that ranged from 8.9 to 34.2% for different age categories. A few studies suggested cost effectiveness of screening strategies and post-fracture care programs in men. Similar findings regarding the cost effectiveness of drugs and intervention thresholds in women and men were captured, with slightly greater incremental cost-effectiveness ratios in men. The quality of the studies included had an average score of 18.8 out of 25 (range 13-23.5). Hip fracture incidence and mortality risk were mainly derived from studies in men, while fracture cost, treatment efficacy, and disutility were commonly derived from studies in women or studies combining both sexes.

CONCLUSIONS

Anti-osteoporosis drugs and nutritional supplements are generally cost effective in men with osteoporosis. Screening strategies and post-fracture care programs also showed economic benefits for men. Cost-effectiveness and intervention thresholds were generally similar in studies conducted in both men and women, with slightly greater incremental cost-effectiveness ratios in men.

Executive summary: Italian guidelines for diagnosis, risk stratification, and care continuity of fragility fractures 2021

Background

Fragility fractures are a major public health concern owing to their worrying and growing burden and their onerous burden upon health systems. There is now a substantial body of evidence that individuals who have already suffered a fragility fracture are at a greater risk for further fractures, thus suggesting the potential for secondary prevention in this field.

Purpose

This guideline aims to provide evidence-based recommendations for recognizing, stratifying the risk, treating, and managing patients with fragility fracture. This is a summary version of the full Italian guideline.

Methods

The Italian Fragility Fracture Team appointed by the Italian National Health Institute was employed from January 2020 to February 2021 to (i) identify previously published systematic reviews and guidelines on the field, (ii) formulate relevant clinical questions, (iii) systematically review literature and summarize evidence, (iv) draft the Evidence to Decision Framework, and (v) formulate recommendations.

Results

Overall, 351 original papers were included in our systematic review to answer six clinical questions. Recommendations were categorized into issues concerning (i) frailty recognition as the cause of bone fracture, (ii) (re)fracture risk assessment, for prioritizing interventions, and (iii) treatment and management of patients experiencing fragility fractures. Six recommendations were overall developed, of which one, four, and one were of high, moderate, and low quality, respectively.

Conclusions

The current guidelines provide guidance to support individualized management of patients experiencing non-traumatic bone fracture to benefit from secondary prevention of (re)fracture. Although our recommendations are based on the best available evidence, questionable quality evidence is still available for some relevant clinical questions, so future research has the potential to reduce uncertainty about the effects of intervention and the reasons for doing so at a reasonable cost.

Prevalence and patterns of anti-osteoporotic drug use based on 2019 real-world nationwide data in Greece

We used the Greek nationwide database to capture individuals on anti-osteoporotic treatment during 2019. From the estimated number of 683,679 osteoporotic individuals, only 42% were receiving treatment, with the total annual cost being almost one-tenth of the total cost of fractures. The treatment gap was significantly higher in males than in females.

INTRODUCTION

Based on the 2019 European scorecard (SCOPE), osteoporosis is diagnosed in an estimated 683,679 individuals in Greece, with the direct cost of incident fractures being €694.7 million, although further relevant real-world data are scarce.

METHODS

The e-Government Center for Social Security Services prescription database, which covers almost 100% of the Greek population, was used to capture all individuals on anti-osteoporotic treatment during 2019.

RESULTS

A total of 288,983 among 8,641,341 people, corresponding to 3.3% of the total adult Greek population, had filled at least one anti-osteoporotic prescription (6.0% and 0.36% for females and males, respectively). Prevalence of anti-osteoporotic treatment increased with age, from 0.15% in those younger than 50 to 8.6% in those older than 70 years. Oral bisphosphonates were more frequently prescribed (58.8%), followed by denosumab (39.4%). Alendronate was more frequently prescribed in males and in people younger than 60 years. Denosumab was more frequently prescribed in females and in people older than 60 years. Selective estrogen-receptor modulators, teriparatide, and parenteral bisphosphonates accounted for 1.1%, 1.0%, and 0.02% of all prescriptions, respectively. Orthopedic surgeons (39.6%), endocrinologists (19.6%), general practitioners (19%), and rheumatologists (9.3%) prescribed the vast majority of anti-osteoporotic regimens, with significant differences in prescription patterns. The annual cost of treatment per patient increased significantly with age, being on average €323.33.

CONCLUSIONS

Less than half of the estimated number of individuals with osteoporosis in 2019 in Greece received treatment, with the total annual cost being far less than the estimated cost of incident-fragility fractures. The impact of this undertreatment on related health care costs merits further investigation.

Anti-Osteoporosis Effect of Perilla frutescens Leaf Hexane Fraction through Regulating Osteoclast and Osteoblast Differentiation

Osteoporosis is the result of an imbalance in the bone-remodeling process via an increase in osteoclastic activity and a decrease in osteoblastic activity. Our previous studies have shown that Perilla frutescens seed meal has anti-osteoclastogenic activity. However, the role of perilla leaf hexane fraction (PLH) in osteoporosis has not yet been investigated and reported. In this study, we aimed to investigate the effects of PLH in osteoclast differentiation and osteogenic potential using cell-based experiments in vitro. From HPLC analysis, we found that PLH contained high luteolin and baicalein. PLH was shown to inhibit RANKL-induced ROS production and tartrate-resistant acid phosphatase (TRAP)-positive multi-nucleated osteoclasts. Moreover, PLH significantly downregulated the RANKL-induced MAPK and NF-κB signaling pathways, leading to the attenuation of NFATc1 and MMP-9 expression. In contrast, PLH enhanced osteoblast function by regulating alkaline phosphatase (ALP) and restoring TNF-α-suppressed osteoblast proliferation and osteogenic potential. Thus, luteolin and baicalein-rich PLH inhibits osteoclast differentiation but promotes the function of osteoblasts. Collectively, our data provide new evidence that suggests that PLH may be a valuable anti-osteoporosis agent.

Circulating microRNAs Related to Bone Metabolism in HIV-Associated Bone Loss

The pathophysiology of human immunodeficiency virus (HIV)-associated bone loss is complex and to date largely unknown. In this study, we investigated serum expression of microRNAS (miRNAs) linked to bone metabolism in HIV-associated bone loss. This was a case-control study. Thirty male individuals with HIV infection (HIV+) and osteoporosis/osteopenia (HIV+/OP+) (cases) and 30 age-matched male HIV+ individuals with normal bone mass (HIV+/OP-) (controls) were included in the analysis. Thirty male individuals matched for age without HIV infection (HIV-), were also included as second controls. The selected panel of miRNAs was as follows: hsa-miRNA-21-5p; hsa-miRNA-23a-3p; hsa-miRNA-24-2-5p; hsa-miRNA-26a-5p; hsa-miRNA-29a-3p; hsa-miRNA-124-3p; hsa-miRNA-33a-5p; and hsa-miRNA-133a-3p. Within the cohort of HIV+ individuals, relative serum expression of miRNA-21-5p and miRNA-23a-3p was significantly lower (p < 0.001) while the expression of miRNA-24-2-5p was significantly higher (p = 0.030) in HIV+/OP+ compared to HIV+/OP-. Expression of miRNA-21-5p demonstrated a sensitivity of 84.6% and a specificity of 66.7 in distinguishing HIV+/OP+ individuals. Expression of circulating miRNAs related to bone metabolism; miRNA-23a-3p, miRNA-24-2-5p, and miRNA-21-5p is significantly altered in HIV+OP+ individuals, in line with data on other causes of osteoporosis, suggesting a common pattern of circulating miRNAs independent of the underlying cause.

The potential of real-time analytics to improve care for mechanically ventilated patients in the intensive care unit: an early economic evaluation

Background

Mechanical ventilation services are an important driver of the high costs of intensive care. An optimal interaction between a patient and a ventilator is therefore paramount. Suboptimal interaction is present when patients repeatedly demand, but do not receive, breathing support from a mechanical ventilator (> 30 times in 3 min), also known as an ineffective effort event (IEEV). IEEVs are associated with increased hospital mortality prolonged intensive care stay, and prolonged time on ventilation and thus development of real-time analytics that identify IEEVs is essential. To assist decision-making about further development we estimate the potential cost-effectiveness of real-time analytics that identify ineffective effort events.

Methods

We developed a cost-effectiveness model combining a decision tree and Markov model for long-term outcomes with data on current care from a Greek hospital and literature. A lifetime horizon and a healthcare payer perspective were used. Uncertainty about the results was assessed using sensitivity and scenario analyses to examine the impact of varying parameters like the intensive care costs per day and the effectiveness of treatment of IEEVs.

Results

Use of the analytics could lead to reduced mortality (3% absolute reduction), increased quality adjusted life years (0.21 per patient) and cost-savings (€264 per patient) compared to current care. Moreover, cost-savings for hospitals and health improvements can be incurred even if the treatment’s effectiveness is reduced from 30 to 10%. The estimated savings increase to €1,155 per patient in countries where costs of an intensive care day are high (e.g. the Netherlands). There is considerable headroom for development and the analytics generate savings when the price of the analytics per bed per year is below €7,307. Furthermore, even when the treatment’s effectiveness is 10%, the probability that the analytics are cost-effective exceeds 90%.

Conclusions

Implementing real-time analytics to identify ineffective effort events can lead to health and financial benefits. Therefore, it will be worthwhile to continue assessment of the effectiveness of the analytics in clinical practice and validate our findings. Eventually, their adoption in settings where costs of an intensive care day are high and ineffective efforts are frequent could yield a high return on investment.

Fracture risk among treatment-naïve postmenopausal women with osteopenia in Greece: results from the "ACROSS" study

Use of the FRAX (Fracture Risk Assessment Tool) tool to assess fracture risk is the most common practice worldwide. Our findings suggest that in treatment-naïve women with osteopenia treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75 years, according to the Greek-specific FRAX-based thresholds.

INTRODUCTION

When evaluating a patient with low bone mineral density (BMD), fracture risk estimation is of paramount importance. Fracture risk assessment using the FRAX tool is the most common and most studied practice worldwide.

PATIENTS-METHODS

The primary aim of the "ACROSS" study was to record the 10-year probability of major osteoporotic fractures and hip fractures, using the Greek version of the FRAX tool, in a rather representative population of 230 postmenopausal treatment-naïve women with osteopenia. Secondary aims of the study were to identify (1) the risk for fractures according to age and the years from menopause, (2) the proportion of patients qualifying for treatment according to the Greek cost-effective FRAX thresholds, and (3) the perception of both the patient and the treating physician regarding the estimated fracture risk.

RESULTS

The mean 10-year risk was 10.7% ± 6.6 for major osteoporotic fractures and 3.4% ± 4.2 for hip fractures. For women up to 75 years of age, the 10-year risk for major osteoporotic and hip fractures was 8.8% and 2.1%, respectively, while for women over 75 years, the risk was 15.2% and 6.6%, respectively. Patients generally believed that they had low fracture risk independently of age, while the physicians considered that the risk increases with advancing age.

CONCLUSIONS

According to the Greek-specific FRAX-based thresholds, the administration of osteoporosis treatment would be cost-effective for approximately one-third of the study population and nearly half of the subjects over 75 years. Patients are not fully aware of their fracture risk.

A Contingent Valuation Study for Eliciting a Monetary Value of a Quality-Adjusted Life-Year in the General Greek Population

OBJECTIVES

To elicit a willingness-to-pay (WTP) per quality-adjusted life-year (QALY) estimate for the general Greek population and assess the impact of individuals' socio-demographic characteristics and motives on this estimate.

METHODS

A telephone-based survey was carried out employing a representative sample of the general Greek population (n = 1342). A computer-assisted telephone-interview method was adopted to ensure random sampling. A total of 528 participants reported a WTP value for a utility improvement from their current health to perfect health. Those individuals' motives were assessed through predefined statements. Test-retest reliability was assessed using intraclass correlation coefficient (ICC). Multiple linear regression (MLR) and one-way analysis of variance (ANOVA) tests were conducted to assess the effect of socioeconomic/demographic determinants and motive statements, respectively, on WTP/QALY. MLR was re-estimated considering as dependent variable the WTP/QALY estimate calculated for participants: (1) stating a WTP value ≤ their household income and (2) presenting higher certainty regarding stated WTP value (sensitivity analysis).

RESULTS

Analysis revealed good reliability for WTP/QALY estimates and motive statements (ICC values > 0.8). Mean WTP/QALY was €26 280. The respective 5% trimmed value was €14 862. Being a student and household income affected WTP/QALY. Sensitivity analysis did not produce markedly different WTP/QALY predictors, implying the robustness of results, irrespective of the participant group considered. Individuals who indicated the inability to cover basic family needs or pay tax claims as motives reported lower WTP/QALY values compared with those not viewing these aspects as motives.

CONCLUSIONS

Findings confirm that the World Health Organization's criterion used currently in Greek cost-effectiveness studies is not unreasonable. Additional research is essential to further explore WTP/QALY estimates in the Greek setting and facilitate informed decision making.

Predicting the intervention threshold for initiating osteoporosis treatment among postmenopausal women in China: a cost-effectiveness analysis based on real-world data

This study built a micro-simulation Markov model to determine the treatment threshold of osteoporosis in postmenopausal women in Mainland China. Treatment with zoledronate is cost-effective when FRAX-based (Fracture risk assessment tool) fracture probability is over 7%.

INTRODUCTION

The purpose of this study is to estimate FRAX-based fracture probabilities in Mainland China using real-world data, at which intervention could be cost-effective.

METHODS

We developed a micro-simulation Markov model to capture osteoporosis states and relevant morbidities including hip fracture, vertebral fracture, and wrist fracture. Baseline characteristics including incidences of osteoporosis and distribution of risk factors were derived from the Peking Vertebral Fracture study, the largest prospective cohort study of postmenopausal women in Mainland China. We projected incidences of fractures and deaths by age groups under two treatment scenarios: 1) no treatment, and 2) zoledronate. We also projected total quality-adjusted life-years (QALY) and total costs including fracture management and osteoporosis drugs for cost-effectiveness analysis. Cost-effective intervention thresholds were calculated based on the Chinese FRAX model.

RESULTS

Treatment with zoledronate was cost-effective when the 10-year probability of major osteoporotic fracture based on FRAX was above 7%. The FRAX threshold increased by age from 51 to 65 years old, and decreased in elder age groups, ranging from 4% to 9%.

CONCLUSIONS

Using real-world data, our model indicated that widespread use of zoledronate was of both clinical and economic benefit among Chinese postmenopausal women. Using a FRAX-based intervention threshold of 7% with zoledronate should permit cost-effective access to therapy to patients and contribute to reducing the disease burden of osteoporosis in Mainland China.

Experience gained from the implementation of the fracture liaison service in Greece

INTRODUCTION

We present the second implementation of a fracture liaison service (FLS) at a national level in Greece.

METHODS

This was a multicenter prospective study, organized by the Hellenic Society for the Study of Bone Metabolism, aiming to investigate the tracking and outcome of patients with low-trauma fractures visiting four university orthopedic departments across the country. The primary endpoint was the participation rate of eligible patients with low-trauma fractures in the program within a time frame of 1 year. Secondary outcomes included the percentage of patients initiating osteoporosis treatment, adherence to treatment, and the percentage of patients experiencing subsequent fractures. A major difference with previous reports was the designed implication of the orthopedic surgeon managing the fracture.

RESULTS

Among the 1350 eligible patients with major osteoporotic fractures, only 396 (29.3%; mean age 78.1 ± 11.6 years; female/male ratio: 4.4) agreed to participate, nearly all of the latter (n = 392) completing the study. With the exception of seven patients, all participants were receiving anti-osteoporotic treatment at the end of the study. Twelve new fractures were recorded at completion of the 12-month follow-up, which were all sustained in patients who either declined to receive anti-osteoporotic treatment or who discontinued treatment despite advice to the contrary.

CONCLUSION

The participation rate remains low and needs improvement. However, we report herein that whenever the treating physician is involved in the FLS structure, patients are more easily convinced to complete the program, to receive anti-osteoporotic treatment, and to stay connected throughout with the outpatient clinic.

The 2018 Guidelines for the diagnosis and treatment of osteoporosis in Greece

We report the updated guidelines for the management of osteoporosis in Greece, which include guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information, and national evidence from Greek clinical practice and the healthcare setting.

PURPOSE

The purpose of this report was to update the Guidelines for the Management of Osteoporosis in Greece that was published in 2011.

METHODS

In line with the GRADE system, the working group initially defined the main clinical questions that should be addressed when dealing with the diagnosis and management of osteoporosis in clinical practice in Greece. Following a literature review and discussion on the experience gained from the implementation of the 2011 Guidelines transmitted through the national electronic prescription network, the Hellenic Society for the Study of Bone Metabolism (HSSBM) uploaded an initial draft for an open dialogue with the relevant registered medical societies and associations on the electronic platform of the Greek Ministry of Health. After revisions, the Central Health Council approved the final document.

RESULTS

The 2018 Guidelines provide comprehensive recommendations on the issues of the timing of fracture risk evaluation and dual-energy X-ray absorptiometry (DXA) measurement, interpretation of the DXA results, the diagnostic work-up for osteoporosis, the timing as well as the suggested medications for osteoporosis treatment, and the follow-up methodology employed during osteoporosis treatment.

CONCLUSIONS

These updated guidelines were designed to offer valid guidance on fracture risk assessment, diagnosis-pharmacological treatment-follow-up of osteoporosis based on updated information and national evidence from clinical practice and the healthcare setting. Clinical judgment is essential in the management of every individual patient for the purpose of achieving the optimal outcome in the safest possible way.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines

We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.

Agreement between the Turkey Guidelines and the Fracture Risk Assessment Tool®-based Intervention Threshold

BACKGROUND

The aim of this study was to evaluate the agreement between the fracture-risk assessment tool (FRAX®)-based intervention strategy in Turkey and the recommendations published in the Healthcare Practices Statement (HPS).

METHODS

This descriptive cross-sectional study included individuals aged 40 to 90 years who were previously diagnosed as having osteoporosis but had not received any treatment. The intervention thresholds recommended by the National Osteoporosis Foundation for treatment were used. The criteria necessary for the start of administration of pharmacological agents in osteoporosis treatment were evaluated on the basis of the HPS guidelines.

RESULTS

Of the 1,255 patients evaluated, 161 (12.8%) were male and 1,094 (87.2%) were female. In the evaluation, according to HPS, treatment was recommended for 783 patients (62.4%; HPS+) and not recommended for 472 (37.6%; HPS-). Of the 783 HPS+ patients, 391 (49.9%) were FRAX+, and of the 472 HPS- patients, 449 (95.1%) were FRAX-. A statistically significant difference was observed between the treatment recommendations of HPS and FRAX® (P<0.001). In the age group of 75 to 90 years, excellent agreement was found between the two strategies (Gwet's agreement coefficient 1=0.94). As age increased, the agreement between the two treatment strategies also increased.

CONCLUSIONS

The FRAX® model has different treatment recommendation rates from the HPS. The agreement between the two is at a minimal level. However, as age increased, so did the agreement between the FRAX® and the HPS treatment recommendations. In the recommendation to start pharmacological treatment primarily based on age, non-medical interventions that preserve bone density should be evaluated.

Assessment of the antiosteoporotic treatment initiation: A retrospective observational study in Greece

Objective:

A study to retrospectively assess the decision to implement treatment for osteoporosis based on Greek version of FRAX tool.

Methods:

The study population was 1000 postmenopausal women aged 45 or above, excluding those with medical conditions demanding specific osteoporosis management. Data were collected regarding their medical history and additionally, risk factors incorporated in FRAX questionnaire. FRAX score was estimated at the time of the anti-osteoporotic treatment initiation.

Results:

The mean age of the study sample was 58.5±8.79 years. 46.8% of the participating osteopenic women had initiated treatment for osteoporosis at their first consultation while the 80.6% met the current national intervention threshold of FRAX tool.

Conclusion:

Stemming from our results there is an indication that women who are borderline eligible for treatment and seek consultation for osteoporosis are likely to be given treatment regardless of the potential benefit. One cannot ignore the fact that a clinician’s good clinical judgment is of the utmost importance and under no circumstances can be replaced by any prognostic assessment tool.

Evaluation of the first fracture liaison service in the Greek healthcare setting

We evaluated the first implementation of FLS in the Greek healthcare setting, at the 251 Hellenic Air Force and VA General Hospital of Athens. Participation rate was moderate (54.5%) and needs improvement; osteoporosis medication was either suggested or reviewed in 74 out of the 116 patients recruited.

PURPOSE

The purpose of this study was to evaluate the first implementation of a fracture liaison service (FLS) in Greece, at the 251 Hellenic Air Force and VA General Hospital, Athens.

METHODS

Single-center, prospective study from May 1, 2013 to April 30, 2015 (first year-second year follow-up) was conducted. Patients of both genders aged 40-90 years old, with a history of a low trauma fracture and willing to participate, were included after identification by an FLS nurse. Following recruitment, osteoporosis risk factors were assessed, FRAX score was calculated for treatment-naïve patients, bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry (DXA), and osteoporosis treatment was suggested where applicable. The rate of participation, the indication of osteoporosis treatment, and the difficulties met were evaluated.

RESULTS

Of the eligible 213 patients, 97 (45.5%) were reluctant to participate for personal reasons. From the 116 initially recruited patients (mean age 74.8 ± 12 years), 77 (66.4%) discontinued their participation at some point for various reasons and 39 patients concluded the study. All 116 patients were assessed for osteoporosis risk factors and given a tailor-made exercise and education program, while FRAX score was assessed in all treatment-naïve patients (74 patients, 63.8%). Osteoporosis medication was suggested or reviewed in 74 patients; however, an adherence rate of 100% is only available for the 24 who concluded the study.

CONCLUSIONS

We report the first implementation of FLS in the Greek healthcare setting. The participation rate is moderate and definitely needs improvement.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

The FRAX-based Lebanese osteoporosis treatment guidelines: rationale for a hybrid model

We describe our approach to develop FRAX-based osteoporosis treatment guidelines in Lebanon, a country with low-moderate fracture rates. A hybrid assessment algorithm that combines a fixed 10 % intervention threshold until age 70 years, and an age-dependent threshold thereafter, was deemed most suitable.

INTRODUCTION

The FRAX risk calculator is used to guide intervention thresholds in several national osteoporosis guidelines. This study aimed to describe the approach in developing FRAX-based osteoporosis treatment guidelines in Lebanon, a country with relatively low fracture rates.

METHODS

We reassessed previous national guidelines combined with an evaluation of age-dependent and fixed FRAX-based intervention threshold models used in the UK, the USA, and Canada. We took into consideration the risk for major osteoporotic fractures (MOF) and the proportions of subjects considered for therapy using such thresholds, before finalizing a model for Lebanon.

RESULTS

The new Lebanese guidelines retained the recommendation to treat individuals with fragility fracture at the hip or spine. A femoral neck T-score ≤-2.5 in subjects without fractures was dropped, since it would imply consideration of therapy for individuals with a 10-year risk for MOF of <10 %, up to age 75 years in women. After considering the impact of both age-dependent and fixed intervention thresholds, we chose a new hybrid algorithm, combining a fixed 10 % treatment threshold until age 70 years and an age-dependent threshold thereafter.

CONCLUSION

The Lebanese FRAX-based hybrid model takes into consideration the risk for MOF and the proportions of subjects considered for treatment. This model avoids consideration of drug therapy in a large proportion of younger subjects at low risk for fracture and targets high risk elderly individuals. It was deemed most suitable for Lebanon and may be an option for other countries with relatively low fracture rates.

A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation

This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific.

INTRODUCTION

In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation.

METHODS

We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds.

RESULTS

Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the 'fracture threshold') should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity.

CONCLUSION

The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.

Cost-Effectiveness of Intervention Thresholds for the Treatment of Osteoporosis Based on FRAX(®) in Portugal

Cost-effective intervention thresholds (ITs) based on FRAX(®) were determined for Portugal. Assuming a willingness to pay (WTP) of €32,000 per quality-adjusted life years (QALYs), treatment with generic alendronate is cost effective for men and women aged 50 years or more, with 10-year probabilities for major osteoporotic fractures and hip above 8.8 and 2.5 %, respectively. The aim of the present study was to identify the 10-year probabilities of a major and hip osteoporotic fracture using FRAX(®) validated for Portugal, above which pharmacologic interventions become cost effective in the Portuguese context. A previously developed and validated state transition Markov cohort model was populated with epidemiologic, economic and quality-of-life fracture data from Portugal. Cost-effectiveness of FRAX(®)-based ITs was calculated for generic alendronate and proprietary zoledronic acid, denosumab and teriparatide were compared to "no intervention", assuming a WTP of €32,000 (two times national Gross Domestic Product per capita) per QALYs. In the Portuguese epidemiological and economic context, treatment with generic alendronate was cost effective for men and women aged 50 years or more, with 10-year probabilities at or above 8.8 % for major osteoporotic fractures and 2.5 % for hip fractures. Cost-effective threshold 10-year probabilities for major osteoporotic and hip fractures were higher for zoledronic acid (20.4 and 10.1 %), denosumab (34.9 and 10.1 %) and teriparatide (77.8 and 62.6 %), respectively. A tool is provided to perform the calculation of cost-effective ITs for different medications, according to age group and diverse levels of WTP. Cost-effective ITs, for different medications, age groups and WTP, based on 10-year probabilities of major and hip fracture probabilities calculated with FRAX are provided.