Osteoporosis cost-effectiveness of therapy
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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]
Overview
44 million people of more than 50 years old in the 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 would be suffering from osteoporosis. Women constitute 80% of the osteoporotic population. Parathormone (PTH) analogues (teriparatide and abaloparatide) have more prices and quality-adjusted life years (QALYs) in contrast with zoledronate. Teriparatide and abaloparatide are $43,440 and $22,061 more costly than zoledronate. 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, the holistic burden of osteoporosis in Europe assumed to be the loss of 1,180,000 life years (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 rise from 1.2 million in 2010 to about 1.4 million years in 2025, with 20% increase.
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, worldwide, 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 a fracture rate 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 by 310% and 240% in male and females, respectively, in contrast with 1990's.[5]
- When the lifetime risk of fractures in hip, forearm, and vertebrae is clinically interpreted, it is equal to 40%, that is the same as cardiovascular events.[6]
- In Europe, the social and economical effect of osteoporosis is greater than that resulting 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 history of at least one osteoporotic fracture, is neither identified nor treated.[8]
- International osteoporosis foundation (IOF) study in 11 countries, showed that lack of osteoporosis 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
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
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
- 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
Syria
- From approximately 15,000 vertebral osteoporotic fractures per year, only one-fifth seek 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
- ↑ Smith R (1984). "Osteoporosis--a problem of bone formation?". Postgrad Med J. 60 (704): 383–5. PMC 2417886. PMID 6379627.
- ↑ Martin AD, Houston CS (1987). "Osteoporosis, calcium and physical activity". CMAJ. 136 (6): 587–93. PMC 1491904. PMID 3545420.
- ↑ 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.
- ↑ "Who are candidates for prevention and treatment for osteoporosis?". Osteoporos Int. 7 (1): 1–6. 1997. PMID 9102057.
- ↑ Gullberg, B.; Johnell, O.; Kanis, J.A. (1997). "World-wide Projections for Hip Fracture". Osteoporosis International. 7 (5): 407–413. doi:10.1007/PL00004148. ISSN 0937-941X.
- ↑ Kanis JA (2002). "Diagnosis of osteoporosis and assessment of fracture risk". Lancet. 359 (9321): 1929–36. doi:10.1016/S0140-6736(02)08761-5. PMID 12057569.
- ↑ Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D (1997). "Guidelines for diagnosis and management of osteoporosis. The European Foundation for Osteoporosis and Bone Disease". Osteoporos Int. 7 (4): 390–406. PMID 9373575.
- ↑ Nguyen TV, Center JR, Eisman JA (2004). "Osteoporosis: underrated, underdiagnosed and undertreated". Med. J. Aust. 180 (5 Suppl): S18–22. PMID 14984358.
- ↑ "How Fragile is Her Future | International Osteoporosis Foundation".
- ↑ "Osteoporosis in the European Community: A Call to Action | International Osteoporosis Foundation".
- ↑ 11.0 11.1 Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J; et al. (2013). "Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA)". Arch Osteoporos. 8: 136. doi:10.1007/s11657-013-0136-1. PMC 3880487. PMID 24113837.
- ↑ Svedbom A, Hernlund E, Ivergård M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jönsson B, Kanis JA (2013). "Osteoporosis in the European Union: a compendium of country-specific reports". Arch Osteoporos. 8: 137. doi:10.1007/s11657-013-0137-0. PMC 3880492. PMID 24113838.
- ↑ Giversen IM (2006). "Time trends of age-adjusted incidence rates of first hip fractures: a register-based study among older people in Viborg County, Denmark, 1987-1997". Osteoporos Int. 17 (4): 552–64. doi:10.1007/s00198-005-0012-y. PMID 16408148.
- ↑ Lönnroos E, Kautiainen H, Karppi P, Huusko T, Hartikainen S, Kiviranta I, Sulkava R (2006). "Increased incidence of hip fractures. A population based-study in Finland". Bone. 39 (3): 623–7. doi:10.1016/j.bone.2006.03.001. PMID 16603427.
- ↑ "www.iofbonehealth.org" (PDF).
- ↑ Meisinger C, Wildner M, Stieber J, Heier M, Sangha O, Döring A (2002). "[Epidemiology of limb fractures]". Orthopade (in German). 31 (1): 92–9. PMID 11963475.
- ↑ Paspati I, Galanos A, Lyritis GP (1998). "Hip fracture epidemiology in Greece during 1977-1992". Calcif. Tissue Int. 62 (6): 542–7. PMID 9576984.
- ↑ 18.0 18.1 18.2 18.3 18.4 18.5 18.6 "Eastern European & Central Asian Audit | International Osteoporosis Foundation".
- ↑ Hernández JL, Olmos JM, Alonso MA, González-Fernández CR, Martínez J, Pajarón M, Llorca J, González-Macías J (2006). "Trend in hip fracture epidemiology over a 14-year period in a Spanish population". Osteoporos Int. 17 (3): 464–70. doi:10.1007/s00198-005-0008-7. PMID 16283063.
- ↑ Kanis JA, Johnell O, Oden A, Sembo I, Redlund-Johnell I, Dawson A, De Laet C, Jonsson B (2000). "Long-term risk of osteoporotic fracture in Malmö". Osteoporos Int. 11 (8): 669–74. PMID 11095169.
- ↑ Kanis JA, Oden A, Johnell O, De Laet C, Jonsson B, Oglesby AK (2003). "The components of excess mortality after hip fracture". Bone. 32 (5): 468–73. PMID 12753862.
- ↑ Schwenkglenks M, Lippuner K, Häuselmann HJ, Szucs TD (2005). "A model of osteoporosis impact in Switzerland 2000-2020". Osteoporos Int. 16 (6): 659–71. doi:10.1007/s00198-004-1743-x. PMID 15517190.
- ↑ Lippuner K, von Overbeck J, Perrelet R, Bosshard H, Jaeger P (1997). "Incidence and direct medical costs of hospitalizations due to osteoporotic fractures in Switzerland". Osteoporos Int. 7 (5): 414–25. PMID 9425498.
- ↑ van Staa TP, Dennison EM, Leufkens HG, Cooper C (2001). "Epidemiology of fractures in England and Wales". Bone. 29 (6): 517–22. PMID 11728921.
- ↑ Tarride JE, Hopkins RB, Leslie WD, Morin S, Adachi JD, Papaioannou A, Bessette L, Brown JP, Goeree R (2012). "The burden of illness of osteoporosis in Canada". Osteoporos Int. 23 (11): 2591–600. doi:10.1007/s00198-012-1931-z. PMC 3483095. PMID 22398854.
- ↑ 26.0 26.1 "cdn.nof.org" (PDF).
- ↑ Cooper C, Campion G, Melton LJ (1992). "Hip fractures in the elderly: a world-wide projection". Osteoporos Int. 2 (6): 285–9. PMID 1421796.
- ↑ Johnell O (1997). "The socioeconomic burden of fractures: today and in the 21st century". Am. J. Med. 103 (2A): 20S–25S, discussion 25S–26S. PMID 9302894.
- ↑ Riera-Espinoza G (2009). "Epidemiology of osteoporosis in Latin America 2008". Salud Publica Mex. 51 Suppl 1: S52–5. PMID 19287895.
- ↑ Clark P, Cons-Molina F, Deleze M, Ragi S, Haddock L, Zanchetta JR, Jaller JJ, Palermo L, Talavera JO, Messina DO, Morales-Torres J, Salmeron J, Navarrete A, Suarez E, Pérez CM, Cummings SR (2009). "The prevalence of radiographic vertebral fractures in Latin American countries: the Latin American Vertebral Osteoporosis Study (LAVOS)". Osteoporos Int. 20 (2): 275–82. doi:10.1007/s00198-008-0657-4. PMID 18584111.
- ↑ "Epidemiology, costs, and burden of osteoporosis in Argentina, 2009 | SpringerLink".
- ↑ Siqueira FV, Facchini LA, Hallal PC (2005). "The burden of fractures in Brazil: a population-based study". Bone. 37 (2): 261–6. doi:10.1016/j.bone.2005.04.002. PMID 15921970.
- ↑ Zabaglia, Silval Fernando Cardoso; Costa-Paiva, Lúcia Helena Simões; Pinto-Neto, Aarão Mendes (2001). "A Ligadura Tubária é Fator de Risco para a Redução da Densidade Mineral Óssea em Mulheres na Pós-menopausa?". Revista Brasileira de Ginecologia e Obstetrícia. 23 (10). doi:10.1590/S0100-72032001001000002. ISSN 0100-7203.
- ↑ Araújo, Denizar Vianna; Oliveira, Juliana H. A. de; Bracco, Oswaldo Luís (2005). "Custo da fratura osteoporótica de fêmur no sistema suplementar de saúde brasileiro". Arquivos Brasileiros de Endocrinologia & Metabologia. 49 (6): 897–901. doi:10.1590/S0004-27302005000600007. ISSN 0004-2730.
- ↑ Clark P, Carlos F, Barrera C, Guzman J, Maetzel A, Lavielle P, Ramirez E, Robinson V, Rodriguez-Cabrera R, Tamayo J, Tugwell P (2008). "Direct costs of osteoporosis and hip fracture: an analysis for the Mexican healthcare system". Osteoporos Int. 19 (3): 269–76. doi:10.1007/s00198-007-0496-8. PMID 18060586.
- ↑ "www.iofbonehealth.org" (PDF).
- ↑ Baddoura R, Hoteit M, El-Hajj Fuleihan G (2011). "Osteoporotic fractures, DXA, and fracture risk assessment: meeting future challenges in the Eastern Mediterranean Region". J Clin Densitom. 14 (4): 384–94. doi:10.1016/j.jocd.2011.03.009. PMID 21839659.
- ↑ "Osteopoorosis Cairo April 2011 v1".
- ↑ Ahmadi-Abhari S, Moayyeri A, Abolhassani F (2007). "Burden of hip fracture in Iran". Calcif. Tissue Int. 80 (3): 147–53. doi:10.1007/s00223-006-0242-9. PMID 17340222.
- ↑ Maalouf G, Bachour F, Hlais S, Maalouf NM, Yazbeck P, Yaghi Y, Yaghi K, El Hage R, Issa M (2013). "Epidemiology of hip fractures in Lebanon: a nationwide survey". Orthop Traumatol Surg Res. 99 (6): 675–80. doi:10.1016/j.otsr.2013.04.009. PMID 24007698.
- ↑ Bubshait D, Sadat-Ali M (2007). "Economic implications of osteoporosis-related femoral fractures in Saudi Arabian society". Calcif. Tissue Int. 81 (6): 455–8. doi:10.1007/s00223-007-9090-5. PMID 18066484.
- ↑ Tuzun S, Eskiyurt N, Akarirmak U, Saridogan M, Senocak M, Johansson H, Kanis JA (2012). "Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study". Osteoporos Int. 23 (3): 949–55. doi:10.1007/s00198-011-1655-5. PMID 21594756.
- ↑ Gullberg B, Johnell O, Kanis JA (1997). "World-wide projections for hip fracture". Osteoporos Int. 7 (5): 407–13. PMID 9425497.
- ↑ Zhang L, Cheng A, Bai Z, Lu Y, Endo N, Dohmae Y, Takahashi HE (2000). "Epidemiology of cervical and trochanteric fractures of the proximal femur in 1994 in Tangshan, China". J. Bone Miner. Metab. 18 (2): 84–8. PMID 10701163.
- ↑ Luo LZ, Xu L (2005). "[Study on direct economic-burden and its risk factors of osteoporotic hip fracture]". Zhonghua Liu Xing Bing Xue Za Zhi (in Chinese). 26 (9): 669–72. PMID 16471214.
- ↑ Lau EM (2001). "Epidemiology of osteoporosis". Best Pract Res Clin Rheumatol. 15 (3): 335–44. doi:10.1053/berh.2001.0153. PMID 11485333.
- ↑ Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N (2005). "Bone status of Indian women from a low-income group and its relationship to the nutritional status". Osteoporos Int. 16 (12): 1827–35. doi:10.1007/s00198-005-1933-1. PMID 15959616.
- ↑ Iki M, Kagamimori S, Kagawa Y, Matsuzaki T, Yoneshima H, Marumo F (2001). "Bone mineral density of the spine, hip and distal forearm in representative samples of the Japanese female population: Japanese Population-Based Osteoporosis (JPOS) Study". Osteoporos Int. 12 (7): 529–37. doi:10.1007/s001980170073. PMID 11527049.
- ↑ Hagino H, Katagiri H, Okano T, Yamamoto K, Teshima R (2005). "Increasing incidence of hip fracture in Tottori Prefecture, Japan: trend from 1986 to 2001". Osteoporos Int. 16 (12): 1963–8. doi:10.1007/s00198-005-1974-5. PMID 16133645.
- ↑ Koh LK, Sedrine WB, Torralba TP, Kung A, Fujiwara S, Chan SP, Huang QR, Rajatanavin R, Tsai KS, Park HM, Reginster JY (2001). "A simple tool to identify asian women at increased risk of osteoporosis". Osteoporos Int. 12 (8): 699–705. PMID 11580084.
- ↑ Sambrook PN, Seeman E, Phillips SR, Ebeling PR (2002). "Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit". Med. J. Aust. 176 Suppl: S1–16. PMID 12049064.
- ↑ Brown P, McNeill R, Leung W, Radwan E, Willingale J (2011). "Current and future economic burden of osteoporosis in New Zealand". Appl Health Econ Health Policy. 9 (2): 111–23. doi:10.2165/1153150-000000000-00000. PMID 21271750.