Accepted Article
Commentary
The osteoporosis treatment gap†
John A Kanis1*, Axel Svedbom2,3, Nicholas Harvey4, Eugene V McCloskey1
1
Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
2
OptumInsight, Stockholm, Sweden; 3Unit of Dermatology and Venerology, Department of Medicine, Karolinska University, Stockholm, Sweden 4 MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK. Author for correspondence Prof John A Kanis ()Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, UK; Tel: +44 114 285 1109; Fax: +44 114 285 1813; [email protected]
†
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: [10.1002/jbmr.2301] Initial Date Submitted April 12, 2014; Date Revision Submitted May 6, 2014; Date Final Disposition Set May 15, 2014 Journal of Bone and Mineral Research © 2014 American Society for Bone and Mineral Research DOI 10.1002/jbmr.2301
1
Accepted Article
Many guidelines for the assessment and treatment of osteoporosis recommend that
intervention be considered in men and women who have sustained a fragility fracture. (1) Guidelines in North America (2, 3) specifically refer to a prior hip fracture
(and spine fracture) as a condicio sine qua non for treatment because of the marked
effect of fractures at these sites on both morbidity and mortality. In addition, hip
fractures have large economic consequences. For example, hip fractures account for 17% of all osteoporotic fractures in Europe but comprise 54% of the direct cost of
fractures. (1) The need for treatment arises because of the increased risk of a second fracture (4) which is particularly acute in the immediate post‐fracture period when
fracture rates are substantially increased. (5‐7) Despite a number of advances, particularly in the diagnosis of osteoporosis, the
assessment of fracture risk, the development of interventions that reduce the risk of
fractures and the production of practice guidelines, many surveys indicate that a
minority of men and women at high fracture risk actually receive treatment. (8‐14) in patients who sustain a fragility fracture, fewer than 20% of individuals receive therapies to reduce the risk of future fracture within the year following the fracture.
(11, 12, 15‐18)
Paradoxically, the therapeutic care gap may be particularly wide in the
elderly in whom the importance and impact of treatment is high; studies have shown that as few as 10% of older women with fragility fractures receive any osteoporosis therapy (oestrogens not considered). (11, 19, 20) Furthermore, treatment rates
following a fracture are lower for those individuals who reside in long term care. (12) This contrasts the situation following myocardial infarction, for which condition a significant care gap has been overcome in the past 15 years: 75% of such individuals now receive beta blockers to help prevent recurrent myocardial infarction. (21)
In this issue of the JBMR, Solomon and colleagues report on the uptake of osteoporosis medications in the year following hip fracture in a large retrospective analysis of nearly 100,000 men and women aged 50 years or more who were hospitalized for hip fracture over a period of one year. (22) The study, based on U.S.
administrative insurance claims data, followed the uptake of osteoporosis medication within 12 months after discharge from hospital. The estimated probability of receiving osteoporosis medication within 12 months after discharge 2
Accepted Article
from hospital was 28.5% over this time period but varied by year. Indeed, the rates declined significantly over a 10 year interval from 40.2% in 2002, to 20.5% in 2011. European studies have compared the treatment gap across countries, albeit indirectly. The number of patients treated in each country was computed from IMS Health sales data for 2010, adjusted for suboptimal adherence, and expressed as
treatment years. (1) The use of hormone replacement therapy was excluded since the majority of women take this treatment for menopausal symptoms rather than for osteoporosis. The proportion of patients eligible for treatment depended on defining an intervention threshold i.e. the risk of fracture above which treatment can be recommended. In this report, the intervention threshold set was at the 10‐year fracture probability equivalent to women with a prior fragility fracture without knowledge of BMD as adopted in several European guidelines. (23‐25) Thus, the intervention threshold can be likened to a ‘fracture threshold’ expressed in terms of fracture probability. The study showed a very wide inter‐country variation in the treatment penetration of individuals at high risk for osteoporotic fractures. The
treatment gap varied from 25% in Spain to 95% in Bulgaria. Large treatment gaps were identified in countries with populations at both high and low risk of fracture.
In total in the EU, it was estimated that, out of the 21.3 million men and women who exceeded the risk level, 12.3 million were untreated in 2010. (1) These figures are
conservative since an undetermined proportion of low risk women will have received treatment.( 8) In an international prospective study, low uptakes of pharmacological intervention after hip fracture was also observed. Among 1,795 patients who sustained a low‐energy hip fractures in ten countries (Australia, Austria, Estonia,
France, Italy, Lithuania, Mexico, Russia, Spain, and the UK), only 27% were prescribed pharmacological fracture prevention after the hip fracture. (26)
It is disturbing that so many in our society at high risk of fracture do not receive appropriate treatment and it is scandalous that this treatment gap is so marked in the case of hip fracture. The most worrying finding, however, is the downward trend in the number of patients being treated after hip fracture which, in the study of Solomon et al, (22) appears to have decreased by about 50% over a 10 year period. 3
Accepted Article
The phenomenon is not confined to hip fracture cases. Nor is it a characteristic only of the US. In Europe, treatment uptake for osteoporosis increased progressively up to 2008, thereafter plateaued, and has subsequently fallen in more recent years (Fig. 1). The phenomenon is most marked in the case of the bisphosphonates and is evident on a country by country basis. (27)
Fig. 1 Estimated sales (Defined daily doses (DDDs)/100 population aged 50+ years) from 2001 to 2011 in the European Union. Reproduced from reference (1) Hernlund et al. Arch Osteoporos. 2013; 8: 136, with kind permission from Springer Science and Business Media.
None of these studies provide an insight into the causes underlying the substantial and increasing treatment gap. Factors that may play a role in the US include a decline in BMD testing due to reimbursement issues and lack of intensive detailing by pharmaceutical companies. Solomon et al point the finger at the lay press for raising awareness over the last decade of the potential side effects of the bisphosphonates such as osteonecrosis of the jaw, atypical femoral fractures and atrial fibrillation. Indeed, many doctors, dentists and patients are now more
frightened of the rare but serious side effects than they are of the disease and the
fractures that arise. Notwithstanding, the lay press is simply the messenger bringing news and opinion from the scientific community, some or much of which may be ill‐
judged. The paradox arises that we seek to treat individual patients to the highest
4
Accepted Article
standards but at the same time disservice and disadvantage the wider osteoporosis community. It is now time for us all to accept a long overdue collective responsibility for our failures and to work cohesively to improve the management of our patients. One hope in decreasing the treatment gap is the international development of fracture liaison services to better identify patients who have had a fragility
fracture.(28)
Competing interests
The authors declare no competing interests with regard to this paper
References
1.
Hernlund E, Svedbom A, Ivergård M et al. 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. 2013; 8:136. DOI: 10.1007/s11657‐013‐0136‐1
2.
National Osteoporosis Foundation (2008) Clinician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation. 2003 www.nof.org
3.
Papaioannou A, Morin S, Cheung AM et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010; 182:1864‐73..
4.
Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, III, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2004; 15: 721‐39
5.
Johnell O, Oden A, Caulin F, Kanis JA. Acute and long term increase in fracture risk after hospitalization for vertebral fracture. Osteoporos Int. 2001; 12:207–214
6.
Johnell O, Kanis JA, Oden A et al. (2004) Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004; 15: 175‐179.
7.
Lindsay R, Silverman SL, Cooper C et al. Risk for new vertebral fracture in the year following a fracture. JAMA. 2001; 285:320–323
8.
Díez‐Pérez A, Hooven FH, Adachi JD et al. Regional differences in treatment for osteoporosis. The Global Longitudinal Study of Osteoporosis in Women (GLOW). Bone. 2011; 49: 493‐8.
9.
Guggina P, Flahive J, Hooven FH et al. Characteristics associated with anti‐osteoporosis medication use: Data from the Global Longitudinal Study of Osteoporosis in Women (GLOW) USA cohort. Bone 2012; 51: 975‐980
10.
Jennings LA, Auerbach AD, Maselli J, Pekow PS, Lindenauer PK, Lee SJ. Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc. 2010; 58: 650‐7.
5
Accepted Article
11.
Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am. 2000; 82‐A:1063‐1070
12.
Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum. 2006; 35:293‐ 305
13.
Nayak S, Roberts MS, Greenspan SL. Factors associated with diagnosis and treatment of osteoporosis in older adults. Osteoporos Int. 2009; 20:1963‐1967
14.
Vaile J, Sullivan L, Bennett C, Bleasel J. First Fracture Project: addressing the osteoporosis care gap. Intern Med J. 2007; 37:717‐720
15.
Papaioannou A, Giangregorio L, Kvern B, Boulos P, Ioannidis G, Adachi JD. The osteoporosis care gap in Canada. BMC Musculoskelet Disord 2004; 5:11
16.
Bessette L, Ste‐Marie LG, Jean Set al. Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti‐fracture patient health‐management programme. Contemp Clin Trials 2008; 29:194‐210
17.
Elliot‐Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004; 15:767‐778
18.
Haaland DA, Cohen DR, Kennedy CC, Khalidi NA, Adachi JD, Papaioannou A. Closing the osteoporosis care gap: increased osteoporosis awareness among geriatrics and rehabilitation teams. BMC Geriatr. 2009; 9:28
19.
Swedish National Board of Health and Welfare. Quality and Efficiency in Swedish Health Care. In. Swedish Association of Local Authorities and Regions Swedish National Board of Health and Welfare, Stockholm 2009.
20.
Borgstrom F, Johnell O, Kanis JA, Jonsson B, Rehnberg C. At what hip fracture risk is it cost‐ effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int. 2006; 17:1459‐1471
21.
Austin P, Tu J, Ko D, Alter D. Factors associated with the use of evidence‐based therapies fter discharge among elderly patients with myocardial infarction. Canad Medl Assoc J. 2008; 179:901‐908
22.
Solomon DH, Johnston SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD. Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res 2014; xx: yyy‐yyy.
23.
Compston J, Cooper A, Cooper C et al on behalf of the National Osteoporosis Guideline Group (NOGG). Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 2009; 62:105‐108.
24.
Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster J‐Y on behalf of the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation ( IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013; 24: 23‐57.
25.
Lekawasam S, Adachi JD, Agnusdei D et al for the Joint IOF‐ECTS GIO Guidelines Working Group. A framework for the development of guidelines for the management of glucocorticoid‐ induced osteoporosis. Osteoporos Int. 2012; 23:2257‐76.
6
Accepted Article
26.
Wintzell V, Ivergård M, Tankó LB et al. Resource use related to hip fractures based on data from the ICUROS study. Value in Health 2013; 16: A573‐A574.
27.
Svedbom A, Hernlund E, Ivergård, et al and the EU review panel of the IOF. Osteoporosis in the European Union: A compendium of country‐specific reports. Arch f Osteoporos. 2013; 8: 137.
28.
Akesson K, Marsh D, Mitchell PJ et al; IOF Fracture Working Group. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013; 24::2135‐52.
7
Commentary
The osteoporosis treatment gap†
John A Kanis1*, Axel Svedbom2,3, Nicholas Harvey4, Eugene V McCloskey1
1
Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
2
OptumInsight, Stockholm, Sweden; 3Unit of Dermatology and Venerology, Department of Medicine, Karolinska University, Stockholm, Sweden 4 MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK. Author for correspondence Prof John A Kanis ()Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, UK; Tel: +44 114 285 1109; Fax: +44 114 285 1813; [email protected]
†
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: [10.1002/jbmr.2301] Initial Date Submitted April 12, 2014; Date Revision Submitted May 6, 2014; Date Final Disposition Set May 15, 2014 Journal of Bone and Mineral Research © 2014 American Society for Bone and Mineral Research DOI 10.1002/jbmr.2301
1
Accepted Article
Many guidelines for the assessment and treatment of osteoporosis recommend that
intervention be considered in men and women who have sustained a fragility fracture. (1) Guidelines in North America (2, 3) specifically refer to a prior hip fracture
(and spine fracture) as a condicio sine qua non for treatment because of the marked
effect of fractures at these sites on both morbidity and mortality. In addition, hip
fractures have large economic consequences. For example, hip fractures account for 17% of all osteoporotic fractures in Europe but comprise 54% of the direct cost of
fractures. (1) The need for treatment arises because of the increased risk of a second fracture (4) which is particularly acute in the immediate post‐fracture period when
fracture rates are substantially increased. (5‐7) Despite a number of advances, particularly in the diagnosis of osteoporosis, the
assessment of fracture risk, the development of interventions that reduce the risk of
fractures and the production of practice guidelines, many surveys indicate that a
minority of men and women at high fracture risk actually receive treatment. (8‐14) in patients who sustain a fragility fracture, fewer than 20% of individuals receive therapies to reduce the risk of future fracture within the year following the fracture.
(11, 12, 15‐18)
Paradoxically, the therapeutic care gap may be particularly wide in the
elderly in whom the importance and impact of treatment is high; studies have shown that as few as 10% of older women with fragility fractures receive any osteoporosis therapy (oestrogens not considered). (11, 19, 20) Furthermore, treatment rates
following a fracture are lower for those individuals who reside in long term care. (12) This contrasts the situation following myocardial infarction, for which condition a significant care gap has been overcome in the past 15 years: 75% of such individuals now receive beta blockers to help prevent recurrent myocardial infarction. (21)
In this issue of the JBMR, Solomon and colleagues report on the uptake of osteoporosis medications in the year following hip fracture in a large retrospective analysis of nearly 100,000 men and women aged 50 years or more who were hospitalized for hip fracture over a period of one year. (22) The study, based on U.S.
administrative insurance claims data, followed the uptake of osteoporosis medication within 12 months after discharge from hospital. The estimated probability of receiving osteoporosis medication within 12 months after discharge 2
Accepted Article
from hospital was 28.5% over this time period but varied by year. Indeed, the rates declined significantly over a 10 year interval from 40.2% in 2002, to 20.5% in 2011. European studies have compared the treatment gap across countries, albeit indirectly. The number of patients treated in each country was computed from IMS Health sales data for 2010, adjusted for suboptimal adherence, and expressed as
treatment years. (1) The use of hormone replacement therapy was excluded since the majority of women take this treatment for menopausal symptoms rather than for osteoporosis. The proportion of patients eligible for treatment depended on defining an intervention threshold i.e. the risk of fracture above which treatment can be recommended. In this report, the intervention threshold set was at the 10‐year fracture probability equivalent to women with a prior fragility fracture without knowledge of BMD as adopted in several European guidelines. (23‐25) Thus, the intervention threshold can be likened to a ‘fracture threshold’ expressed in terms of fracture probability. The study showed a very wide inter‐country variation in the treatment penetration of individuals at high risk for osteoporotic fractures. The
treatment gap varied from 25% in Spain to 95% in Bulgaria. Large treatment gaps were identified in countries with populations at both high and low risk of fracture.
In total in the EU, it was estimated that, out of the 21.3 million men and women who exceeded the risk level, 12.3 million were untreated in 2010. (1) These figures are
conservative since an undetermined proportion of low risk women will have received treatment.( 8) In an international prospective study, low uptakes of pharmacological intervention after hip fracture was also observed. Among 1,795 patients who sustained a low‐energy hip fractures in ten countries (Australia, Austria, Estonia,
France, Italy, Lithuania, Mexico, Russia, Spain, and the UK), only 27% were prescribed pharmacological fracture prevention after the hip fracture. (26)
It is disturbing that so many in our society at high risk of fracture do not receive appropriate treatment and it is scandalous that this treatment gap is so marked in the case of hip fracture. The most worrying finding, however, is the downward trend in the number of patients being treated after hip fracture which, in the study of Solomon et al, (22) appears to have decreased by about 50% over a 10 year period. 3
Accepted Article
The phenomenon is not confined to hip fracture cases. Nor is it a characteristic only of the US. In Europe, treatment uptake for osteoporosis increased progressively up to 2008, thereafter plateaued, and has subsequently fallen in more recent years (Fig. 1). The phenomenon is most marked in the case of the bisphosphonates and is evident on a country by country basis. (27)
Fig. 1 Estimated sales (Defined daily doses (DDDs)/100 population aged 50+ years) from 2001 to 2011 in the European Union. Reproduced from reference (1) Hernlund et al. Arch Osteoporos. 2013; 8: 136, with kind permission from Springer Science and Business Media.
None of these studies provide an insight into the causes underlying the substantial and increasing treatment gap. Factors that may play a role in the US include a decline in BMD testing due to reimbursement issues and lack of intensive detailing by pharmaceutical companies. Solomon et al point the finger at the lay press for raising awareness over the last decade of the potential side effects of the bisphosphonates such as osteonecrosis of the jaw, atypical femoral fractures and atrial fibrillation. Indeed, many doctors, dentists and patients are now more
frightened of the rare but serious side effects than they are of the disease and the
fractures that arise. Notwithstanding, the lay press is simply the messenger bringing news and opinion from the scientific community, some or much of which may be ill‐
judged. The paradox arises that we seek to treat individual patients to the highest
4
Accepted Article
standards but at the same time disservice and disadvantage the wider osteoporosis community. It is now time for us all to accept a long overdue collective responsibility for our failures and to work cohesively to improve the management of our patients. One hope in decreasing the treatment gap is the international development of fracture liaison services to better identify patients who have had a fragility
fracture.(28)
Competing interests
The authors declare no competing interests with regard to this paper
References
1.
Hernlund E, Svedbom A, Ivergård M et al. 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. 2013; 8:136. DOI: 10.1007/s11657‐013‐0136‐1
2.
National Osteoporosis Foundation (2008) Clinician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation. 2003 www.nof.org
3.
Papaioannou A, Morin S, Cheung AM et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010; 182:1864‐73..
4.
Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA, III, Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2004; 15: 721‐39
5.
Johnell O, Oden A, Caulin F, Kanis JA. Acute and long term increase in fracture risk after hospitalization for vertebral fracture. Osteoporos Int. 2001; 12:207–214
6.
Johnell O, Kanis JA, Oden A et al. (2004) Fracture risk following an osteoporotic fracture. Osteoporos Int. 2004; 15: 175‐179.
7.
Lindsay R, Silverman SL, Cooper C et al. Risk for new vertebral fracture in the year following a fracture. JAMA. 2001; 285:320–323
8.
Díez‐Pérez A, Hooven FH, Adachi JD et al. Regional differences in treatment for osteoporosis. The Global Longitudinal Study of Osteoporosis in Women (GLOW). Bone. 2011; 49: 493‐8.
9.
Guggina P, Flahive J, Hooven FH et al. Characteristics associated with anti‐osteoporosis medication use: Data from the Global Longitudinal Study of Osteoporosis in Women (GLOW) USA cohort. Bone 2012; 51: 975‐980
10.
Jennings LA, Auerbach AD, Maselli J, Pekow PS, Lindenauer PK, Lee SJ. Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc. 2010; 58: 650‐7.
5
Accepted Article
11.
Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am. 2000; 82‐A:1063‐1070
12.
Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum. 2006; 35:293‐ 305
13.
Nayak S, Roberts MS, Greenspan SL. Factors associated with diagnosis and treatment of osteoporosis in older adults. Osteoporos Int. 2009; 20:1963‐1967
14.
Vaile J, Sullivan L, Bennett C, Bleasel J. First Fracture Project: addressing the osteoporosis care gap. Intern Med J. 2007; 37:717‐720
15.
Papaioannou A, Giangregorio L, Kvern B, Boulos P, Ioannidis G, Adachi JD. The osteoporosis care gap in Canada. BMC Musculoskelet Disord 2004; 5:11
16.
Bessette L, Ste‐Marie LG, Jean Set al. Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti‐fracture patient health‐management programme. Contemp Clin Trials 2008; 29:194‐210
17.
Elliot‐Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004; 15:767‐778
18.
Haaland DA, Cohen DR, Kennedy CC, Khalidi NA, Adachi JD, Papaioannou A. Closing the osteoporosis care gap: increased osteoporosis awareness among geriatrics and rehabilitation teams. BMC Geriatr. 2009; 9:28
19.
Swedish National Board of Health and Welfare. Quality and Efficiency in Swedish Health Care. In. Swedish Association of Local Authorities and Regions Swedish National Board of Health and Welfare, Stockholm 2009.
20.
Borgstrom F, Johnell O, Kanis JA, Jonsson B, Rehnberg C. At what hip fracture risk is it cost‐ effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int. 2006; 17:1459‐1471
21.
Austin P, Tu J, Ko D, Alter D. Factors associated with the use of evidence‐based therapies fter discharge among elderly patients with myocardial infarction. Canad Medl Assoc J. 2008; 179:901‐908
22.
Solomon DH, Johnston SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD. Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res 2014; xx: yyy‐yyy.
23.
Compston J, Cooper A, Cooper C et al on behalf of the National Osteoporosis Guideline Group (NOGG). Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 2009; 62:105‐108.
24.
Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster J‐Y on behalf of the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation ( IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2013; 24: 23‐57.
25.
Lekawasam S, Adachi JD, Agnusdei D et al for the Joint IOF‐ECTS GIO Guidelines Working Group. A framework for the development of guidelines for the management of glucocorticoid‐ induced osteoporosis. Osteoporos Int. 2012; 23:2257‐76.
6
Accepted Article
26.
Wintzell V, Ivergård M, Tankó LB et al. Resource use related to hip fractures based on data from the ICUROS study. Value in Health 2013; 16: A573‐A574.
27.
Svedbom A, Hernlund E, Ivergård, et al and the EU review panel of the IOF. Osteoporosis in the European Union: A compendium of country‐specific reports. Arch f Osteoporos. 2013; 8: 137.
28.
Akesson K, Marsh D, Mitchell PJ et al; IOF Fracture Working Group. Capture the fracture: a best practice framework and global campaign to break the fragility fracture cycle. Osteoporos Int. 2013; 24::2135‐52.
7
