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'''China'''
'''China'''


70 million cases of osteoporosis are leading to 678,000 hip fractures, annually. Men are more suffering from hip fracture than women. The holistic prevalence of osteoporosis in women is about two folds of men. Total economic burden of one hip fracture is about $ 3,603, which may measured as $ 1.5 billion per year. It is assumed to grow to $ 12.5 billion in 2020 and more than $ 264.7 billion in 2050. <ref name="pmid10701163">{{cite journal |vauthors=Zhang L, Cheng A, Bai Z, Lu Y, Endo N, Dohmae Y, Takahashi HE |title=Epidemiology of cervical and trochanteric fractures of the proximal femur in 1994 in Tangshan, China |journal=J. Bone Miner. Metab. |volume=18 |issue=2 |pages=84–8 |year=2000 |pmid=10701163 |doi= |url=}}</ref>
70 million cases of osteoporosis are leading to 678,000 hip fractures, annually. Men are more suffering from hip fracture than women. The holistic prevalence of osteoporosis in women is about two folds of men. Total economic burden of one hip fracture is about $3,603, which may measured as $1.5 billion per year. It is assumed to grow to $12.5 billion in 2020 and more than $ 264.7 billion in 2050. Facility limitation is the major problem of China in managing osteoporosis; in 2008 the whole DXA scanners number for the whole 1.3 billion Chinese was 450. <ref name="pmid10701163">{{cite journal |vauthors=Zhang L, Cheng A, Bai Z, Lu Y, Endo N, Dohmae Y, Takahashi HE |title=Epidemiology of cervical and trochanteric fractures of the proximal femur in 1994 in Tangshan, China |journal=J. Bone Miner. Metab. |volume=18 |issue=2 |pages=84–8 |year=2000 |pmid=10701163 |doi= |url=}}</ref><ref name="pmid16471214">{{cite journal |vauthors=Luo LZ, Xu L |title=[Study on direct economic-burden and its risk factors of osteoporotic hip fracture] |language=Chinese |journal=Zhonghua Liu Xing Bing Xue Za Zhi |volume=26 |issue=9 |pages=669–72 |year=2005 |pmid=16471214 |doi= |url=}}</ref>


<ref name="pmid16471214">{{cite journal |vauthors=Luo LZ, Xu L |title=[Study on direct economic-burden and its risk factors of osteoporotic hip fracture] |language=Chinese |journal=Zhonghua Liu Xing Bing Xue Za Zhi |volume=26 |issue=9 |pages=669–72 |year=2005 |pmid=16471214 |doi= |url=}}</ref>
'''Hong Kong, China'''


Facility limitation is the major problem of China in managing osteoporosis; in 2008 the whole DXA scanners number for the whole 1.3 billion Chinese was 450.
For a 6 million population, hip fracture management are in charge of 1% of whole hospital economic burden, $17 million.<ref name="pmid11485333">{{cite journal |vauthors=Lau EM |title=Epidemiology of osteoporosis |journal=Best Pract Res Clin Rheumatol |volume=15 |issue=3 |pages=335–44 |year=2001 |pmid=11485333 |doi=10.1053/berh.2001.0153 |url=}}</ref>


'''Hong Kong, China'''
* Epidemiological studies showed that hip fracture incidence had increased by 300% from the 1960s to 1990s, and has stabilized from 2001-2006. The reasons are not clear, but may possibly be due to a number of factors including improved availability of medical intervention, increases in BMI, use of HRT, and improved falls prevention strategies (155,221).
* Despite the stabilization of hip fracture rates, fractures remain a major burden on health services and society. The acute hospital care cost of hip fractures amounted to 1% of the total annual hospital budget, or 17 million USD for a population of 6 million (154).
* The prevalence of vertebral fractures is estimated at 30% in women and 17% in men between the ages of 70-79 years of age. These rates are comparable to those in American Caucasians (148,149,156).
'''Chinese Taipei'''
* The prevalence of osteoporosis in 1996-2001 among those ages 50 years and older was 1.6% in men and 11.4% in women (232). A study showed a high incidence rate of hip fractures, close to those of Western countries, and substantially higher than the rates in Beijing (3-5 times) and Hong Kong (1-2 times), except after age 85 (230). During 1996-2002, the incidence of hip fractures in the 65 years and older population increased by 30%, with rates greater in males (36%) than females (22%) (233).
'''India'''
'''India'''
* Expert groups peg the number of osteoporosis patients at approximately 26 million (2003 figures) with the numbers projected to increase to 36 million by 2013 (157).
 
* In a study among Indian women aged 30-60 years from low income groups, BMD at all the skeletal sites were much lower than values reported from developed countries, with a high prevalence of osteopenia (52%) and osteoporosis (29%) thought to be due to inadequate nutrition (193).
From 2003 to 2013, the prevalence of osteoporosis become from 26 million to 36 million patients. 52% of osteopenia and 29% of osteoporosis was recorded.<ref name="pmid15959616">{{cite journal |vauthors=Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N |title=Bone status of Indian women from a low-income group and its relationship to the nutritional status |journal=Osteoporos Int |volume=16 |issue=12 |pages=1827–35 |year=2005 |pmid=15959616 |doi=10.1007/s00198-005-1933-1 |url=}}</ref>
 
'''Japan'''
'''Japan'''
* The prevalence of osteporosis in the Japanese female population aged 50-79 years has been estimated to be about 35% at the spine and 9.5% at the hip (150).
 
* New hip fractures increased 1.7-fold during 1987-1997 (158).
The postmenopausal women involved in vertebral osteoporosis (35%) more than hip osteoporosis (9.5%). Hip fractures are growing from 153,000 in 2010 to 238,000 in 2030.<ref name="pmid11527049">{{cite journal |vauthors=Iki M, Kagamimori S, Kagawa Y, Matsuzaki T, Yoneshima H, Marumo F |title=Bone mineral density of the spine, hip and distal forearm in representative samples of the Japanese female population: Japanese Population-Based Osteoporosis (JPOS) Study |journal=Osteoporos Int |volume=12 |issue=7 |pages=529–37 |year=2001 |pmid=11527049 |doi=10.1007/s001980170073 |url=}}</ref>
* The total number of hip fractures is forecast to be 153,000 per year in 2010 and 238,000 in 2030 (202).
 
*
<ref name="pmid16133645">{{cite journal |vauthors=Hagino H, Katagiri H, Okano T, Yamamoto K, Teshima R |title=Increasing incidence of hip fracture in Tottori Prefecture, Japan: trend from 1986 to 2001 |journal=Osteoporos Int |volume=16 |issue=12 |pages=1963–8 |year=2005 |pmid=16133645 |doi=10.1007/s00198-005-1974-5 |url=}}</ref>
 
'''Korea'''
'''Korea'''
* The occurrence of hip fractures increased about 4-fold over 10 years (1991-2001) (159).
 
* The number of hip fractures after 75 years of age was 4.3 per 1000 in women and 2.97 per thousand in men (160).
In a 10-year period, number of hip fractures raised 300%. In people more than 75 years hip fracture occurs in 4.3 per 1000 women and 2.97 per 1000 men.
'''Pakistan'''
 
* Osteoporosis seems to be a significant problem due to major nutritional issues as well as limited and underutilised diagnostic facilities (221).
'''Singapore'''
'''Singapore'''
* The incidences of hip fracture in 1998 have gone up 5 times in women and 1.5 times in men compared to those observed in the 1960s (161). During 1991-1998, the incidence of hip fracture increased by 0.7% annually in men and by 1.2% annually in women (234).


Hip fracture in men and women have became 1.5 times and 5 times, respectively, in 1998 compared to 1960's.<ref name="pmid11580084">{{cite journal |vauthors=Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, Huang QR, Rajatanavin R, Tsai KS, Park HM, Reginster JY |title=A simple tool to identify asian women at increased risk of osteoporosis |journal=Osteoporos Int |volume=12 |issue=8 |pages=699–705 |year=2001 |pmid=11580084 |doi= |url=}}</ref>
=== Oceania ===
=== Oceania ===
'''Australia'''
'''Australia'''
* 2.2 million Australians are affected by osteoporosis (163). About 11% of men and 27% of women aged 60 years or more are osteoporotic, and 42% of men and 51% of women are osteopenic (162).
 
* The lifetime risk of osteoporotic fracture after 50 years of age: 42% in women, 27% in men (163).
Total economic burden of the osteoporosis is $7.4 billion, annually. Whole number of osteoporosis are 2.2 million cases, while 42% of men and 51% of women are encountering bone density loss. Lifetime risk of women for fragility fractures is about twice the risk of men.<ref name="pmid12049064">{{cite journal |vauthors=Sambrook PN, Seeman E, Phillips SR, Ebeling PR |title=Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit |journal=Med. J. Aust. |volume=176 Suppl |issue= |pages=S1–16 |year=2002 |pmid=12049064 |doi= |url=}}</ref>
* There are 20,000 hip fractures per year in Australia (increasing by 40% each decade) (163).
 
* Total costs relating to osteoporosis are $7.4 billion per year of which $1.9 billion are direct costs (163).
'''New Zealand'''
'''New Zealand'''
* There were an estimated 84,000 osteoporotic fractures in 2007, with 60% of these occurring in women. Hip fractures were estimated to account for 5% of all fractures (138).
* The total cost of osteoporosis is estimated to be over $1.15 billion per year (138).
* It is estimated that both the number of osteoporotic fractures and the cost of healthcare associated with osteoporosis will increase by over 30% between 2007-2020 (138).


Total economic burden of osteoporosis is more than $1.15 billion, annually. It is assumed to be increased by more than 30%, in 2020. Women encounter osteoporotic fractures more than men. 5% of all fractures occurred in hip<ref name="pmid21271750">{{cite journal |vauthors=Brown P, McNeill R, Leung W, Radwan E, Willingale J |title=Current and future economic burden of osteoporosis in New Zealand |journal=Appl Health Econ Health Policy |volume=9 |issue=2 |pages=111–23 |year=2011 |pmid=21271750 |doi=10.2165/1153150-000000000-00000 |url=}}</ref>
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 21:29, 16 August 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Cost-Effectiveness of Therapy

  • In 1984, femoral fracture, the main complication of osteoporosis costed about ₤48 million per year, in England and Wales.[1]
  • In 1987, osteoporosis was the most prevalent musculoskeletal disorder in North America. 15-20 million adults were affected, involves 1.3 million fractures; led to annual cost of $3.8 billion for treatment. The estimated 267000 femoral neck fractures, in 1980, caused costs of $1.3 billion just for acute management. The average hospital stays were 21 days.[2]

Osteoporosis - Incidence and burden

  • Regarding that osteoporosis is the main cause of 8.9 million fractures in a year, whole over the world, it can be concluded that osteoporosis leads to one fracture in every 3 seconds.[3]
  • The estimated women population under the burden of osteoporosis influence is about 200 million, worldwide; two third of them 90, two fifth of them 80, one fifth of them 70, and one tenth of them 60 years old.
  • The total share of Europe, USA, and Japan in osteoporosis is about 75 million people.[4]
  • Women have rate of fracture in forearm, humerus, hip, and spine as 80%, 75%, 70%, and 58%, respectively. However, women encounter the fractures 1.6 times more than men, total of 61% of osteoporotic fractures.[3]
  • It is estimated than in 2050, the rate of hip fracture will increase 310% and 240% in male and females, respectively, in contrast with 1990.[5]
  • When the lifetime risks of fractures in hip, forearm, and vertebrae become clinically interpreted, it will equal to 40%, that is the same as cardiovascular events.[6]
  • In Europe the social and economical effects of osteoporosis is greater than that resulted from cancers (except lung cancer), and also higher than rheumatoid arthritis, asthma, and cardiac disease due to hypertension.[3]
  • Women of more than 45 years old spend more days in hospital due to osteoporosis and its complications than any other disease, such as diabetes, myocardial infarction, and breast cancer.[7]
  • It is assumed that large percentage (almost 80%) of individuals with high risk of fracture and already history of at least one osteoporotic fracture, are neither identified nor treated.[8]
  • International osteoporosis foundation (IOF) study in 11 countries, showed that lack of oteoporosis suitable diagnosis and treatment were because of some factors, including denial of personal risk by postmenopausal women, lack of dialogue about osteoporosis with their doctor, and restricted access to diagnosis and treatment before the first fracture.[9]

Europe

  • In most of the European countries, bone mineral density (BMD) measurements are not so utilized; it is assumed to be due densitometers limited availability, limited technicians in charge of performing scans, low attitude and insight in using the test, and limited or nonexistent reimbursement.[10]
  • WHO estimation of the osteoporosis population in Europe is 22 million females and 5.5 million males in 2010 (total of 27.5 million); which is going to rise about 23% until 2025 (total of 33.9 million). New fractures in the EU during 2010 was estimated at 3.5 million, including approximately 620,000 hip fractures, 520,000 vertebral fractures, 560,000 forearm fractures and 1,800,000 other fractures. The number of fractures in a year assumed to grow from 3.5 million in 2010 to 4.5 million in 2025, suggesting a 28% increase. 43,000 people have died in 2010 because of osteoporosis complications. It is assumed that osteoporotic fractures are the main reason of 26,300 life-year lost in Europe, in 2010.[11]
  • In Europe the whole cost of medical therapies for osteoporosis in 2010 was €37 billion, in which 66% was for acute fractures management, 29% was for long-term fracture outcome management, and 5% was for medical prevention. On the other hand, holistic burden of osteoporosis in Europe assumed to be loss of 1,180,000 life years (quality adjusted (QALY)), most of them because of prior osteoporotic fractures. Regarding that one QALY is equal value of 2xGDP, it is assumed that the total burden of osteoporosis become €60.4 billion, in 2010. Surprisingly, the QALY number will raise from 1.2 million in 2010 to about 1.4 million years in 2025, with 20% increase.[11]
The economic burden of osteoporosis, in 2010 and 2025[12]
Country New osteoporotic fractures

in 2010

People over 50 with osteoporosis

in 2010

Economic burden each year Economic burden

by 2025

Increase percentage

by 2025

Germany 725,000 5,020,000 € 9 billion (€ 9,008 million) € 11.2 billion (€11,261 million) 25%
UK 536,000 3,210,000 £ 3,496 (€ 5,408) million £ 5,465 (€ 6,723) million 24%
France 377,000 3,480,000 € 4,853 million € 6,111 million 26%
Spain 204,000 2,450,000 € 2,842 million € 3.68 billion 30%
Sweden 107,000 520,000 € 1,486 million € 1.8 billion (€ 1,828 million) 23%
Denmark 66,000 280,000 € 1,055 million €1.3 billion (€ 1,344 million) 27%
Greece 86,000 640,000 € 680 million € 814 million 20%
Belgium 80,000 600,000 € 606 million € 733 million 21%
Romania 94,000 590,000 € 577 million € 151 million 17%
Czech Republic 72,000 530,000 € 273 million € 352 million 29%
Slovenia 16,000 590,000 € 56 million € 77 million 37%

Denmark

From 1987-1997, in a 10-year period, the rate of osteoporosis increased by 56%; among which 41% was in women and 104% was in men, more than 50 years old.[13]

Finland

Hip fracture rate increased by 70% from 1992 to 2002, in a 10-year period.[14]

Georgia

It is assumed that only one patient with hip fracture out of four is seeking hospital care.[15]

Germany

A study of fracture rate showed that 45% of men and 31% of women between 25 to 74 years old experience fracture; while 42% of men and 40% of women between 65 to 74 years old encounter fractures.[16]

Greece

Hip fracture rate was increased by 7.6% from 1977 until 1992, in a five year period.[17]

Kazakhstan

Due to some various factors, more than half of the people with hip fracture are not hospitalized. Whereas more than 70% are not admitted for hip surgery.[18]

Romania

The whole prevalence of postmenopausal osteoporosis is 11.5%. It is assumed that in Romanian women more than 55 years old, one out of three people involved in osteoporosis or osteopenia.[18]

Russia

14 million people (about 10%) are involved in osteoporosis, while 20 million suffer from osteopenia; however, Russia has 34 million high fracture risk people. It is assumed that in some cities 45-52% of patients with a severe osteoporotic fracture have not suitable hospitalization or surgery until 1 year. Among those patients with hip fracture who could survive, only about 10% would have previous daily activity level.[18]

Slovenia

General hip fracture rate has been increased by 40% from 1998 to 2005, a seven year period.[18]

Spain

The increase rate of new hip fracture case was 54% from 1998 to 2002, a 14-year period. However, the women (64%) were more increased than men (19%).[19]

The fracture was leading to demise of 13% of patients after 3 months, and 38% of them after 24 months. Furthermore, patients suffered from vertebral fracture would experienced loosing functionality (45%) or disability (50%).

Sweden

23% of women and 11% of men over 50 years of age are probable to involved in osteoporotic fracture. Also, 15% of women and 8% of men have the risk of vertebral fractures. Any other oteoporotic fractures during lifetime are 46% in women and 22% in men.[20] The total death rate resulting from hip fractures is the same as breast cancer deaths.[21]

Switzerland

It is predicted that with maintaining the current conditions of osteoporotic prevention and treatment, in a 20 years period from 2000, the osteoporotic fracture rates of hip, vertebrae, and wrist grow by 33%, 27%, and 19%, respectively.[22]

It is assumed that annual economic burden of osteoporosis is commonly greater than myocardial infarction, cerebrovascular strokes, and also breast cancer; slightly less than chronic obstructive pulmonary disease. Taking only women, the burden become more than all of the diseases.[23]

Ukraine

7 million womens (28% of all women) are involved in bone mass loss and in risk of osteoporosis. Most of the Ukrainians experiencing vitamin D insufficiency or deficiency.[18]

UK

Half of women and one-fifth of men would have fracture when pass 50 years of age.[24]

North America

Canada

About one and half million Canadians, mostly postmenopausal and elderly are suffering from osteoporosis. 25% of women and 12.5% of men of more than 50 years old experience degrees of vertebral fractures. It is assumed that total amount of hip fractures are 30,000 occurrence, annually; which it to grow to quadruple measure until 2030. [25]

USA

44 million people of more than 50 years old in US are suffering from osteoporosis, more than half of over 50 years people. Remaining the current conditions and utilities, it is estimated that more than 61 million people in 2020 will involved in osteoporosis. Women are 80% of the osteoporotic population.[26]

Antiresorptive drugs' cost input table, based on National Osteoporosis Foundation (NOF), 2017[26]

Drug Name, Labeled Dose, Administration Route Strength

(Pen Size)

Pen cost Net Price

after modulation

Base-Case Tx Duration Acquisition Cost Per Tx Course
Teriparatide 20 mcg SC QD 250 mcg/ml (2.4 ml) $2,997.90 $1,866.34 2 years $48,691
Abaloparatide 80 mcg SC QD 3,120 mcg/1.56 ml $1,625 $1,186.25 2 years $29,312
Zoledronic Acid 5 mg IV Q year 5 mg/100 ml $306 $306 6 years $1,837

PTH analogues (teriparatide and abaloparatide) have more prices and QALYs in contrast with zoledronate. Teriparatide and abaloparatide are $43,440 and $22,061 more costly than zoledronate.

Latin America

It is estimated that in a period of 60 years, from 1990 to 2050, Latin America are experiencing a 5 times increase in hip fracture, in men and women between 50 to 64 years of age. Surprisingly, it will be 8 times for age of more than 65 years.[27]

Regarding 655,648 hip fractures in 2050, it will directly cost about $13 billion.[28]

23% to 30% of the patients with hip fracture will die in the first year after fracture, more in men compared to women.[29]

Vertebral fractures prevalence in women more than 50 years of age is 15%, in which 7% is among 50-60 years and 28% is among more than 80 years women.[30]

Argentina

Half of the over 50 years women suffer from osteopenia and one fourth of them involved in osteoporosis. It is estimated to be 5.24 million osteopenic and 2.62 million osteoporotic women in 2050. Population of above 50 years old are encountering 90 hip fractures a day (34,000 per year). It will be more than 63,000 one in women and more than 13,000 in men, by 2050. Vertebral fracture rate in postmenopausal women is 16.2%. Total burden of both hip and vertebral osteoporotic fractures, including hospitalization costs, is more than $190 million per each year.[31]

Brazil

One person in every 17 people, totally about 10 million people are suffering from osteoporosis. 37.5% of men and 21% of women would have osteoporotic fracture during life.[32] One person in every 3 patients encountering hip fracture would have osteoporosis, however, one out of five will receive treatment.[33] The total economic burden of osteoporotic fracture is assumed to be $6 million.[34]

Chile

46% of women of more than 50 years of age were osteopenic and 22% were osteoporotic, in 1985.

Mexico

25% of people has lowered bone mineral density (BMD), making them prone to hip fracture (8.5% males and 4% females). The whole economic burden of hip fracture in 2006 was $97 million.[35]

Venezuela

5.5% of women and 1.5% men of 50 years of age would have hip fracture. For other sites of fractures the percentages are 13.6% and 3.5% for women and men, respectively. It is assumed that 9.6 hip fracture a day in 1995, will grow to 67 fractures a day in 2030. After 70 years of age only one out of ten people may have normal bone mineral density.[36]

Middle East and Africa

Vitamin D deficiency is really prevalent in this region, despite vast majority of day hours sun there. The rate of death after osteoporotic fracture in the area is 2-3 times of Western societies. The major reason for the issue is lack of utilities, less than one DXA scan for 1 million people in country of Morocco.[37]

Egypt

Among postmenopausal women 53.9% have osteopenia and 28.4 have osteoporosis.[38]

Iran

In 2010, the hip fracture rate was 50,000, and will become 62,000 in 2020. The hip fracture rate of Iran is 0.85% of worldwide and 12.4% of Middle east whole burden.[39]

Jordan

Hip fractures are growing from 1008 per year in 2008 to four times of the original size in 2050.[18]

Lebanon

Surprisingly, the age and BMD measures in patients with hip fractures are different from other countries, they are younger and osteopenic instead of old and osteoporotic.[40]

Saudi Arabia

Total cost of managing femoral fracture is $ 1.14 billion.[41]

Syria

From approximately 15,000 vertebral osteoporotic fractures per year, only one-fifth seeking medical services.[18]

Turkey

It is assumed that 24,000 hip fracture in male and female above 50 years of age will become 36,000 in 2020.[42]

Asia

In 2050, more than half of the whole hip fractures of the world would be from Asia. The main reason is improving the utilities and developing the medical services availability; currently, more than half of the population of China are living in rural area, managing fractures conservatively at home and not seeking any medical services. On the other hand major facilities, like densitometers, will become more accessible for everyone.[43]

China

70 million cases of osteoporosis are leading to 678,000 hip fractures, annually. Men are more suffering from hip fracture than women. The holistic prevalence of osteoporosis in women is about two folds of men. Total economic burden of one hip fracture is about $3,603, which may measured as $1.5 billion per year. It is assumed to grow to $12.5 billion in 2020 and more than $ 264.7 billion in 2050. Facility limitation is the major problem of China in managing osteoporosis; in 2008 the whole DXA scanners number for the whole 1.3 billion Chinese was 450. [44][45]

Hong Kong, China

For a 6 million population, hip fracture management are in charge of 1% of whole hospital economic burden, $17 million.[46]

India

From 2003 to 2013, the prevalence of osteoporosis become from 26 million to 36 million patients. 52% of osteopenia and 29% of osteoporosis was recorded.[47]

Japan

The postmenopausal women involved in vertebral osteoporosis (35%) more than hip osteoporosis (9.5%). Hip fractures are growing from 153,000 in 2010 to 238,000 in 2030.[48]

[49]

Korea

In a 10-year period, number of hip fractures raised 300%. In people more than 75 years hip fracture occurs in 4.3 per 1000 women and 2.97 per 1000 men.

Singapore

Hip fracture in men and women have became 1.5 times and 5 times, respectively, in 1998 compared to 1960's.[50]

Oceania

Australia

Total economic burden of the osteoporosis is $7.4 billion, annually. Whole number of osteoporosis are 2.2 million cases, while 42% of men and 51% of women are encountering bone density loss. Lifetime risk of women for fragility fractures is about twice the risk of men.[51]

New Zealand

Total economic burden of osteoporosis is more than $1.15 billion, annually. It is assumed to be increased by more than 30%, in 2020. Women encounter osteoporotic fractures more than men. 5% of all fractures occurred in hip[52]

References

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  3. 3.0 3.1 3.2 Johnell O, Kanis JA (2006). "An estimate of the worldwide prevalence and disability associated with osteoporotic fractures". Osteoporos Int. 17 (12): 1726–33. doi:10.1007/s00198-006-0172-4. PMID 16983459.
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