Osteoporosis and Fragility Fractures – International Perspective

1. Osteoporosis and Fragility Fractures– International Perspective Kristina Åkesson Professor of Orthopedics Clinical and Molecular Osteoporosis Unit Lund University and Department of Orthopedics Malmö University Hospital Malmö, Sweden

2. Demographic disparities

5. Expectation of life at birth and from selected ages in England Age (in years) Expectation of life (in years) in 1999 Male Female At birth (0) 75.4 80.2 5 71.0 75.7 20 56.2 60.8 30 46.7 51.0 50 27.9 32.0 60 19.4 23.0 70 12.2 15.1 80 7.0 8.7 and life expectancy is increasing

6. Quality of life and osteoporotic fractures

7. 3250 Projected to reach 3.250 million in Asia by 2050 668 400 600 629 1950 1950 2050 2050 1950 2050 1950 2050 100 Projected number of osteoporotic hip fractures worldwide 742 Total number ofhip fractures:1950 = 1.66 million 2050 = 6.26 million 378 Estimated number of hip fractures: (1000s) Adapted from Cooper et al, Osteoporos Int. 1992; 2:285-9

8. Back Pain prevalence rates for WHO regions, 2000

9. Epidemiological disparities • Regional differences within countries • Northern vs southern Sweden • Rural vs urban settings • Regional differences within continents • North eastern Asia vs Arabia • Northern vs southern US • Differences between continents • Africa vs Europe & North America

10. Epidemiological disparities • Regional differences within countries • National programs must consider these differences • Local adaptation necessary Example • Vitamin D deficiency is greater in northern Sweden than southern • Life expectancy shorter and health care technology unavailable in rural compared to urban Indonesia • National policies need to consider inequity and meet the local needs in osteoporosis care • in less developed areas proper fracture management will be more important than pharmacological prevention of future fractures in terms of quality of life

11. Epidemiological disparities • Regional differences within continents • Regional policies difficult to establish and implement • Local adaptation necessary Example • Hip fracture incidence varies extremely over continents, however, accurate data is lacking from many regions and countries • Vitamin D deficiency is pronounced in the Middle East also among young women but not in Thailand • Socioeconomic differences within South America is mirrored by availability to DXA and treatment • In the large continents sub-regional policies are likely to be more successful • EU Call for Action & Audits for the past 10 years have raised the awareness of discrepancies within Europe and promoted osteoporosis management

12. Epidemiological disparities • Differences between continents • Health policies are at best national and regional and do not apply “inter-continentally” • Local adaptation necessary Example • Data on fragility fracture incidence from Africa highly deficient, mainly from north Africa (Egypt, Morocco) and South Africa. • Fracture management and outcome depending on socioeconomic status and human resources • At best – successful programs from developed countries, can allow for rapid and cost-effective knowledge and practice transfer when adjusted to the local needs

13. Identify needs to improve prevention and outcome of osteoporotic fractures COMPREHENSIVE DATA COLLECTION • Systematic collection • National databases based on WHO ICD classification • Researcher driven studies – comparative data • Hip fracture registers • Sweden, UK, Lebanon, Slovenia, Norway, Denmark • Procedure registers for fracture • Hip replacement (Sweden, Norway, Finland, Netherlands…) • Treatment registers • PTH (Denmark, Sweden)

14. Fragility Fracture Management Restored function ? Pre-fracture functioning Fracture event Hospital care / fracture management Rehabilitation ACTIVITY & PARTICIPATION Quality of life Fragility FractureNetworkOsteoporosis Fracture Line

15. Approaches to prevent fractures CLINICAL SYSTEMS APPROACH TO SECONDARY FRACTURE PREVENTION • Fracture Liaison Service • Fracture Chain • Coordinator led fracture service • …. • ….

16. Prevention Package – Falls and fracture careA road map for a systematic approach Best practice example • Stepwise implementation • based on size • of impact Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1st fragility fracture or other injurious falls Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Older people 1. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_103146

17. Prevention Package – Falls and fracture careA systematic approach to fracture prevention Best practice example Fracture Liaison: Acute-care based Secondary fracture prevention Patients with new fragility fracture Fracture Liaison: Primary-care based Patients with prior fragility fracture GP case-finding stratified by age + Direct Access DXA Services Primary fracture prevention Patients at high risk of suffering 1st fragility fracture Patients at intermediaterisk of suffering 1st fragility fracture Patients at low risk of suffering 1st fragility fracture 1. (Adapted from) Curr Med Res Opin 2005;21:4:475-482 Brankin E et al